Arya M. Sharma, MD

Hard to imagine a few years ago, but a surprising number of kids today have their own mobile phones. One of the most popular use of these phones is text messaging.

A new study by Shapiro and colleagues from the University of North Carolina, Chapel Hill, published in J Nutr Educ Behav looks at the use of text messaging for monitoring sugar-sweetened beverages, physical activity, and screen time in children.

Following a brief psychoeducational intervention (1 session weekly for 3 weeks), 58 children (age 5-13) were randomised to SMS with feedback, use of paper diaries (PD) or to a no-monitoring control (C) for 8 weeks. The education sessions aimed to encourage the kids to increase physical activity, decrease “screen time” and reduce consumption of sugar-sweetened beverages. All of the children were given pedometers to track the number of steps they took each day, as well as goals to meet for the number of steps taken, minutes of screen time and number of sugar-sweetened beverages consumed per day.

The text messaging and paper diary groups answered three questions each day: (1) what was the number on your pedometer today?; (2) how many sugar-sweetened beverages did you drink today?; and (3) how many minutes of screen time did you have today?

Unfortunately, only 31 kids (53%) completed the study (SMS: 13/18, PD: 7/18, C: 11/22). Children in SMS had somewhat lower attrition (28%) than both PD (61%) and C (50%), and significantly greater adherence to self-monitoring than PD (43% vs 19%, P < .02).

While the authors conclude that text messaging may be a useful tool for self-monitoring healthful behaviors in children, I remain skeptical.

Indeed, I am yet to be convinced that childhood obesity can be effectively addressed by targeting individual behaviours - a far more promising approach would be to change the overall environment (fewer pizza days, neighbourhoods that are condusive to walking to school and playing outside (less screen time), parents who have time to sit down with their kids for a home-cooked meal, etc.).

Texting kids (or for that matter adults) to promote healthy living strikes me as little more than a gimmick, with minimal long-term impact, if at all.

AMS
Edmonton, Alberta

Yesterday I had lunch at the Cafeteria of the Glenrose Rehabilitation Hospital just across the street from my office at the Royal Alexandra Hospital.

The cafeteria is built on Capital Health’s own Healthy Choice Trendz(TM) philosophy that includes a Bistro concept that makes the healthy choice the easy choice. Not only is there no sign of a deep fryer (a rarity for North America) but one really has to look for the unhealthy stuff on the menu.

The standard meat servings are smaller and the plate comes heaped with stir fried vegetables (no oil!) and roast potatoes. Soups come in low-sodium versions, there are even low-fat biscotti, and all breads are whole-grain by default.

Finally, at the coffee outlet, you have a choice of skimmed and 2% milk - cream you have to ask for.

Yes there are some unhealthy choices like pop but the water and juices are up front - the pop you have to actually bend over to pick up.

No problem getting a healthy lunch there - of course, if you try hard, you can find the stuff that it’s better to avoid - but they sure don’t make it easy on you.

Obviously, Capital Health, which developed and is currently establishing the healthy Trendz concept in all of its food outlets, is not only proud of the concept but has assured me that they have even found that offering healthy choices is profitable.

Hopefully the role-out across the region and beyond will not take too long.

AMS
Edmonton, Alberta

p.s the picture is not of the actual food I got, but it certainly comes close

Now here is a counter intuitive finding from Catherine Sabiston, of McGill University, and P.R.E. Crocker, of the University of British Columbia (UBC) published in the Journal of Adolescent Health earlier this year.

In their study of 900 Vancouver-area 16-18 year-old teenagers in Grades 10 through 12, neither was there a link between body mass index (BMI) values and levels of physical activity nor did the physically active teens eat a markedly healthier diet than their less-active counterparts.

If anything, the heavier teens were actually the ones making healthier food choices while the teens with “healthier” BMI values were no more likely to be physically active than those with higher, “unhealthier” values.

According to Dr. Sabiston (quoted in a press release from McGill University)

“A lot of people are surprised, but when you think about it, BMI doesn’t have a huge impact on physical activity. And in terms of diet, it actually makes sense that someone who is not happy with their body might try to eat more healthily. What this study really says, is that one cannot assume that someone who is physically active necessarily eats a healthy diet – or the reverse, that someone who is more sedentary or has a high BMI by definition eats a diet of junk food.“

To me the findings aren’t all that surprising. I have always maintained that health cannot be simply deducted from the number on your scale and that for every overweight kid who eats mostly junk food and spends every spare minute on his Xbox, there’s a skinny kid out there who’s no better.

The simple truth is that eating healthy and exercising is important at any weight!

On the other hand, just as simply eating poorly and not exercising by no means guarantees weight gain - simply eating healthy and exercising does not guarantee a so-called “healthy” weight.

When everyone eats too much and no one moves, it’s likely the poor kids with the “wrong” genes that pack on the pounds - the kids with the “right” genes are simply lucky and can apparently get away with their lousy lifestyles - who says life has to be fair!

Of course, the words “wrong” and “right” in the previous sentence refer to these genes in today’s world. Until not all too long ago in the history of mankind, the “wrong” genes would have been just “right” and vice versa (talking of thinking in circles).

AMS
Edmonton, Alberta

[Hat tip to Michael Dwyer of CIHR for sending me the McGill press release]

This weekend, I was invited to participate in a panel discussion following a public viewing of the documentary Super Size Me.

The event was part of the University of Alberta’s Centenary Celebrations and was co-hosted by the Faculty of Medicine and Dentistry’s Arts & Humanities in Health & Medicine program and the Edmonton Public Library in their film series called “Good Medicine”.

As a panelist, I had the opportunity to see the film again and to reflect on what the film is actually about.

Of course, given that the film shows how Morgan Spurlock super sizes himself by eating nothing but McDonald’s for 30 days, this film can easily be interpreted to simply show how bad fast food is for you.

While there is no question that given its high content of fat, sugar and salt, fast food is certainly not the most nutritious food, to me, this is not what the film actually proves.

In fact, when you think about it, Morgan could have splurged on 5000 KCal a day of even the most nutritious and expensive foods for 30 days and probably have gained as much weight and felt as sick in the end. Yes, you can gain weight on healthy foods!

Even the most pricey restaurants, do not necessarily design their meals to be healthy and balanced and I am probably not the only one who has eaten over 2500 KCal in food and wine at a single meal even in restaurants featuring celebrity chefs - no shortage of fat, sugar and salt in those foods either.

So eating at McDonald’s was just a cheaper way to make this film - no doubt, had Morgan eaten all his meals at a 3-star restaurant, he would have needed a much larger budget for his film. In other words - this was just a “cheap” shot at McDonald’s.

Don’t get me wrong - there is nothing healthy about McDonald’s or most of the food you can get at any fast food chain. But the film does not prove this.

What the film does show though, is that eating 5000 KCal a day can lead to weight gain and make you feel pretty sick. What the film also shows is that this is quite easy to do on fast food. Part of this is because the food is so cheap (=affordable). But another important reason why it is so easy to overeat is because the food is designed to be eaten fast.

I have previously blogged about the notion that the problem with fast food is more the “fast” than the “food” (see my post No Time to be Thin). It is indeed very hard to significantly overeat on “slow” food. This is because, when you eat slow, you will be quite full long before you have managed to tuck away 2000 KCal at a single meal. In fact, the bulkier and greater the volume of the food (i.e. the lower the caloric density), the harder it is to eat 2000 KCal at a single meal.

In the film Morgan also criticizes McDonald’s for offering to super size your order (which they have since stopped doing). This, however, is also not so different from what happens in any restaurant, where the servers are trained to offer an appetizer, salad, dessert and more wine if you don’t remember to order these extra calories yourself. They will also be happy to “super size” your steak order by offering to add a lobster tail or extra cream or cheese on you baked potato.

So here is what I think the film does show:

a) eating 5000 KCal a day leads to weight gain, which in turn is likely to make you sick

b) McDonald’s (and no doubt other fast food restaurants) make it easy and affordable for you to do so

c) McDonald’s (and virtually every other restaurant I know of) wants you to eat more and will try any trick in the book to get you to do so

How do we deal with this - for one, we could begin by posting calories on ALL menus - hopefully a disincentive to overeating, no matter how fast or slow the food.

AMS

Imagine walking into an emergency room with chest pain and simply being sent away with a leaflet advising you to quit smoking.

Imagine arriving at a hospital with signs of stroke and simply being referred to a lecture on reducing sodium intake.

Imagine being diagnosed of colon cancer and just receiving well-meanining advise on the virtue of eating more fibre.

What is fundamentally wrong with the above scenarios? The simple fact that they are confusing prevention with treatment.

While giving up smoking, excessive salt and eating more fibre may be valuable in preventing heart disease, stroke and cancer, as treatments (at least in the short term) they are near to useless.

Once patients present with the disease, they need treatment.

This is not to say that lifestyle changes are not as important for secondary prevention - but they are rarely enough.

While many may agree with the above, they seem to have a hard time applying this knowledge to obesity.

While every politician, non-government organization and legions of health workers are campaigning for more efforts on preventing obesity, rarely do I hear the cry for more treatments - this is blatant discrimination!

When a quarter of the population or around 11,000,000 Canadians already have the “disease” focussing all available resources solely on prevention is a joke.

Not that efforts at prevention are not important - of course they are. Yet, even the most optimistic experts do not think that the current epidemic can be reversed in the forseeable future. It will take time to rebuild our cities, force people to abandon their cars, regulate our food chain, focus on calories and change our culture of overconsumption and sedentariness.

Even if any of these measures worked, no one expects them to have an immediate impact on those struggling with obesity today.

A 200 lb 17 year-old does not have 10 years to wait for “prevention” to kick in - he/she needs help today.

Even if treatment focussed only on providing minimal obesity treatments to those who most need them, i.e. those already experiencing the complications of diabetes, knee pain, sleep apnea, fatty livers, infertility - we would still need to provide obesity treatments for millions of Canadians.

Ignoring their plight and focussing all resources on “prevention” is not only demeaning and in-human, it also perpetuates the wide-held notion that obesity is entirely preventable and that anyone who has obesity has obviously “failed” at doing the right thing and therefore simply deserves no better.

The more we promote the idea that all it takes to prevent obesity is simply for individuals to eat less and move more - the more we can rest in our armchairs and blame people with obesity for just eating too much and not moving enough.

What message could be more powerful in cementing the already widespread bias and discrimination against individuals struggling with this condition?

Perhaps only worse is the message that anyone can become masters of their own weight if they only tried hard enough (as in Biggest Loser?). This idea is even more discriminating, because it implies that anyone who is too heavy is simply not making the effort.

All of this flies in the face of the fact that recidivism of obesity in our current obesogenic environment is almost 100%.

No matter how much weight people lose and irrespective of the weight-loss method (perhaps short of surgery) weight sooner or later comes back. In the exceptional few who do manage to keep the weight off, it remains nothing short of a daily obsession, where the slightest slip-up is punished with immediate weight re-gain.

Simply losing weight is not treatment for obesity - keeping it off is!

Continuing to channel all our efforts solely into prevention and ignoring the plight of the millions who have no where to turn for help except to commercial weight-loss scams is a direct reflection of and only promotes the bias and discrimination against people with obesity.

Fortunately, treating obesity is not more difficult or even more expensive than dealing with other chronic conditions - but it does require at least the same attention and commitment of resources as we devote to other chronic diseases. Not providing treatment is perhaps only a reflection of the bias and discrimination towards people struggling with this condition (they deserve no better!).

We cannot afford to simply write off a quarter of all Canadians. Health ministers, health authorities, NGOs and health professionals now have to step up to the plate!

AMS