IUDs and implants have checkered pasts but a pretty awesome present

This week, US pediatricians (in agreement with a previous report from US gynecologists) announced a set of recommendations on contraceptives for young women. The headline grabber: IUDs and implants should be first-line choices. After all, they’re safe, effective, and as “set it and forget it” methods, reliable.

IUDs, formerly obscure, have become a little more popular in recent years. But implants? I didn’t know they were even still on the market.

20101009 1705 - Museum Of Sex - vintage IUDs - IMG_2282

Vintage IUDs at the Museum of Sex. The finger is pointing at the one you want (it looks like the Copper T). You do not want the other ones.
Photo by clintjcl, CC BY-NC-SA 2.0

Both have bad reputations based on ancient history, although (as the AAP and ACOG say) modern versions beat out other forms of contraception on almost any cost/benefit analysis. To those who object to potential side effects of hormonal contraceptives, it’s important to remember that contraceptives are safer than pregnancy.

So what’s the deal with these devices and why are they so obscure? Let’s step back into the time machine. First stop: 1971.

IUDs: the past

The Dalkon Shield, an IUD introduced that year, ended up being sold to 2.5 million women, of whom 17 died and 200,000 experienced infection, miscarriages, and hysterectomies. Lawsuits followed, some with hefty settlements, and it was pulled from the market.

IUDs: the present

Discussing this history, Anna Bahr of Ms. Magazine quips that “the new and improved IUDs are like iPhones compared to the telegrams of old.”

As the AAP report discusses, today’s IUDs are safe even for women who have never had children (in spite of old warning labels that said otherwise). Another concern, that women who contract a sexually transmitted infection are at higher risk of getting pelvic inflammatory disease, is only a risk in the first few weeks after insertion, and so providers can test for STIs at insertion time.

Implants: the past

If you’ve heard of contraceptive implants, you’re probably thinking of Norplant, the 6 implantable rods that were offered to, and perhaps pushed on, poor women and especially poor women of color in the early 1990s. The mini-documentary Skin Deep talks to some of these women, who experienced side effects they say they weren’t warned about, and who found it easy and cheap to get the device inserted but are having trouble getting it out. A doctor explains how difficult the removal process will be; a woman on public assistance says that she knows women who paid to get it inserted and removed, but that her doctor refuses to remove it. (The same laws that provided free insertion didn’t cover removal.)

About 10 minutes in, the Dalkon Shield makes a cameo, as the women compare the two methods, saying they felt like they were experimented on.

 Implants: the present

Like the Dalkon Shield, Norplant is no longer on the market. Single-rod implants (Implanon and Nexplanon) are now available, which have milder side effects and are easier to remove.

Two hour wait in doc's office + Implanon rod removal + Lots of gauze = End of side effects.  Huzzah

This lady is happy she got her implant removed.
Photo by Mandy Lackey, CC BY-NC-SA 2.0

What now?

But still, old-fashioned attitudes are a major barrier, among both patients and providers. Take this op-ed from a doctor on Fox News. He says that while as an obstetrician he understands that IUDs are a great choice, as a father he would never recommend one to his teenage daughter. Why? He brings up issues from the bad old days, and neglects to consider that the risks of modern IUDs are far less than the risks that accompany pregnancy.

What does he recommend instead? Abstinence. In case the flaw in his logic isn’t clear, here is what the AAP’s report says about this method, which should be 100% effective with “perfect use” (compare to 99.95% for implants and 99.8% for IUDs, rates that are nearly identical for typical and perfect use in these methods):

…existing data suggest that the ["typical use"]

effectiveness of abstinence for preg-

nancy and STI prevention over ex-

tended periods of time is likely low. For

example, among adolescents reporting

virginity pledges in the National Longitu-

dinal Study of Adolescent Health, at 6-year

follow-up (wave 3), 88% had engaged in

sexual intercourse (most premarital), and

5% were infected with STIs.

They go on to recommend that providers check in with the patient at each visit to ask if they still intend to remain abstinent, and to make sure that they understand the other options available. (This includes gay and lesbian teens, because some will occasionally have opposite-sex partners.) It’s a smart attitude for doctors, and it would be a smart attitude for parents to adopt, too.

The AAP report devotes several pages to the minefield of confidentiality and consent, noting that girls are better about using contraceptives when they don’t have to explain it to their parents, but insurance billing, among other things, makes this difficult.

After all, the age when a person starts having sex, and the age when they are ready to be a parent, are typically many years apart—no matter what their old-fashioned father thinks.


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The rising global burden of dementia


“Dementia is costlier in societal terms than the other four NCDs put together” Image: Shutterstock

The World Alzheimer’s Report has just been released. The report, commissioned by Alzheimer’s Disease International and led by Prof. Martin Prince at King’s College London in the UK contains staggering, yet not well-known statistics about dementia (1,2):

- Worldwide, 44 million people are estimated to be living with dementia. This figure is estimated to rise to 135 million by 2050.

- Every 4 seconds, someone in the world is diagnosed with dementia. This figure does not include undiagnosed cases, which are common.

- Middle- and low-income countries will be the most vulnerable to rising dementia incidence over the next few decades.

- The global societal economic cost of dementia exceeded $600 billion USD in 2010, over 1% of global GDP. These costs are estimated to rise.


“It’s never too early or too late” Image: Flickr

Dementia often tends to be dismissed as a disease of the elderly. It isn’t given the same weight as cancer or cardiovascular disease in the media, in terms of of research funding, or in the younger public’s collective psyche.

However, given the rising incidence of Alzheimer’s, and the fact that overall brain health is inextricably linked to similar risk factors as chronic diseases such as cardiovascular disease and cancer means we all need to be more aware.

The World Alzheimer’s Report focuses in on four key risk factors for Alzheimer’s disease, as found in their systematic review and meta-analysis of current evidence (1):

  1. Early life education
  2. High blood pressure in mid-life
  3. Diabetes in late life
  4. Smoking in late life

This type of information is probably going to reach few of those who are the most vulnerable to dementia – those already in poor health, with low education, and with low levels of cognitive engagement in later life. Particularly given global inequalities in dementia, which are likely to rise, it is necessary that dementia and Alzheimer’s disease are included in global strategies to reduce non-communicable diseases (NCDs). This achievement would include emphasizing the importance of preventive behaviours in later life, a time that tends to be ignored by existing recommendations.

If we can all enter old age with better developed, healthier brains we are likely to live longer, happier and more independent lives with a much reduced chance of developing dementia. With an estimated global societal economic cost of dementia of over $600 billion, and rising, the stakes could hardly be higher.


  1. Prince M, Albanese E, Guerchet M, Prina M. World Alzheimer Report: Dementia and Risk Reduction: an analysis of protective and modifiable factors. Alzheimer’s Disease International, 2014.
  2. Alzheimer’s Disease International. Dementia: the facts. http://www.alz.co.uk/world-alzheimers-month/dementia-facts (accessed 23 September 2014).
Category: Epidemiology, Health systems, Preventable Deaths | Tagged , , , , , , , | Leave a comment

Rare enterovirus in US children: what’s going on?

Enterovirus 71

Enterovirus 71. Image source

Recently, a mild-to-severe respiratory illness in children in the Southeast and Midwest United States has been emerging. The US Centers for Disease Control and Prevention (CDC) report that between mid-August and September 11th, 2014, their laboratory has confirmed 82 cases in six states of Enterovirus-D68 (1). This figure doesn’t include non-confirmed cases and cases tested outside of the CDC laboratory; the true number of cases is certainly higher, with hundreds of children reportedly showing symptoms.

What is Enterovirus-D68?

The culprit of this outbreak, Enterovirus-D68 or EV-D68, is a rare member of the non-polio enterovirus family. According to the CDC, it was first reported in California in 1962, but has rarely been seen in the United States since (1).

What are the symptoms of EV-D68 infection?

EV-D68 causes respiratory illness. At the mildest, the virus acts like the common cold, causing coughing, sneezing, and a runny nose. It may act like the flu, causing fever, and muscle and body aches.

A main concern is for children with a history of asthma or wheezing. These children are prone to more severe cases of EV-D68, which involves difficulty breathing and wheezing.

About 15% of cases among children have resulted in hospitalization, which is unusual and concerning (2).

Mark Pallansch, director of the CDC’s Division of Viral Diseases, stated that the number of hospitalizations reported could be “just the tip of the iceberg in terms of severe cases” (2).

Why are there so many hospitalizations?

The plain answer: we don’t know. Public health is a challenging field, where scientists and doctors have to act quickly and in real time as outbreaks unfold. Enteroviruses typically do spread amongst children at this time of year – but they tend to cause simple colds rather than surges in hospitalizations. The CDC is working hard to unravel the source of the current outbreak.

Earlier this year, we reported on an outbreak of another enterovirus, EV-68, among children in California. EV-68 was incredibly rare, but caused polio-like symptoms including muscle paralysis. Could the causes of the two outbreaks be related?

Should I be worried?

EV-D68 has been reported in Alabama, Colorado, Michigan, Georgia, Ohio, Iowa, Illinois, Missouri, Kansas, Oklahoma, North Carolina, Kentucky, and Utah (3,4). If you live in or near these areas and have children, keep an eye out for symptoms, especially if your child has asthma or a history of wheezing.

It is recommended that you take your child to the doctor if he or she develops a rash, fever, or has difficulty breathing (2). Fortunately, most cases will be self-limiting, and will only require treatment for symptoms.

How do I prevent EV-D68?

The CDC has provided a useful infographic, below:




  1. Centers for Disease Control and Prevention. Non-polio enterovirus: Enterovirus D68. http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html (accessed 12 September 2014).
  2. Martinez M, Newsome J, Cohen E, Dyerm K, Hughes T, Biery-Colick K. 10 states report outbreak of respiratory illness in kids. USA Today [Internet]. http://www.usatoday.com/story/news/nation-now/2014/09/08/respiratory-virus-midwest-children/15269751/ (accessed 12 September 2014).
  3. Wilson J. What parents should know about EV-D68. CNN [Internet]. http://www.cnn.com/2014/09/08/health/enterovirus-d68-symptoms/index.html (accessed 12 September 2014).
  4. Shankar S. Enterovirus EV-D68, causing respiratory infection in children, reported in 10 US states. International Business Times [Internet]. http://www.cnn.com/2014/09/08/health/enterovirus-d68-symptoms/index.html (accessed 12 September 2014).
Category: Epidemiology, Health systems, Infectious disease, Time trends | Tagged , , , , , , , | Leave a comment

Ethical dilemmas of giving Ebola drugs to the people who need them most

Ebola in Guinea

Credit: European Commission’s Humanitarian Aid and Civil Protection department (ECHO). CC-BY-ND

Although the outbreak is bursting beyond efforts to contain it, and daily finds ways to reach whole new levels of scary (for example, there have been a handful of cases in Lagos, a city the size of New York), hope is on the way. We’ve been hearing about experimental drugs and vaccines for the past few weeks, some being tried in humans and others yielding results from animal trials. But so far, they haven’t reached the places in West Africa where they are most needed.

Take ZMapp, the famous “experimental treatment” that Americans Kent Brantly and Nancy Writebol received. Both survived, although there’s no way to know if it’s because of ZMapp, because of other care they received, or because they were among the roughly 50% who would survive anyway.

ZMapp is a collection of human antibodies produced (in a feat of genetic engineering) by tobacco plants. There is none of it left; the company that makes it only had a small amount on hand for testing, and says it shipped out all the doses it could spare, at no cost, filling every request it got, first come first served.

Only a handful of doses were ever available. As far as we know, Brantly and Writebol’s employer, Samaritan’s Purse, requested two. Around that time, they were treating about 17 other Ebola patients in their center in Liberia, who presumably did not get the drug.

The Wikipedia article on ZMapp catalogues seven people who are known to have received the drug. Only three are African. A pharmacist in Guinea, in an AP interview, said what we’re all thinking:

“There’s no reason to try this medicine on sick white people and to ignore blacks. We understand that it’s a drug that’s being tested for the first time and that could have negative side effects. But we have to try it in blacks, too.”

But here is the dilemma: if a drug or vaccine turns out to be harmful, have we unethically experimented on a vulnerable population? A South African researcher summed it up for the New York Times:

“It would have been the front-page screaming headline: ‘Africans used as guinea pigs for American drug company’s medicine.’ ”

NPR reported that foreign leadership of Ebola treatment may be contributing to distrust., so fear of being a guinea pig may not seem farfetched. But as the situation grows more desperate, untested drugs and vaccines are looking better and better.

Still 50 white people away?

The Onion’s take on this issue is harsh: Experts: Ebola vaccine is at least 50 white people away. (“[W]hile progress has been made over the course of the last two or three white people, a potential Ebola vaccination is still many more white people off.”)

Life nearly imitates the Onion, as the fast-tracked safety trials enroll 60 people in the UK and 20 Americans (race unspecified). If the vaccines prove safe, though, larger quantities will be sent to Africa in November, where they will be offered first to health care workers.

That will leave us with further dilemmas about how to distribute the vaccine (who gets it first when there are limited supplies?) and the possibility that, if the vaccine doesn’t provide the promised protection, people may behave as if it does, perhaps touching and taking care of loved ones with the disease, believing they are protected when they aren’t. While we can assume workers will do their best to explain that the vaccine’s efficacy is untested and its safety only somewhat known, will everyone understand? Will they feel coerced to try it? If the vaccine doesn’t work after all, a large scale vaccination program would amount to a waste of time and resources at a time when clinics are already under-staffed and over-worked.

A treatment we already have

Last week’s WHO meeting on Ebola treatments discussed vaccines and experimental drugs, but the biggest action item they recommended was using a raw material already in abundant supply in Ebola-stricken regions: the blood of Ebola survivors.

Survivors’ blood should contain plenty of antibodies against the virus; in this sense, ZMapp is essentially an imitation of it. There are downsides here, too, including the possibility for transmitting other diseases such as HIV. While it may not sound as snazzy as a newly developed drug, blood is probably the most practical treatment to roll out on a large scale.

Even with effective drugs and vaccines, Ebola treatment in this outbreak will still depend heavily on basic medical care, since so many people are sick and, with or without drugs, isolation and supportive care are essential for patients.

But maybe, with luck, this will be the last big Ebola outbreak.

Category: Uncategorized | Leave a comment

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



Caveat: only if medically necessary. Image source.

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

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

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

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

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

2. Celebrity endorsement – the Gwyneth Paltrow effect

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

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

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

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

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

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

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



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

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

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

Category: Uncategorized | 4 Comments

Do multivitamin supplements increase mortality risk?

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

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

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

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

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

The ‘sick-user’ effect – another explanation?

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

Holding the evidence in balance

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

What’s the conclusion?

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

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

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

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

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

Should we be told more than we are?

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



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

Why the ice bucket challenge is different

Ice bucket challenge

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

How much does a healthy diet actually cost?

Access to healthy food is a major source of social inequality

Access to healthy food is a major source of social inequality

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

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

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

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

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

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

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

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


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

The Eatwell Plate - UK National Health Service

The Eatwell Plate – UK National Health Service


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

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

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

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

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

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



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

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


Image sources

Image 1: Newcastle University

Image 2: National Health Service ‘Eatwell’ plate

Category: Epidemiology, Food industry, Industry, Preventable Deaths, Uncategorized | Tagged , , , , , | 12 Comments

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

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

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

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

Treatments and vaccines in the pipeline

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

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

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

What we’re doing in the meantime

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

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

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

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

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

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


Epilogue: The three big questions

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

  1. As reported above, we don’t know any good treatments to offer patients and their contacts–just supportive care, quarantine and isolation.
  2. We don’t know enough about how the virus works in the human body. There are animal models that provide some glimpses, but to study humans you have to be able to do research in the middle of a raging outbreak of a rare disease. That’s tough. We have recently learned, for example, that it doesn’t always cause extensive bleeding. That’s why its name was changed from “Ebola hemorrhagic fever” to the simpler “Ebola virus disease.”
  3. We don’t know enough about how the virus spreads. Probably it circulates in bats and is occasionally transmitted to other animals, including humans, as a dead-end host–but the disease is so rare we don’t have a good way of studying it in the wild. Bausch says that while he was in Guinea recently, a group of ecologists started collecting bats from the local population, but their results are not yet published.
Category: Uncategorized | 9 Comments