What to do with The Refugees?

The truth is, I don't really have a solution.

Just some brief thoughts on the refugee problem around the world:

Yesterday, in Yom Kippur Services we spoke how a famous Rabbi (Hillel) summed up the Torah (Old Testament) while standing on one leg. He simply said, "“That which is hateful to you, do not unto another: This is the whole Torah. The rest is commentary — [and now] go study.” This line comes from the Torah, "Love thy neighbor as thyself”(Leviticus 19,18)". 

To follow Yom Kippur's Torah Reading, the Pope said today ,"We, the people of this continent, are not fearful of foreigners, because most of us were once foreigners."

Now comes the Jewish Holiday of Sukkot, which we remember that we were once nomads in the desert after fleeing a Egypt. We were refugees from a brutal dictator. How is this much different from today? One of our Rabbis encourages us to reach out to these people:

This Sukkot, I challenge us not to turn the page when confronted with their faces, but rather, to learn more about them, seek out opportunities to volunteer with refugees in our own communities, advocate on refugee issues or give tzedakah. We must also address the root causes of refugee crises around the world, by helping to build just societies where each person is valued and persecution is not tolerated. 

 But what about the economics of taking in more immigrants? The fiscally conservative magazine, The Economist, says:

Migrants are net contributors to the public purse. They inject economic dynamism. They are, almost by definition, self-starters.

Compassion and economics often work in the same direction. This may be an example.

Supplements are Not Helpful for Athletes or Regular People

I am an avid cyclist. I would be happy to take any "natural" substance that helped my performance, but did not harm my body. Today, a well know professional pulled out of the Tour of Utah due to a positive finding of synthetic testosterone in a blood sample from July. (Cycling now tests riders randomly, even when they are not racing. They can just show up at your door any day and ask for a test. This is why I believe cycling is getting cleaner.)

Tommy Danielson believes that the positive sample was from a contaminated supplement he was taking . (Let's assume that this former doper, who rode with Lance Armstrong, has reformed as is not lying. I tend to believe him.) Why was he taking a supplement? He likely was taking something that someone recommended as a legal way to improve his performance.

However, there is little evidence that any sports supplements actually improve performance. I haven't reviewed the literature recently. But the last time I checked, the only two supplements that had some minor evidence were: Vitamin C for prevention of colds in endurance athletes and creatine for some body builders and vegetarians who did not get it from their diet.

The supplement industry is basically unregulated. It is a multi-billion dollar industry, but a law in the United States (DSHEA) prevents the Food and Drug Administration from regulating it. Basically, the supplement companies can make any claims they want, as long as they do not say it prevents a disease. Additionally, they are not subject to inspections or quality controls, so contaminants can get into them. (I'm not clear how synthetic testosterone gets into them, but maybe it was made in the same facility as testosterone.)

So why risk taking a supplement that is not going to help you? It might get you disqualified from a race, affect your career, and could even harm you. If you have to take one, and there is solid randomized controlled evidence for it, get it tested or use one certified by USP.

What if you are not an athlete? Maybe you just hear you should take glucosamine, Vitamin D, or Vitamin C to be healthy? As I've said before, multivitamins are not helpful, and may even cause harm. The evidence is clear. STOP taking them.

One of the last hopes of the Vitamin industry was Vitamin D. There was controversy for many years with many recommending its use, despite an National Academy of Medicine report advising against. Now we finally have a good study that supplementing with Vitamin D does not help women with mild "deficiency".

Many people tell me that eating healthy is too expensive. Yet Americans spend billions of dollars a year on supplements that do little to nothing. Let's put that money into buying healthy food. Until the supplement industry can produce high quality randomized controlled trials showing that a product works, I suggest staying away from them.

New Recommendations on Obesity Prevention in Kids

The American Academy of Pediatrics just issued a new report on how to prevent excessive weight gain in kids. Here are the highlights:

1. Education and advice are unlikely to be effective. Environmental change and more advanced behavior modification are more effective.
2. Beverages: eliminate sugary beverages. Limit juice and encourage fruit instead. Water is the ideal beverage for kids to drink. 
3. Limit foods with high caloric density. (I think they got this terminology slightly wrong. Nuts, for instance, are highly caloric, but are also highly healthy. I think they should have said "limit processed food".)
4. Children less than 2 years of age should not have any interaction with electronic entertainment/communication (including tablets, phones, TVs). Those older than 2 should be limited to 2 hours. (My thought: Parents might consider doing the same for themselves!)
5. Kids should be active for 60 or more per day. 
6. Prevention should start before birth by focusing on healthy weight gain and other practices in pregnancy. (My comment: it is hard to work on "healthy habits" once women are pregnant. It is much more effective to get healthy before getting pregnant.)

Of course, these recommendations are worded as being just focused on pediatricians. But, they really apply to any physician or provider taking care of children. Family physicians have a critical role, as we often take care of the Mother before she comes pregnant, and can help initiate prevention earlier than pediatricians and obstetricians. 

Remember 5-2-1-0 for kids (and families):

5 Fruits/Veggies a Day 

2 or less hours of screen time (for those older than 2)

1 hour of physical activity

0 sugary beverages

Reducing Saturated Fat: Worth it?

We recently published an article that was a "Mythbusters" on nutrition.  One of the controversial parts of the article was whether reducing saturated fats was a worthwhile nutritional focus. Of course, all of the major groups, including the IOM, reinforce the importance of reducing saturated fats.

One of the major studies we relied on was a Cochrane review. Cochrane reviews are the "gold standard" of evidence-based medicine. They take all the of the studies on a topic and use a standardized method to compile the evidence. The Cochrane review we relied on was just updated with new data. The results are the same. The plain language summary is:

"The review found that cutting down on saturated fat led to a 17% reduction in the risk of cardiovascular disease (including heart disease and strokes), but no effects on the risk of dying."

Let's break this down. If you replace saturated fats with other fats (but not with carbs), you will not reduce your risk of death. However, you will reduce your risk of a cardiovascular event. But here are what the numbers look like.

In the regular saturated fat group 83 people out of 1000 had Cardiovascular Events over 4.7 years, compared to 70 (95% CI 61 to 80) out of 1000 for the reduced saturated fat group.

Here is the visual for the regular group:

 And here it is for the reduced saturated fat group:

So out of 1000 people on the reduced diet, 13 less will have an event, with no effect on mortality.

Is it worth it?

Either way, it is beneficial to eat less meat and more vegetables. That reduces mortality.

Nutrition Confusionism

The new draft Dietary Guidelines were just released. I won't post the link here, because few people will read the dense document. The major take home points were: eat more whole fruits and vegetables, less sugar, less meat, less saturated fat, less salt, and don't worry about cholesterol too much.

I was just at the Partnership for a Healthier America conference, where lots of nutrition experts mingled with lots of food company executives. There was a lot of confusion and snickering amongst the group. Some decried the Committee for stating that how much cholesterol you eat is not that important. Others asked why saturated fat and salt were still emphasized, even though the best evidence does not support reducing these food ingredients to improve health.

The non-scientists asked the scientists why nutrition is so confusing. They made it sound like the science was constantly changing, but the guidelines committees ignored the science. I listened to this segment of NPR's Science Friday, where the host asks why the nutritionists, "have known that eggs are ok to eat, but the rest of us didn't."

Who is at fault here? I'm not sure. But I recently skimmed through my nutrition courses from when I was an undergraduate at Cornell. I went through my notes where I indicated that we were taught that is very difficult to find an association between salt and hypertension within a population. I also had copious notes stating that the connection between calcium intake and bone health was weak. (Thanks to Charles McCormick for this great class!)

I then went to my intro course table of contents and found our lecture titles: "Diet and serum cholesterol: environment or biology?", implicating that cholesterol in the diet doesn't matter that much. Another was, "Ambiguous connections: salt and hypertension". Thank you Dr. Levitsky for teaching us how to think about the facts without the hype.

The "new" news that we do not have great evidence dietary cholesterol, salt, and other nutrients are critical for health, is really not that new. I was learning it back in 1997.

So now people are telling us nutrition is confusing and that we said salt, cholesterol, and fat are bad and then good. I'm not sure where the confusion comes from. Is it from nutrition researchers who devote their careers to studying the role of one nutrient and its effect on health? Is it from journalists who love to sensationalize the latest food craze based on one study? Or is it from food companies who make so many claims about food and health, that we end up just buying whatever sounds good at the time?

I'm not going to blame one group. We are all part of the problem. But, one thing has been consistent throughout the years. This fact is summed up in this line in the new dietary guidelines report:

"Vegetables and fruit are the only characteristics of the diet that were consistently identified in every conclusion statement across the health outcomes."

So just follow the simple advice to eat more (whole) fruits and vegetables. (Sorry smoothies and vegetable juices don't count.) Avoid the processed junk. That advice is probably a few generations old. 

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Thoughts on the Berkeley Soda Tax

This is a repost from the National Physician's Alliance Blog:

Many political pundits are trying to decipher the lessons from the 2014 midterm elections. I will not try and do that here. But, some of the most interesting results have come from ballot measures. While many people voted for conservative officials, these same voters voted to legalize marijuana, prevent a personhood amendment, and raise the minimum wage.

One of the most interesting measures that passed was the soda tax in Berkeley. San Francisco voters also voted in favor of the tax, but did not reach the 2/3rds majority needed to pass. (The 2/3rds threshold has to do with California law on new taxes.) Others have tried institute a soda tax. The two most notable examples were New York City and Richmond, CA. Both resulted in the American Beverage Association (ABA), an industry trade group, spending millions of dollars to defeat the measures. The ABA spent a few more million in the recent ballot initiative in Berkeley. By law, companies have a fiduciary responsibility to maintain profits for their shareholders. Thus, my conclusion is that they had to spend this money. They feared profits would decline if these measures passed.

The evidence is fairly clear on the likely effects of a soda tax. Various economists have done simulations to show that a tax will likely decrease consumption and purchasing. The health economists have also simulated how many people will be prevented from getting diabetes and heart attacks. Of course, all simulations are based on assumptions. Since we do not have an actual soda tax yet, it is hard to predict exactly what will happen.

But, early indications from data in Mexico, after their soda tax was instituted recently, is that sales are decreasing. If other assumptions hold up (e.g. that people will not go eat candy instead), Mexico’s policy could have an impact on public health. The effects will be more difficult to measure in Berkeley. Berkeley is a small city with many surrounding urban areas without a soda tax. It also has a population that is often changing, due to the University population. However, it still offers us an interesting experiment to see the possible effects of a soda tax. Particularly interesting will be the effect on Berkeley youth.

A signifiant consequence of Berkeley passing a soda tax is a possible ripple effect. Other cities interested in experimenting with public health policy could think about passing a soda tax. California has often been an experimentation ground for innovative policies. The policies preventing smoking in public places started here, leading the way for cities worldwide to institute these bans.

While libertarians may protest against these policies, people still have the freedom to choose whatever they like to purchase. Taxes already exist on other foods in California, such as restaurant food and frozen meals. The soda tax just adds sugary beverages to the mix, albeit at a slightly higher rate.

Finally, many believe that the actual tax is not the real intervention here. The tax on sugary beverages just gets us all talking about the harms of drinking 10 (or many more) teaspoons of sugar at a time. The media is talking about it. Social media is talking about it. If the tax in Berkeley signals to people that drinking sugar is not the “cool” thing to do, than maybe a few more parents will think twice about buying their kids a sugary drink.

Childhood Obesity, Headlines, and Jelly Beans

Remember that game where you guess how many jelly beans are in a jar? Well, if I guess once, I'll probably be wrong. But if I'm allowed to guess 500 times, I might get it right once. But that doesn't mean I'm a good guesser of jelly beans numbers.

The same concept applies to research studies. The more times you test a question, the more likely you are to get a postive result. That doesn't mean that the answer to the question is "yes". It just means you guessed so many times that your were bound to get a correct answer.

The New York Times Missed this point in their article when they wrote the headline:

"Obesity Rate for Young Children Plummets 43% in a Decade"

Sounds like a huge drop. I wish it was. But the researchers tested many age groups to see if there was a decline over 10 years. They checked the age ranges 2-5, 6-11, 12-19, 20-39, 40-59, and >60. When you "guess" if there is a decrease in obesity in all of these age groups, you are likely to find one "yes".

The researchers admit this and even caution interpreting their results this way:

"When multiple statistical tests are undertaken, by chance some tests will be statistically significant (eg, 5% of the time using α of .05). " 

And they conclude:

"Overall, there have been no significant changes in obesity prevalence in youth or adults between 2003-2004 and 2011-2012. "

Yet some how the New York Times missed this, and focused their headline on a minor result. While we might have made small gains against childhood obesity, we haven't really begun to change the trajectory of the epidemic.