Your germy digital footprints are everywhere. Scientists are watching.

H1N1 Influenza Virus Particles. Photo from NIAID, CC-BY

H1N1 influenza virus particles. Image from NIAID, CC-BY

Looked up something on Wikipedia lately? That may be enough for a computer to guess if you’re sick. According to a new study in PLOS Computational Biology, the most accurate, timely data about how the flu is spreading in the US may come from Wikipedia. Lookups of pages like Influenza, Flu Season, and Tamiflu matched the CDC’s official estimates of influenza-like illness better than the alternately lauded and derided Google Flu Trends.

While CDC data is considered a gold standard for flu tracking, it relies on clinic reports and lab testing, and so is always a week or two behind what’s happening in the real world. Timely flu tracking helps hospitals, health departments, and the like to plan ahead: Do we need a new shipment of flu vaccine? How many doctors and nurses should be working the emergency room this weekend?

The biggest name in digital epidemiology, for the moment, is Google Flu Trends, which launched in 2008 and has performed well for the most part, with notable blips in 2009 and 2012 that led to harsh criticism (and, of course, updates to the algorithm). But Google doesn’t make its data or methods public, so David McIver and John Brownstein from Boston Children’s Hospital ran their analysis on Wikipedia lookups, which are publicly available. “Making everything more open makes it more collaborative,” says McIver, who hopes that others will build on his project to improve the althorithm or expand its use to other diseases–maybe heart disease or diabetes, maybe STIs. “Maybe we’ll get a different answer [about a disease's prevalence] than what traditional sources have given in the past.”

But is it a problem that disease data is so publicly available? I asked McIver if there was a data set he wishes he could get his hands on, and while he said there was no “holy grail,” he mentioned that some of his colleagues are trying to tease trends from electronic medical records. Hospitals keep those records accurate and up-to-date, but researchers can’t play with them willy-nilly: nobody wants their medical records made public.

So, for now, digital epidemiology works from public data and voluntary surveys. It’s hard to argue with disease tracking projects that can provide early detection of outbreaks, as with cholera in Haiti, or pinpoint restaurants that could give you food poisoning. Google tracks not just flu but also dengue. One flu-tracking project even gives participants nasal swab kits to verify their disease status.

If digital epidemiology does reach out to other diseases–actually, not if, but when–will we wish our seemingly innocuous online traces were less public? What if you were a data point in, say, a gonorrhea study? An early facebook analysis found that individuals were indeed identifiable from “anonymized” data. “Just because [data is] accessible doesn’t make it ethical,” wrote a pair of analysts in 2011. Our digital footprints, like our DNA, are turning out to contain more information about us than we thought.

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Thinspo, eating disorders and the seedy underbelly of The Internet

Trigger warning: I’m going to avoid triggering language as much as possible, but I will be discussing eating disorders and body image in this post.


We’ve all seen those photos. The inspirational quote, set to a background of a sunset, or a “One More Rep” picture with airbrushed model standing there, glistening ever so slightly while doing squats/deadlifts that is supposed to give us the motivation to push through. If we do that one extra rep, or run that one extra mile, maybe we too can look like that person. We all have that model in us, we just need to push through the pain to get there. However, what happens when this mentality goes too far?

The internet, like all tools, can be used for good and for evil, especially when it comes to exercise. Perhaps the biggest strength is the ability to get really good information from people you otherwise wouldn’t. Eric Cressey, Kelly Starrett and others give you access to information and videos based on sound science. They can push you to be stronger, workout smarter, and live the healthiest life you can. And sometimes, you can use those pictures of people being physically active as inspiration, a trend the kids these days call “fitspo,” a portmanteau for fit-inspiration. This can motivate you and gives you a goal to strive towards. Indeed, it’s a trope that has been used in movies ad nauseum. Who can forget the montage in Rocky IV where Rocky keeps looking at the picture of Ivan Drago in the mirror through his montage, eventually crumpling it in a most dramatic fashion (with heavy metal guitars playing in the background). The two ads featured here use the same idea to try and capitalize on this sense of greatness that we all hope is within all of us. However, like all behaviours, this is a balancing act, and can have devastating consequences.

When “fitspo” is taken too far, health consequences such as eating disorders and poor body image can manifest. Feelings of inadequancy, body dysmorphia and pushing yourself to unhealthy limits are all very real consequences faced by athletes of all stripes and at all levels from the rookie to the professional. The advent of the internet, and in particular, social media, has made this a bigger concern. While before finding like-minded people used to be difficult, now it has become easier than ever to find reinforcing opinions. At one extreme, you have internet-based subcultures growing that promote unhealthy weight loss. However, this also exists in the mainstream, and even using social media sites like Facebook can have similar consequences.

The former are communities built around both unrealistic ideas of beauty, as well as acting as forums that promotes unhealthy weight loss patterns via anorexic and bulimic behaviours. Two of the most popular are “thinspo” and “pro-ana,” representing thin-inspiration, and pro-anorexia respectively. Posting photos of those who they view as “thinspo” (thin-inspiration), these communities can provide “support” for people, preventing them from getting help and encouraging to indulge in these dangerous weight loss behaviours. The internet has created a way that anyone with internet access can join a community of like-minded individuals, who provide tips on how to achieve that “goal” as well as motivation on how to “succeed.” While some might think this is a relatively minor subculture, they are incredibly easy to find with an internet connection and Google. There are dedicated thinspo Tumblrs, Pinterest boards and other sites one can subscribe to for updates. What’s scariest about this is just how dedicated some of these members are. Regular updates, group support, advice on how to deal with others, as well as blogs that document progress lead to a terrifying community of young people who are encouraging each other with this incredibly dangerous behaviour. It’s led to shady communities that provides risky and dangerous support for potentially debilitating conditions.

This represents one significant outcome that people actively seek out. However, there are also other, more insidious, consequences from using social media. Since social media is inherently based on comparisons with others, this has consequences for how you perceive yourself relatively to everyone else. Rather than seeing both the good and bad of others, you perceive others as living happier and better lives than they actually do, a fact that exists by design since most people put forward their best face forward to represent their virtual selves. This is further compounded by the “friendship paradox” which states that, on average, your friends will have more friends than you (click the link for a more in depth discussion of how this works). Recent research has started to evaluate these ideas using the scientific method, and supports this hypothesis. In fact, increased usage of Facebook has been shown to be associated with a decline in subjective well-being among young adults in a 2013 PLOS ONE study. Similarly, a recent finding among 881 college women was that increased Facebook use was associated with more negative feelings and more comparisons to the bodies of friends. Both of these represent significant and important outcomes that we may not consider as “public health threats” yet, but can start health concerns such as body dysmorphia, and may lead people down the path towards the aforementioned online communities.

Public health practitioners need to be at the forefront of these trends, and be aware of them as they materialize. As we transition to a life where not only do we spend more time online, but are expected to be, more and more interactions take place exclusively in the virtual realm. The impact this can have on our physical, mental and emotional health is a burgeoning area that needs more research in order to best equip those in public health with the tools on how to succeed.


Additional resources: If you’re looking for help with any of these disorders or would like to learn more, consider calling National Eating Disorder Information Centre in Canada or National Eating Disorders Association in the US. Both organizations have helplines available. There is also more information via the Canadian Mental Health Association and National Eating Disorders Association.



Kross E, Verduyn P, Demiralp E, Park J, Lee DS, et al. (2013) Facebook Use Predicts Declines in Subjective Well-Being in Young Adults. PLoS ONE 8(8): e69841. doi: 10.1371/journal.pone.0069841

Category: Determinants of health, Epidemiology, Nutrition, Social Media | Tagged , , , , , , , , , , | 1 Comment

To live longer, eat 7 servings of fruits and vegetables per day

Image source: LoveFood

Image source: LoveFood Copyright 2014

A paper investigating whether the consumption of fruit and vegetables actually affects health in the general population of England was published online in the Journal of Epidemiology and Community Health last week (1). The paper measured health as death due to any cause, and also specifically due to cancer and cardiovascular disease as they are the two biggest killers of older adults in developed countries (1-3). They found that consumption of 7 or more servings of fruit and vegetables per day reduced risk of death by 42% in the general English population, a finding which is making a major media splash. This paper and the reactions against it are interesting for several reasons. First, let’s talk how the study was done and what the results actually mean.

The authors of the paper took data from the Health Survey for England, which is an annual national survey assessing the health of the nation. Data on over 65,000 people aged 35 and over who participated in the survey from 2001 to 2008 were included in the newly published paper. All of the participants were asked about all vegetables and fresh, canned, and frozen fruit, and salad, pulses, dried fruit, and fruit juice/smoothies they consumed (1). The study authors then linked data on fruit and vegetable intake to mortality data, with people being followed up for an average of 7.7 years between the time when their intake was measured and mortality data collected.  The authors then modelled the association between an increasingly greater amount of fruit and vegetables per day (0 to less than 1 portion, 1 to 2 portions, 3 to 4 portions, 5 to 6 portions, and 7 or more portions) and risk of dying.  They found that people who ate 7 or more portions per day of fruit and vegetables had a 42% lower chance of dying (1).  They accounted for factors including age, sex, social class, cigarette smoking, body mass index, education, physical activity, and alcohol intake, meaning that the effect of fruit and vegetable intake on death was independent of all of these factors.

Image Source: LoveFood

Image Source: LoveFood Copyright 2014

This finding obviously sounds very splashy, and was highly media worthy.  The reduced risk of death was true for cancer and cardiovascular diseases, in addition to all other causes (1).  If we all ate more fruit and veg every day, we could all live longer. Sounds simple, right? One problem is that knowledge often doesn’t translate to behaviour. We all know that eating greens is good for us, but we don’t always do it. With respect to this latest finding, media frenzy over health issues has given epidemiological research a bad rap by causing uncertainty and confusion over what’s healthy and what’s not. We hear news all of the time about some new magic bullet or evil detrimental factor to health, and sometimes things fall into both categories in the news. A great example is alcohol, where some research shows that drinking low-to-moderate amounts of red wine appears beneficial to health, but large amounts of alcohol consumption cause increased risk for several chronic diseases (4-7). Given our continual frustrated experiences with gaining health information through the media (8), it would be no surprise if people tend to glaze over when reading the new 7 per day headline in the news.

One reaction against the new research in the media is backlash against state-backed recommendations for individual dietary choices. A Guardian commentator, Alex Renton, makes the mildly inflammatory point, ‘Nanny Britain’s fruit and veg regime will never work while the list includes fruitcake and sugar-laden drinks’ (9). This point is interesting. Leaving aside the welfare state discussion, the question of responsibility for individual dietary intake in the context of what is available given the food industry is interesting. The onus is largely on individuals when it comes to fruit and vegetable intake – one only needs look at the NHS ‘5-a-day’ website or the American equivalent to see this. However, it can be difficult to eat 5 servings of fruit and vegetables per day when so many processed and refined foods that taste good and are easy to access are available. Particularly for people on a low income, the most cost effective foods in terms of energy density are usually not fruit and vegetables[LCK11] . The food industry places governments in a catch-22 of providing recommendations for the public on healthy eating and other behaviours, which is certainly easier than regulating the food industry, but can be called ‘nannying’. So, what are governments to do? Alex Renton of the Guardian says that the state must police the business sector in order to make it feasible for people to follow dietary recommendations (9). He laments that this doesn’t happen, and it certainly doesn’t seem like it will change.

Given that our health is in our hands, what do we do as individuals? First, empower yourself with knowledge. We now know that eating an abundance of fruit and vegetables can help us live longer (1). These results are sound, although there is a question left unanswered – because the study didn’t account for total caloric intake or dietary fat, we don’t know whether the people in the study who ate 7 or more servings per day experienced a lower risk of dying directly from eating fruit and vegetables, or if they were eating less unhealthy foods and/or overall calories because they were eating more fruit and vegetables. Regardless, eating plants doesn’t hurt. Echoing the famous words of Michael Pollan, who said ‘Eat food. Not too much. Mostly plants’, Alex Renton states ‘Don’t eat crap. Three times a day. And try to cook something every day that makes you and those you love happy’ (9).

I wholeheartedly agree with these words. Michael Pollan’s book, ‘In Defense of Food: an Eater’s Manifesto’ is worthwhile read. For something a bit more bite-sized, the BBC has compiled a fabulous list of tips for eating 7-a-day, as has the Guardian.

Happy eating!



1)      Oyebode O, Gordon-Dseagu V, Walker A, Mindell J. Fruit and vegetable consumption and all-cause, cancer, and CVD mortality: analysis of Health Survey for England data. J Epidemiol Community Health Published Online First: [31 March 2014] doi:10.1136/jech-2013-203500

2)      Office for National Statistics. Leading Causes of Death.–deaths-registered-in-england-and-wales–series-dr-/2012/info-causes-of-death.html (accessed 08 April 2014).

3)      Centers for Disease Control and Prevention. Leading Causes of Death. (accessed 08 April 2014).

4)      Corder R, Mullen W, Khan NQ, Marks SC, Wood EG, Carrier MJ, et al. Red wine procyanidins and vascular health. Nature 2006;444:566.

5)      Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ 2011;342:d671.

6)      Boffetta P, Hashibe M. Alcohol and Cancer. Lancet Oncol 2006;7(2):149-56.

7)      Kozararevic DJ, Vojvodic N, Dawber T, McGee D, Racic Z, Gordon T, et al. Frequency of alcohol consumption and morbidity and mortality: the Yugoslavia Cardiovascular Disease Study. Lancet 1980;315(8169):613-6.

8)      Arora NK, Hesse BW, Rimer BK, Viswanath K, Clayman ML, Croyle RT. Frustrate and confused: the American public rates its cancer-related information-seeking experiences. J Gen Intern Med 2007;23(3):223-8.

9)      Renton A. So now it’s seven a day? Here’s my easy alternative: just stop eating rubbish. The Guardian. 6 April 2014. (accessed 8 April 2014).

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Cell-to-cell spread of HIV and its possible implications for antiretroviral therapy


Today’s post features a conversation with an inspiring person about HIV transmission, health inequality in sub-Saharan Africa, and future directions for HIV control. Dr Boghuma Kabisen Titanji is a physician from Cameroon with a deep caring for people and how research can affect their lives. Boghuma has an MSc in Tropical Medicine and International Health from the London School of Hygiene and Tropical Medicine, and she is currently a Commonwealth Scholar completing her PhD in Infectious Diseases at University College London.


Why did you decide to make the transition from a medical doctor to HIV researcher?

My first encounter with HIV research was in the final year of my medical training at the University of Yaoundé, in Cameroon, when I did a fellowship at the Centers for Disease Control and Prevention in the United States. My research project was on the development of drug resistance following the use of prophylactic antiretrovirals for the prevention of mother-to-child transmission of HIV. This experience made a lasting impression on me because although it was a small study of 40 patients, we were able to feed back the information from the study to the clinic in Cameroon where HIV-positive mothers were receiving pre- and post-natal care. That information was used to adjust their treatments and take them off of the drugs that were no longer effective due to the development of drug resistance. Because they were part of the study we were able to get the tests done, which they would normally not have been able to afford. That struck a chord in me about the importance of linking research to clinical practice, especially in my environment. After two years of clinical work, I decided to do my PhD to get more HIV research training.

Your research paper titled ‘Protease inhibitors effectively block cell-to-cell spread of HIV-1 between T cells’ was recently published in the journal Retrovirology and is already one of its most highly cited articles (1). The paper shows that a certain class of antiretroviral drug inhibits the spread of HIV directly between cells within the body. What was the rationale for this study?

Antiretroviral therapy (ART), which is given as a combination of drugs, is the current treatment we have for HIV. ART reduces the spread of HIV within the body to make it a manageable chronic disease. When I started my PhD in 2011, it had just been discovered that although ART reduces ‘cell-free’ spread of HIV within the body, it is less effective at reducing ‘cell-to-cell’ spread (2). Cell-free spread is the classical way in which HIV particles spread by diffusing in the bloodstream and local environment to infect cells. The virus also has the ability to spread directly from cell-to-cell. Cell-to-cell spread occurs when an infected cell forms a stable point of contact with an uninfected cell and transmits HIV particles directly to the uninfected cell. Cell-to-cell spread is more efficient, quicker, and does not require diffusion in the bloodstream, compared to cell-free spread. Basically, cell-to-cell spread equals good news for the virus, but very bad news for us.

Cell-free spread of HIV: the HIV virions diffuse through the bloodstream, and attach to receptors on the surface of uninfected cells, then enter the cell to infect it

Cell-free spread of HIV: the HIV virions (in yellow) diffuse through the bloodstream, and attach to receptors on the surface of an uninfected cell, then enter the cell to infect it

This is an interesting paper for a number of reasons, one of which is something that many people don’t understand: although treatment reduces the multiplication of the virus, HIV forms ‘reservoirs’ within the body, which make it impossible for existing drugs to eliminate the virus from the body. Researchers are constantly seeking ways to improve existing treatments and to understand how and why these HIV reservoirs persist. My research group and others now think that ongoing cell-to-cell spread within HIV reservoirs is maybe one of the reasons why ART does not cure HIV.  It had already been shown that one class of ART drugs called Reverse Transcriptase Inhibitors (RTIs) were ineffective in preventing cell-to-cell spread. The effect of Protease Inhibitors (PIs), another class of antiretroviral drug, on this mode of virus spread, was not known. PIs are potent antiretroviral drugs, which are commonly used in treatment combinations and for second-line therapy when first-line RTI-based combinations fail. Their mode of action is different from that of RTIs, so it was interesting to investigate whether PIs could inhibit cell-to-cell spread of HIV.

Cell-to-cell spread of HIV: the HIV particle (in yellow) is spread from an infected cell directly to an uninfected cell

Cell-to-cell spread of HIV: the HIV virions (in yellow) are spread from an infected cell directly to an uninfected cell

What were the main findings of your study?

We were able to show that all drugs are not the same in terms of blocking cell-to-cell spread . Confirming previous reports, the RTIs were inefficient in blocking cell-to-cell spread of HIV in this study. By contrast, we found that the PIs were equally effective in blocking both cell-to-cell and cell-free spread. This is an important finding because it gives us an idea of which drug class is most likely to reduce cell-to-cell HIV spread.

In the clinic, RTIs and PIs are administered together to HIV patients in a combination, rather than as single drugs as you’ve tested here. Are you planning to test actual combinations that are given to patients to see how these drugs might work in clinical practice?

Yes. It is important to test the impact of different combinations of antiretroviral drugs on all modes of virus spread. If a particular combination of drugs is less effective in blocking one method of spread than another, then administering the less effective combination to patients may facilitate the emergence and proliferation of drug resistant viruses. To elaborate on this work, I will test drug combinations containing PIs, which are commonly used in the clinic to see how well they block the different modes of HIV spread. We would like to inform on the best combination of drugs to use in treating patients. Another HIV research group has recently tested several different combinations of RTIs on cell-free and cell-to-cell spread and they saw a synergistic effect – drugs acting in combination work better than drugs acting alone against cell-to-cell spread (3).

Obviously, your research shows that PIs might be more effective than RTIs in blocking cell-to-cell spread. Why are PIs often second line therapy in Africa when they are the only class of drugs approved to be given alone as monotherapy?

A ‘public health’ approach is recommended for the treatment of HIV in Africa. We have to focus on getting effective treatment to the greatest number of patients and cannot do personalised treatment. For example, if you have HIV and you live in the UK, you get drugs free of charge to start with. You will get top end triple-therapy (three drugs), where your first line of treatment would consist of RTIs and a PI. If the first line treatment fails, you will have options for second, third, and even fourth line treatments – just because they are available and the National Health Service covers the cost.

The use of PIs as monotherapy is reserved for patients with very well-defined clinical characteristics and is not generalizable to the large numbers of patients in sub-Saharan Africa. In Africa, it’s different. The first line consists of RTIs only. Drug combinations containing PIs are reserved for second-line treatment when RTIs fail. There is a very limited pool of drugs available to the treatment programs in sub-Saharan Africa and this makes the options for third and fourth line treatments virtually non-existent. Some of the newer drugs such as Integrase Inhibitors are simply not available in that environment due to their cost. We need to use limited resources wisely, especially in the context of a weak and resource-limited healthcare system.

What could be the future public health and HIV policy implications of your work?

Knowing that different classes of antiretroviral drugs have variable effects on cell-to-cell spread, with some being effective and some being less effective is useful information, as we think this will need to be considered in future therapeutic strategies for treating HIV. It is  important to note that studies like this, while informative, are done in-vitro and we only  know for sure what works through clinical trials which assess the efficacy of drug combinations in actual patients. Over the last 10 years the role of cell-to-cell spread of HIV has become increasingly recognised, and in-vitro studies such as this, will allow drugs still in development to be tested on their ability to block all modes of virus spread.

Any final words?

HIV/AIDS has come a long way – we are 30 years into the epidemic and in that time intensive research efforts have transformed what used to be a death sentence into a manageable chronic condition with treatment. We should not lose sight of the fact that there are still many people who need these life-saving drugs and are not getting them. Whatever we are able to show in the lab is useful, but the main challenge remains translating this information into the clinic to improve outcomes for those most affected by the disease, especially in resource-limited sub-Saharan Africa. The best treatment and the same standard of care should be available everywhere – a patient diagnosed in London should have the same options as a patient diagnosed in Cameroon, and we are not there yet.


1)      Titanji BK, Aasa-Chapman M, Pillay D, Jolly C. Protease inhibitors effectively block cell-to-cell spread of HIV-1 between T cells. Retrovirology 2013;10:161

2)      Sigal A, Kim JT, Balazs AB, Dekel E, Mayo A, Milo R, et al. Cell-to-cell spread of HIV permits ongoing replication despite antiretroviral therapy. Nature 2011; 477(7362):95-8.

3)      Agosto LM, Zhong P, Munro J, Mothes W. Highly active antiretroviral therapies are effective against HIV-1 cell-to-cell transmission. PLOS Pathogens 2014;doi: 10.1371/journal.ppat.1003982

Images created by BK Titanji

Category: Determinants of health, Epidemiology, Guest Posts, Health systems, Infectious disease | Tagged , , , , , , , , | 1 Comment

My doctor is out to get me!

An article from JAMA Internal Medicine came across my desk last week titled “Medical Conspiracy Theories and Health Behaviors in the United States.” Growing up with a cousin obsessed with the X-Files, being a huge fan of 24, and having read every Tom Clancy novel, I like a good conspiracy theory as much as the next person. So I was curious to see what would be published in a reputable peer review journal with that title.

Public health, like most fields, has detractors. And those detractors use a combination of methods for discrediting public health – Fluoride in drinking water is poisonous! Vaccines cause autism! The FDA is deliberately suppressing natural cures for cancer! We’ve all heard these campaigns, which tend to be based on nothing more than fear mongering and faulty information, often provided by individuals who offer “the cure.” The paper in JAMA Internal Medicine sought to investigate the prevalence of these opinions, as well as then to look at how belief in these views predicted other health behaviours. They asked about six theories, the three most popular of which are presented below:

  1. Doctors and the government still want to vaccinate children even though they know these vaccines cause autism and other psychological disorders,
  2. The FDA is deliberately preventing the public from getting natural cures for cancer and other diseases because of pressure from drug companies, and
  3. Health officials know that cell phones cause cancer but are doing nothing to stop it because large corporations won’t let them.

In terms of prevalence of opinions, 69%, 63% and 57% of respondents respectively had heard of the theories above. That’s not entirely surprising, especially when you consider that Jenny McCarthy, who needs no introduction, has an estimated audience of 3 million people from her position on The View (for more, check out Seth Mnookin’s excellent articles on the issue). When you have someone who has built an industry, reputation and livelihood on the first falsehood, and who has a national platform to raise her profile, it’s not surprising many people have heard of it.

What is interesting is how the respondents then felt about these theories. First, they were asked if they had heard about the conspiracy theory. Then, they were also asked if they agreed with the theory. This is what fascinated me. A shocking 37% believe that there is a natural cure for cancer, and that it is being suppressed, and a further 31% neither agree or disagree. That’s around 68% of the population who are either unsure of, or believe that, there is a cure for cancer out there. This is a large segment of the population that not only believes something exists, but that it is being actively suppressed for the sake of profit.

Now, you’ll notice many of the theories have a common theme. To quote the site TVTropes (which outlines many common literacy devices/cliches in popular culture):

A Conspiracy Theorist attributes the ultimate cause of an event or chain of events (usually political, social or historical events), or the concealment of such causes from public knowledge, to a secret and often deceptive plot by a group of powerful or influential people or organizations (emphasis mine).

So the shadowy organization there is either the government, Big Pharma, or a combination of the two.

The tweet above by Timothy Caulfield led to a discussion on Twitter and this tweet below by Jason Tetro:

We’ve discussed this on the blog before (link 1, link 2, link 3, link 4), and I agree with Jason’s point. There is a need for outreach and education, although I’m not sure how effective it can and will be. As outlined in my piece over at Sci-Ed, the people with extreme opinions are very difficult to sway, and will often double-down on these extreme opinions when pushed. So we focus on the bulk of people in the middle and get them to see the light, which is the most efficient and effective way to spend limited public health dollars. Hopefully, this is enough to prevent diseases and other avoidable public health problems from arising.

Some of these theories are blatantly untrue, and no amount of convincing those who hold these dear will be able to sway them. Indeed, the worst case scenario is that it might actually make things worse by validating and legitimizing their opinion. So we focus on the people in the middle who are able to listen to reason and evidence that shows these theories are nothing more than fairy tales and the stuff of fiction.

But then again, if I was in on the conspiracy, that is exactly what you’d expect me to say, isn’t it?


Oliver, J. Eric, and Thomas Wood. “Medical Conspiracy Theories and Health Behaviors in the United States.” JAMA Internal Medicine. Available online here:

Category: Cancer, Determinants of health, Epidemiology, Food industry, Industry, Infectious disease, Science Outreach | Tagged , , , , , , , , , , , | 7 Comments

Good and bad ideas from 1875′s “City of Health”

Hygeia, Montreal General Hospital

Hygeia, Greek goddess of health (shown, as she often is, with her father Asclepius’s magic pet snake)

If you could design a city to make disease impossible or at least rare, what would it look like? In 1875,  Benjamin Ward Richardson (inventor of several early anesthetics and a proponent of public health before it was cool) gave a speech describing his idea of utopia: Hygeia, he called it, A City of Health.

The speech was printed the next year, sold well, and lives for posterity on Project Gutenberg and elsewhere. It contains some really good ideas, but also some that now seem off-the-wall. Come with me as we tour the ideal of health in 1875.


Credit: Jon Doe

1. Sewers

In the city of health, toilets and storm drains alike empty into airy “subways,” or in other words, sewers. The design, only 20 years old at that point, was a wonderful way of getting human (and animal) waste out of cities. Unfortunately, since sewage wasn’t treated, the results were dumped into local waterways. So sewers just moved the problem.

(Even with treatment plants, combined sewers can still overflow and dump raw sewage where it shouldn’t go. This is an ongoing problem in many cities.)

OK to eat, but not to smell? Credit: Nicole Abalde

OK to eat, but not to smell? Credit: Nicole Abalde

2. No smelling any smells

Richardson was reportedly a holdout against germ theory, and through the whole speech he emphasizes cleanliness without getting specific about what you’re cleaning away.

Instead, he seems to be operating under the idea that smells (the technical term is miasma) are what transmit disease. After getting human waste into the sewers, we still have smells to contend with: for example, he directs kitchens to be built on the top floor, so that “the smell which arises from cooking is never disseminated through the rooms of the house.”

Flowery Wallpaper

Credit: William Warby

3. No wallpaper

Walls are to be made of glazed bricks, in any color you like. Just, for the love of god, don’t cover them in wallpaper. Wallpaper and its paste can harbor mold (yes, even today), but one other concern was surprisingly legitimate: wallpaper can be “poisonous.” One color in particular, known as Scheele’s Green, was made with huge amounts of arsenic. Pro: bedbugs died in green-wallpapered rooms. Con: Sometimes people did too.


Credit: Otis Historical Archives

4. Fresh air in hospitals

The hospitals of Hygeia would feature private rooms, central heating, and a holistic approach (“The still more absurd idea of building hospitals for the treatment of special organs of the body, as if the different organs could walk out of the body and present themselves for treatment, is also abandoned.”) Tucked into the description of the wards is something unusual and scandalously simple: a door to a garden, where patients’ beds can be wheeled on nice days.

Recent research shows that opening hospital windows admits germs–but there are germs everywhere, and those from outside may be healthier than the ones that build up in hospital ventilation systems.

5. And many more…

Need more ideas for your next model city? Don’t forget to ban alcohol, cover the floor of every room in gray tile, have flat asphalt roofs (but feel free to plant flowers up there), and outlaw private laundromats. Good luck!

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The worst thing you can eat is sugar: an update

The WHO recommends that sugar be no more than 5% of daily energy intake

The WHO recommends that sugar be no more than 5% of daily energy intake

Refined sugar is one of the worst things found in the Western diet. Back in January, this blog covered the release of a major report from ‘Action on Sugar’, which stated that the obesity epidemic could be reversed if, on average, each person ate 100 fewer calories of refined sugar per day (1).  For example, with half of the U.S. population drinking sugar drinks on any given day (2), and a 330 mL can of Coca-Cola or Pepsi clocking in at 9 tsp of sugar (139 calories), removing soft drinks alone could make a huge difference.

On 5 March 2014, the World Health Organization updated their global sugar intake guidelines (3).  The existing guidelines, developed in 2002, were that sugars should make up no more than 10% of total energy (calorie) intake per day.  The new WHO draft guideline proposes a further reduction limiting sugars to be below 5% of daily energy intake (3).  For a person of a health body mass index (BMI), 5% of daily energy intake would be around 6 teaspoons of sugar (3).  For comparison, this table shows the amount of sugar that are ‘hidden’ in common processed foods.

The WHO has stated:

There is increasing concern that consumption of free sugars, particularly in the form of sugar-sweetened beverages, may result in both reduced intake of foods containing more nutritionally adequate calories and an increase in total caloric intake, leading to an unhealthy diet, weight gain, and increased risk of noncommunicable diseases (3).

The new sugar intake guidelines are a rough draft at this point and the WHO is inviting public consultation from 5 to 31 March 2014.  This page has the information necessary for those members of the public who are interesting in providing comments to the WHO on the new draft guidelines (4).  This is the chance for members of the public to give input on policy that may have a wide effect on populations.

The proposed sugar intake is less than a can of Coke per day (5).  I believe this is perfectly advisable to anyone wanting to improve their health, but is in practical terms, is it realistic?  The guidelines, when taken as personal health advice, might be unrealistic for some people as sugar-laden processed foods such as soda are readily available, the food industry spends millions on advertising these foods to us, and drinking Coke and eating processed foods is often a social norm.  Is it right to put the onus on individuals for their dietary behaviour when personal food intake is so heavily influenced by the external environment?  A person would have to be terribly health conscious and strong willed to nearly eliminate sugar from their diet when it is so easy to access.

Regardless of any initial teething problems (sorry, I had to), these new guidelines are a positive step forward in improving the nutritional value of food systems.  The WHO suggests that the new guidelines can be used by policymakers to ‘assess current levels of free sugars relative to a benchmark and develop measures to decrease intake of free sugars, where necessary, through public health interventions’.  These actions are needed and would be beneficial.  However, reducing the content of added, refined sugar by the food industry itself is another crucial step that must be taken in addition to health sector intervention.  Hopefully the new sugar intake guidelines can be a stepping stone for health policy and the food industry to move forward together in reducing refined sugars in processed foods.

  1. Action on Sugar. Worldwide experts unite to reverse obesity epidemic by forming ‘Action on Sugar’. (accessed 9 March 2014).
  2. Centers for Disease Control and Prevention. Consumption of sugar drinks in the United States, 2005-2008. (acessed 9 March 2014).
  3. World Health Organization. Draft guideline: Sugars intake for adults and children. (accessed 9 March 2014).
  4. World Health Organization. WHO opens public consultation on draft sugars guideline. (accessed 9 March 2014).
  5. Boseley S. Adults should cut sugar intake to less than a can of Coke a day, says WHO. The Guardian. 5 March 2014. (accessed 9 March 2014).
Category: Food industry, Health systems, Industry, Nutrition, Uncategorized | Tagged , , , , , , , | 2 Comments

Is Tylenol safe during pregnancy? Trick question.

Medicine Drug Pills on Plate

There aren’t many choices for safe drugs in pregnancy. Photo by, CC-BY

Tylenol use in pregnancy is now linked to ADHD. Tylenol was considered the safest analgesic (pain relief) for pregnant women, but in truth there is only one way for pregnant women to avoid potentially dangerous medication:

Don’t get sick.

There are vanishingly few drugs that are officially considered safe in pregnancy. The system we use in the US is a letter-graded pregnancy category. The top ranking, category A, is awarded to drugs where “adequate and well-controlled studies” have looked for risks in the first trimester, and failed to find any. Those studies don’t have to examine the second and third trimesters, but if a study does turn up a risk in later pregnancy, the drug is disqualified from Category A.

Which means that this, the safest category, has a lot of blind spots. But I’ll bite. Which drugs fall into Category A? Is it a big list?

Not exactly: according to the SafeFetus lookup, it comprises thyroid medications, a few vitamins, and a salt solution used to stave off preterm labor. That’s it.

What we should be asking instead

“Is this safe?” is a trick question. Drugs mess with the biochemistry of your body in myriad ways, and many drugs aren’t tested on pregnant women at all. (In fact, until 1993 drugs could not be tested on “women of childbearing potential” in the US.) We have a serious lack of evidence of risks, which is not the same as knowing something is safe.

The question that’s most important to answer is, instead, this: If I’m pregnant and in pain, what can I do? (Or, from the doctor’s perspective: My patient is pregnant and in pain, should I prescribe something and, if so, what?)

Here’s a table of over-the-counter pain medications from American Family Physician that shows what our hypothetical pregnant lady is up against:


Drug name FDA pregnancy risk classification by trimester (1st/2nd/3rd) Drug class Crosses placenta? Use in pregnancy
Acetaminophen (Tylenol) B/B/B Non-narcotic analgesic/antipyretic Yes Pain reliever of choice
Aspirin D/D/D Salicylate analgesic/antipyretic Yes Not recommended except for specific indications*
Ibuprofen (Advil, Motrin) B/B/D NSAID analgesic Yes Use with caution; avoid in third trimester†
Ketoprofen (Orudis) B/B/D NSAID analgesic Yes Use with caution; avoid in third trimester†
Naproxen (Aleve) B/B/D NSAID analgesic Yes Use with caution; avoid in third trimester†

OTC = over-the-counter; FDA = U.S. Food and Drug Administration; NSAID = nonsteroidal anti-inflammatory drug.

*—Associated with increased perinatal mortality, neonatal hemorrhage, decreased birth weight, prolonged gestation and labor, and possible teratogenicity.5

†—Associated with oligohydramnios, premature closure of the fetal ductus arteriosus with subsequent persistent pulmonary hypertension of the newborn, fetal nephrotoxicity, and periventricular hemorrhage.6

Information from Collins E. Maternal and fetal effects of acetaminophen and salicylates in pregnancy. Obstet Gynecol 1981;58(5 Suppl):57S–62S, and Macones GA, Marder SJ, Clothier B, Stamilio DM. The controversy surrounding indomethacin for tocolysis. Am J Obstet Gynecol 2001;184:264–72.


Even if acetaminophen (Tylenol) is a factor in developing ADHD, does it change the answer to the real question?

Tara Haelle breaks down the study and its caveats here: the risk is very small (most women in the study did not have children with ADHD), and there are plenty of confounding factors that can’t be ruled out. The most affected kids came from mothers who took acetaminophen for over 20 weeks of their pregnancy; if someone is popping Tylenol for five months straight, they may have an underlying condition that separates them from people who aren’t. And it might not be fair to compare them with somebody who takes Tylenol just occasionally.

That’s not to say the study is wrong; the link may be real. But consider this: given that information, as well as what we know about the risks of ibuprofen and other alternatives (see table), what should you take if you’re pregnant and in pain?

Maybe, given these results, you might try to tough it out a little longer without drugs. That may be an option for some women, depending on what the source of their pain is, and whether it responds to non-medical treatments like rest, massage, hydration, or the simple “Doctor, it hurts when I do this.” / “So don’t do that.”

But if you need some kind of medication? We’re comparing Tylenol, which is Category B all through pregnancy with meds that have Category D rankings in the third trimester or more. Take a look at the risks there: ibuprofen (Advil) and naproxen (Aleve) are associated with “oligohydramnios, premature closure of the fetal ductus arteriosus with subsequent persistent pulmonary hypertension of the newborn, fetal nephrotoxicity, and periventricular hemorrhage.” It’s your call, but in those cases–at least in the third trimester–I’d stick with Tylenol.

Why this is so hard

Risk assessment is tricky when complicated and incomplete information has to funnel into a yes-or-no decision. In fact, the FDA’s letter grade system is on its way out, for many reasons. Among them: a lack of data can earn a drug a high grade–after all, we don’t know of any risks. The grades also gloss over differences in safety or dosage that may occur during pregnancy. Drugs may be perceived as safer than they are, or vice-versa. Instead, the grades will be replaced with summaries describing what risks are known, and what evidence they’re based on.

The Society for Maternal-Fetal Medicine issued a statement today on the Tylenol case that included this sage piece of advice from president Vincenzo Berghella: “We need prospective studies of all drugs used in pregnancy and lactation*, not just acetaminophen, so that pregnant women or women considering pregnancy can make informed decisions about treatment.” The absence of pregnant women in drug trials is a serious problem that medicine has been dancing around for years: nobody wants to give untested drugs to pregnant women, which results in pregnant women taking drugs that are untested. Ruth Macklin pointed out in a Lancet editorial that the thalidomide tragedy can be pinned on a lack of testing in pregnant women: when it appeared in pharmacies, nobody had any idea it would be dangerous.

Pregnant women deserve drug trials, Melinda Wenner-Moyer wrote a few years ago. It’s still true. In the meantime, we need to drop the safe/unsafe dichotomy and take a smart look at what little data we have on risks.

* Don’t get me started on lactation. Many health care professionals don’t realize that for most medications, the risk from medication is outweighed by the benefit of continuing breastfeeding. Check LactMed for information on your favorite drugs.

Category: Uncategorized | Tagged , , , , , , , , | 1 Comment

A rare, polio-like disease is emerging in California: what you need to know

Correction 28/02/14: The original article states that polio has been eradicated from all countries except for Afghanistan, Pakistan, and Nigeria.  An outbreak of polio was also detected in Syria in late 2013. Cases have also occurred recently in Cameroon and Somalia.

Over the past 18 months, up to 20 young children in California have fallen ill with a polio-like disease.  The major symptom is paralysis.  This potential outbreak is concerning for several reasons: polio was eliminated in the United States years ago, and all of the children had been vaccinated against polio.  A team of researchers has been investigating the new cases, with research still ongoing according to the Centers for Disease Control and Prevention in Atlanta.  Public health officials and researchers warn that the cases are extremely rare, but whether they are isolated or if they indicate an impending full-blown outbreak is still unclear.

Here is what you should know now:

Is this a polio outbreak?

No.  Thanks to vaccination programmes, polio no longer exists in most countries.  Polio has not been seen in the United States since 1979 .  The virus responsible for the current illness has been identified as enterovirus-68 (EV-68) in a detailed analysis of five cases.  Along with the polio virus, EV-68 belongs to the enterovirus family.  Enteroviruses commonly have cold-like symptoms and can carry a risk for nerve problems and paralysis.

What are the symptoms?

Doctors suspect that the initial symptoms are similar to that of a cold, but so few children have fallen ill that it’s difficult to establish a common thread of disease progression among them.  The cases have all been diagnosed at a later stage, which makes it difficult to identify what the early symptoms are.  Paralysis of at least one limb is common to all children who have fallen ill with EV-68.

What exactly is going on?

A physician and researcher at Stanford University, Dr Keith Van Haren, and his colleagues began noticing some children unusually falling ill with a polio-like disease in their medical centres.  Dr Van Haren notified the California Department of Public Health, which has been monitoring the cases.  They have not yet identified any potential cause of the virus common to all of the children who have fallen ill. Samples from around 20 children with polio-like symptoms that were submitted to the California’s Neurologic and Surveillance Testing Program are still being analysed for presence of the EV-68 virus, and the public health department is still monitoring potential causes.  In sum, it’s still early days.

Should I be worried?

In short, no.  The Centers for Disease Control and Prevention are not looking country-wide for cases of EV-68, so there is no national response needed at this point.  Dr Van Haren has stated:

 We want to temper the concern, because at the moment, it does not appear to represent a major outbreak but only a rare phenomenon.

If you don’t have children and don’t live in California, then there is probably no need to worry.  If you are interested, keep following the news as more information is sure to come through as researchers find out more.  If you do have children, this point made by Dr Van Haren is important:

We would like to stress that this syndrome appears to be very, very rare.  Anytime a parent sees symptoms of paralysis in a child, the child should be seen by a doctor right away.

There you have it.  We may be watching an emerging new disease outbreak in real time, or, more optimistically, we may be sensitively monitoring isolated cases of a rare disease.  Either way, the physicians whose sharp judgement picked up these unusual disease cases should be applauded, and are a credit to public health in America.



Barbara Bronson Gray. Mysterious polio-like illness strikes kids in California. WebMD News [Internet]. 2014 February 23 [cited 2014 February 26]. Available from:

James Gallagher. Rare ‘polio-like’ disease reports. The BBC [Internet]. 2014 February 24 [cited 2014 February 26]. Available from:

Laila Kearney. Polio-like illness seen in up to 25 California children. Reuters [Internet]. 2014 February 25 [cited 2014 February 26]. Available from:

Polio-like disease appears in California children. The CBC [Internet]. 2014 February 24 [cited 2014 February 26]. Available from:

Rare polio-like disease strikes five kids in California. Medical News Today [Internet]. 2014 February 14 [cited 2014 February 26]. Available from:

Category: Epidemiology, Health systems, Infectious disease | Tagged , , , , , , | 2 Comments

Where I politely explain to a politician that they’re wrong

Last week, I was forwarded an opinion piece written by the Honorable Leo Glavine for the King’s County News. Now, if there’s one thing that I hate, it’s when people who are in positions of power, wealth and/or privilege tell “the others” how to live their lives – whether that be “work harder,” or “be healthier,” with absolutely no idea or acknowledgement about their own privilege.

In short, the road to health that many prescribe to the unhealthy is a two step model:

1) Be healthy
2) Don’t be not healthy

Which is why, when I read pieces that blame the poor or unhealthy for their situation, it makes me very angry. And you wouldn’t like me when I’m angry.

The Joggins Fossil Cliffs UNESCO World Heritage Site | Photo via

The Joggins Fossil Cliffs UNESCO World Heritage Site | Photo via

But lets get back to Mr Glavine’s commentary. In case you didn’t know, Mr Glavine is the Minister of Health and Wellness for the Province of Nova Scotia, and has been in politics since 2003. Prior to that, he was a school teacher. By all metrics, he’s very popular in his riding – winning the last election with a whopping 74% of the votes.

Mr Glavine starts off his piece rather innocuously, stating that the objectives of government are to represent the people, to provide services, and to take care of their health. We’re in agreement there. He also points out that they have to do more with less funding, and that will require creative and innovative thinking to continue to provide services for the populace. So far, we’re on the same page, and I don’t envy how difficult it is to balance all those demands.

And then things take a wild left turn.

WARNING: If you are drinking anything, now is a good time to put down your glass.

“Canadian banking systems are highly regulated to help thwart abuses. Clients must be approved before receiving financial assistance. They must prove that they practice a healthy financial lifestyle before being able to borrow money … Imagine if healthcare worked like banks. Patients would have to prove they practice a healthy lifestyle before receiving assistance. They would have to prove that they practice the basic tenets of proper eating and exercise. “


To call this myopic would be generous. To say it misses the underlying problems would be generous. It would be like seeing that someone has a flat tire and offering them pancakes. It makes absolutely no sense, and starts the victim blaming this article is rampant with. Now, Mr Glavine then acknowledges the ridiculousness of this viewpoint, but then goes on to say:

“These people need help to break unhealthy habits, because the consequences of smoking, uncontrolled eating and avoidance of physical activity deplete funds that could otherwise go toward saving lives and finding cures. Then there are people who are cognizant abusers of the system. “

The first excerpt was him being factitious and providing a deliberately provocative example. This however, is clear victim blaming. If only you stopped smoking, if only you ate healthier, if only you got more physical activity, we’d all be fine. That’s all a great pipe dream, but the evidence is simply not there.

Lets start with smoking. Data suggest that 42.7% of all adult smokers in the US are trying to quit, and that only 4-7% can quit without medication or other help, and EVEN IF we give people intensive behavioural counselling and pharmacological treatment, this increases to… 20-25%. Yup, if we give people the very best in support and help, only 1 in 4 make it. How about healthy eating? Well, the data suggest that to healthy rather than unhealthy will cost you around $550 extra per year (and link to BMJ Open article, published under open access) So, unless you’re willing to help people afford to eat healthier through subsidies of healthy foods, providing them with the skills to cook healthy or a livable wage, the problem won’t fix itself. I’m not saying we shouldn’t give people support but implying that it’s as simple as “just have a little more willpower,” does a great disservice to the underlying issue.

Unfortunately, that’s what is being proposed. The “lazy, unmotivated person” who is a drain on our healthcare dollars is a character that people can despise and vilify. The populace can assign blame to this criminal mastermind for their lack of effort and desire to get healthier, along with stigmatizing them even further (in this narrative, they are also twiddling a moustache while eating pizza and potato chips).

The underlying issue here is a poor understanding of the social determinants of health – defined as what leads to health, what impacts our behaviours, and what factors result in illness in our society. It’s not as simple as one person deciding to “take responsibility for their actions” and “pull themselves up by their bootstraps.” These are nice slogans and political buzzwords, and look nice on a photo of a sunset on a beach somewhere, but are ultimately meaningless. We’ve covered the idea of social determinants of health extensively on the blog, but it’s still not something people outside of public health are familiar with. It falls to us to educate others about the multifaceted nature of health, and how dangerous preconceived notions can be.

Given the opinion piece opened with a story, I thought it appropriate to end mine in a similar way. This story is the opening to Inside the Outbreaks, and has been called the Parable of the Clinician and Epidemiologist:

The Brown River usually flows lazily through the middle of town. But today it is a torrent carrying human bodies. Some, still alive, are gasping for air and thrashing the water.

Approaching the river to enjoy lunch on its banks, two doctors, horrified by what they see, begin to haul people out of the water. There are no signs of violence, but the victims’ eyes are glazed, their weak pulses racing.

The doctors cannot keep up with the flow of bodies. They save a few and watch helplessly as the others drift beyond them.

Suddenly, one of the doctors lowers an old man to the ground and starts to run. “What are you doing?” yells the other doctor. “For God’s sake, help me save these people!”

Without stopping, she yells back over her shoulder, “I’m going upstream to find out why they’re falling in.”

Looking at why people are unhealthy rather than blaming them for their circumstances is the only way we’ll ever be able to help. Victim blaming and assuming their character, rather than their circumstances, are solely responsible for their conditions is not only callous, it’s an easy way to perpetuate the cycle of inequality that got us here in the first place.

Category: Determinants of health, Epidemiology, Science Outreach, Time trends | Tagged , , , , , , , , , | 2 Comments