Gluten-free does not equal healthy. But the food industry doesn’t want you to know that.

 

1940s-gluten-image1

Caveat: only if medically necessary. Image source.

In the late 1990’s, my grandmother who lived with my family was diagnosed with celiac disease. The experience of planning meals became mildly traumatic for all of us. My most vivid recollection that of is breakfast time: my grandmother pulling a heavy, spongey-looking, yellow loaf of bread out of the fridge and peeling apart two slices to toast and slather with jam to mask the (lack of) taste and awful sandy texture.

Fast forward ten years, and you could now throw a stone and hit someone with celiac disease or gluten intolerance, or who has tried a gluten-free diet for the sake of their health. Why have recent years seen a crazily rising prevalence of gluten intolerance in wealthy Western countries? I won’t address this question today – but rather why eating gluten-free has risen in popularity, and why that’s not a good thing.

Let’s begin with the basics. Gluten is a protein found in wheat, rye, barley, and other whole grains. Celiac disease is an autoimmune disorder, where the immune system attacks the small intestine upon ingestion of gluten and blocks the absorption of nutrients from gluten-containing foods. Symptoms of celiac disease include abdominal bloating and pain, fatigue, tingling hands and feet, joint pain, and depression or anxiety. The process of diagnosing celiac disease is a terrible experience that I wouldn’t wish on anyone. So why has eating like you have celiac disease become so popular?

1. We are more aware and accepting of dietary restrictions than we used to be.

In itself, this is a good thing. Vegetarian and allergen-free food options are now available almost everywhere. A plethora of (good!) gluten-free recipe websites can be found online. Food labelling has improved, with the FDA Food Allergen Labelling and Consumer Protection Act enacted in 2004 (1); this legislation has probably contributed to popular awareness of dietary restrictions.

2. Celebrity endorsement – the Gwyneth Paltrow effect

Perhaps it’s not entirely fair to blame poor old Gwyneth for all this mess. On the other hand, she was perhaps the first to show us the health benefits of eating gluten-free, via on her GOOP website in a carefully constructed self-promotion exercise. Kim Kardashian, Jessica Alba, Victoria Beckham, and Miley Cyrus have all publicly touted the benefits of the diet. Miley has tweeted ‘Everyone should try no gluten for a week! The change in your skin, (physical) and mental health is amazing! U won’t go back!”. These statements are problematic, as a gluten-free diet is not good for you unless medically necessary.

3. The multi-billion dollar gluten-free food industry

This is the biggest and most powerful culprit. The food industry has capitalised on social trends in eating gluten-free, and in particular the widespread assumption that gluten-free equals healthy. This fallacy is shameful. Gluten free does not equal healthy, and it certainly doesn’t equal low carb. Peter Green, MD, director of the Celiac Disease Center at Columbia University said,

The market for gluten-free products is exploding… Many people may just perceive that a gluten-free diet is healthier. Unless people are very careful, a gluten-free diet can lack vitamins, minerals, and fibre (2).

What replaces the whole grain flour in gluten-free foods? Often, it’s corn flour, white rice flour, or potato flour. These are high GI grains that spike and then crash blood sugar levels, and they are low in protein and fibre. They have less nutritional value than whole grain flours. Remarkably, food companies have managed to sell products made with these ingredients under a health-food guise, resulting in a gluten-free food industry expected to produce $15 billion in annual sales by 2016 (3).

The food industry is making billions by selling nutritionally void gluten-free products to a public that mostly has no need for them.

Unless you have celiac disease or a gluten intolerance – estimated to be about 1% of the population – or if you suspect that you do, do yourself a favour and avoid gluten-free products.

 

References

1. U.S. Food and Drug Administration. Food Allergen Labeling and Consumer Protection Act of 2004 (Public Law 108-282, Title II). http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Allergens/ucm106187.htm (accessed 23 August 2014).

2. Jaret P. The truth about gluten. http://www.webmd.com/diet/healthy-kitchen-11/truth-about-gluten (accessed 23 August 2014).

3. Strom, S. A big bet on gluten-free. http://www.nytimes.com/2014/02/18/business/food-industry-wagers-big-on-gluten-free.html (accessed 23 August 2014).

Category: Uncategorized | 2 Comments

Do multivitamin supplements increase mortality risk?

Should we be taking these? A complicated public health question. Image cred

Should we be taking these? A complicated public health question. Image cred

Earlier this week, I was innocently scrolling through the latest research on the JAMA Internal Medicine website. The top headline on the ‘Most Read’ side panel instantly caught my eye: ‘Dietary Supplements and Mortality Rate in Older Women’. Reading, I was amazed to find that taking multivitamins, vitamin B6, folic acid, magnesium, zinc, copper, and in particular iron supplements were all associated with increased risk of death in this study (1). Even more of a surprise, the research was dated from 2011. Why was this not more widely publicized between then and now? A quick Google search ruled out the possibility that I have been deaf to a roaring thunder of anti-vitamin sentiment, as there is little news reporting on potential adverse effects of vitamin supplements.

Before the question of why this topic hasn’t been well-publicized comes the underlying question of whether taking vitamin and mineral supplements truly increases risk of death.

Asking this question is a bit like asking what causes obesity – research can tell us a lot, but it also makes us aware of how little we know, and how clumsy and flawed we humans are when attempting to uncover truths through science. The JAMA Internal Medicine study was the Iowa Women’s Health Study, which investigated the risk of mortality attributed to taking several common types of multivitamin, vitamin, and mineral supplements among 38,772 older women (1). In this study, supplement use was self-reported from memory, which notoriously and tragically often fails even the best of us. The food questionnaire used in the study was well-developed, tested, and validated – it is one of the best tools we have to efficiently assess dietary patterns in large groups of people – but it is not perfect. Incorrect recall, if randomly distributed in the study sample, adds noise to the data to give us null results. Also, are we confident that the biological effect of vitamin supplements in white, post-menopausal women is the same across people of other ages, genders, and races?

The ‘sick-user’ effect – another explanation?

Perhaps another explanation for the mortality effect is that sicker people more commonly take vitamin and mineral supplements than healthy people. In the Iowa Women’s Health Study, the researchers statistically accounted for several healthy behaviors such as physical activity and smoking, and some health problems such as diabetes and high blood pressure. After ruling out these factors that could impact both of whether or not someone takes supplements and their likelihood of dying, there was still an effect of supplements on mortality risk (1). Again, not being perfect, the authors could not account for many other health conditions. A ‘sick-user’ effect may be what we’re seeing in these studies of vitamin and mineral supplementation and mortality (2). It’s also been seen in studies of alcohol and health, where people who drink moderately are often actually healthier than complete abstainers, who sometimes have health problems that preclude them from drinking (3).

Holding the evidence in balance

As always, we have to look at the balance of the research to make decision about causality. In addition to the Iowa Women’s Health Study, a body of high-quality research indicates that a range of dietary supplements have either no effect whatsoever or a small increased effect on mortality risk (1,2,4-6). Importantly, in April 2014, the U.S. Preventive Services Task Force recently released a new recommendation statement regarding vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer (7). The Task Force concluded that ‘current evidence is insufficient to assess the balance of benefits and harms of the use of multivitamins for the prevention of cardiovascular disease or cancer’ (7). They also recommended against the use of beta-carotene or vitamin E supplements for the prevention of cardiovascular disease or cancer. Beta-carotene has been found to increase the risk of lung cancer among smokers.

What’s the conclusion?

The American Heart Association recommends that healthy people get adequate nutrients by eating a variety of foods in moderation, rather than by taking supplements (8). They emphasize that:

Vitamin or mineral supplements aren’t a substitute for a balanced, nutritious diet that limits excess calories, saturated fat, trans fat, sodium and dietary cholesterol.

It seems that if you have no nutritional need for a particular vitamin or mineral, then it’s best to hold off on consuming extra.  Of course, if you have a concern about your own health, then definitely talk to your doctor.  In cases of malnutrition, vitamin and mineral supplementation is a whole other story; this is more of an issue in the developing world.

A varied and nutritious diet is enough for most people. Image cred

A varied and nutritious diet is enough for most people. Image cred

Should we be told more than we are?

Coming full circle, it is curious that the media hasn’t well-covered the adverse health effects of vitamin supplements. There have been informative reports here and there, but nothing like the media storm that has come after other health discoveries.  Given that multivitamins are the most commonly used supplement in the developed world (2), we should reduce (read: stop) our intake to match the seeming fact that they don’t help us prevent two of our biggest killers, cardiovascular disease and cancer, or death itself. The medical community seems to have reached this conclusion, why is it not more widely spread in the public? Let’s not forget that the business of supplementation is just that – a business that aims to make money. An unescapable facet of public health is that we lumber forward with our scientific methods in an inescapable fight against powerful industries that produce the conditions in which ill-health forms and is reproduced. Let’s hope that science outweighs industry in this case to improve the public’s health.

 

References

  1. Mursu J, Robien K, Harnack LJ, Park K, Jacobs DR. Dietary supplements and mortality rate in older women: The Iowa Women’s Health Study. JAMA Intern Med 2011;171(18):1625-1633.
  2. Li K, Kaaks R, Linseisen J, Rohrmann S. Vitamin/mineral supplementation and cancer, cardiovascular, and all-cause mortality in a German prospective cohort (EPIC-Heidelberg). Eur J Nutr 2012;51(4):407-13.
  3. Ng Fat L, Cable N, Marmot MG, Shelton N. Persistent long-standing illness and non-drinking over time, implications for the use of lifetime abstainers as a control group. J Epidemiol Community Health 2014;68(1):71-7.
  4. Macpherson H, Pipingas A, Pase MP. Multivitamin-multimineral supplementation and mortality: a meta-analysis of randomized controlled trials. Am J Clin Nutr 2013;97(2):437-44.
  5. Watkins ML, Erickson JD, Thun MJ, Mulinare J, Heath CW. Multivitamin use and mortality in a large prospective study. Am J Epidemiol 2000;152(2):149-62.
  6. Guallar E, Stranges S, Mulrow G, Appel LJ, Miller III, ER. Enough is enough: stop wasting money on vitamin and mineral supplements. Ann Intern Med 2013;159(12):850-51.
  7. U.S.  Preventive Services Task Force. Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer. http://www.uspreventiveservicestaskforce.org/uspstf14/vitasupp/vitasuppfinalrs.htm (accessed 20 August 2014).
  8. American Heart Association. Vitamin and mineral supplements. http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/Vitamin-and-Mineral-Supplements_UCM_306033_Article.jsp (accessed 20 August 2014).
Category: Epidemiology, Food industry, Industry, Nutrition | Tagged , , , , , | 3 Comments

Why the ice bucket challenge is different

Ice bucket challenge

From the University of Central Arkansas. Click for the story behind this one. CC BY-NC-ND 2.0

When something starts to show up enough on your Facebook or Twitter feed, you get sick of it. I get it. The ALS ice bucket challenge is now so big that TV news shows, while reading tweets to fill time on slow news days, can show footage of stadium-seated crowds dousing themselves. My Facebook feed now has posts like “I swear I can HEAR somebody doing an ice bucket challenge outside.”

So of course there is backlash: for example this Slate article reminding us you don’t need an ice bucket to donate to ALS research. Which is true, but privately donating is boring. Sharing something ridiculous with your friends is far more fun. And while the meme’s growth contributes to our fatigue, it also means we get to watch the likes of Bill Gates and Lady Gaga do it too.

Awareness is a dangerous word. You can spend a ton of effort to raise awareness with only minimal effect on research efforts and patients’ health. And that is how the ALS Ice Bucket Challenge can prove it is different: it has raised money—to date, $22.9 million compared to a typical year’s $1.9 million in the same timeframe.

Compare to the last few awareness memes that made it big:

  • No-makeup selfies to somehow fight cancer
  • Mamming, “embracing the awkwardness of mammograms” by taking pictures of your boobs smushed on surfaces (I swear I am not making this up)
  • Mysterious postings that supposedly have something to do with breast cancer awareness: this year it’s fruits representing your relationship status; in the past it was the color of your bra or where you like to keep your purse.

Now you see how the ice bucket challenge is different: It’s about a specific disease (not a broad category like “cancer”), and there is a clear call for donations. To pass on the meme without the mention of donations seems kind of selfish, and so far people seem to be passing it on. In the original challenge, a friend tags you to donate $100 OR dump ice water on your head. I’ve seen people saying they donated AND dumped water, or others say they couldn’t afford $100 but donated $10. Money talks: as a fundraiser, it worked.

We’ve covered awareness on this blog before: Atif wrote about men’s health & mustaches and I wrote about where cancer awareness can directly help patients.

 

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Public health’s biggest weakness, as illustrated by e-cigarettes

Recently, I was sitting in a meeting with some people, and during a lull in the conversation, they asked me:

“Hey, you’re in public health. What is the biggest problem you face?”

I paused. That’s a tough question. The Western World is facing a number of issues ranging from social to political, and include areas such as increased inequality, an aging population, rising student debt and the issues associated with young people starting their careers already owing six figures to a bank or their government, among other things. However, while others might pick the more “sexy” health issues of the day such obesity or cancer, I’m going to go off the board. I think the biggest problem public health faces is Time. I’ll explain what I mean through e-cigarettes.

E-cigarettes use battery powered vaporizers that turn a liquid solution into an aerosol that can be inhaled, similar to smoking. The solution can include a range of ingredients, but most importantly, do not (necessarily) include nicotine. Nicotine itself forms one of the addictive elements of conventional cigarettes, and so it has been proposed that these could be used as quitting aids by slowly reducing the dependence people have for nicotine. Plus, in addition to a chemical dependence, there’s also a behavioural element to smoking. My friends who have tried to quit struggle with behavioural cues associated with smoking – having a cigarette with coffee, or while driving to work, or after a long day to unwind. Those environmental cues can be as effective at creating a desire for smoking as the chemical component. For those trying to quit, there are thus multiple issues that need to be addressed. This can be where e-cigarettes become useful. As a quitting aid, e-cigarettes can help step people down from the chemical addiction with lower and lower doses of nicotine, ultimately culminating in no nicotine, as well as provide a way for them to get that feeling of smoking without “all the bad stuff.” Or at least, that’s the theory. However, since these devices are so new, there isn’t much, if any, research to substantiate this (yet).

EDIT: This systematic review  and this study were pointed out to me on Twitter, and reported reductions in conventional cigarette use when e-cigarettes were used. This is a promising finding, and this is something public health professionals can use to build programming and advocate for e-cigarette use (especially if more studies can confirm this experimentally, as well as evaluate them for long term ). However, both highlight the crux of this piece, and that is that these were both only published this year. That delay between the introduction of e-cigarettes, and data suggesting that they can be useful for cessation, is an important issue within public health.

Now, the liquid that gets vapourized comes in a number of different types, but the one that is the most concerning are the flavoured varieties. While the nicotine component could, potentially, help people, the flavouring is a completely separate concern and serves no purpose other than to make the product tastier and more enticing. This is a particular concern, especially among our youth. Dr Leia Minaker and colleagues did a study out of the University of Waterloo and found 52% of Canadian students who identified as smokers in Grades 9 through 12 used flavoured tobacco products. This was even higher among smokeless tobacco users (70%) (1). So not only do we know kids are drawn to these products, we know they’re likely to be using the flavoured versions of them if they do use them.

Flavours such as strawberry, "great grape" and juicy peach are all available for consumption

Flavours such as strawberry, “great grape” and juicy peach are all available for consumption

Now herein lies the problem. We know there are concerns with e-cigarettes. We know there are health problems that are a direct result of smoking, and we know that this is targeting children who will (most likely) become smokers as they grow up. However, we need evidence to make such claims. Tobacco companies follow the law – maybe not the spirit of it (that’s up for debate), but the, written down, carved in stone, law. So if you say you can only have a certain amount of nicotine in a product, they’ll put in less than that. They won’t open the floodgates to lawsuits and litigation. However, due to the lack of regulations on e-cigarettes, suddenly there is an open market available, and so they put energy into marketing them, and selling them to the market that can legally buy them (including children). On top of this, kids will market them to each other. Cigarettes have always had an allure to them, both in terms of making you seem “grown up,” as well as a “rebel.” Those are things that youth crave as they navigate the tempestuous waters of elementary and high school.

However, just because there isn’t evidence they can’t harm you, doesn’t mean they won’t. Indeed, the FDA initially came out against them, banning them back in 2010. However, this was overturned soon afterwards, ostensibly due to the lack of evidence saying they would cause harm (why wasn’t the fact that there was no evidence to the contrary a concern, I don’t know). Research is slowly coming out now that is highlighting the risks of e-cigarettes. In fact, increasing the voltage from 3.2V to 4.8V results in a 4 to 200 fold increase in the amount of formaldehyde, acetaldehyde, and acetone – to levels comparable to that of a regular cigarette (2)

However, this all takes time. Performing these studies, following up users of these products and determining if they can be used as a quitting aid, this all is all required to determine whether or not this is a substantiated claim. And it’s not just the research that has to be performed – the law then has to be amended. The EU decided right off the bat to restrict sales to minors, well before research was available. Even then, it took a bill proposed on the 19th of December 2012 until February 2014 to finally be approved. Thus, e-cigarettes point out a massive flaw in public health, which is ironically its biggest strength. The fact that we take time to collect data before making a decision is essential, but it means we’re waiting months and even years to collect the evidence, analyze the data, write and publish the reports that we can then present to policymakers to say “hey! Fix this!” And it doesn’t stop there. We’re then waiting for policymakers to propose the idea, have them vote on it, fight any backlash from industry or the public (and there will be backlash from the $1.2 billion e-cigarette industry). On the flip side, it means that if there are benefits to use – maybe e-cigarettes can have benefits for those trying to quit – we can’t claim that either. We’re stuck in a holding pattern until the data comes back with an answer.

Currently, while there might be some good reasons to have e-cigarettes available for people, there’s no evidence to support that claim. There is, however, a growing body of research is showing that there are drawbacks to having them available. In the meantime, people are freely using them and suffering adverse health effects associated with their use. That time delay, between a product being introduced and public health being able to tackle it, is one of the biggest problems that public health faces.

References

1. Minaker LM, Ahmed R, Hammond D, Manske S. Flavored Tobacco Use Among Canadian Students in Grades 9 Through 12: Prevalence and Patterns From the 2010–2011 Youth Smoking Survey. Prev Chronic Dis 2014;11:140094. DOI:http://dx.doi.org/10.5888/pcd11.140094

2. Kosmider, Leon, et al. “Carbonyl Compounds in Electronic Cigarette Vapors—Effects of Nicotine Solvent and Battery Output Voltage.” Nicotine & Tobacco Research (2014): ntu078. Available online at http://ntr.oxfordjournals.org/content/early/2014/05/14/ntr.ntu078.full

Category: Cancer, Industry, Preventable Deaths, Social Media | Tagged , , , , , , , , , | 9 Comments

How much does a healthy diet actually cost?

Access to healthy food is a major source of social inequality

Access to healthy food is a major source of social inequality

We’re all told to eat 5 (or more!) servings of fruit & veg per day, to cut down on fatty red meat, eat lean proteins, and whole grains. We’re told to cut down on processed and packaged foods, and refined sugars. These are good things. However, clever marketing schemes have also added fashionable trends like gluten-free products, so-called ‘superfoods’, and organic products into the mix of an essential ‘healthy diet’. But, how much does it actually cost to eat in a truly healthful way? In a world where the food industry dictates the types of food available (or not) to people, where ‘food deserts’ are found impoverished pockets of urban centres, and where Western countries are, on the whole, over-fed and under-nutrified with many developing countries not far behind, you begin to wonder how money plays into the complex dietary landscape.

New research from a nutritional epidemiology group at the University of Leeds in the United Kingdom has set out to answer this question (1). The researchers characterised six different types of eating patterns typical in the UK:

1. ‘Monotonous Low Quality Omnivore’: high in white bread, milk, and sugar; moderate in potatoes and meat; low in all other foods – low diet diversity and nutrient poor

2. ‘Traditional Meat, Chips, and Pudding Eater’: high in white bread, chips, meat, sugar, high-fat and creamy food, biscuits, cakes; low in wholemeal food, soya, vegetables, salad, and fruit – energy dense and nutrient poor

3. ‘Conservative Omnivore’: no foods eaten in high quantity; moderate quantities of a range of foods; low in cereals, chips, wholemeal foods, chocolates, biscuits, lower in red meat than the above two groups – a more diverse diet but has lower quantities of nutritious foods than recommended

4. ‘Low Diversity Vegetarian’: high in wholemeal bread, soya products, pulses, fruit, vegetables; low in butter, eggs, meat, and fish – close to dietary guidelines, but does not meet recommended nutrient intakes

5. ‘Higher Diversity Traditional Omnivore’: high in chips, white pasta and rice, high-fat and creamy food, eggs, meat, fish, chocolate, more diversity than the ‘Traditional Meat, Chips, and Pudding Eater’; moderate in vegetables, fruit, and alcohol; low in cakes and pudding – good dietary diversity and nutrient content, but still has fatty and refined foods

6. ‘High Diversity Vegetarian’: high in wholemeal bread, cereals, wholemeal pasta and rice, soya products, nuts, pulses, vegetables, fruit, herbal tea; low in white bread, meat, and fish – meets daily nutrient intake recommendations

 

Going down the list, the diets increase in healthiness according to the ‘Eatwell’ plate.

The Eatwell Plate - UK National Health Service

The Eatwell Plate – UK National Health Service

 

The researchers then used a food cost database to estimate the daily price of each type of diet. The findings were striking: the cost of each type of eating pattern steadily increased with how healthy it was. The ‘Monotonous Low Quality Omnivore’ diet – the most nutrient poor – was estimated to cost £3.29 (approx. $5.56 USD) per day, while the ‘Health Conscious’ diet cost over double that, at £6.63 (approx. $11.21 USD) per day (1). Over the course of a year, that’s a difference of £1219.10, or $2061.50, for just one person. This difference has huge implications: it highlights the disparity between the rich and poor in accessing nutrient-rich and high-quality foods, even within wealthy countries.  A difference of £3.34 or $5.65 per day might not mean much a good proportion of the UK’s or America’s population, but it means a lot to the most vulnerable groups who can’t afford it.

Access to healthy food is a major source of social inequality, even in wealthy countries.

Another, larger investigation from the Harvard School of Public Health came out with similar figures using data from 10 countries, where they adjusted for inflation, World Bank purchasing power parity, and standardised prices to the international dollar ($1 USD) (2). For individual food items, they found the biggest price differences between healthy and unhealthy meats/proteins (e.g. lean vs. high-fat ground beef), at $0.29 per serving, or $0.47 per 200 kcal (2). The price differences per serving of healthy vs. unhealthy grains, dairy products, snacks/sweets, and fats/oils were smaller, but still statistically significant. Overall, having a more healthy diet (at 2000 kcal per day) was estimated to cost about $1.50 more per day than an unhealthy diet. Overall, that’s a difference of $547.50 in one year. Harvard Magazine interviewed the senior study author, Dariush Mozaffarian, stating,

‘The research shows that a healthy diet is affordable for most people, Mozaffarian says, given that “for 60 percent to 70 percent of Americans, $1.50 per day is not a big deal.” Nevertheless, he adds, it is a “big barrier” for the remaining 30 percent to 40 percent of the population – even though the economic costs of chronic diseases related to poor diet vastly exceed the higher price of healthy food.’ (2)

As long as food remains a consumer product, with many companies aiming to produce flavourful, nutrient-poor, and cheap-to-produce foods for profit, this problem is not going to go away. It’s not realistic. However, it isn’t necessary to exhaust your finances in order to eat well. For one thing, ‘superfoods’ are not essential, and the nutrients they provide can be found for much cheaper in other produce options. For example, broccoli contains chlorophyll, vitamins A, C, and E, iron, and calcium. Moreover, it is easy to find and it is cheap. I say this in almost every post, but educating yourself goes a long way in understanding the political/social/economic context in which you live your life, and how to best make even small daily decisions for yourself based on that context.

On a broad scale, one would hope that results from studies like these would help further investigations to understand why the price gap exists (a complex issue for another blog post!), and to push strategies to reduce the price gap between healthy and unhealthy foods. Do you think this is possible?

 

References

1. Morris MA, Hulme C, Clarke GP, Edwards KL, Cade JE. What is the cost of a healthy diet? Using diet data from the UK Women’s Cohort Study. J Epidemiol Community Health 2014 Published Online First on 22 July 2014. doi: 10.1136/jech-2014-204039.

2. Rao M, Afshi A, Singh G, Mozaffarian D. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis. BMJ Open 2013;3: e004277. doi: 10.1136/bmjopen-2013-004277

 

Image sources

Image 1: Newcastle University

Image 2: National Health Service ‘Eatwell’ plate

Category: Epidemiology, Food industry, Industry, Preventable Deaths, Uncategorized | Tagged , , , , , | 11 Comments

Why there’s no Ebola treatment or vaccine yet, in one chart

This is the second of two posts this week on Ebola. Read yesterday’s here: Why here, why now, and why so deadly?

I didn’t make a mistake in the chart above. Ebola’s 1,323 cases barely register when lined up next to killers like AIDS and cancer.

Drugs and vaccines have been in the works for a while, but drug companies aren’t interested in something that infects a handful of people each year in poor countries. (They, like the fictional Samuel Gall, are perhaps happiest specializing in “diseases of the rich”).

Treatments and vaccines in the pipeline

A better source of funding would be governments concerned about Ebola being used as a bioterror weapon. That’s how BioCryst is positioning its antiviral drug, currently known as BCX4430, which seems to be effective in monkeys but hasn’t been tested in humans yet. A Canadian company, Tekmira, is taking a similar approach with their RNA-based treatment; their studies were funded by the US Department of Defense.

Antibody treatments are another possible option, and Kent Brantly, a doctor who contracted Ebola, is reportedly being given antibodies from a boy he treated, who survived the disease.

Inspired by the recent outbreaks, the US’s NIH and FDA are working together to fast-track a Phase 1 clinical trial of an Ebola vaccine that works in animals and could be given to humans as soon as next month.

What we’re doing in the meantime

Ebola patients receive basic supportive care, for example to maintain hydration, but there’s no treatment that can make the disease go away. Antibiotics don’t work because it’s a virus; the antiviral treatment Ribavirin that works on some other hemorrhagic fevers isn’t effective against Ebola.

The only public health tools we have to prevent spread of the disease are good old fashioned isolation (for sick people) and quarantine (for those who have been exposed and may be sick). To find people who have been exposed, health workers track down people who have been in contact with someone who has the disease.

“None of us would be thrilled about the prospect of being admitted to an isolation ward,” says Daniel Bausch, the Ebola expert I spoke with for yesterday’s post. NPR reports that some families are choosing to hide a loved one’s infection rather than risking the “panic and ostracism” that may come from seeking treatment.

Health workers are seeing serious resistance to medical care in some areas. Another NPR report explains:

A plague hits, and then a bunch of foreigners in spacesuits come and whisk away the corpses in shiny white body bags. There have been stories that this is all a scheme to harvest organs from the locals. … Dr. Tim Jagatic of Doctors Without Borders says the misperceptions are understandable: “We created a hospital, and a lot of people started to get sick and die.”

Bausch says that a good treatment or vaccine could reverse that trend: instead of tracking down patients and contacts who believe they have a good reason to hide from health workers, people “would be knocking on the door: ‘I think I have Ebola, could you please give me that treatment?’”

 

Epilogue: The three big questions

I asked Daniel Bausch what big questions still remain in Ebola research. He named three broad areas:

  1. As reported above, we don’t know any good treatments to offer patients and their contacts–just supportive care, quarantine and isolation.
  2. We don’t know enough about how the virus works in the human body. There are animal models that provide some glimpses, but to study humans you have to be able to do research in the middle of a raging outbreak of a rare disease. That’s tough. We have recently learned, for example, that it doesn’t always cause extensive bleeding. That’s why its name was changed from “Ebola hemorrhagic fever” to the simpler “Ebola virus disease.”
  3. We don’t know enough about how the virus spreads. Probably it circulates in bats and is occasionally transmitted to other animals, including humans, as a dead-end host–but the disease is so rare we don’t have a good way of studying it in the wild. Bausch says that while he was in Guinea recently, a group of ecologists started collecting bats from the local population, but their results are not yet published.
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Ebola: Why here, why now, and why so deadly?

This is the first of two posts on Ebola this week. Tune in tomorrow for a look at the big questions facing Ebola researchers.

You’ve probably heard that the current outbreak of Ebola virus is the largest ever, and thus the deadliest. Today’s death toll is 729 out of 1,323 infected since the outbreak began late last year.

Unlike other diseases, Ebola is not always around. Measles infects twenty million people a year; Ebola, outside of outbreaks, infects (as far as we know) zero. Before the current outbreak, the previous infection was more than a year earlier. In between outbreaks, the disease doesn’t exist at a baseline level in the population; it is simply gone.

So why is a huge outbreak occurring now? Why in western Africa, thousands of miles from the place this strain of virus was last seen, in 2009? And why has it gotten so large? Those are the questions Daniel Bausch discusses in an article published today in PLOS Neglected Tropical Diseases. Bausch is an expert in infectious tropical diseases who has been part of the response to the current outbreak, treating patients and training medical staff.

Doctors and scientists know precious little about Ebola virus: how it travels, how it kills, why it emerges when it does. Ebola is suspected to circulate among fruit bats, but nobody has yet isolated the virus in a wild bat.

What’s a deadly little virus like you doing in a place like this?

There’s more than one kind of Ebola virus. Analysis of the genome of the virus in the current outbreak shows that it isn’t related to the Tai Forest virus from nearby Cote d’Ivoire, but rather to the Zaire ebolavirus whose stomping grounds are half a continent away.

How did the virus travel so far without any human cases detected in the meantime? Bausch thinks it wasn’t due to a human traveler. Getting to Gueckedou, where the outbreak seems to have started, requires 12 hours of driving just for the last leg of the trip from any of the nearby capital cities, hardly something you’d do if you were suffering from Ebola. I asked Bausch if an asymptomatic carrier could be the culprit in a Typhoid Mary-like situation, but he says that a person’s ability to shed the virus seems to correlate strongly with how severe their symptoms are. “The likelihood of this being introduced by a sick human is very low,” he says, and by an asymptomatic human even lower.

That leaves the bats. Bats do migrate, and if the virus is in regular circulation among bats it may be less severe, letting a sick bat make the trip more easily than a sick person.

When did the virus make its trip? A recent analysis of blood samples collected from the area over the last 18 years (when they were collected from patients suspected of having Lassa fever) shows that years before the current outbreak, the Ebola virus may have been popping up occasionally in humans in this part of Africa.

Why now?

The current outbreak started in December 2013, at the beginning of the dry season; based on previous outbreaks Bausch believes there may be a connection with the weather, but without knowing more about the ecology of the virus, it’s hard to say if that’s a factor or just a coincidence.

We don’t know how many places in Africa may have Ebola virus circulating in bat populations and occasional Ebola cases in humans that miss diagnosis. But the key factor that sustains an outbreak may not be biological at all.

Why is this outbreak so bad?

Bausch traveled to Guinea every year for a decade while investigating other diseases in the area, and writes that every time he traveled from the capital Conakry to the forest region, “the once-paved road was worse, the public services less, the prices higher, the forest thinner.”

That area where the outbreak started, around Guéckédou, is in a pocket of forest where the borders of three countries converge: Liberia, Sierra Leone, and Guinea. They rank 174, 177, and 178, respectively, on the UN’s Human Development Index; in other words, they are three of the poorest countries in the world. Sierra Leone and Liberia were embroiled in civil war until the early 2000s; Guinea has suffered from a devastatingly corrupt government. None of the countries are in a good position to respond quickly and efficiently to a disease outbreak, and health centers in the region are not always equipped with necessities like gloves and clean needles.

Another complication is that the outbreak area covers three countries. In this area, Bausch says, people identify more with their ethnic group than with their country; borders aren’t much of a dividing line in everyday life. If you live in the area you might cross a border to go to the market or attend school, and you may speak your local language rather than the national language of French (Guinea) or English (Liberia and Sierra Leone).

This all adds up to a situation where a health worker in one country can’t just call up the other side to say hey, this patient had contacts on your side of the border, can you follow up? Even when language is not a barrier, there may not be a phone line to deliver that message nor the organization and resources to do the job.

As the virus spreads–it’s now in Nigeria–socio-economic factors like these will likely determine where an outbreak will catch fire and where it will fizzle out. “I think a military analogy is appropriate here,” Bausch says. “How many fronts can you fight on?”

Correction: A previous version of this post stated that Liberia and Sierra Leone were “embroiled in civil war.” This isn’t currently true, and I’ve corrected the statement above. Thanks to Adia Benton for pointing out the error.

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Immigrant youth to Canada are less active than Canadians, but only for a little bit

Regular readers of the blog and my Twitter profile will know that my PhD dissertation is focused on the health of young people to Canada. In particular, I’m interested in how their health changes over time – does it get better? Does it get worse? Does it stay the same? And in particular, I’m interested in how they compare to peers born in Canada, and whether this is the same between different ethnic groups.

So, for example, if you took two South Asian kids, one born in Canada and one born abroad, what happens to their health? Is the one born abroad healthier? The same? What about after they move to Canada – if the one born abroad starts off healthier, does that persist, or does that benefit disappear with time?

I did a few interviews for this study with the media, and I’ve embedded them throughout the piece. So if you don’t want to read anymore, just hit play on the video below.

(Note: The video should be 16:9, but Vimeo made it 4:3 and I can’t figure out how to change it. Sorry about that).

Now, there’s been a lot of research on this in the US. But the research in the US has focused on the ethnic groups that are of interest to the US – Black, Hispanic and Asian Americans. In Canada though, the major immigrant groups are from East and South East Asia and South Asia. Combine that with two different views on immigration (melting pot vs multiculturalism), and there’s not much evidence out there for what happens to kids once they move to Canada in terms of their physical health.

And that’s where I come in.

We just had a study published in PLOS ONE that looked specifically at the physical activity of young immigrants to Canada, and how their physical activity changes over time.

What did we do?
The Health Behaviour in School Aged Children Survey (HBSC) is an international survey coordinated by the World Health Organization in 43 countries in Europe and North America. We used data from Cycle 6 of the Canadian HBSC, which had data on approximately 26,000 youth in all provinces and territories in Canada, except PEI and New Brunswick. We categorized kids by ethnic group: Canadian, Arab, African, South Asian, East and South East Asian, Latin American and Other. We also categorized them by how long it had been since they moved to Canada: “1 to 2 years,” “3 to 5 years” “6+ years” and then “born in Canada.”

We then were interested in their physical activity levels, and put them into one of three groups based on the number of days of 60+ minutes of physical activity they reported. The first group was 1-3 days, the second was 4-6 days, and the third was 7 days a week. Only the last group met the Canada Physical Activity Guidelines, but then we were also interested in kids who were close (the 4-6 days a week group).

I was interviewed by Wei Chen for CBC Ontario Morning – take a listen here!

What did we find?
As we expected, kids born outside of Canada were less active than those born in Canada. In fact, only 11% of those born abroad got 7 days a week of 60+ minutes of physical activity compared to 15% among those born in Canada. However, the longer you were in Canada, the higher your physical activity was. For example, while kids who moved here 1-2 years before were much less likely to meet the physical activity guidelines, those who moved here 3-5 or 6+ years ago were just as likely as those born in Canada to meet the guidelines. This is a really positive finding – while their initial levels of physical activity might be low, they correct this really soon after immigrating.

But here’s where things got interesting. When you start looking at this by ethnic group, certain trends emerge. We found that East and South-East Asian youth were less active, regardless of time since immigration. They were less likely to be active on 4–6 days/week (0.67; 0.58–0.79) and 7 days/week (0.37; 0.29–0.48), compared to (White) Canadian peers. So whether they were born in Canada, or whether they just moved here, their physical activity levels were consistently lower than other kids.

What is the take home message?
There a few things you can take from this. We found that immigrant kids were less active than Canadian-born peers, although this difference disappears over time. However, this is impacted by ethnicity, with some groups reporting higher levels of physical activity than others. Perhaps most interesting was how East and South East Asian youth have lower levels of physical activity levels regardless of where they were born or how long they have lived in Canada.

Below is an interview that I did with Philip Till from CKNW Radio in Vancouver.

Throughout the piece, I’ve embedded clips of me talking about the study. Take a listen, and I’d love to hear your thoughts! Does this resonate with your experiences/what you’ve seen? And for my international readers, how does this compare to your countries?

Finally, this study wouldn’t be possible with our funders and the respondents to the HBSC Survey. Thank you all for your support!

References:
Kukaswadia, Atif, William Pickett, and Ian Janssen. “Time Since Immigration and Ethnicity as Predictors of Physical Activity among Canadian Youth: A Cross-Sectional Study.” PloS one 9.2 (2014): e89509. Link: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0089509

Category: Determinants of health, Epidemiology, Nutrition, Running, Time trends | Tagged , , , , , , , , , | Leave a comment

“Oh no! What happened?” “W220.2XD: Walked into lamppost, subsequent encounter.”

Last week, I ran across this very entertaining piece over in Healthcare Dive about the new ICD-10 codes. The International Classification of Diseases (ICD) is an incredibly useful tool in public health that basically can reduce an injury to a series of numbers. As you can imagine, this is very powerful when it comes to determining if something is on the rise. Researchers can easily count the number of times something occurs, and if it’s up from previous years, there might be something there.

Part of the beauty of the ICD-10 codes is how specific they are. The previous system, ICD-9 (creative, I know) wasn’t nearly as specific as they only had 13,000 codes compared to the 68,000 in ICD10. With the advent of ICD-10, The Powers That Be have gone into painstaking detail breaking down injuries, diseases and other maladies into incredible precise codes that can be used by researchers and public health professionals.

Today, we’re going to go through my favourite ones.

Do you know what code it is if you get hit by a Macaw? Because one exists. | Photo via National Geographic

Do you know what code it is if you get hit by a Macaw? Because one exists. | Photo via National Geographic

W55.89XA: Other contact with other mammals
There are many codes for contact with mammals. Raccoons, cows, pigs and cats are all represented. However, the mighty seal is not covered, which made Buster Bluth very sad. He would have suffered from W55.89XA.

 

W61.12XA: Struck by macaw, initial encounter. ​

Look like our patient
*puts on sunglasses*
Is a little Macaw-struck
YEAHHHHHHHHHHHHHHHHHHHHHHHHHHH

(The other option here was for an AC/DC reference…)

 

V97.33XD: Sucked into jet engine, subsequent encounter.
Now, I’m not an MD. But, if you are getting sucked into a jet engine on more than one occasion, you may want to re-evaluate your life choices.

Lamp posts are sneaky, and when you're not looking will clock you over the head. | Photo via Wikipedia

Lamp posts are sneaky, and when you’re not looking will clock you over the head. | Photo via Wikipedia

 

W22.02XD: Walked into lamppost, subsequent encounter.
I don’t really know if going to see a doctor is the best solution here, or just looking where you’re going. I do imagine this being on the rise as the epidemic of texting and walking continues to rise.

(Ed note: Subsequent encounter here means they have seen the doctor previously for the same complaint, not that they have done it several times, even though the latter does make it funnier).

 

Y93.44: Activity, trampolining
When searching for “trampoline fail” yields a 5 minute montage on YouTube, you know this is a necessary code.

 

I also looked at some and realized they could be for superheroes…

T63.301A: Toxic effect of unspecified spider venom, accidental (unintentional), initial encounter
Spiderman, spiderman, does whatever a T-63-301-A can!

 

T75.01XA: Shock due to being struck by lightning, initial encounter
When he was hit by lightning, Barry Allen turned from a police scientist to become The Flash! One of the greatest superheroes of the Silver Age!

 

W88.1: Exposure to ionizing radiation
HULK NO LIKE BAD CODES. HULK LIKE WELL CATEGORIZED DATA. HULK LIKE PUBLIC HEALTH.

 

And my favourite code in the ICD10 manual:

V91.07XA: Burn due to water-skis on fire, initial encounter
Frankly, if you manage to set water-skis on fire, I’m not sure whether I want to give you a hi-five, a Darwin award, or video the whole thing for YouTube. I’m not even mad, that’s amazing.

 

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While I make fun of the codes, they’re incredibly useful for public health and for collecting data. Knowing person, place and time, i.e. this idea of who is getting injured, where they’re hurting themselves and how can make all the difference when it comes to analyzing data and creating programs to prevent these injuries and illnesses from occurring. Whenever you present to a doctor, if they record the information that will allow for your ailments to be categorized using the ICD10 system, it goes a long way to helping researchers figure out what is going on at a macro, population level.

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1 weird tip to not die of smallpox

Cartoon about vaccination ("The Cow Pock") from http://en.wikipedia.org/wiki/File:The_cow_pock.jpg

How weird is vaccination? So weird they’re putting cow disease juice under your skin. Ew.

Sawbones is a hilarious podcast about the ways medicine has, historically, gone wrong. On long drives with nerdy friends, I whip out my phone and we consider which episode to listen to and laugh at: Leprosy? Trepanation? Bloodletting? Plague?

The hosts, Justin and Sydnee McElroy, offer a “marital tour of misguided medicine.” Dr. Sydnee, who is an actual doctor, provides the medical and historical knowledge. Meanwhile her husband, Justin, plays dumb—for example, thinking he’s got leprosy, or positing that menstruation is a disease that needs to be cured.

But last week, Sawbones released a Very Special Episode about vaccines. It was their most requested topic, the hosts said, and they really, really didn’t want to do it. The show is supposed to be light entertainment, and they’ve avoided taking sides on any controversy—even, in the episode on homeopathy, going easy on modern-day adherents of the practice. What made them jump into the fray for vaccines? In Justin’s words: “It’s 2014, and kids are getting the measles.”

You can listen to the episode here:

The other problem with featuring vaccines on Sawbones was simply that medicine got it right. While most of the treatments they lampoon on the show are ones that sort of sound plausible, but were wrong, vaccines sound totally weird (give my kid a sick person’s pus?!) but actually work. So it’s not a history of mistakes, but for the most part a string of successes.

It is also, touchingly, at many times a story of parents trying to save their children from death. I saw in the story of Lady Mary Wortley Montagu a reflection of today’s “mommy wars” over vaccines. She was a young mom who had lost her brother to smallpox. Her husband was the English ambassador to Turkey, and while she lived there she learned about variolation, in which a healthy person is given liquid from a smallpox pustule. (If the virus involved is Variola minor, you’ll gain immunity to both that and the more serious Variola major.)

Lady Mary had her 5-year-old son inoculated in Turkey, and after returning to England, had her daughter inoculated in the midst of a smallpox epidemic. She encouraged others to try variolation, but it didn’t catch on (too foreign) until Princess Caroline allowed it for her children. And she didn’t try it until after it had been tested, first on a group of death row prisoners, and later (for good measure) on a half-dozen orphans.

OK, so they got the science right, but the ethics way, way wrong. Several times.

When Edward Jenner famously made the first vaccine—from vacca for cow—he gave it to James Phipps, the son of a poor worker. Dr. Sydnee and Justin speculate that money may have changed hands (would YOU volunteer your son to catch a cow disease?), but there’s no record of a payoff at the time (he did give Phipps a free lease on a house, later in life). Jenner then attempted to infect the child with smallpox twenty more times in his life. Fortunately for the kid, the vaccine had worked.

Worse yet, to provide colonies with the vaccine, cowpox was given to five orphans who were then shipped across the ocean.

Throughout the story, our Sawbones hosts marvel at how weird the techniques were. And yet, they worked. Weirder still, they caught on. Vaccination was such a success that smallpox was, in 1977, officially eradicated. Dr. Sydnee recalls learning the progression of smallpox lesions in medical school: “macule to papule to vesicle to pustule,” she recites, and adds that, fingers crossed, she should never have to use that knowledge.

But you know what comes next. As soon as they released that episode, mentioning in an offhand way that smallpox now only exists in two labs in the world (one in the US, one in what is now Russia), a third stash of smallpox virus was found in the back of a fridge in Bethesda.

Still, the World Health Organization keeps stockpiles of smallpox vaccine and recommends that the existing virus stocks not be destroyed, an idea that is floated from time to time. We don’t know what other refrigerators smallpox might lurk in; best to be prepared.

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