Everything you need to know about social determinants of health you can learn from IKEA

It’s that time of year again. Summer is ending, undergrads are flooding university campuses, and people are moving. When people move, a few things become mandatory, for example, pizza or some other reward for those who help you move.

But one of the most important things anyone will do though is the annual trek to IKEA.

Darwin the monkey was very confused when he got lost in Ikea (photo from Instagram)

Darwin the monkey was very confused when he got lost in IKEA (photo from Instagram)

Every parent knows what I’m talking about. You pile into a car (generally a minivan or Subaru station wagon), already stuffed to the brim with things, and go to a store that actively advocates for you to acquire more things. And their things are practical! And useful! I mean, this year they introduced a mirror with hooks on the back to hang up tomorrow’s outfit! It’s genius!

Here’s where it gets interesting though. Have you ever gone into IKEA for just one thing? It’s impossible. You have to go through the whole store to get what you need, and while shortcuts exist, it’s often difficult to figure out where they go, and if you’re not careful, you’ll end up back where you started. And some sections are unavoidable – the children’s section and the section at the end with random knick knacks especially. And inevitably you pick up something for your apartment. A small potted plant. A bamboo tablet stand. An 8-bit model deer. Something.

This is all easy to wrap your head around. Everyone has lived this struggle. However, once you extend this idea to how the built environment and how it might shape our health, people shut down. We know it can and does.

Now, I’ve given the example of IKEA above, but this is true of many shops. Items placed at eye level are more likely to be sold. Somewhat creepily, characters on the front of children’s cereal look down – that way they’re looking at kids. The whole environment has been crafted to make you act a certain way, and, in the “best” cases, created so you experience it the way the designer wanted you to. This is a whole science, with the layouts referred to as “planograms.” For those interested in this in a practical retail context, this document details how this applies to an alcohol retailer in Ontario. You can see exactly where products are placed in order to make it easy to get what you want, and to therefore encourage you to purchase products.

An example of a planogram

An example of a planogram

However, the idea that the environment is making you subconsciously act a certain way extends beyond the retail sector. The neighbourhoods we live, work and play in all impact our health, all impact our health:

… our health is shaped by how income and wealth is distributed, whether or not we are employed and if so, the working conditions we experience. Our health is also determined by the health and social services we receive, and our ability to obtain quality education, food and housing, among other factors. And contrary to the assumption that Canadians have personal control over these factors, in most cases these living conditions are – for better or worse – imposed upon us by the quality of the communities, housing situations, work settings, health and social service agencies, and educational institutions with which we interact. (Source: The Canadian Facts, emphasis mine)

At a higher level, the political context, social norms and social policies all influence our health as well. These differences can impact our ability to make decisions and choices, and disproportionately impact some communities.

So next time someone questions the idea that the environment doesn’t impact their health and behaviours, and believes that we’re totally into control of everything around us, give them one simple task:

Take them to an IKEA, leave them in the middle, and say “escape.”


Category: Determinants of health, Epidemiology, Food industry, Health systems, Industry, Nutrition | Tagged , , , , , , , , | 1 Comment

Overcoming the Breastfeeding Barriers Black Women Face

We started August with World Breastfeeding Week and a post on how women aren’t getting the support they need to meet their own breastfeeding goals. August ends with another important theme: Black Breastfeeding Week. (This year’s hashtag: #LiftEveryBaby)

Black women are less likely to breastfeed their children than white women (although the gap may be narrowing). They often have an extra layer of the “booby traps” that make breastfeeding inconvenient, difficult, or impossible. For example, a report released last year from the US’s Centers for Disease Control found that the more Black women a hospital served, the less likely it was to promote and support breastfeeding. These hospitals were more likely to offer formula and less likely to encourage women to keep their baby with them in their hospital room (rather than sending the baby to a nursery).

The report didn’t test specific hypotheses about why these hospitals were less breastfeeding-friendly, but one factor–likely both cause and effect–is an apparently common assumption that Black women don’t breastfeed. Studies have found that Black women are less likely to get breastfeeding support from their health care providers and from WIC nutrition counselors. Here’s the good news: when hospitals transition to Baby-Friendly Hospital status, they’re able to increase breastfeeding rates for all women, Black and otherwise.

Unfortunately, there are very few such hospitals, and they aren’t always available in the communities where breastfeeding support is needed the most. As of 2013, 85% of Baby-Friendly Hospitals in the US were located in communities with a lower-than-average Black population.

A report from the Centers for Social Inclusion, released this month (which, by the way, is US National Breastfeeding Month) details some of the barriers to breastfeeding that non-white women encounter. The report cites statistics on medical, community, and employment-related barriers, and tells them in a series of stories about fictional composite women who encounter both support and obstacles. “Nicole,” who is Black, isn’t able to drive three hours to the only lactation classes in her area, and isn’t able to confirm that her insurance would cover a birth at a far-away baby friendly hospital. She gets bad advice from a local doctor, can’t find a lactation consultant she can afford, and eventually transitions her baby to formula.

The report’s conclusions: women need better and more consistent policies in the workplace and at health care facilities; and breastfeeding needs to become more publicly acceptable. This is especially true in the areas that have been dubbed “first food deserts” because breastfeeding is rare there. These areas are less likely to have LLL groups or stores with explicit policies allowing breastfeeding; they’re also places where nursing in public is likely to earn you rude comments or stares.

On why a Black Breastfeeding Week is needed, Kimberly Sears Allers explains it beautifully. I’ll end by handing over the mic to her:

It is not debatable that breastfeeding advocacy is white female-led. This is a problem. For one, it unfortunately perpetuates the common misconception that black women don’t breastfeed.  It also means that many of the lactation professionals, though well-intentioned, are not culturally competent, sensitive or relevant enough to properly deal with African American moms.

And the bonus #1 reason why we need a Black Breastfeeding Week is: Because. We. Said. So. We, the people who are from and of the black community. Those of us who are respected for leading the charge in increasing breastfeeding rates among black women. Those of us who are on the ground, doing the work and working for change.  Those of us who have faced the cultural struggles while breastfeeding our own children and want something better for future mothers and babies. I’m confident that the majority of people who are complaining about Black Breastfeeding Week haven’t seen what I’ve seen. They haven’t driven some 30 miles outside Birmingham, AL just to find a breastfeeding support group–or other urban areas where La Leche League doesn’t exist.  They haven’t held a premature baby who desperately needs breast milk but keeps spitting up formula. They haven’t stood on street corners and in front of WIC offices surveying new mothers and fathers, who said that their doctors never even gave them information about breastfeeding.  They have likely never stepped into a black community or a black home or a black church to understand the lack of resources available or the negative sentiment and myths that linger about breastfeeding. So until you have walked where I have walked, seen what I have seen and stood where I have stood, please do not have the audacity to tell me and my community what we do and do not need.

Yes, we are all in this together. But some of us need more attention to get us there.

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The Narrative of Privilege

Today we welcome Luckett to the blog. Her biography is at the end of the post.

‘Miss,’ she said, as I bit my tongue. I was choking on the worst insult a female junior doctor can bear, ‘I know that crystal meth is really my problem. I’m going to quit the meth.’

‘Love,’ I started, a reflex term of endearment for the wretched young woman in front of me, ‘What I need you to do is dry out your socks at night.’

She was tweaking in front of me, her eyes wild and her feet wet and macerated from her unwashed socks. She was earnest and somehow sweet despite the holes burned in her teeth and the scabs she had relentlessly picked on her face, arms, and legs. I was a bit afraid to touch her. Afraid, I guess, that I would become infected with whatever made her so diseased and broken. But when I looked into her huge, nearly-vacant eyes, I also wanted, badly, to give her a hug.

Choices I made when I was 16 - or, in this case, 20 - are not choices I want to be bound to for life.
Choices I made when I was 16 – or, in this case, 20 – are not choices I want to be bound to for life.

They tell me that I’ll get over that as I become more senior. With increasing experience in seeing patients who abuse substances, I will become inured to the pathetic faces they present to the emergency department. In time, I won’t care so much about the intoxicated guy in Room 9 who the nurses all hate; he comes in once a week, hurling abuses, and then leaves against medical advice when he needs his next fix. When I’ve seen more patients, I won’t waste my time on the tweaking addict who believes there are threads embedded deep inside his skin and shows me his abscessed track marks as proof. With experience, I won’t want to hug the addled young woman addicted to meth and covered in open sores, looking over her shoulder and telling me about how she really will get off meth tomorrow.

They tell me I shouldn’t care so much because the dirty, scabby woman in front of me made a choice to use drugs. Ultimately, we all deal with difficult life circumstances – admittedly, some more adverse than others – but most do not turn to a bottle or a crack pipe. I shouldn’t waste my time on those who are careless with their lives when there are so many responsible, upstanding individuals in the emergency department who ‘legitimately’ need our care.

Amongst my colleagues, there is a false narrative of choice. Smart and well-educated individuals construct a life story that reads as a series of decisions. The narratives they construct for others are similarly linear. They reflect a perceived agency on the part of the protagonist, the main character who appears before us in the emergency department.

I know that as a successful young professional, I contribute to this narrative, especially because I come from a troubled background. In a sense, my story is evidence that overcoming adversity is a matter of personal fortitude. People like me are proof that we create our own stories and are not bound by the haphazard circumstances into which we are born. But this narrative of personal agency we cleave to is not a narrative of choice; it is the narrative of privilege.

When I see patients who abuse substances in the emergency department, I imagine the hairstyle I wore when I was 16. I wore blunt bangs and a bob that nearly reached my shoulders. My hair was dyed pink, streaks of bleach blonde and deep black woven into the bright highlighter hue. I think about the clothes I chose when I was 16. I wore absurdly flared pants in bright colours, fastened to my hips with a seatbelt buckle and topped with a shirt held together by safety pins. I imagine how my choices changed as I matured; from pink hair to blonde, from blond to my natural brown with its streak of grey. From Geek Boutique pants and skirts from Ola, I have moved on to cotton dresses and scrubs. I imagine what it would be like to be trapped in the choices I made as a teenager, when my prefrontal cortex was still cooking and I couldn’t see beyond the five minutes ahead of me.

When people, often teenagers, make choices to use substances, they do so for a variety of reasons. Some choose substances because they seem fun, or because they want to fit in. Others choose drugs to escape the deplorable circumstances of their own regrettable reality. Still others choose drugs because that is simply what is done in their circle; perhaps they have learned from parents, older siblings, or a peer group saturated with GHB or crystal meth. Regardless, without the neurological machinery to delay gratification or think of a future they are not sure will even exist for them, they make a choice that then excludes them from interacting with mainstream society for many years to come, perhaps for their whole lives. Some do get clean, and fewer still stay clean, but many remain trapped in choices they made when they were 16. It’s like being forced to wear the dyed hair and flared fleece pants you chose when you were in grade 11, only the consequences are much graver.

I was a cute kid who could have grown up to become anyone. Just like you. And just like every crack-addled homeless person who visits the emergency department.
I was a cute kid who could have grown up to become anyone. Just like you. And just like every crack-addled homeless person who visits the emergency department.

I was the recipient of immeasurable luck and privilege, and, if you are reading this, you were too. We were fortunate to be graced with intellect and the ability to make decisions based on our knowledge of the world. We were fortunate to have people interested in us – be they teachers, coaches, or parents – who provided opportunities. We may have chosen to accept or reject the opportunities presented to us, but rest assured that we were privileged even in the offering. We were lucky that circumstances allowed for us to make smart choices, to strive toward good lives. To fool ourselves into thinking that our successes are the result of our own agency is to subscribe blindly to a blatantly false narrative. It undermines both our understanding of our own stories and our understanding of the stories of others.

When I reflect on the journey that brought me to my current career in medicine, I see that I could not have arrived where I am without considerable luck. I am an agent in my own life, and I made important choices that brought me great success. I was also, however, fortunate to have been a smart kid with a flare for athletics and the arts. I was chosen for academic enrichment groups, and a music teacher provided me private lessons – for free! – during my lunch hour in grades 4 and 5. I sang in choirs and played sports. I was given the opportunity to go to summer school, play in bands, receive special development in my sport, and I was only able to make the choice to take advantage of these opportunities because they were offered. As I moved through the school system, I was encouraged to attend an alternative school, and then pushed to apply to university. When I reached university, mentors found me and pulled me through the hardest parts of my journey. I made choices and worked very, very hard, but none of these choices would have been available to make were it not for the considerable luck I experienced.

I made other choices, too, and they weren’t as positive. Yet, every step of the way, there was some interested party who intervened and helped me dig myself back out. I am acutely aware that it is only through luck that I am not a scabbed and scarred young woman tweaking in an emergency department at 2 a.m.

You, my colleagues and peers, are also fortunate. You are privileged if you were smart and born into a family that valued education and provided you with the opportunity to develop your intellect. You were lucky if you lived in a good school district with interested teachers and support staff. You were fortunate if someone enrolled you in sports or gave you the chance to go to summer camp. You were lucky many times over when circumstances conspired – in ways you cannot even imagine or fathom – to bring you the opportunity to make choices. You chose to work hard, but you also were given the opportunity to choose to work hard.

May everyone you love be blessed with the opportunities to make choices that bring happiness.
May everyone you love be blessed with the opportunities to make choices that bring happiness.

It is easy to construct personal narratives that pit us as protagonists. We imagine ourselves bravely making a series of decisions that bring us success, love, and money while those around us make the poor choices that condemn them to failure, loneliness, and destitution. It is gratifying to believe that we are the sole operating agents of our own lives. It is uplifting to believe in stories of redemption, wherein those with nothing make the independent choice to strive and turn their lives around. It is unsettling to imagine the great fortune we have in a confluence of circumstances that is entirely outside of our control. It undermines the distinction between us and those less fortunate. It is scary, because it makes us just like the young woman with damaged feet, only luckier.

Maybe with time and experience I will lose the love and compassion I felt for that scarred young woman with macerated feet. Maybe I will forget her humanness. Maybe I will no longer be able to forgive the carelessness with which she treats her body and mind. But, if I do lose that part of me, if I lose my understanding of our false narrative of choice, I will be worse for it.

About the author

LuckettLuckett is an emergency medicine resident at McMaster University in Hamilton, ON. Her interests include near peer mentorship, medical education, and the relationship between literacy and health outcomes. Luckett’s work can be found at sluckettg.wordpress.com, aliem.com, and boringem.org. Connect on Twitter @SLuckettG. This post originally appeared on her blog.

Category: Determinants of health, Health systems, Infectious disease, Preventable Deaths, Science Outreach | Tagged , , , , , , , , , , , | 8 Comments

By how much does light alcohol consumption increase cancer risk?

oak aging

How much is safe to drink? Image: Mick Stephenson, WikiMedia Commons CC-BY-SA-3.0

The relationships between alcohol and long-term health outcomes such as cardiovascular disease and cancer are controversial and confusing. Regular alcohol consumption has been associated with increased risks for many cancers, including breast, colorectal, stomach, liver, prostate, esophageal, and pharyngeal cancers (1-4). But, previous evidence has been conflicting with respect to the strength of association and the volume, frequency, and lifetime duration of alcohol consumption that raises risk. Some longitudinal evidence from epidemiological cohort studies shows that alcohol consumption at even lower volumes than what is recommended by public health guidelines raises cancer risk (1).

To make things more complicated, headlines both proclaiming and questioning whether red wine protects against cancer appear on a regular basis. There is a chemical called resveratrol found in the skin of grapes, as well as other foods such as some berries, peanuts, and cocoa. Resveratrol affects the metabolism of cells in a mechanism that may act to prevent cancer – these biological effects are responsible for the ‘antioxidant’ and ‘super food’ hype that has been built up around these foods. However, recent research has indicated that the amount of resveratrol in wine does not counteract the carcinogenic effect of ethanol (5). Overall, the balance appears to tip in favour of avoiding excess red wine.

A remaining question with major public health implications is how much alcohol is safe to drink without cancer risk being affected?

A new study published in the BMJ this week provides some answer to this question (6). A group of Harvard investigators used data from 88,804 women and 47,881 men in the Nurses’ Health Study (1980 to 2010) and the Health Professionals Follow-up Study (1986 to 2010) to quantify the risk of cancer across all levels of alcohol consumption among women and men.

Alcohol consumption was measured as grams per day, calculated by multiplying the daily number of drinks by the average alcohol content per type of alcoholic beverage:

– 12.8 g of alcohol per 355 mL serving of beer

– 11.3 g per 355 mL of light beer

– 11.0 g per 118 mL of wine

– 14.0 g per 44 mL of liquor

‘Light to moderate’ alcohol consumption was defined as <15 g per day for women and <30 g per day for men, equivalent to about one glass of wine per day for women and two glasses of wine per day for men.


Figure reproduced from the BMJ (CC BY-NC 4.0). Non-parametric regression curves showing the association between alcohol consumption and risk of cancer (total and alcohol related). Blue lines=relative risk; dotted lines=95% confidence intervals.

As shown in the Figure above, alcohol consumption was associated with overall cancer risk in men and women, with a linear dose-response relationship (6).

Consumption within the light to moderate range was weakly associated with increased risk for overall cancer. Women who drank between 4 and 14.9 g of alcohol per day – up to one glass of wine daily – had a 4% increased risk of developing any cancer than women who never drank over the study period (RR=1.04; 95% CI: 1.00-1.09) (6). For known alcohol-related cancers (colorectal, oral cavity, pharynx, larynx, liver, esophagus, and breast), the increase in risk was 13% (RR=1.13; 95% CI: 1.06-1.20). Breast cancer was the leading alcohol-related cancer in women.

Men who drank between 15 and 29.9 g of alcohol per day – up to two glasses of wine daily – had a non-statistically significant 6% increase in risk of developing any cancer over the study period (RR=1.06; 95% CI: 0.90-1.24) (1). The risk associated with known alcohol-related cancers was similar, with RR=1.06; 95% CI: 0.90-1.24.

Although these study results have made a major media splash today, the association between regular light-to-moderate drinking as defined in this study appears to be weak: in women, 13% increased risk for known alcohol-related cancers and 4% increased risk for all cancers. While notorious for overstating the protective effect of red wine on cancer, the media seems to now have gone the other way in somewhat overstating the risk associated with alcohol consumption.

The interpretation of the 13% increase in risk depends on one’s absolute risk for cancer, which depends on many other factors as well.

Today’s headlines lack harm, however, as they adhere to the precautionary principle in public health. The message given to Time Magazine from the lead author of the study, postdoctoral fellow Dr Yin Cao, is certainly precautionary (7):

“For men, especially those who ever smoked, they should limit alcohol to even below the recommended limit,” she says. “And smoking and heavy alcohol consumption should be absolutely avoided to prevent cancer.”



  1. National Cancer Institute. Alcohol and cancer risk. http://www.cancer.gov/about-cancer/causes-prevention/risk/alcohol/alcohol-fact-sheet (accessed 19 August 2015).
  2. Bagnardi V, Rota M, Botteri E, Tramacere I, Islami F, Fedirko V, et al. Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis. Br J Cancer 2015; 112:580-93.
  3. Tramacere I, Negri E, Pelluchi C, Bagnardi V, Rota M, Scotti L, et al. A meta-analysis on alcohol drinking and gastric cancer risk. Ann Oncol 2011;23:28-36.
  4. McGregor SE, Courneya KS, Kopciuk KA, Tosevski C, Friedenreich CM. Case-control study of lifetime alcohol intake and prostate cancer risk. Cancer Causes Control 2013;24:451-61.
  5. Lachenmeier DW, Godelmann R, Witt B, Riedel K, Rehm J. Can resveratrol in wine protect against the carcinogenicity of alcohol? A probabilistic dose-response assessment. Int J Cancer 2014;134:144-53.
  6. Cao Y, Willett WC, Rimm EB, Stampfer MJ, Giovannucci EL. Light to moderate intake of alcohol, drinking patterns, and risk of cancer: results from two prospective US cohort studies. BMJ 2015;351:h4238.
  7. Park A. The connection between light drinking and cancer: study. Time Magazine [Internet]. http://time.com/4002182/drinking-alcohol-cancer/ (accessed 19 August 2015).
Category: Cancer, Epidemiology, Health systems, Nutrition | Tagged , , , , , | Leave a comment

The evolution of sedentary time

This post originally appeared on Mr Epidemiology on 16 April 2012.

The negative health effects of sedentary behaviour are a hot topic gaining scientific and popular attention. News outlets have emphasised that sitting is killing us. Given the tsunami-like obesity epidemic that has risen over North America over the past few decades, critical investigations of the degree to which sedentary behaviour contributes to overweight and obesity is highly warranted.

Every time I hear someone talk about how the amount of time we spend sitting these days kills us, I return to the same question:

If I was born 50 or 100 years earlier, would I be less sedentary than I am now?

The figure below depicts my average 16-hour day (waking hours only). Exemplary of a big question in the sedentary behaviour research domain, I am what you would call an “active couch potato” – I spend 6-7 hours week engaged in moderate-to-vigorous exercise, yet I still spend 50% of my waking hours sitting in front the computer. What does this mean for my health? And yours too – if you are reading this, you are probably somewhat similar to me. Is this sort of sedentary behaviour a new phenomenon of the latter part of 20th and early 21st century?

A simple yet elegant piece of evidence for the puzzle would be if population time trends in sedentary behaviour were found to partially explain increasing population obesity rates. A starting place to look is Statistics Canada’s General Social Survey, where time use of Canadians is estimated (1,2). Between 1998 and 2010, average time spent in “passive leisure activities” (including TV, reading, etc.) decreased from 2:52 (hours and minutes) to 2:39 among men over age 15, and from 2:35 to 2:20 among women over age 15. Average time spent at work decreased from 4:32 to 4:15 among men, and increased from 2:47 to 3:00 among women. Household work increased from 2:24 to 2:29 among men and decreased from 4:03 to 3:53 among women. Sadly, no indication of intensity of these activities is available in these estimates – but, tangentially, interesting in terms of gender roles in Canada!

So, what’s in the published literature? We have evidence on time trends in physical activity and inactivity, but not so much on sedentary behaviour. Some research shows that prevalence of leisure-time physical inactivity and “sedentary” behaviour (definitions are inconsistent) has been decreasing among adults (3–5), while prevalence of inactivity at work is increasing (3). The trouble is, we can’t go back in time and objectively measure sedentary behaviour of previous generations of adults. Despite limitations, these findings are disconcerting, especially since it appears that exercise may not save those of us with sedentary jobs (6,7).

Another pertinent question is: Do genetics play a role in resistance or susceptibility to negative health effects of sedentary time, just as they do in the physical response (such as weight loss) to moderate and vigorous intensity exercise?

Returning to my original thought – the second figure, directly above, shows what I think my physical activity/sedentary profile would look like if I was if I was born in the early 20th century. My guess is I would spend more waking hours engaged in household work, likely ranging from light to moderate intensity, and would be less likely to have a job I would spend all day sitting at. Exercise and sport would probably not happen.

What’s better or worse for health – the first or the second pie chart?

And how do genetics play a role in susceptibility to the ill health effects of time spent at various physical intensity levels? This is a new and growing area of inquiry (8,9). The simplified example I give in this article is only one, but it is representative of bigger questions at the population level. I’m looking forward to future work explaining the changing social nature of sedentary time, and how we can move toward becoming a healthier society.


  1. Statistics Canada. Table 1.1 Average time spent per day on various activities, for the population and participants aged 15 and over, by sex, Canada, 2010 [Internet]. General Social Survey – 2010 Overview of the Time Use of Canadians: Highlights. 2011 [cited 2015 Aug 12];Available from: http://www.statcan.gc.ca/pub/89-647-x/2011001/tbl/tbl11-eng.htm
  2. Statistics Canada. Table 1.2 Average time spent per day on various activities, for the population and participants aged 15 and over, by sex, Canada, 1998 [Internet]. General Social Survey – 2010 Overview of the Time Use of Canadians: Highlights. 2011 [cited 2015 Aug 12];Available from: http://www.statcan.gc.ca/pub/89-647-x/2011001/tbl/tbl12-eng.htm
  3. Juneau CE, & Potvin L (2010). Trends in leisure-, transport-, and work-related physical activity in Canada 1994-2005. Prev Med, 51 (5), 384-6 PMID:20832417
  4. Bruce MJ, & Katzmarzyk PT (2002). Canadian population trends in leisure-time physical activity levels, 1981-1998. Can J Appl Physiol, 27 (6), 681-90 PMID: 12501004
  5. Li FX, Robson PJ, Chen Y, Qiu Z, Lo Siou G, & Bryant HE (2009). Prevalence, trend, and sociodemographic association of five modifiable lifestyle risk factors for cancer in Alberta and Canada. Cancer Causes Control, 20 (3), 395-407 PMID: 18998220
  6. van der Ploeg HP, Chey T, Korda RJ, Banks E, & Bauman A (2012). Sitting time and all-cause mortality risk in 222 497 Australian adults. Arch Intern Med, 172 (6), 494-500 PMID: 22450936
  7. Finni T, Haakana P, Pesola AJ, & Pullinen T (2012). Exercise for fitness does not decrease the muscular inactivity time during normal daily life. Scand J Med Sci Sports PMID: 22417280
  8. de Geus EJ, Bartels M, Kaprio J, Lightfoot JT, & Thomis M (2014). Genetics of regular exercise and sedentary behaviors. Twin Res Hum Genet, 17 (4), 262-71 PMID: 25034445
  9. Smith CE, Arnett DK, Tsai MY, Lai C-Q, Parnell LD, Chen J, et al (2009). Physical inactivity interacts with endothelial lipase polymorphism to modulate high density lipoprotein cholesterol in the GOLDN study. Athersclerosis, 206 (2), 500-4 PMID: 19380136


Category: Epidemiology, Fitness, Preventable Deaths, Running, Time trends | Tagged , , , | 1 Comment

The impact of Obamacare, one year on

I used to bike to work every day in grad school. I lived around 2km away from the hospital I was based at (~ 1.24 miles), so biking was just the most efficient way to get to work every morning. One sunny July morning though, it all came crashing down. I was biking in, following the same route I’d taken literally hundreds of time before. And a pedestrian (with headphones in, oblivious to the world) walked out in front of me. I swerved to avoid them, hit the curb and then flew off my bike.

I don’t remember the next 15 seconds or so. I remember avoiding the pedestrian, losing control, and then the next thing I remember is being flat on my back. I then sat up and remember thinking that my left arm felt funny. I reached over and pulled it onto my lap, and then realized I was in trouble. The fact it was bent in ways it should never be bent in was one indication, the other was the shard of bone sticking out. A bystander yelled “Hey! Are you okay?” to which I replied “CALL AN AMBULANCE! MY INSIDES ARE OUTSIDE!!” (I’m quite proud of broken me for saying that).

This was my arm after the accident. I’m sure these are the technical terms the Ortho and ER staff use to describe such injuries (photo credit: Atif Kukaswadia)

This was my arm after the accident. I’m sure these are the technical terms the Ortho and ER staff use to describe such injuries (photo credit: Atif Kukaswadia)

So I’m lying there, covered in blood, bits of gravel and bike, with random strangers helping me out until the paramedics show up. The paramedics arrived quickly, and after bandaging my arm, took me to the emergency. There, doctors and nurses attended to me – taking several x rays, giving me pain medications, and reset my arm (not as easy as resetting a computer). That night I went in for orthopaedic surgery, and had two plates, along with several screws inserted to hold the whole thing back together. Throughout the whole process they made sure I was okay, and made sure I knew what was going on. Following surgery, I spent three days in recovery getting IV antibiotics and medications to ensure the healing went well, before being discharged and being sent on my way.

About a month after my accident I received my bill. I had received round-the-clock medical attention, a host of medications and procedures, as well as amazing care from doctors, nurses, and patient care assistants. The entire bill for my stay came to $45 – the ambulance trip. The rest was completely covered by our public healthcare system.


My accident has been on my mind a lot recently, especially with the US election buzz. While Republican candidates were talking about repealing the Affordable Care Act as recently as February and June of this year, only one candidate actually brought up repealing the ACA in the Republican debate last week, prompting Vox to call Obamacare the biggest winner at that debate. Since now millions of Americans receive health insurance as a result, fighting to repeal that would be disaster for any serious candidate.

That’s not to say Obamacare isn’t without it’s flaws – it’s definitely a work in progress that will require refinement and modification as problems and errors emerge. These include the absolutely disastrous rollout, backlogs in applications, as well as unintended consequences of the wording of the ACA. Since employers only need to provide health insurance for those working more than 30 hours a week, many changed their hours to give employees 29.5 hours a week, thus adhering to the letter of the law, but not it’s spirit. However, this is to be expected when rolling out a program as large and as ambitious as the ACA. It’s how these problems are dealt with that is the key indicator of success.

Percentage of uninsured Americans, by quarter

Percentage of uninsured Americans, by quarter

Recent data from Gallup shows a stark decrease in the number of uninsured Americans from 2014 (the start of the ACA) to 2015. There are other factors at play here as well (falling unemployment being one), but the levels are lower than 2008 pre-financial levels, which suggests this is more than just an improving economy. What this graph doesn’t show, however, is which groups this benefits the most. While the average number of uninsured individuals dropped 5.2% for all Americans from 2013 to 2015, this number was higher among those aged 18-25 (-6.7%) and 26-34 year old Americans (-7.4%). It was also highest among those earning less than $36,000 a year (-8.7%), as well as among Hispanic and Black Americans (-8.3% and -7.3% respectively).

The benefits of higher coverage are still being studied. A survey of physicians showed that “59 percent said that their ability to provide high-quality care to their patients has stayed about the same, while 20 percent said it has improved, and 20 percent said it has gotten worse.” In addition, many said the expansion has more positive effects than negative ones.

Image from Washington Post

Image from Washington Post

However, these differed significantly on party lines. Physicians who identify as Democrats were almost three times more likely to say the ACA has had a positive effect than Republican physicians, who were almost seven times more likely to say that the ACA has had a negative impact on their practice. This divisiveness could be a result of confirmation bias, or possibly due to these physicians being clustered within different states that have different levels of implementation of the ACA. This will have to be revisited in the future to determine how these attitudes change, and to look at the impact of the ACA on care received by patients. The benefits aren’t just for patients either; recent earning reports from Universal Health Services found a decrease in the number of unpaid services rendered (i.e., those without insurance):

The provision for doubtful accounts at our acute care hospitals amounted to approximately $149 million during each of the three-month periods ended June 30, 2015 and 2014, and $274 million and $331 million during the six-month periods ended June 30, 2015 and 2014, respectively. During the three and six-month periods ended June 30, 2015, as compared to the comparable periods of 2014, our acute care hospitals experienced a decrease in the aggregate of charity care, uninsured discounts and provision for doubtful accounts as a percentage of gross charges (emphasis mine) (source).


I can’t imagine how stressful it would be to be in the hospital dealing with a serious health concern, and imagining how you were going to be able to afford treatment (and mine wasn’t that bad in the grand scheme of things). Despite a dropping number of uninsured Americans, the US still has approximately 36 million people without insurance. With further improvements to the ACA, and as it continues to gather steam and build momentum, hopefully everyone can have access to affordable healthcare.

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Few Women Meet Their Own Goals: Readings for World Breastfeeding Week

It’s World Breastfeeding Week, but I’m not going to belabor the point of why breastfeeding is important. That too often makes women feel criticized for their choices–so I’ll just leave this  summary of benefits here and ask the question: Do women actually get support to follow through on their choice?

They don’t. Sixty percent of American women didn’t meet their own breastfeeding goals, as reported in a 2013 Pediatrics study. The average goal was 8.3 months, but among those 60% who fell short, the average actual duration of breastfeeding was 3.8 months. The most common reasons for stopping early were problems with breastfeeding (like pain), concerns that they weren’t producing enough milk, or concerns that the baby wasn’t satisfied with the milk or wasn’t gaining enough. These concerns are often based on misconceptions and can be overcome with good support–but women often don’t get the support that would help them succeed.

Why not? This list of “booby traps” describes some typical experiences for women in industrialized countries. None represent people trying to stop you from breastfeeding, but they contribute to making it difficult enough that, in combination, they discourage women from persevering. For example:

Your ob/gyn … is too short on time to deal with this post-birth issue and expects the pediatrician to fill in the gap, even though by the time the mother sees the pediatrician, too much time has gone by, and breastfeeding problems may already have set in.  Or (s)he is tired of enouraging mothers to breastfeed only to see them quit under family and peer pressure, or to see them be undermined by poor hospital policies. – Institutional Booby Trap!

The clock is ticking and your husband or partner hates to see you suffer and struggle, so he tells you “it’s okay to give the baby formula, I wasn’t breastfed and I turned out fine,” instead of helping you get expert help to fix the problem.   He means well, but he doesn’t know any better either.  You go online and don’t realize you are swimming in a sea of misinformation–even from well-respected, popular parenting sites.  You go to a breastfeeding website, and it is either totally unappealing, or the language is so technically scientific, it’s over your head.- Cultural Booby Trap!

You try to find a lactation consultant or counselor to help you, but your insurance company sends you into a tailspin trying to find one that is covered by your insurance.   You don’t live near a peer support group such as a La Leche League meeting or Breastfeeding USA group, or if you belong to WIC, the quality of breastfeeding support is inconsistent.  You may get lucky and get a tremendously supportive and knowledgeable peer counselor, or you may get one that tells you to just supplement with formula or who assumes that because you are low-income or African-American you won’t breastfeed anyway.

I experienced 7 of the 19 “booby traps” they describe, and I’m a person who was very lucky, well-informed, and committed to breastfeeding. I dodged the three quoted above:

  1. My midwife practice had a staff member whose job was to follow up with new moms to ask how breastfeeding was going and connect them with help as needed.
  2. My partner was extremely supportive, and we had both read extensively about breastfeeding before the baby came and knew the myths from the facts.
  3. When I needed a lactation consultant, that person at the midwife practice was able to connect me with both an LLL group near me and an IBCLC who took my insurance.

The first few days, even the first few hours, are critical for a woman to establish her supply and her (and her baby’s) habit of breastfeeding. For some women, those early days are way harder than she expected, and they give up on their own goals right away. Others may find it’s easier or more satisfying than they thought it would be. That’s why I love this collection of anecdotes about the first 48 hours of breastfeeding. Many of the 15 women succeed despite obstacles, but in most cases the experience is a mixed bag. This is real life: ups and downs, surprises, bad advice and good advice each coming from unexpected corners. And in each story, in hindsight, you can see where good support was crucial or where better support might have helped.

But what happens after a woman leaves the hospital, assuming she establishes breastfeeding and she and the baby are doing well? The booby traps aren’t over.

Cost is one factor that public health folks often ignore. Breast milk might be free, but breastfeeding can be tremendously expensive in terms of opportunity costs and needing to make choices that have a serious impact on your career. Tara Haelle takes down the myth of cost-free breastfeeding here, after experts objected to a breezy line in a study about breast milk benefits: “Breastfeeding is a highly accessible, low-cost public health measure.” That’s not true:

[T]he idea that breastfeeding is “low cost” [is] an assertion that does not “assign value to the time that mothers spend breastfeeding,” Stuebe pointed out. For example, mothers who return to work but want to continue breastfeeding should have a breast pump covered by insurance, but that’s not always how it plays out. Then, even though she is legally guaranteed unpaid break time to pump, she has to stay at work longer to get in her full work day, which means paying for more childcare. “This is not ‘low cost.’ It’s a substantial cost, borne by the mother so that she can follow medical recommendations to breastfeed her baby,” Stuebe said. “If a mother opts not to return to work in order to sustain breastfeeding, she forfeits her income and professional advancement, which, again, is not ‘low cost.’”

This year’s theme for World Breastfeeding Week is breastfeeding and work. Paid maternity leave (they recommend 4+ months) can help women breastfeed without giving up as much income. Employers should consider options like working from home, on-site child care, and allowing mothers to bring their babies to work. Supporting breastfeeding mothers shouldn’t be only about offering time and space to pump.


And yet pumping is still a major issue. Little has changed since this eye-opening 2006 New York Times piece on the “2-class system” at Starbucks–which isn’t really about Starbucks. At corporate jobs (like Starbucks HQ), you’re more likely to find an accessible, comfortable place to pump milk for your baby. At a lower-level job (like if you’re a barista at an actual Starbucks cafe) there’s no such thing. You have to make do with a bathroom, or a closet, or a manager’s office where you ask if it’s OK to do your thing now, and the person has to leave the room and you try to block off the window. How long would YOU last if you had to do this three or four times a day?

I love this interview with a woman who pumped in an open office plan. She didn’t have a private place, but she did have guts and a poncho.

How many people were in the office?

I’d say on average maybe eight people.

Did you tell people you were going to pump, or did you just start pumping? Either way, did people say anything about it?

I didn’t ask for permission—what would they say? “That’s not cool”? “Go to the utility closet”? People eventually just tuned it out, apart from the occasional, “What is that rhythmical, very annoying sound?” And occasionally a few giggles. I was pretty discreet, because of the poncho.

This wouldn’t work at every workplace, clearly. She speaks later in the interview about the culture in the office: she thinks it helps that the workers were young, mostly male, and already privy to more details of each other’s lives than co-workers typically are. At many workplaces, I’m sure, stares or complaints could make a pumping mom too uncomfortable to continue. Not everyone can get by on just guts and a poncho.

Here’s the last essay I’d like to put on the reading list: a lactation consultant explaining that she “[doesn’t] care what you do with your boobs.” She neither wants, nor has the time, to berate people for not breastfeeding. She’s too busy helping people who, by their own judgment, aren’t meeting their breastfeeding goals.

Here’s what I do when I am helping someone breastfeed: I ask how things are going (and not just how breastfeeding is going). I ask what things need to change. I ask about anything I feel is relevant and think critically about the situation to try to come up with a plan that involves feeding the baby appropriately and protecting (or, sometimes, decreasing) the milk supply in a way that everyone can be happy with and that is sustainable. I offer encouragement and understanding.

Here is what I do not do: chase down people who are not breastfeeding and ask why; tell women they need to breastfeed their babies at any cost; or slaughter people because of their infant feeding choices. I have only had someone’s kneecaps broken once. (That’s a joke.)

Not breastfeeding when you wanted to sucks. That’s what any breastfeeding supporter understands and is trying to prevent. So we help.

A woman who has decided to breastfeed, and who is biologically capable–which includes most women–shouldn’t be stopped by institutional, cultural, or economic roadblocks.

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Correcting the myths about missing drug trials

Not all drug trials get published. This is a problem because doctors, journalists, and others look to published data for the fullest picture of whether and how a drug works, and in whom.

The international AllTrials campaign launched a US branch this week. We need better reporting of clinical trials: Although we have legislation supposedly mandating trials to be published, many still aren’t. A 2012 study found that only 22% of trials complied with the law. According to Alltrials.net, the FDA hasn’t ever fined anyone for violating the law.

The last time I wrote about publication bias in drug trials—just a quick pointer to this excellent Salon piece by Rob Waters—some readers just didn’t get it. Here are a few of the comments that show why we need to communicate better about why publication bias is a problem:

“There’s really no use for the data if it shows that [a drug] doesn’t work.” (here)

“People generally aren’t interested in failure. Failure isn’t progress.” (here)

“So drug co’s don’t waste their time publishing tests of products that don’t work? #efficient #Scary #journalism #WellDuh” (here)

These readers assume the missing trials are unimportant ones. If a handful of trials show that a drug works, and only those get published, don’t we have the information we need?

No, we don’t. Say there’s an antidepressant, and half the trials show that it works and half show that it doesn’t. (Why the difference? Maybe they were done on different patient populations, or maybe some were done with better methodology than others.)

Trials aren’t just for the FDA to read at approval time.

  • Researchers build their future projects on what has and hasn’t worked in the past—which they know about from published studies and data sets.
  • Writers like me look up studies to understand the evidence behind how and whether a drug works.
  • Doctors read summaries of the latest studies to find out what drugs are more effective than others, and how best to use them. (I know because I write a lot of these summaries.)
  • Reviewers, like those that write the Cochrane reviews, collect and compare trials to figure out the big picture of a treatment’s effectiveness. (Not surprisingly, the Cochrane group is a major sponsor of Alltrials.)

In addition to answering the question “Does this drug work?” published data also helps answer questions like “Does this drug work better than these older ones?” and “How do the benefits stack up against harms?” (data that theNNT presents very clearly, by the way—mostly based on Cochrane reviews.)

If a large fraction of the trials for an antidepressant are missing, we could end up with a skewed view of how well it works. That’s exactly what happened with antidepressants as a class, according to this study led by Erick Turner. Trials published in journals painted a much rosier picture of the drugs’ effectiveness than the data submitted to the FDA. And we don’t know if the FDA had complete data, either; Alltrials suggests that regulators often don’t.

Evidence-based medicine is only as good as the evidence it’s based on. Hiding data skews the understanding that doctors and researchers rely on; it isn’t harmless.

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Using math to make Guinness

If you ever read public health research, you’ve probably encountered the term “Student’s t-test,” or just “t-test.” The experimenters will do this magical test, and suddenly conclude that everything is awesome. But even when you’re familiar with the t-test and what it does, very little thought goes into where this came from, or who came up with it. Well, today I’m going to tell you the origins of this staple of public health research.

William Sealy Gosset, statistician and rebel | Picture from Wikimedia Commons

Let me tell you a story about William Sealy Gosset. William was a Chemistry and Math grad from Oxford University in the class of 1899. After graduating, he took a job with the brewery of Arthur Guinness and Son, where he worked as a mathematician, trying to find the best yields of barley.

But this is where he ran into problems.

One of the most important assumptions in (most) statistical tests is that you have a large enough sample size to create inferences about your data. You can’t make many comments if you only have 1 data point. 3? Maybe. 5? Possibly. Ideally, we want at least 20-30 observations, if not more. It’s why when a goalie in hockey, or a batter in baseball, has a great game, you chalk it up to being a fluke, rather than indicative of their skill. Small sample sizes are much more likely to be affected by chance and thus may not be accurate of the underlying phenomena you’re trying to measure. Gosset, on the other hand, couldn’t create 30+ batches of Guinness in order to do the statistics on them. He had a much smaller sample size, and thus “normal” statistical methods wouldn’t work.

Gosset wouldn’t take this for an answer. He started writing up his thoughts, and examining the error associated with his estimates. However, he ran into problems. His mentor, Karl Pearson, of Pearson Product Moment Correlation Coefficient fame, while supportive, didn’t really appreciate how important the findings were. In addition, Guiness had very strict policies on what their employees could publish, as they were worried about their competitors discovering their trade secrets. So Gosset did what any normal mathematician would.

He published under a pseudonym. In a startlingly rebellious gesture, Gosset published his work in Biometrika titled “The Probable Error of a Mean.” (See, statisticians can be badasses too). The name he used? Student. His paper for the Guinness company became one of the most important statistical discoveries of the day, and the Student’s T-distribution is now an essential part of any introductory statistics course.

So why am I telling you this? Well, I’ve talked before about the importance of storytelling as a way to frame scientific discovery, and I’ve also talked about the importance of mathematical literacy in a modern society. This piece forms the next part of that spiritual trilogy. Math is typically taught in a very dry, very didactic format – I recite Latin to you, you remember it, I eventually give you a series of questions to answer, and that dictates your grade in the class. Often, you’re only actually in the class because it’s a mandatory credit you need for high school or your degree program. There’s very little “discovery” occurring in the math classroom.

Capturing interest thus becomes of paramount importance to instructors, especially in math which faces a societal stigma of being “dull,” “boring” and “just for nerds.” A quick search for “I hate math” on Twitter yields a new tweet almost every minute from someone expressing those sentiments, sometimes using more “colourful” language (at least they’re expanding their vocabulary?).

There are lots of examples of these sorts of interesting anecdotes about math. The “Scottish book” was a book named after the Scottish Café in Lviv, Ukraine, where mathematicians would leave a potentially unsolvable problem for their colleagues to tackle. Successfully completing these problems would result in you receiving a prize ranging from a bottle of brandy to, I kid you not, a live goose (thanks Mariana for that story!) The Chudnovsky Brothers built a machine in their apartment that calculated Pi to two billion decimal places. I asked for stories on Twitter and @physicsjackson responded with:

Amalie (Emmy) Noether is probably the most famous mathematician you’ve never heard of | Photo courtesy Wikimedia Commons

There’s also the story of Amalie Noether, the architect behind Noether’s theorem, which basically underpins all modern physics. Dr Noether came to prominence at a time when women were largely excluded from academic positions, yet rose through the ranks to become one of the most influential figures of that time, often considered at the same level of brilliance as Marie Curie. Her mathematical/physics contemporaries included David Hilbert, Felix Klein and Albert Einstein, who took up her cause to help her get a permanent position, and often sought out her opinion and thoughts. Indeed, after Einstein stated his theory of general relativity, it was Noether who then took this to the next level and linked time and energy. But don’t take my word for it – Einstein himself said:

In the judgment of the most competent living mathematicians, Fräulein Noether was the most significant creative mathematical genius thus far produced since the higher education of women began.

While stories highlight the importance of these discoveries, they also highlight the diversity that exists within the scientific community. Knowing that the pantheon of science and math heroes includes people who aren’t all “math geniuses” can make math much more engaging and interesting. Finally, telling stories of the people behind math can demystify the science, and engage youth who may not consider math as a career path.



This post originally appeared on PLOS Sci-Ed

Category: Epidemiology, History of Public Health | Leave a comment

The ‘Dad Bod’ Explained: A Study of Weight Gain during Fatherhood



The ‘Dad Bod’ | Image source: Flickr

Does a woman’s pregnancy affect the weight of her partner? And is weight gain sustained while the kids grow up? Anecdotally, many people would undoubtedly say yes from their own experiences. Lack of sleep, less time for exercise, and having a cheeky bite of junk food with the kids all add up in a serious way. We poke fun at the ‘dad bod’, but is it a real phenomenon among fathers?

This is actually a difficult question to answer. The transition to parenthood occurs over time. As we also inevitably age over time, our metabolisms sadly slow down and we usually gain weight. So, how to disentangle the causal effect on weight gain of becoming a parent versus simply getting older?

A study published last week in the American Journal of Men’s Health set out to answer this exact question. They investigated the effect of the transition to fatherhood on young men’s body mass index (BMI) at the population level in America.

Data were from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative study of 10,263 young men aged 12-21 years old when the study began in 1994-1995 (1). They followed the men up for over 20 years, until they were aged 25-34 years old in 2007-2008. The authors assessed the men’s BMI, whether and when they had had children, and many other important demographic and lifestyle factors.

Men were grouped into three categories: resident fathers, non-resident fathers, and non-fathers. The trajectory of standardized BMI over time is shown below.


Time is shown in “Fatherhood years”, where negative years are pre-birth of the child, 0 years is at the birth of the child, and positive years are post-birth of the child.

The ‘Fatherhood effect’ was an average weight gain of 4.4 pounds (2.6% increase in BMI) for a 6-foot tall man becoming a first-time dad and residing with his children.

First-time dads who did not live with their children had a 2% increase in BMI, on average, from the time they became fathers. For a 6-foot tall man, this translates to 3.3 pounds gained.

During the time period when the fathers gained weight post-birth, the childless men actually declined by about 1% in BMI until the end of the study. For a 6-foot tall man, this translates to 1.4 pounds lost. Weight change in the non-father group was attributable to age (there was a small overall increase in BMI in this group, despite the slight decline in the latter half of the study), while additional weight change in fathers was attributed to the life transition of having children (1).

In a press release, the lead author of the study, Dr Craig Garfield, Associate Professor of Pediatrics and Medical Social Sciences at Northwestern University Feinberg School of Medicine and attending pediatrician at Ann & Robert H. Lurie Children’s Hospital of Chicago, said,

Fatherhood can affect the health of young men, above the already known effect of marriage. The more weight the fathers’ gain and the higher their BMI, the greater the risk they have for developing heart disease as well as diabetes and cancer.

You have new responsibilities when you have your kids and may not have time to take care of yourself the way you once did in terms of exercise. Your family becomes the priority.

We now realise the transition to fatherhood is an important developmental life stage for men’s health. It’s a magical moment where so many things change in a man’s life. Now the medical field needs to think about how can we help these men of child-rearing age who often don’t come to the doctor’s office for themselves.

There you have it. The ‘Dad Bod’ is a real phenomenon, and not just a joke on social media. Weight gain associated with life transitions such as parenthood is a real concern, and public health, social, and clinical supports should be available for men during this time.


1. Garfield CF, Duncan G, Gutina A, Rutsohn J, McDade TW, Adam EK, Levine Coley R, Chase-Lansdale PL. Longitudinal study of body mass index in young males and the transition to fatherhood. Am J Mens Health 2015; Epub ahead of print DOI: 10.1177/1557988315596224

Category: Determinants of health, Epidemiology, Nutrition, Time trends | Tagged , , , , , | 3 Comments