A healthy holiday guide

Image cred - foodswallpaper.com

Image cred – foodswallpaper.com

Whether you’ve embraced it or not, the holiday season is upon us. This time of year can be a wonderful and indulgent break, but it can also be hell. On top of the blatant consumerism, rushing around, and stressful family dynamics, we often overindulge and neglect exercise. I’ve been a victim of too many hours curled up on the couch with a Bailey’s and book in hand (don’t get me wrong, that is a wonderful thing)… But, the sluggish feeling and extra body padding come January are less welcome. This year, I’m planning ahead to find a balance between holiday indulgences and feeling energized and healthy.  In this spirit, Public Health Perspectives today offers a guide on staying health over the holidays.

First, a disclaimer: I am not a registered dietician.  But, some things are just common sense and we’ll talk about those. Also, this is written with North American Christmas in mind, but I think it remains true for anyone trying to eat well and exercise during this season.

Image cred - foodswallpaper.com

Image cred – foodswallpaper.com

Problem 1: I have a major sweet tooth.

I know, me too. One of my usual rules is that homemade treats are an acceptable treat, due to their relatively rarity and use of whole ingredients. Processed and packaged sweets are not. At this time of year though, if your holiday experience is anything like mine, homemade goodies are almost everywhere and you simply can’t follow this rule. There is no one way to eat that works for everyone, but I always go for quality over quantity.  Eat the sweets that you absolutely love and can’t get at any other time of year. For me, these are pecan butter tarts, soft ginger cookies, and pumpkin pie.  Skip the ones that are just ‘ok’ or that you can have anytime. Don’t anything packaged when there are better,homemade treats available.  Don’t eat sweets within one hour of a meal, and as always, don’t eat so many that you feel ill!

Image cred - foodswallpaper.com

Image cred – foodswallpaper.com

Problem 2: I want all of the things at Christmas dinner… and beyond.

Like with sweets, quality over quantity is key.  Eat those foods that you love, that are well-prepared, and made using high quality ingredients.  Are there instant mashed potatoes and gravy? Skip it. Has your aunt prepared a sweet potato casserole from scratch with glazed nuts on top? Go for it. However, don’t forget to fill half of your plate with vegetables first. Brussels sprouts, green beans, and carrots are all wonderful. Don’t forget that parsnips, potatoes, and sweet potatoes are carbohydrates that will spike your blood sugar (so go easy on the sweet potato casserole, although you should eat some, by all means). White meat is lower in fat than brown meat, and you don’t want it swimming in gravy.  Go for a lot of variety on your plate, and don’t overdo it with any one dish. Pace yourself… after you’ve finished, wait 15 minutes, take yourself away from the food, and mindfully decide whether you are actually still hungry or not. And save room for dessert!

Image cred - 123RF Stock photo

Image cred – 123RF Stock photo

Problem 3: I have no time or means to exercise.

This one depends on your regular exercise routine. If you never exercise anyway, I don’t really know what to say to you. It’s not easy to take up exercise over the holiday season, but everyone should be active to a level that fits in their life, so think about starting in the New Year. For the rest of us, the holidays often disrupt routine in a way that makes exercise difficult. For those who go away to visit family, lack of access to a gym or a good running route can pose a problem. Quick, indoor workouts can be a nice way around those problems. Even 15 minutes of high intensity cardio – use a skipping rope and do burpees – can be a great boost. You can find many home workout videos on YouTube (I’m a fan of the Jillian Michaels series), including yoga and Pilates. An after dinner family walk around the neighbourhood is a great way to help a heavy dinner digest and get some bonding time in. Take the dog out, if you have one.  Of course, winter sports like skiing and snowboarding are great if you have the means to do it. If you live a snowy climate, get outside for some snowman building, snowforts, and tobogganing. Having youngsters in the family helps!

And, finally, the bottom line is don’t be too hard on yourself. We have the holidays for a reason. You should relax and indulgence. The trouble is when we tip the balance to fall so hard of routine that we don’t feel well. Don’t forget to slow down and de-stress if the holidays are a busy time for you. No matter what, keep your body active and metabolism healthy to keep yourself going in the New Year.

Happy holidays from all of us at Public Health Perspectives!

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Deadly dose? No. Here’s what we’re really wondering about the HPV vaccine.

 Katie Couric spotlighted the HPV vaccine in a recent show, asking a very odd question: “The HPV vaccine is considered a life-saving cancer preventer, but is it a potentially deadly dose for girls?” It’s pretty clear that the answer is no. Matthew Herper at Forbes has a great explanation of why Couric’s story is a skewed telling of what we really know about the vaccine.

Now, I’m not a Katie hater. I love that on her website, the headline “What You Need to Know About the HPV Vaccine” leads to a doctor’s explanation of why she recommends the vaccine for her patients, and why the stories of people who believe they were harmed by the vaccine—like, ahem, some of the guests on Couric’s show—don’t add up to a real safety concern.

If you’re swayed by the personal stories of women who claim their daughters were hurt by the vaccine, take a minute to look more closely at the cases. They typically involve an “unexplained death” or a disease that can develop spontaneously or with unknown causes. This is tough on anyone, and certainly the deaths and diseases are tragic. But that doesn’t mean they’re linked to the HPV vaccine. In dozens of these stories, the only connection to the shot is the patient or, more often, the parent deciding that there was no obvious cause, so by process of elimination, a shot received days, weeks, or months earlier was blamed. Even one researcher fell into this trap; primary ovarian failure, basically early menopause, has no discernable cause in many cases. She found three of those girls who had gotten the HPV vaccine, and declared the vaccine to be the cause. It’s a classic “after this, therefore because of this” observation: not a convincing argument on its own, but a hint that there may be safety concerns worth investigating.

And safety concerns have been investigated, most recently in a study of nearly a million girls in Sweden and Denmark. It was a beautiful opportunity to find dangerous effects of the vaccine, if there were any. And the researchers came up empty-handed. One of the researchers told Reuters, “There were not really any concerns before our study, and no new ones after.”

Another reason to applaud Couric: it’s great to ask and answer questions about the vaccine, especially a new and somewhat confusing one like HPV, in a public forum. In fact, there are some really important questions to ask about the HPV shot, but most of them weren’t highlighted on Couric’s show. Here’s what I really want to know:

1. How long does immunity last?

A researcher on the show, Diane Harper, claimed there was no evidence that the HPV vaccine is effective beyond 5 years. That’s worrying if true: a boy or girl who gets the shot at age 10 could be unprotected at age 15. In that case, the shot would have to be given every five years or so, and might lead parents to delay the shot (why not skip the 10-year shot, and start at 15?) if they are in denial about the possibility of their child becoming sexually active as a teen. As we’ve discussed here before, that happens, both with and without consent.

But there’s reason to doubt Harper’s claim of a 5-year limit. For example, these two studies found good protection after 8 years. The study is ongoing, so we’ll get updates in years to come.

2. Can it prevent throat cancer?

OK, first I have to correct something I said last time I wrote about HPV. It turns out that Michael Douglas did not have an HPV-caused throat cancer. That was a story released to the press, to cover for what he actually had: a very scary tongue cancer. In the end, Douglas got to keep his tongue and jaw, and revealed the truth.

But it’s true that HPV causes many head and neck cancers. Unfortunately, it’s hard to study prevention of oral HPV. The vaccine might prevent it, but there’s no oral counterpart to the HPV testing done in cervical screening, so no way to test whether a vaccine prevents oral cancer without a truly massive, long term study.

3. Why not give it to people older than 26?

The vaccine is only approved for the causes and populations it was tested on, which include women up to age 26. Another valid question would be: why not give it to 27-year-olds and up? Many adult women today never had a chance to get the vaccine as a teen, but are still being exposed to the virus and at risk for cancer. Currently, they’re being told their only defense against HPV is keeping up with cervical screening. Admittedly, this catches most HPV before it becomes cancer, but not everybody keeps up with screening.

4. Are we using the right strains?

HPV comes in many flavors, some harmless, some cancer-causing. Both the Gardasil and Cervarix vaccines include types 16 and 18, because they were thought to account for 70% of cervical cancers. But that number may reflect limited test populations. A recent study shows that types 16 and 18 are less common in African-American women than in white women. Both groups have similar screening rates, but African-Americans are more likely to die of cervical cancer. This adds up to a suspicion that there are other cancer-causing HPV types that tests aren’t looking for and vaccines aren’t preventing.

(Virus image from jiparis via Flickr.)

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On Men’s Health and Moustaches

In Canada, the top three causes of death for men are cancer (31.1%), heart disease (21.6%) and unintentional injuries (5.0%). The top two are the same for women, although with slightly different percentages: cancer and heart disease account for 28.5% and 19.7% of all deaths among women, with stroke (7.0%) coming in third. In the US, men die at an overall rate 1.4-times higher than women, of heart disease 1.6-times more, and are twice as likely to die from an unintentional injury.

In fact, women outlive men by 4.5 years on average worldwide – 66.5 years vs 71.0 years. This difference increase to 7 years in the developed world. Not only are men more likely to die from the causes above, men are also more likely to commit suicide than women. This gender difference increased following the recession. A time trend analysis from the UK found that approximately 850 more men, and 155 more women committed suicide than would have been expected based on historical trends following the 2008 economic downturn, with the highest increases in those regions that were most affected by rising unemployment.

But what leads to these outcomes? Given we live in a world where people can get help when they need it, why should men be dying at a rate that is that much higher than women for (almost) the same diseases? And why are they dying younger than women?

Movember is one of, if not the biggest, charity aimed at raising awareness about men’s health (Click image for more)

Much of it is a direct result of the socialization of men at a young age. Admitting weakness is drilled out of you, and men as a result do not seek out help when they need it. Much research has investigated differences in health seeking behaviour between genders, with examples as innocuous as back pain. A study by Jensen et al found that women were more likely to seek out care if they had moderate levels of back pain vs low back pain, while men would not seek out help. Meanwhile, both men and women were likely to seek out help if they experienced high levels of back pain. The difference observed here highlights one of the major differences between men and women on health behaviours: women are more likely to see a health professional before things escalate compared to men. A recent study by Pinkhasov and colleagues further investigated this phenomena using data from the CDC on health care utilization and concluded:

Men are less likely to utilize health care visits to doctor’s offices, emergency departments (ED), and physician home visits than women. They are also less likely to make preventive care, hospice care, dental care visits, and have fewer hospital discharges and shorter hospital stays than women.

So how do we tackle this. We’ve talked a lot about building “awareness,” on the blog and the inherant problems with it at a societal level. “Awareness” can manifest in a number of ways, ranging from slacktivism at worst, i.e. “I know it exists, and that’s enough,” and overuse of health systems at worst, i.e. exposing people to unnecessary tests. But as long as people know about health risks and preventative health measures, this is inherently a good thing. If it helps people seek out help when they need it, this is a positive outcome, and if it means people encourage others to seek out help, this is even better.

Movember created an overview on PSA testing. Click the image to read (PDF)

However, raising awareness around men’s health issues is different to raising awareness for women – as mentioned above, women will seek out help while men won’t. So while men might know about a health concern, they won’t actually seek out help if they suspect they have it. As a result, the first act of any “awareness” campaign is to normalize the discussion of men’s health, and normalize seeking help. One example is the Real Men, Real Depression campaign, which aimed to tackle the stigma around admitting and discussing mental health problems among men, especially depression*. The Canadian Mental Health Association summarized the campaign best:

What do a firefighter, police officer, US Air Force First Sergeant, college graduate and publisher have in common? They are all male and they have all suffered from serious depression. They told their stories for the National Institute for Mental Health “Real Men. Real Depression.” campaign.

This is one of the biggest problems facing men’s health. Open, supportive venues where men can talk about their health, and this is the major reason why I support the Movember campaign. While Movember started off as a charity to raise awareness about prostate cancer, the #1 cancer among men in the US and Canada, it has since expanded to include other aspects of men’s health, including testicular cancer and mental health. For those who aren’t familiar with Movember, the campaign aims to increase awareness by encouraging men (Mo Bros) to grow moustaches (Mo’s) for the month of November, and raise funds that will be given to various men’s health initiatives, as well as promote men’s health by encouraging the open and frankly discussion of men’s health. They also encourage women to get involved and support the cause (Mo Sistas). As I said last year:

If you’re a Mo Bro, get your annual physical. Get checked out. Go see the doctor if you need it – don’t wait. Talk to a healthcare professional if you need it, and make an informed decision on your future. Many health issues are curable and treatable if caught early – the longer you wait the worse they can get. For all the Mo Sistas and Mo Bros out there, support your Bros. Mo Bros are likely to put off seeing the doctor and ignore health concerns, but with support this attitude can shift.

And this is why I really like Movember. It’s encouraging society as a whole to change attitudes around (men’s) health. If seeking out help is considered “normal,” then men are more likely to seek out help when they need it, and that could make all the difference between early and late diagnosis, and thus positive and negative outcomes. In addition to the obvious benefits to men, opening up conversations about health issues has benefits for society at large. If we, as a society, feel comfortable discussing issues such as cancer screening and especially mental health, this should result in us being more accepting and accommodating to others, regardless of gender. And that’s a good thing.

If you would like to support my Movember campaign, feel free to donate here. (EDIT: Fixed link)

Gordon, Derrick M., et al. “The Many Faces of Manhood Examining Masculine Norms and Health Behaviors of Young Fathers Across Race.” American journal of men’s health (2013). Link
Barr, Ben, et al. “Suicides associated with the 2008-10 economic recession in England: time trend analysis.” BMJ: British Medical Journal 345 (2012). Link.
Jensen, Jens Christian, et al. “The significance of health anxiety and somatization in care-seeking for back and upper extremity pain.” Family practice 29.1 (2012): 86-95. Link.
Pinkhasov, Ruben M., et al. “Are men shortchanged on health? Perspective on health care utilization and health risk behavior in men and women in the United States.” International journal of clinical practice 64.4 (2010): 475-487. Link.

*I’d be remiss to not point out here that women are typically diagnosed from depression a rate higher than men, although there is evidence to suggest that women recognize their symptoms more readily, and thus seek out help while the numbers for men may be underreported. This is an area that needs to be further researched to disentangle the reasons for these differences between genders.

Category: Cancer, Determinants of health, Epidemiology, Health systems | Tagged , , , , , , , , , | 7 Comments

Teflon for Teeth

I may come to regret the title of this post given the chemophobia and fear surrounding fluoride and water fluoridation, but recent research suggests that fluoride may help prevent bacteria from causing cavities by creating a non-stick surface on teeth.

There are several ways that fluoride may prevent cavities. Tooth enamel is made of a mineral called hydroxyapatite that, though strong, can be eroded by acids made by the bacteria in our mouths or contained in our food and drink. Fluoride treatment replaces the hydroxyl group in hydroxyapatite with fluoride ions to form a new mineral called fluorapatite. Conventional thinking is that this replacement strengthens the enamel so that it can better resist an acidic onslaught. There is also evidence that fluoride can slow bacterial metabolism and prevent the formation of biofilms making it harder for bacteria to live on our teeth. More recently, studies have begun to suggest that fluoride may also make it harder for bacteria to adhere to the surface of our teeth.


“Block diagram of atomic force microscope using beam deflection detection. As the cantilever is displaced via its interaction with the surface, so too will the reflection of the laser beam be displaced on the surface of the photodiode.”

Using  atomic force microscopy, researchers from Germany set out to measure how strongly cavity-causing bacteria clung to fluoride-treated versus untreated surfaces. This technique makes use of bacteria-coated probes fixed to a cantilever that is lowered to make contact with the the “tooth” surface. The probe is then retracted, which tugs on the bacteria touching the surface. A laser is used to measure the displacement of the cantilever from which the force applied can be calculated.

Performing these experiments on actual teeth, however, is complicated because the surface of teeth and the presence of fluoride vary from tooth to tooth. Instead, the scientists opted to use hydroxapatite pellets as sort of “false teeth.” These pellets have smoother surfaces and the same chemical composition to better control for these variabilities. Fluoride treatment was carried out by soaking the pellets for 5 minutes in a solution containing fluoride at 1000 ppm (parts per million), which is the typical concentration of fluoride in toothpastes. The fluoride gel treatments you might get a dentist’s office can be as high as ~12,000 ppm.

lower adhesion forces after fluoride treatment

Bacteria stick to fluoride-treated “tooth” surfaces with ~50% less adhesive force than to non-treated surfaces.

The scientists tested the adhesion of two bacterial strains ( Streptococcus mutans and Streptococcus oralis) that are associated with cavities and one strain that is not (Staphylococcus carnosus). They found that treating the pellets with fluoride made it harder for bacteria to stick to the surface. All of the bacterial strains they tested clung to the fluoride-treated pellets with roughly 50% less adhesive force than to the untreated pellets.

One thing to keep in mind, however, is that the pellets used in these experiments were treated with fluoride only once, whereas our teeth are subject to a lifetime of fluoride exposure–meaning our actual teeth may even be slipperier. Also, it would have been great if the researchers had tested fluoride treatments at different concentrations, such as found in tap water and in dental treatments, to see if using more fluoride would make it even harder for the bacteria to adhere to the pellets and vice versa.

But the question remains: how exactly does fluoride make it harder for bacteria to stick to fluoride-treated teeth. The authors of the study suggest that fluoride treatment increases the negative charge on the surface of teeth, which would repel the negative charge on the surface of bacterial cells. In turn, this would make it easier to dislodge bacteria when you brush your teeth–provided you remember to brush them (yeah, you know who you are).


1. Loskill P., Zeitz C., Grandthyll S., Thewes N., Müller F., Bischoff M., Herrmann M. & Jacobs K. (2013). Reduced Adhesion of Oral Bacteria on Hydroxyapatite by Fluoride Treatment, Langmuir, 29 (18) 5528-5533. DOI:

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Countering Misinformation in Science, a #Solo13links Storify

PLOS held a science outreach workshop at Spot On London ’13 on science communication using falling vaccination rates as a focus. Panelists included PLOS ONE Editorial Director Damian Pattinson, PLOS authors Marc Baguelin, Tammy Boyce and Stephan Lewandowsky, and PLOS Public Health Perspectives blogger, Beth Skwarecki.

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Is technology good for healthcare?

Photo cred: SecurEdge Blog

Photo cred: SecurEdge Blog

Last week I had blood testing done through my local clinic.  As some of our regular readers may know, I live in London, England where we have a great public health care system called the National Health Service (NHS).  I booked an appointment day of, showed up, and had my blood drawn.  Upon leaving, I expected them to tell me that my GP would be in touch with results.  Nope.  They informed me that I would receive results by text message within 7-10 days.  Hmm, ok, that sounds easy.

I completely forgot about it until yesterday, when my iPhone dinged with the following message, all in caps lock:




I laughed.  First of all, that was an aggressive message to receive from major governmental organization, both in content and tone.  Second, think of the excruciatingly embarrassing situations in which a message like that could appear.  What if I had some terrible or terribly embarrassing diagnosis and it popped up in a public place – at work, on a date, waiting in line at the coffee shop?  iPhones don’t have the most private new message system, at least by default.  Or what if someone borrowed my phone and saw the message?  Anyway, I wasn’t hugely worried, but the thought was funny and I’m sure someone has gotten into an awkward situation before.  There’s probably a tumblr out there somewhere on awkward text messages from the doctor.  Regardless, I deleted the message to avoid it ever coming up in conversation.

Aside from the hilarity, are text messages from the GP/specialized clinics a good thing?  I would whole-heartedly say, yes!  The blood clinic cut out the middleman, my GP, and relayed the results directly to me.  They saved the time of NHS employees and therefore also cost, and I’m sure sending the text message was cheap.  I’m not sure what other health care systems/providers in different countries do and maybe I’m behind the times, but I was quite impressed with the novelty.

Of course, technology is necessarily permeating health care.  The introduction of electronic medical records that can be instantly transferred so that our health care practitioners have access to our full medical histories when we go to different doctors is a major positive undertaking  (1,2).  Another example is the mass amounts of health apps available for smart phones.  You can calculate your BMI, type II diabetes risk, consult WebMD, or check your skin for melanomas using your smart phone.  However, these apps are not always reliable – an investigation of melanoma-checking apps found that 3/4 apps incorrectly classified 30% of more of melanomas as unconcerning (3).

Photo cred: The Onion

Photo cred: The Onion

There are also major growing pains with introducing technology into health care.  Right now, millions of Americans are frustrated with the wide-scale crashing of the Obamacare website, which just became active on October 1.  The website is the online portal for Americans to sign up to health care provided through the government, commonly referred to as ‘Obamacare’.  As an optimist, I feel it will turn out fine in the end and the United States will hopefully be left with a legacy of more equitable and affordable health care for all citizens.  It is a serious glitch to occur in the first steps of implementation though, and only time will tell what will happen.  In the meantime, the ‘mysterious girl’ on the Obamacare website has become the subject of countless Internet memes, and is probably hating her life right now.  And that’s yet another joy of the technology-healthcare intertwining – countless opportunities for social media and cultural phenomena. Bring on the rest of the 21st century!

1)      Silversides A. Canadian physicians playing “catch-up” in adopting electronic medical records. CMAJ 2010;182(2). doi: 10.1503/cmaj.109-3126.

2)      Cimino JJ. Improving the electronic health record – are clinicians getting what they wished for? JAMA 2013;309(10):991-2. doi: 10.1001/jama.2013.890

3)      Wolf JA, Moreau JF, Akilov O, et al. Diagnostic accuracy of smartphone applications for melanoma detection. JAMA Dermatol 2013;149(4):422-6. doi: 10.1001/jamadermatol.2013.2382.

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Cutting through the ribbon rainbow: What good does awareness do?

Ribbon Lines

Photo by David Charlebois

The first disease to get an awareness ribbon was AIDS. Jeremy Irons famously wore one at the 1991 Tony awards, a handmade gift from a group called Visual AIDS. They were, in turn, inspired by yellow ribbons for soldiers.

In those early days, fashion designer Isaac Mizrahi described the red ribbon’s ugliness as its strength: “It ruins whatever you’re wearing, it doesn’t work compositionally, it’s the wrong color, it throws your hair off, and who cares, because you have human feelings and you’re showing them. That’s the sacrifice: taking away your individuality in honor of those who have died.”

But the AIDS ribbon campaign was successful because it was unobjectionable, even fashionable. A previous year’s “Silence = Death” button hadn’t gone over nearly so well: Act Up LA made a thousand, and 997 were unworn at the end of the night. One of the original ribbon makers explained to the New York Times that the AIDS ribbon was designed to be as ambiguous as people wanted it to be: “We wanted … something that could mean ‘I hate this Government’ or just ‘I care about people with AIDS.’ ”

Other colors and causes followed suit, and the New York Times declared 1992 the Year of the Ribbon. Self Magazine and Estee Lauder put 1.5 million pink ribbons on cosmetics counters across the country that year. Then a shift to pink products began with Cone Communications, a PR firm hired by Avon. Their research showed that consumers would switch brands for the sake of supporting a cause, so Carol Cone helped Avon design and sell a pink ribbon lapel pin. Lauder and Komen followed with their own products. Unlike AIDS, breast cancer was uncontroversial. Cone summed it up in a 1998 interview: “Companies want to support breast cancer. Breast cancer is safe.”

In the pink

It’s October, and you can buy pink products everywhere, watch pink-accented football games, or endure ridiculous facebook stunts in the name of awareness. But what good does “awareness” actually do?

If you’re already heathy, getting a mammogram isn’t necessarily in your own best interests, as Christie Aschwanden explains here. Many of the tumors caught by screening are ones that would never have been a problem, and yet the women with positive tests end up going through a grueling and expensive series of treatments. Three women are overdiagnosed for every life saved.

Those three have paid a steep price for their awareness. Was it worthwhile? Perhaps—and that’s why screening should be a personal decision and not a mandate.

As Breast Cancer Awareness Month draws to a close, I’d like to focus on cancers where awareness can make a big difference in early detection. The National Cancer Institute names three, besides breast cancer.

Cervical cancer: Annual pap smears are an outdated practice. Current guidelines in the US are a pap test every three years for young women; HPV tests can be used, too. And there’s more good news: there is a vaccine against the strains of HPV that cause cervical cancer.

Lung cancer: Spiral CT scans can save heavy smokers’ lives; other methods don’t have the numbers behind them yet.

Colorectal cancer: Four different tests can save lives, prompting the Colon Cancer Alliance to piggyback on the pink frenzy of October with a cheeky (ha!) campaign that says “Screen this too!”

Screen This Too / Colon Cancer Alliance

Let it never be said that I missed an opportunity to post a picture of a butt.


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Book Review: Deadly Outbreaks: How Medical Detectives Save Lives Threatened by Killer Pandemics, Exotic Viruses, and Drug-Resistant Parasites

Deadly Outbreaks: How Medical Detectives Save Lives Threatened by Killer Pandemics, Exotic Viruses, and Drug-Resistant Parasites | Click image to go to CSTE website

Anyone who follows my writing knows that I’m a big proponent of using stories to talk about science. We’ve discussed how you can use science fiction teach science, zombies to talk about disease outbreaks, and my TEDx talk discussed using principles of storytelling in how we discuss science. So when I was asked to review (see disclaimer below) Dr Alexandra Levitt’s new book “Deadly Outbreaks: How Medical Detectives Save Lives Threatened by Killer Pandemics, Exotic Viruses and Drug-Resistant Parasites,” I jumped on the opportunity.

The CDC has a program known as the Epidemiologic Intelligence Services, where individuals trained in fields such as epidemiology, medicine, statistics and veterinary sciences come together to identify causes of diseases. For an overview of the EIS, check out this review of “Inside the Outbreaks” by Travis Saunders over at Obesity Panacea. The EIS was set up Alexander Langmuir, who has been profiled on the blog, and their work has been instrumental in learning about, and thus containing, disease outbreaks all over the world. Dr Levitt is well positioned to speak on these issues, having worked at the CDC since 1995, although it should be noted that this was written in her free time, not as part of her position at the CDC.

The book is comprised of 7 distinct chapters, each one covering a unique disease outbreak. In an almost “House-ian” style, the EIS agent will hear about an outbreak, go into an area, and then have to uncover what it is that is causing people to get sick, often with very little information to go on. I’m going to keep the details deliberately vague, as part of the joy of reading the book is guessing what is causing the outbreak, and following the train of thought of the investigators. The outbreaks range from West Nile Virus in New York City (Chapter 1), malaria in Cambodia (Chapter 2) to a Salmonella outbreak in Minnesota (Chapter 5). Each is a unique outbreak with dire consequences. However, once the cause has been identified and isolated, these outbreaks have led to direct and tangible changes that have gone on to save countless lives.

Much of the investigations are based around ascertaining what people had in common: Did they eat the same meal? Stay in the same hotel? Go to the same ball game? What is it about this group of people that makes them unique, and could that lead to the source problem? Using interviews to ascertain data and understand what is happening in the underlying population, the investigators can leverage the power of “simple” statistical tests, such as chi-squares, t-tests and others we typically brush off early in our training in favour of more advanced statistics, to uncover the cause of this disease outbreak. This was one of my favourite parts of the book, as it highlighted how powerful “simple” statistics can be. However, as highlighted in one chapter, data does not tell the whole story, and sometimes you need to talk to people on the ground to determine what is leading to the results you’ve observed.

Another thing I really enjoyed about the book was how Dr Levitt deals with all important stakeholders, and talks about their history. One chapter deals with a Native American population that has undergone a disease outbreak, and does a great job explaining the history of these people. This is very pertinent information, as the problems of going into this community are a direct result of how these communities have been treated historically, and everything from the equipment you bring in, to the name of the disease, has to be cleared by elders and community leaders. The history of a group is something public health practitioners need to be aware of and sensitive to in order to work with these people to identify causes of disease, and this was illustrated well in this book.

Finally, at a more stylistic level, a conscious decision the author makes is to provide context for the characters. For example, in Chapter 1 the “protagonist” is eagerly anticipating her wedding, and at one point goes for dinner and discusses this with a colleague while talking about the case at hand. In a later chapter, the author describes Dr Stacy Holzbauer, a veterinarian, as someone whose “plan was to become a large-animal veterianian, marry a cowboy, live on a ranch on the Great Plains, and raise cowboys,” a vivid and charming description. While she did become a veterinarian, she then pursued a MPH and now does brilliant public health work. This makes the characters that much more fleshed out and human, rather than being 2-dimensional and alien, a welcome respite from the socially awkward, comically inept, and often evil, scientist of television and film. At points I found this transition jarring, but it adds to the overall feel of the book, and I think helps the book connect with the general public.

And the general public, especially those with an interest in public health, is the target audience. I would recommend this book to those interested in learning more about public health, both from an infectious disease standpoint, as well as from a practical, i.e. how do we actually investigate disease outbreaks, standpoint. It’s written for a lay audience, and avoids jargon and delving too far into statistics or biology, which makes it easy and straightforward to follow. If you’re considering pursuing an MPH and want to do “shoe leather epidemiology,” it’s a must read.

Publication Date: September 1, 2013
ISBN-10: 1626360359
ISBN-13: 978-1626360358
Edition: 1
CSTE Website
Amazon.com link
Amazon.ca link

Disclosure: My review copy of the book was provided by the author.

Category: Book Reviews, Determinants of health, Epidemiology, Industry | Tagged , , , , , , , , , | 7 Comments

The Food Stamp Vaccine

What if there were a vaccine against the harmful effects of hunger? According to researchers at Children’s HealthWatch, there is. But these vaccines aren’t shots or sprays. They’re food stamps.

Unlike other vaccines, these certainly aren’t a high priority for many lawmakers. In September, the House of Representatives voted for $40 billion in cuts over ten years to the Supplemental Nutrition Assistance Program (SNAP). Regardless, on November 1, the 13% increase to SNAP benefits from the 2009 stimulus expires. This means a family of three will have $29 less per month – and live on only $1.40 per person per meal.

This is dangerous. Like a vaccine, food stamps protect young children against immediate and future disease. “The right immunizations in the right doses at the right time save untold health and education dollars, not to mention personal anguish and pain,” Children’s HealthWatch wrote in their 2012 report, The SNAP Vaccine. “Hunger and food insecurity in the U.S. also endanger the bodies and brains of millions of children.”

Hunger cracks open a fault line in a child’s life. Like a vaccine, food stamps are especially critical in a child’s first years. Without enough food, kids are at an increased risk for delays in motor skills and cognitive deficits.

When kids don’t get this vaccine, they don’t only suffer damage to their bodies. They also suffer damage to their life chances. By third grade, kids who went hungry in kindergarten pay, on average, a 13 percent penalty in reading and math scores. By age 11, food-insufficient children are more likely to have lower test scores, have repeated a grade, been suspended, and had trouble making friends.

There’s little mystery why. But researchers at Cornell and the National Center for Health Statistics wanted to dig deeper. They analyzed data from the third National Health and Nutrition Examination Survey. Kids from food-insufficient families had more stomachaches, headaches, and colds. They were generally in poorer health. And they didn’t deal with food-insufficiency in a vacuum. They also dealt with the environmental risks of poverty.

"Family Dinner.” US Department of Agriculture. CC BY 2.0, 2012.

“Family Dinner.” US Department of Agriculture. CC BY 2.0, 2012.

Children’s HealthWatch piles on additional evidence – and provides a stark forecast for what may happen because of the cuts to SNAP. They analyzed the health records of 17,000 young children. These children were admitted to an emergency room or a hospital between 2004 and 2010. The researchers compared the health of children who received food stamps with children who did not. Kids who did not receive food stamps were more likely to be underweight and suffer from developmental delays. It gets worse. The kids who did not receive food stamps, according to Children’s HealthWatch, were likely eligible for them. Their malnutrition and developmental issues were preventable.

Like most vaccines, food stamps are especially important for our most vulnerable citizens: children and the elderly. But the new House bill seeks to slash the funding for food stamps in half. These cuts don’t only threaten their health. They also strangely take shots at their character.

The House bill tries to criminalize populations who need food stamps, stacking drug testing onto the requirements for food. Of course, we know that drug testing of welfare recipients is an absurd exercise. Arizona, for example, tested nearly 87,000 people over three years. They caught one person and saved $560. Virginia, more wisely, abandoned their welfare drug testing program, once they realized it would cost them more than six times what they’d save. Still, it presents us with a thought experiment: would we refuse a MMR shot for the child of a drug user? If food stamps provide vaccine-like protection against disease, don’t we have a moral obligation to provide it, regardless of a parent’s recreational drug habit?

Budgets are not only fiscal plans. They are moral ones. They document what – and who – is valuable. Food stamps prevent health problems and promote healthy lives for poor children. Why should their lives be any less nurtured?

Category: Determinants of health | Tagged , , , , , , | 1 Comment

The most overlooked public health intervention may be your thermostat!


Calvin and Hobbes by Bill Watterson. Available from Universal Uclick

Calvin and Hobbes by Bill Watterson. Available from Universal Uclick

I know this is a stereotype, but your grandmother/father/grumpy uncle/whoever in your life fits this anecdote was right: if you’re cold, put on a sweater.  Growing up, my family was not so economical with the temperature control in our house, and I can remember the specific pleasure of curling up with a good book next to the gas fireplace until my back began to sear with heat.  Even now as I write, I am abating the cold (September!) grimness of London, England with the cosy warmth that only central heating can provide.  You may be a person of creature comforts like me – and I know that many of you Generation Y Yuppies are – or you may be a little bit more puritanical.  But regardless, some new research findings might make you think a little bit.

The new research comes from a pair of studies – one from Japan and one from the Netherlands – about brown adipose tissue, or fat (1, 2).  What is brown fat ?  As opposed to white fat, which lies under the surface of our skin and when in excess marks a person as overweight or obese, brown fat is a highly metabolically active tissue found in small amounts in the neck, upper back, and clavicles  (3, 4).  Aside from knowledge of its anatomic presence, little was known about brown fat in humans until the past few years.  The new study from the Netherlands found that brown fat plays a role in what’s called ‘nonshivering thermogenesis’ – it burns calories to generate heat from within our bodies  during exposure to cold (5).  The researchers subjected a group of people to a 10-day cold acclimation programme (exposure to 15-16 degree C temperature for 6 hours per day), and found significant increases in brown fat metabolic activity and less shivering among the participants, who reported feeling less sensitive to cold at the end of the study (2).  Therefore, regular exposure to cold makes brown fat more efficient in keeping us warm – it achieves this through increased nonshivering thermogenesis, resulting in less of a need to shiver.

This information makes sense – we all have experienced getting used to colder and warmer temperatures.   But, let’s think about brown fat in the context of the so-called obesity epidemic that has emerged in Western countries.  One contributor among many may be the ubiquitous regulated indoor temperatures privileged upon us by technology.  With less exposure to cold, brown fat cannot be activated to burn at its metabolic potential (4).  Of course, diet and exercise are major factors.  Middle income countries such as Mexico that have warmer climates than many of the rich, Western countries are experiencing rising obesity rates that are unlikely to be due to artificial home heating.  But regardless of any speculation about the causes of obesity, brown fat has incredible potential to reduce obesity in the population.

In the Japanese study, the investigators exposed health human subjects to cold (17 degrees C) for two hours per day for 6 weeks (1).  They found an increase in brown fat activity and energy expenditure, and a decrease in body fat mass at the end of study (1).  This means that getting brown fat active through cold exposure is actually effective in reducing body fat.  Of course, this is good.  We are not concerned with the ability of brown fat to keep us warm, as cold exposure is not really a health concern nowadays, but, we are interested in whether it can help combat the obesity epidemic  (4).  The trouble is that brown fat has to be activated by cold to become metabolically active: i.e. you have to be a cold place for brown fat to start burning calories for you.  The authors of both the Japanese and Dutch studies conclude that regular exposure to colder temperatures could be effective in reducing the prevalence of obesity in the population.

Calvin and Hobbes by Bill Watterson. Available from Universal Uclick

Calvin and Hobbes by Bill Watterson. Available from Universal Uclick

Therefore you should keep your hand off the thermostat. Let yourself be slightly cold – just outside of the comfort range that the human body is physiologically conditioned to remain at, which is around 23 degrees C (3).  There’s no need to torture yourself – around 17 degrees C will suffice.  You will burn calories, and according to the scientific evidence, you will eventually get used to it and feel the cold less.  And hey, you will definitely save money on heating while helping out the environment at the same time.  That’s a self-congratulatory pat on the back that any self-respecting Generation Y can get on board with, right? The next steps are vegetarianism, regular gym attendance, and a bicycle in place of car.  If you’re already there, gold star for you, and if not, well, you’ve managed to read through yet another internet argument to be healthy and environmentally friendly, so my mission here has been achieved.



1)      Yoneshiro T, Aita S, Matsushita M, Kayahara T, Kameya T, Kawai Y, et al. Recruited brown adipose tissue as an antiobesity agent in humans. J Clin Invest 2013;123(8):3404-8.

2)      van der Lans AAJJ, Hoeks J, Brans B, Vijgen GHEJ, Visser MGW, Vosselman MJ, et al. Cold acclimation recruits human brown fat and increases nonshivering thermogenesis. J Clin Invest 2013; doi:10.1172/JCI68993.

3)      Hutchinson A. Want to burn body fat? Step up to the thermostat. Globe and Mail. 08 September 2013. http://www.theglobeandmail.com/life/health-and-fitness/fitness/want-to-burn-body-fat-step-up-to-the-thermostat/article14171995/

4)      Cannon B, Nedergaard J. Yes, even human brown fat is on fire! J Clin Invest 2013;122(2):486-9.

5)      Cannon B, Nedergaard J. Brown adipose tissue: function and physiological significance. Physiol Rev 2004;84(1):277-359

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