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Obesity medicine doctor and cynical realist.

Weighty Matters
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May 12, 2009
05:30 AM
1,070 views

Is "vicarious goal fulfillment" to blame for that order of French fries?

by Yoni Freedhoff in Weighty Matters

How simply having healthy menu options available makes a person feel they've already fulfilled their goal of eating healthy and sends them to the French fries!... Read more »

Wilcox, K., Vallen, B., Block, L., & Fitzsimons, G. (2009) Vicarious Goal Fulfillment: When the Mere Presence of a Healthy Option Leads to an Ironically Indulgent Decision. Journal of Consumer Research, 2147483647. DOI: 10.1086/599219

June 2, 2009
05:30 AM
1,066 views

Refreshments Canada President playing from Big Tobacco's playbook

by Yoni Freedhoff in Weighty Matters

There was a letter to the editor in yesterday's Edmonton Journal. The letter was written by Mr. Justin Sherwood, the President of Refreshments Canada. According to their website Refreshments Canada, "represents more than 30 brands of beverages including bottled waters, juices and carbonated soft drinks, all of which have a place in a healthy, balanced lifestyle and offer consumers choice and variety."Justin was writing in response to a column written by Dr. Louis Francescutti (an ER doc and the President of the Alberta Public Health Association) who called for government regulations to ban trans fats, regulate advertising targeting children and remove harmful foods (trans fats, high-sugar and high-fat foods, and low-nutrient foods) from school vending machines.That madman!In any case, Justin was understandably upset. You see Justin represents many of the beverages that Dr. Francescutti's plan would see leave the schools. So what did Justin do? He proved Dr. Francescutti's point that Big Food is playing by Big Tobacco's playbook. If you'd like to read the playbook have a gander at Kelly Brownell and Kenneth Warner's recent paper, The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? in which the authors spell out how Big Tobacco's spin machine set out to delay the inevitable taxation and vilification of their product and then draw comparisons with Big Food.According to Brownell and Warner if Big Food plays by Big Tobacco's rules these are the plays we'll be seeing (with excerpts from Justin's letter italicized throughout):Focus on personal responsibility as the cause of the nation’s unhealthy diet."Proper nutrition education at home and in the school system is the most effective way to teach young people to make choices in a healthy and balanced way"Raise fears that government action usurps personal freedom."I am writing to express concern over the heavy-handed approach to the theme of this opinion article."Vilify critics with totalitarian language, characterizing them as the food police, leaders of a nanny state, and even “food fascists,” and accuse them of desiring to strip people of their civil liberties."The author is obviously an experienced medical practitioner, but his misguided advice reflects his role as a civil and public servant, in that he insists on more government regulations to protect adults and children from making poor food choices."Criticize studies that hurt industry as “junk science.”Emphasize physical activity over diet.State there are no good or bad foods; hence no food or food type(soft drinks, fast foods, etc.) should be targeted for change."Obesity is a very complex issue which cannot be blamed on a single food or beverage group as the major cause."Plant doubt when concerns are raised about the industry."Refreshments Canada members have been working closely with nutrition experts in the education system to ensure that healthy beverage choices, which are age appropriate, are presented in public schools across Canada." Pretty impressive Justin - you hit almost all the plays and in only 225 words! No wonder you're the President of Refreshments Canada.Justin, if you're reading this, I don't hate your products. I do believe in choice. I don't however believe in misleading the public, spinning the truth and doctoring the message. Let's all hope that this time around the public is more savvy than during those bad old days of Big Tobacco.Kelly D. Brownell, & Kenneth E. Warner (2009). Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? The Milbank Quarterly, 87 (1), 259-294 PMID: 19298423... Read more »

Kelly D. Brownell, & Kenneth E. Warner. (2009) Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food?. The Milbank Quarterly, 87(1), 259-294. DOI: 19298423

May 19, 2009
05:30 AM
974 views

Does just thinking about exercise make your heart beat faster?

by Yoni Freedhoff in Weighty Matters

I certainly hope not because if a recent study holds true, if thinking about exercise causes your heart to race you're twice as likely to die of a sudden heart attack.Of course it occurs to me that the folks whose hearts are likeliest to race at the thought of exercise would be those who are the least fit as they'll be worried about the prospect of exercising which in turn might cause their adrenalin to flow and their hearts to race.So perhaps the results aren't so surprising - those who are the least fit are the most likely to suffer sudden heart attacks.Bottom line? We should all do more exercise.Jouven, X., Schwartz, P., Escolano, S., Straczek, C., Tafflet, M., Desnos, M., Empana, J., & Ducimetiere, P. (2009). Excessive heart rate increase during mild mental stress in preparation for exercise predicts sudden death in the general population European Heart Journal DOI: 10.1093/eurheartj/ehp160[via bookofjoe]... Read more »

Jouven, X., Schwartz, P., Escolano, S., Straczek, C., Tafflet, M., Desnos, M., Empana, J., & Ducimetiere, P. (2009) Excessive heart rate increase during mild mental stress in preparation for exercise predicts sudden death in the general population. European Heart Journal. DOI: 10.1093/eurheartj/ehp160

June 30, 2009
05:30 AM
947 views

Quit smoking (and junk food?) through brief exercise?

by Yoni Freedhoff in Weighty Matters

Brains are crazy places.So neuroscientists using fancy brain imaging (fMRI) devices have demonstrated that nicotine stimulates the brain's mesocorticolimbic system (a reward centre).Other research has demonstrated those same centres lighting up with food cravings.Old news, no?Sure, but new fMRI studies combining smoking cues with exercise may help to explain how exercise helps with weight loss.Now most people believe exercise's role in weight loss is purely mathematical - it burns calories. While indeed that does play a role, unfortunately exercise doesn't burn nearly as many calories as would be fair and really is generally a minor mathematical player in weight loss. Yet despite it's minor role there's a robust evidence base that suggests exercise is essential in weight management, especially weight maintenance.So how does it help? If it doesn't burn many calories, what exactly does it do to help with weight control?Perhaps it changes your brain.You see a recent study published last year in the journal Psychopharmacology demonstrated that smokers who were nicotine abstinent for 15 hours, when faced with images of smoking had their mesocorticolimbic systems light up like Christmas trees. Yet Those same smokers, when exposed to 10 minutes of exercise prior to the smoking images showed no such lighting. So could the role of exercise in weight management have more to do with craving control than burnt calories? Do the folks who exercise more effectively turn off the parts of their brains that at times make cravings irresistible?Only one way to find out. If there's a time of the day that's more difficult for you to manage cravings why not try to build in 10 minutes of brisk walking, gardening, stationary biking, dance or active play and see if it helps to take the edge off? Worst case scenario? You get 10 extra minutes of healthy exercise.Janse Van Rensburg, K., Taylor, A., Hodgson, T., & Benattayallah, A. (2008). Acute exercise modulates cigarette cravings and brain activation in response to smoking-related images: an fMRI study Psychopharmacology, 203 (3), 589-598 DOI: 10.1007/s00213-008-1405-3... Read more »

Janse Van Rensburg, K., Taylor, A., Hodgson, T., & Benattayallah, A. (2008) Acute exercise modulates cigarette cravings and brain activation in response to smoking-related images: an fMRI study. Psychopharmacology, 203(3), 589-598. DOI: 10.1007/s00213-008-1405-3

October 7, 2009
05:30 AM
933 views

For the poor in NYC costs count more than calories

by Yoni Freedhoff in Weighty Matters

On July 18th, 2009 New York City's mandatory menu calorie law went into action and restaurants with 15 or more locations were forced to post calories on menu boards and/or menus for their patrons.The hope has always been that armed with this information people would choose fewer calories.Well, so far the results aren't too promising - at least not for a very specific population.In a paper published online in the journal Health Affairs, Brian Ebel and colleagues explored the purchasing behaviour of 1,156 adults at 4 different fast food locations in New York City. Researchers tracked purchases 2 weeks prior to the labeling law's implementation and 4 weeks after its implementation. Participants were told before purchasing that if they provided researchers with their receipt and answered a brief survey that they would receive $2. Prior studies using similar methodology for recruitment reported roughly 55% of restaurant goers participate. Researchers then used the receipts to determine the calories of the menu items ordered.The population studied was quite distinct. 85% were from minorities, and half had only a high school diploma or less education. The neighbourhoods were poor neighbourhoods and on average respondents reported that they frequented fast food restaurants an average of 5x weekly.What the researchers found was that for this sampling of poor, uneducated, fast-food addicted, minorities unless they specifically stated that they both noticed calories on the menu boards and changed their behaviours accordingly, calories consumed were the same both before and after the labeling law came into effect.Given the sample, these data are clearly not necessarily representative to the rest of the population. I would also expect that there will be far less change in caloric purchasing in fast food restaurants with fairly limited menus than in fast casual restaurants with more varied fare and patrons with more disposable income. Looking at McDonald's menu specifically, there really isn't much variety in calories in that even salads, when combined with dressings, tend to have calories comparable to their burgers. Furthermore given the nature of the sample and the recruitment I wonder whether or not they selected for the poorest of these poor patrons who actually would bother taking time out of the middle of their weekday for $2.The authors also admit that because the study took place so soon after the law went into effect perhaps they hadn't had enough exposure to have the numbers sink in. Personally I suspect that the exposure that truly would be necessary wouldn't be the actual calories on the menu boards but rather exposure to education as to just how many calories the body needs per day and in fact there have been studies that suggest menu labeling works far better when combined with that type of information. At the end of the day what this study tells me is that cost matters to this group far more than calories, and pragmatically I don't blame them one bit. It also impresses upon me the real need of finding innovative means to provide affordable, healthy food for the poorly educated and impoverished.So should we shelve these initiatives?Of course not, though it will certainly make the results from the much larger sampling of 12,000 receipts being collected by the public health department of New York that much more interesting. It's still a hill I'd be willing to die on. Brian Elbel, Rogan Kersh, Victoria L. Brescoll, & L. Beth Dixon (2009). Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City Health Affairs

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Brian Elbel, Rogan Kersh, Victoria L. Brescoll, & L. Beth Dixon. (2009) Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City. Health Affairs. info:/

August 16, 2010
05:30 AM
910 views

Healthy Dads, Healthy Kids, and Unhealthy Peer Review.

by Yoni Freedhoff in Weighty Matters

Last week Colby Vorland tweeted a link to a new study that looked at the impact of a lifestyle modification program geared at overweight fathers and their children.The study set out to randomly investigate something called the Healthy Dads, Healthy Kids Program - a 3 month program that delivers 10 hours of behavioural change counseling to overweight dads and their kids (where the kids showed up for 4 of those). The study looked at dads' and kids' weights at the end of the program and 3 months later, and for a control group they used dads and kids on the program's waiting list.The 6 month outcomes were quite predictable.Healthy dads lost significantly more weight (15lbs vs zip), and had statistically significant improvements in their waist circumferences, blood pressures and physical activity compared to controls. Importantly, they did not report any difference in their dietary intakes.Healthy kids showed an increase in physical activity and their mothers reported a dramatic decrease in the kids' caloric intake, reporting them eating on average 20 calories less per kilogram. Given the reported average weight of the children was 33kg, that'd be a decrease of 660 calories per kid per day - yet there was no change in weight in the children.So is this a slam dunk? Should we be rolling out this program across the globe?Not yet.You see there's an enormous flaw in the study, and it's a flaw that the folks who designed the study absolutely knew beforehand. Simply put, if you graph weight loss over time for virtually any weight management program, the losing phase lasts roughly 6 months which is then almost invariably followed by the regaining phase.Put another way, it's not particularly exciting to see a program effectively leading to weight loss at 6 months given that pretty much any intervention can do so. In fact I'd go so far as to say that publishing 6 month results of a weight loss program is a knowingly misleading thing to do and something that should be considered heavily by peer reviewers when evaluating such papers.Furthermore the study illustrates the difficulty of food frequency questionnaires in accurately tracking intake because here we've got a pile of kids who are apparently not governed by the laws of thermodynamics in that they're supposedly exercising significantly more and purportedly eating dramatically less and yet they aren't losing any weight.Dads wise - the study's fairly predictable too. Having treated over one thousand men in my program I can tell you, without frequent and explicit guidance to the contrary, men tend to hit the gym hard and fast and ignore food. While that may work in the short run, I've never seen it work in the long run in the absence of dietary change.So before you enroll in one of these programs I'd suggest you wait for the 18 month data.Of course the cynic in me says that data's never going to get published, not because of the International Journal of Obesity's negative publication bias, but rather because it's not data the researchers will likely want to brag about.Morgan, P., Lubans, D., Callister, R., Okely, A., Burrows, T., Fletcher, R., & Collins, C. (2010). The ‘Healthy Dads, Healthy Kids’ randomized controlled trial: efficacy of a healthy lifestyle program for overweight fathers and their children International Journal of Obesity DOI: 10.1038/ijo.2010.151

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Morgan, P., Lubans, D., Callister, R., Okely, A., Burrows, T., Fletcher, R., & Collins, C. (2010) The ‘Healthy Dads, Healthy Kids’ randomized controlled trial: efficacy of a healthy lifestyle program for overweight fathers and their children. International Journal of Obesity. DOI: 10.1038/ijo.2010.151

January 13, 2010
05:30 AM
907 views

Obesity, weight gain and pregnancy. Are the guidelines flawed?

by Yoni Freedhoff in Weighty Matters

Last year the Institute of Medicine (IOM) revised their guidelines on weight gain in pregnancy.The new recommendations state that obese women should gain between 11 and 20lbs during pregnancy (compared with a previous recommendation of 15lbs).The Institute didn't stratify these recommendations to different classes of obesity and consequently whether you've got a BMI of 30 or a BMI of 45 the recommendations remain the same.Many physicians (myself included) found this to be odd - both in terms of not stratifying recommendations for different obesity classifications and also for recommending any weight gain at all for women with moderate to severe obesity and this week a few like minded physicians took the IOM to task in an article published in the January issue of Obstetrics and Gynecology.The issues of course are the risks for both mother and baby associated with maternal prenatal obesity. The authors suggest that weight gain during pregnancy and that gain's effect on subsequent weight gain in life (not losing post pregnancy), "are causes of a permanent increase in weight for every BMI category and are significant contributors to the obesity epidemic and associated comorbidities"They believe that the recommendations are skewed towards the theoretical health of the fetus only and fail to factor in weight gain's risks to the mother which include higher likelihoods of gestational diabetes, hypertension, operative deliveries, pre-eclampsia and neonatal complications which of course in turn put the fetus at risk.The authors recommend that diet should be tailored for women of different classes of obesity resulting in gestational weight gains of 10lbs or less and in some, weight loss.I couldn't agree more and while my sincere belief is that 1,500-2,000 calorie diets are sufficient to nourish a fetus and to effect in weight losses for pregnant women with class II and III obesity, thankfully there are studies underway to test that very hypothesis. Belief is a bad way to practice medicine.Artal R, Lockwood CJ, & Brown HL (2010). Weight gain recommendations in pregnancy and the obesity epidemic. Obstetrics and gynecology, 115 (1), 152-5 PMID: 20027048

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Artal R, Lockwood CJ, & Brown HL. (2010) Weight gain recommendations in pregnancy and the obesity epidemic. Obstetrics and gynecology, 115(1), 152-5. PMID: 20027048

June 1, 2010
10:45 AM
894 views

Is air pollution responsible for rising rates of diabetes?

by Yoni Freedhoff in Weighty Matters

A recent study says so.The study, Traffic-related Air Pollution and Incident Type 2 Diabetes: Results from the SALIA Cohort Study set out to look at 1,775 non-diabetic middle aged women and their incidence of developing type 2 diabetes over a 16 year period as a function of their exposure to traffic-related air pollution. The study was conducted in Germany and the authors hypothesized that particulate matter air pollution may promote the development of type 2 diabetes with the proposed mechanism having to do with the development of subclinical inflammation in response to the pollution and that in turn impairing glucose metabolism.The researchers compared women leaving in the "highly industrialized" Ruhr district those living in two rural reference counties. They controlled for socio-economic status, smoking, second hand smoke exposure, occupational pollutant exposure, home heating with fossil fuels, and body mass index. The main outcome measure of the study was a physician's diagnosis of diabetes during the course of the study.The results?Living closer to traffic was associated with a 15% increased relative risk of developing type 2 diabetes for every increase in interquartile range in particulate matter or nitrogen dioxide.So, should you move to the country?Not based off this study.Two huge flaws. The first? The end point was physician diagnosed diabetes. Sounds like a fair end point but having worked in rural and urban centres I can tell you the access to physicians in rural settings is not comparable to urban ones. Consequently without controlling for physician visits (or even having a physician) this study may simply be a reflection of the fact that the rural folks don't have physicians to actually diagnose them with diabetes.The second? And this one should have been a deal breaker for the peer reviewers, the study didn't control for diet. Given the incredible impact of diet on the development of type 2 diabetes, not controlling for diet in a study looking at the development of type 2 diabetes is rather mind boggling. Diets with consumptions of the highest quartile of refined carbohydrates confer a 400% relative risk increase in the development of type 2 diabetes when compared diets inclusive of the highest quartile of whole grain consumption. Given the differences in availabilities of fast food and farm fresh foods in urban versus rural settings, and given the small relative risk increase found in this study, there's no doubt diet differences could easily account for all of it. So, while there may indeed be ills associated with air pollution, this study does nothing to suggest that diabetes is one of them.(Sorry for the late post. Experimenting a bit with timing)Krämer, U., Herder, C., Sugiri, D., Strassburger, K., Schikowski, T., Ranft, U., & Rathmann, W. (2010). Traffic-related Air Pollution and Incident Type 2 Diabetes: Results from the SALIA Cohort Study Environmental Health Perspectives DOI: 10.1289/ehp.0901689

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Krämer, U., Herder, C., Sugiri, D., Strassburger, K., Schikowski, T., Ranft, U., & Rathmann, W. (2010) Traffic-related Air Pollution and Incident Type 2 Diabetes: Results from the SALIA Cohort Study. Environmental Health Perspectives. DOI: 10.1289/ehp.0901689

July 7, 2009
05:30 AM
885 views

Fortified ice cream - an osteoporotic miracle?

by Yoni Freedhoff in Weighty Matters

Oy.From the labs at Unilever comes a study that calcium absorption following the consumption of calcium fortified ice-cream was comparable to absorption following the consumption of milk.Huzzah!?I suppose that given obesity's ability to increase bone density, by creating calcium fortified ice-cream we might finally have the "natural" cure for osteoporosis.Some great quotes from the researchers in Food Navigator, "Concerns over the unhealthy image of ice cream appear unfounded however, with the ice cream being “formulated responsibly in terms of nutritional profile”, wrote van der Hee and her co-workers. Indeed, the energy value for both did not exceed 115 kcal"So no worries - because no one ever eats more than one serving of ice-cream, right?van der Hee, R., Miret, S., Slettenaar, M., Duchateau, G., Rietveld, A., Wilkinson, J., Quail, P., Berry, M., Dainty, J., & Teucher, B. (2009). Calcium Absorption from Fortified Ice Cream Formulations Compared with Calcium Absorption from Milk Journal of the American Dietetic Association, 109 (5), 830-835 DOI: 10.1016/j.jada.2009.02.017... Read more »

van der Hee, R., Miret, S., Slettenaar, M., Duchateau, G., Rietveld, A., Wilkinson, J., Quail, P., Berry, M., Dainty, J., & Teucher, B. (2009) Calcium Absorption from Fortified Ice Cream Formulations Compared with Calcium Absorption from Milk. Journal of the American Dietetic Association, 109(5), 830-835. DOI: 10.1016/j.jada.2009.02.017

October 13, 2009
05:30 AM
879 views

Big Milk PhD bares her bias

by Yoni Freedhoff in Weighty Matters

Meet Dr. Susan Barr.Dr. Barr is a professor of nutrition at the University of British Columbia and she has had a truly illustrious career, having published dozens of peer reviewed articles. She's also been a workhorse for the milk industry serving as a member of the Medical Advisory Board of the Milk Processors' Education Program, the Medical Advisory Board for the International Dairy Foods Association and speaking and writing regularly for the Dairy Farmers of Canada.So what's got my knickers in a knot about Dr. Barr? It's her quotes from the recent "article" published in CanWest papers across the country last week where she tries to make the case that increased dietary dairy consumption reduces blood pressure. I put the word article in quotations because CanWest reports that the articles are "a joint venture with Dairy Farmers of Canada"and refer to them as a "special advertising feature".Dr. Barr's case for dairy's role in reduction of blood pressure rests on a famous study from 1997, the Dietary Approaches to Stop Hypertension Study which resulted in what's now known as the DASH diet. Dr. Barr reports, "The findings showed that those on the fruit and vegetable rich diet experienced a significant reduction in blood pressure. Those on the diet with milk products as well showed an even more significant reduction."A true statement, except of course it omits the fact that the study was not designed to examine the specific effects of dairy on blood pressure and more importantly omits the fact that the diet with dairy had other differences from the fruit and vegetable rich diet including lower overall saturated fat, lower total fat and lower cholesterol.Looking at the last 15 years of clinical trials research I was able to find only a handful of studies that were specifically designed to investigate the effects of dairy on blood pressure, and of those none were large or robust enough to draw firm conclusions.Thankfully I was able to find a recent review article published in the Journal of the American College of Clinical Nutrition which summarized the most pertinent studies detailing dairy's effects on blood pressure. The review reported that a few studies indeed showed decreases in blood pressure with increased dairy, another showed increases in blood pressure with yogurt but not cheese, and many showed no dairy/blood pressure relationship at all. Regarding the DASH study the review specifically concluded, "The greater reductions in BP seen with the DASH diet compared to the high fruits and vegetable diet cannot be ascribed to dairy products per se"and the review goes on to conclude that there are certainly some plausible mechanisms by which dairy might improve blood pressure and that further research is warranted.Fair enough, and really that's it? That's what's got me hot and bothered? The fact that Dr. Barr perhaps misconstrued the DASH study and overblew the preliminary suggestion that maybe blood pressure and dairy have a connection?Nope.It was this. The review article summarized the only studies that have ever been conducted that were designed specifically to address whether or not an intervention involving increasing dairy would have a positive impact on blood pressure, all 5 of them. According to the review none of those studies showed significant improvements to diastolic blood pressure while 3 showed minor improvements to systolic pressure, the greatest of which was 5mm Hg.Again, so? So why are you so pissy you're actually devoting an entire post to Dr. Barr and suggesting she's "bared her bias", yeah it doesn't look like there's much data to conclusively recommend increasing dairy for blood pressure benefit, but so what, at least there's some?It was this. Included in those 5 studies was this one, "Effects of increased consumption of fluid milk on energy and nutrient intake, body weight, and cardiovascular risk factors in healthy older adults"This study, conducted in the year 2000, followed 204 healthy, middle aged men and women and tracked what happened to their blood pressure and their weight following randomization to either stick with their current diets (low in dairy) or to add 3 glasses per day of milk to their diets for 12 weeks. At the end of 12 weeks researchers found that the increased dairy group did not see any statistically significant reduction in their blood pressures (nor did the subgroup of pre-existing hypertensives in the sample), but they did see statistically significant increases in weight, triglycerides and blood sugar - not exactly healthful results.Want to know who the lead author of this study, one of only 5 studies ever published which was actually designed to determine the effect of increasing dietary dairy consumption on blood pressure, the results of which showed increasing milk not only failed to have a positive effect on blood pressure but rather, significantly worsened weight, triglycerides and blood sugar? You guessed it, Dr. Susan Barr.Ain't it funny (and by funny I mean awful) that she didn't mention the paucity of conclusive research linking increased dairy with decreased blood pressure along with her own study's negative and potentially harmful results while misrepresenting the findings of the DASH study in the "article", I mean "joint venture", I mean "special advertising feature" meant to sell more milk?Kris-Etherton PM, Grieger JA, Hilpert KF, & West SG (2009). Milk products, dietary patterns and blood pressure management. Journal of the American College of Nutrition, 28 Suppl 1 PMID: 19571168BARR, S. (2000). Effects of Increased Consumption of Fluid Milk on Energy and Nutrient Intake, Body Weight, and Cardiovascular Risk Factors in Healthy Older Adults Journal of the American Dietetic Association, 100 (7), 810-817 DOI: 10.1016/S0002-8223(00)00236-4Appel, L. (1997). A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure New England Journal of Medicine, 336 (16), 1117-1124 DOI: 10.1056/NEJM199704173361601
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Kris-Etherton PM, Grieger JA, Hilpert KF, & West SG. (2009) Milk products, dietary patterns and blood pressure management. Journal of the American College of Nutrition. PMID: 19571168

BARR, S. (2000) Effects of Increased Consumption of Fluid Milk on Energy and Nutrient Intake, Body Weight, and Cardiovascular Risk Factors in Healthy Older Adults. Journal of the American Dietetic Association, 100(7), 810-817. DOI: 10.1016/S0002-8223(00)00236-4

Appel, L. (1997) A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. New England Journal of Medicine, 336(16), 1117-1124. DOI: 10.1056/NEJM199704173361601

September 21, 2009
05:30 AM
873 views

Danone's latest sexy health claim (sarcasm alert).

by Yoni Freedhoff in Weighty Matters

Somehow I don't think you'll be seeing this one on the side of your Activia anytime soon, but not because it isn't true.If you remember a while back I observed that if Danone's Activia health claims were really as robust as they like to present them, that perhaps they wouldn't have withdrawn them from consideration in the EU where the rules of proving your claim to be true are much, much more stringent.Well Danone's resubmitted a claim all right, but it's not the claim that Activia helps keep you regular, instead it's, “Fermented milk that contains the probiotic Lactobacillus casei, reduces the presence of Clostridium difficile toxins in the gut, associated with the incidence of acute diarrhoea.” Sexy.And very possibly true as Danone funded a double blind, placebo controlled trial involving 135 hospitalized patients taking antibiotics and found that only 12% of the probiotic group contracted diarrhoea associated with antibiotic use compared with 34% of the controls.So once again I've got to wonder aloud - if their evidence regarding their Activia health claims were as robust as those referred to above, why did they withdraw them from consideration in the EU and why haven't they been resubmitted?Hickson, M., D'Souza, A., Muthu, N., Rogers, T., Want, S., Rajkumar, C., & Bulpitt, C. (2007). Use of probiotic Lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial BMJ, 335 (7610), 80-80 DOI: 10.1136/bmj.39231.599815.55

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Hickson, M., D'Souza, A., Muthu, N., Rogers, T., Want, S., Rajkumar, C., & Bulpitt, C. (2007) Use of probiotic Lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial. BMJ, 335(7610), 80-80. DOI: 10.1136/bmj.39231.599815.55

February 16, 2011
05:30 AM
873 views

Think the gym's gonna make you slim? Think again.

by Yoni Freedhoff in Weighty Matters

Not sure why we're still funding exercise for weight loss studies as two recent comprehensive reviews of the medical literature have concluded that weight loss by means of exclusively exercise interventions run in the order of a 1-3% loss in response to 180 mins/wk of exercise and no loss at all if less than 150 mins/wk, but yet here's another one to discuss.What's a bit different about this study is that it was long - 18 months and hence perhaps will yield a different outcome.So what'd the study involve?Dr. John Jakicic and colleagues recruited and followed 248 initially sedentary, overweight adults between 2003 and 2006 to examine the impact of exercise on their weights. Recruits' ages ranged between 18-55 and their BMIs between 25-29.9. To help ensure completion of this long study, subjects were paid $50 at each of their biannual assessments, but remuneration wasn't dependent on exercise, just following up. The study set out to examine the effect of 3 different prescribed doses of moderate to vigorous exercise on body weight - self-help with no prescribed duration, 150 mins a week, or 300 minutes a week. Secondary outcomes included body composition, fitness and minutes of activity.Methodology wise, let me tell you, for folks in the 150 and 300 minutes/week groups, this was the Cadillac of exercise interventions.Those prescribed 150 minutes per week participated in a behavioural intervention to promote progression to and maintenance of those 150min/week of structured physical activity. Subjects were encouraged to spread their activity out over at least 5 days per week, in bouts of at least 10 minutes duration, with intensity being moderate to vigorous. During months 1-6 subjects attended weekly behavioural intervention sessions to encourage exercise, and during months 7-18 they attended two monthly group intervention sessions and received two monthly telephone calls such that weekly contact was sustained for the full 18 months of the study. Subjects also received "healthy eating" guidance, but were not prescribed calorie reduced diets, along with monthly newsletters pertaining to the study. They were also encouraged and invited to exercise-on-site with their intervention staff following their meetings as well as on weekends during the first 3 months.Those prescribed 300 minutes per week enjoyed all of the same interventions as the 150 minutes per week group, they were just aimed higher.The control or so-called, "self help" group only attended assessment visits biannually with no additional intervention or personal contact. They did however receive a physical activity self-help manual along with the same monthly newsletter as the activity groups.The results?Don't worry about holding on to your hats.There was a very significant group x time interaction effect whereby there was a dramatic increase in activity from baseline. 18 months later the previously sedentary self-help folks were averaging 74.6 mins weekly, the 150 minute folks 66.1 mins weekly and the 300 minutes group 154.8 minutes weekly. The fact that there was no statistically significant difference in activity between the 150 minute intervention and self-help, this despite tremendous resources thrown at the 150 minute group, suggests to me that if you're going to encourage physical activity through a behavioural intervention you should go big or go home.Intake wise, there was no between group differences and an overall self-reported decrease in intake averaging 201 daily calories.Weight wise, there was no between group differences with percent weight change at 18 months in the 300 minute group being -1.2%, the 150 minute -0.9% and the self-help -0.7%.The authors then subdivided folks into people who lost more than 3% of their weight, stayed within 3% of their weight and gained more than 3% of their weight and did some further analysis.What'd they find?Overall, despite an 18 month significant increase in exercise 72.6% of subjects either stayed the same or gained weight while only 27.4% lost more than 3% of their initial weight. Looking at the losers specifically the authors did find a dose-dependent association with exercise however as the authors themselves noted, "despite these findings, concluding that physical activity alone can result in the magnitude of weight loss observed in the weight loss within the retrospective secondary analysis may be misleading."Why?Because the losers ate better as measured by their more significant changes in their completed Eating Behaviour Inventories.Worth spending a moment on too was the finding that a full 20% of participants gained more than 3% of their presenting weight over the course of this very rigorous exercise intervention. Sadly too, their weight gain was also associated with an increase in their abdominal adiposity - the bad apple place to put weight.The good news?A very minimal intervention ($150, newsletters and a self-help manual) led the initially sedentary self-help group to markedly increase their daily amount of exercise and also markedly improve their fitness as measured by the increase in time it took for those same individuals to achieve 85% of their age-predicted maximal heart rate - an improvement that almost certainly has health benefits.Bottom line?We have to stop linking exercise with weight loss. Exercise should be promoted for its phenomenal health benefits, not for its role in weight management.Weight's about food, not fitness, whereas health's about both.Jakicic, J., Otto, A., Lang, W., Semler, L., Winters, C., Polzien, K., & Mohr, K. (2010). The Effect of Physical Activity on 18-Month Weight Change in Overweight Adults Obesity, 19 (1), 100-109 DOI: 10.1038/oby.2010.122

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Jakicic, J., Otto, A., Lang, W., Semler, L., Winters, C., Polzien, K., & Mohr, K. (2010) The Effect of Physical Activity on 18-Month Weight Change in Overweight Adults. Obesity, 19(1), 100-109. DOI: 10.1038/oby.2010.122

July 19, 2010
05:30 AM
871 views

Not everything's caused by obesity: Brain and memory function edition

by Yoni Freedhoff in Weighty Matters

Good lord.I know people like to blame obesity for everything. Every disease, every problem - everything.You know what I'm blaming on it today? Authors' and peer reviewers' attitudes about their studies and results.Last Tuesday I was asked by CTV to read a study that was pending publication in the Journal of the American Geriatrics Society so that I could comment on it for the national news. The study looked at 8,745 women between the ages of 65-79 free of dementia and evaluated their weight and waist to hip ratios in relation to their scores on the 3MSE, a modified mini-mental state examination validated to give an overview of cognitive function.So I read the study.Want to know what I found out?That after controlling for age and education the test scores of folks whose BMI's were 40 were 94.1. I also discovered that the authors failed to provide the p value (the number whereby you'd see what the likelihood simple chance would lead to the result) for that comparison but they did provide a p value for the larger difference when age and education weren't controlled for and guess what, that p value, the one that looked at an even larger variance in test scores, wasn't even close to significant (at 0.10 there was a 10% likelihood the result occurred solely due to chance).Another odd result? Women with abdominal weight distributions (apples) scored better than those with truncal distributions (pears) suggesting that unlike pretty much everything else weight related, abdominal obesity was protective against this supposed negative impact on cognition.So basically in a best case scenario the authors could conclude that obesity may lead people to score a single percentage point lower on a test of global cognition but they'll point out at least that the difference in scores could easily have occurred due to chance. Worst case? They'll make it sound important so that they could get published.My take? I took it to read that obesity doesn't lead to any statistically significant differences in a test of global cognition and that consequently it would seem that obesity and cognition aren't too tightly linked - a result that perhaps is bolstered by the fact that abdominal obesity appeared to be beneficial (though I should note, it may simply be due to the fact the researchers didn't measure waist circumference properly as rather than use a consistent bony landmark they used the floating umbilicus).So what did the authors conclude? "Higher BMI was associated with poorer cognitive function in women with smaller WHR....Further research is needed to clarify the mechanism for this interaction".What I wrote back to CTV was the following, "It would have to be an unbelievably slow news day for this to make the rotation."And yet it was all over the news.Sigh.The media? I can forgive them, they're just trying to sell stories. The authors? I can almost forgive them too as certainly negative publication bias might have precluded this piece and it's a publish or perish world.The peer reviewers? I got nothin'.Kerwin, D., Zhang, Y., Kotchen, J., Espeland, M., Van Horn, L., McTigue, K., Robinson, J., Powell, L., Kooperberg, C., Coker, L., & Hoffmann, R. (2010). The Cross-Sectional Relationship Between Body Mass Index, Waist-Hip Ratio, and Cognitive Performance in Postmenopausal Women Enrolled in the Women's Health Initiative Journal of the American Geriatrics Society DOI: 10.1111/j.1532-5415.2010.02969.x

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Kerwin, D., Zhang, Y., Kotchen, J., Espeland, M., Van Horn, L., McTigue, K., Robinson, J., Powell, L., Kooperberg, C., Coker, L.... (2010) The Cross-Sectional Relationship Between Body Mass Index, Waist-Hip Ratio, and Cognitive Performance in Postmenopausal Women Enrolled in the Women's Health Initiative. Journal of the American Geriatrics Society. DOI: 10.1111/j.1532-5415.2010.02969.x

April 27, 2011
05:30 AM
853 views

Food addiction. Chicken or egg?

by Yoni Freedhoff in Weighty Matters

Food addiction's a hot topic these days.Proponents posit that food addiction is a real phenomenon that leads people to almost irresistibly eat.Opponents believe that it doesn't exist, and it's just a means with which people justify their difficulties with food.What if they're both right?A recent study's got me thinking. Now be forewarned, it's an animal study and therefore not necessarily attributable to human beings, but nonetheless....The study looked at minipigs (which as evidenced by the photo up above are almost unbearably cute), where brain activation of seven diet-induced obese minipigs, were compared to brain activation of nine lean minipigs following an overnight fast.The findings were striking. The obese minipigs had a great deal more activation of their prefrontal cortices compared to the lean minipigs, where the prefrontal cortex has been shown to be involved in addictive behaviour in humans.They also found decreased activation in the reward centres of the obese minipigs (the ventral tegmental area and the nucleus accumbens), which suggests the possibility that food "addiction" might in fact cause some sort of habituation in these brain regions which in turn would lead to individuals to require larger hits of food, to get the same brain-based reward.But here's the thing. The minipigs, with clearly different brain chemistries, didn't self select for being obese, they were chosen to be fed more. At first they ate fairly normally, despite having ready access to food all day long (as opposed to their brethren), but then over time, and living in their all-you-can eat buffet hutches, they started to eat more. By the end of the experiment, they weighed nearly double the weight of their peers. And by the end of their experiments, their brains had changed.This may in fact suggest that while food addiction may indeed have neurophysiologic foundations, that it's the egg and not the chicken. Meaning that these pigs weren't born addicted to food, they developed food addictions after living in what might be described as a toxic food environment.That's exciting to me, in that if we can help people regain control over their food environments. if we can help people ease into more satiating patterns of eating, maybe we can rewire their brains, and in so doing, short-circuit these unnaturally derived neural pathways and responses.And ultimately, I think we can. Why? Because I see it in my offices on a very regular basis (though not every time mind you, there are some folks who seem to truly struggle with these behaviours regardless of the tweaks we try).Which is why I think both proponents and opponents are right, where food addiction has a physiological foundation, but where there is certainly a pattern of eating that may, in some cases, predispose people to heightened neurophysiological drives to eat.Of course when you think about it, none of this is particularly surprising. After all, couldn't the same can be said about pretty much every addiction?[And remember, for extra tidbits, or if you'd prefer to follow this blog there, you can also follow Weighty Matters on Facebook]Val-Laillet D, Layec S, Guérin S, Meurice P, & Malbert CH (2011). Changes in brain activity after a diet-induced obesity. Obesity (Silver Spring, Md.), 19 (4), 749-56 PMID: 21212769

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Val-Laillet D, Layec S, Guérin S, Meurice P, & Malbert CH. (2011) Changes in brain activity after a diet-induced obesity. Obesity (Silver Spring, Md.), 19(4), 749-56. PMID: 21212769

June 9, 2009
05:30 AM
851 views

What the American Beverage Association and Philip Morris have in common.

by Yoni Freedhoff in Weighty Matters

There was a letter to the editor in yesterday's New York Times. The letter was written by Ms. Susan K. Neely, the President of the American Beverage Association. According to their website the ABA`s members, "market hundreds of brands, flavors and packages, including regular and diet soft drinks, bottled water and water beverages, 100-percent juice and juice drinks, sports drinks, energy drinks and ready-to-drink teas."Susan was writing in response to an editorial where the New York Times called on the imposition of an excise tax on sugary beverages given their clear cut linkage to obesity and their dearth of health benefits.Those madmen!In any case, Susan was understandably upset. You see Susan represents many of the beverages upon which such a tax would impact. So what did Sally do? She followed the Big Tobacco Playbook. If you'd like to read the playbook have a gander at Kelly Brownell and Kenneth Warner's recent paper, The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? in which the authors spell out how Big Tobacco's spin machine set out to delay the inevitable taxation and vilification of their product and then draw comparisons with Big Food.According to Brownell and Warner if Big Food plays by Big Tobacco's rules these are the plays we'll be seeing (with excerpts from Sally's letter italicized throughout):Focus on personal responsibility as the cause of the nation’s unhealthy diet.Raise fears that government action usurps personal freedom."There are better initiatives to tackle obesity than discriminatory taxes."Vilify critics with totalitarian language, characterizing them as the food police, leaders of a nanny state, and even “food fascists,” and accuse them of desiring to strip people of their civil liberties.Criticize studies that hurt industry as “junk science.”"As policy makers seek ways to finance health care reform, we encourage them to seek broad-based, equitable solutions based on science, economic realities and common sense."Emphasize physical activity over diet."Balancing calories consumed with those expended through physical activity is the critical factor in preventing obesity."State there are no good or bad foods; hence no food or food type (soft drinks, fast foods, etc.) should be targeted for change."Scientists agree that there is no single cause of obesity, and there will be no single solution. In fact, a recent study published in The New England Journal of Medicine reaffirms that calories are calories, regardless of their source. "Plant doubt when concerns are raised about the industry.Not bad Sally. You hit 4 of 7 plays in only 159 words! Thanks to the refreshments industry in both Canada and the US for providing such easy fodder for blogs.Oh and Brownell and Warner, you guys rock.Kelly D. Brownell, & Kenneth E. Warner (2009). Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? The Milbank Quarterly, 87 (1), 259-294 PMID: 19298423... Read more »

Kelly D. Brownell, & Kenneth E. Warner. (2009) Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food?. The Milbank Quarterly, 87(1), 259-294. DOI: 19298423

August 10, 2009
05:30 AM
834 views

The unintended consequences of banning trans-fats

by Yoni Freedhoff in Weighty Matters

While Health Canada continues to ignore its own task force's recommendations to ban trans-fats, New York is off an running.A recent report published in the Annals of Internal Medicine revealed that since their regulation in 2006 98% of restaurants are trans-fat free and that it has been a "cost neutral" shift.What's more interesting is that preliminary studies suggest that while indeed the shift from trans-fats have increased the use of saturated fats, it also increased the use of unsaturated fats, the healthy fats, leading to an overall improvement in the fat profile of trans-fat substituted foods.What this means of course is that not only is there the benefit of removing a dietary toxin from the food supply, there's the added benefit of increasing the food supply's provision of healthy fats.It's been 51 days since the two year free pass Tony Clement gave the food industry to shape up ended - and still our government does nothing.Pathetic.Angell SY, Silver LD, Goldstein GP, Johnson CM, Deitcher DR, Frieden TR, Bassett MT. (2009). Cholesterol control beyond the clinic: New York City's trans fat restriction. Annals of Internal Medicine, 151 (2), 129-134 PMID: 19620165... Read more »

Angell SY, Silver LD, Goldstein GP, Johnson CM, Deitcher DR, Frieden TR, Bassett MT. (2009) Cholesterol control beyond the clinic: New York City's trans fat restriction. Annals of Internal Medicine, 151(2), 129-134. DOI: 19620165

December 17, 2009
05:30 AM
831 views

(Podcast) Obesity's dangerous. Period.

by Yoni Freedhoff in Weighty Matters

Why?Not sure.But Dr. Jennifer Kuk and Dr. Chris Arden from my undergraduate Alma mater York University in Toronto recently published a paper that looked at 6,011 adults and then subdivided them into those who were "metabolically normal" and obese and "metabolically abnormal" and obese and then followed those individuals' mortality rates over the course of 10 years.The results?Obesity doesn't generally occur in the absence of metabolic abnormalities (only about 6% of the obese folks fall into this slot), but when it does, it's still associated with the same increase in risk of all-cause mortality.A little while ago I had the chance to interview Dr. Kuk about her study.Click below to download the audio file, or you can listen on the embedded player (won't work with email subscribers) and hear Jen discuss her findings.Click here to download this podcast or click here to subscribe in iTunes!Kuk JL, & Ardern CI (2009). Are metabolically normal but obese individuals at lower risk for all-cause mortality? Diabetes care, 32 (12), 2297-9 PMID: 19729521

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Kuk JL, & Ardern CI. (2009) Are metabolically normal but obese individuals at lower risk for all-cause mortality?. Diabetes care, 32(12), 2297-9. PMID: 19729521

May 10, 2011
05:30 AM
831 views

Is sodium a dietary red herring for the effects of processed foods?

by Yoni Freedhoff in Weighty Matters

You may have read or heard about a research paper that came out a few weeks ago in JAMA. The study followed 3,681 Europeans and looked for relationships between sodium excretion (the gold standard means of determining sodium intake), and cardiovascular disease and death.The study's findings were in contrast with what most would have expected. Though higher sodium excretion did in fact correlate with higher blood pressures, surprisingly, it also correlated with decreased mortality.So what's going on here?Well here are two obvious possibilities:1. We've been barking up the wrong tree sodium wise, and that it's not something the general public should be worrying too much about (unless they suffer from congestive heart disease or hypertension).2. We're right, sodium's bad, and that this study, due to methodological limitations, shouldn't be one that influences guidance on lowering dietary sodium.I think there's at least one more possibility:3. Sodium's isn't a causal agent of disease but instead given that processed foods are phenomenally high in sodium, is a useful biomarker for the degree of processed foods a person's consuming, and that it's the huge volumes of sugar and pulverized flour that's more often than not packaged with sodium that's actually causal for cardiovascular disease and death.This study, where data was amassed from European countries from in some cases as far back as 26 years ago, may be looking at a days gone by Europe where processed foods and meals out were anything but the norm, and where a high sodium consumption reflected some other, in this case protective, dietary pattern. I wonder if the study were repeated here and now in North America, if the findings wouldn't stand in stark contrast, with sodium excretion here likely reflecting a highly processed lifestyle which in turn would correlate dramatically with cardiovascular disease? Of course if option #3's viable it would mean that sodium reduction will likely only benefit those who rely on a return to actual cooking to reduce their dietary sodium, and not to those who eat large volumes of sodium reduced processed foods.The great news is that science marches ever forward, and while it may take some time, eventually we'll have solid answers. Until then, and before I'd worry about absolute sodium intake, I'd recommend we all work on markedly reducing our consumption of processed and restaurant foods. No doubt in my mind, sodium be damned or not, if we could all just re-discover our kitchens, the world would rapidly become a much healthier place.Stolarz-Skrzypek K, Kuznetsova T, Thijs L, Tikhonoff V, Seidlerová J, Richart T, Jin Y, Olszanecka A, Malyutina S, Casiglia E, Filipovský J, Kawecka-Jaszcz K, Nikitin Y, Staessen JA, & European Project on Genes in Hypertension (EPOGH) Investigators (2011). Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA : the journal of the American Medical Association, 305 (17), 1777-85 PMID: 21540421

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Stolarz-Skrzypek K, Kuznetsova T, Thijs L, Tikhonoff V, Seidlerová J, Richart T, Jin Y, Olszanecka A, Malyutina S, Casiglia E.... (2011) Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA : the journal of the American Medical Association, 305(17), 1777-85. PMID: 21540421

June 20, 2011
05:30 AM
830 views

Obesity's contagious, or is it? A sober second look at obesity and social networks.

by Yoni Freedhoff in Weighty Matters

Right off the top let me say I'm not well versed enough in statistics to know who's right.On one side of the fence are the findings of Christakis and Fowler, famously published in the New England Journal of Medicine that posited obesity is socially contagious. Non-statistically, their paper didn't sit right with me, but as far as stats go, I'm no maven.On the other side of the fence is a new paper published by Russel Lyons who posits that Christakis' and Fowler's work is a great example of statistical illiteracy, and that the conclusion drawn from their data, that obesity is socially contagious, is severely flawed and can't be made.Lyons' paper, in a nutshell, gives statistical meat to my gut's firm belief - that shared environments and self-selection may well be explanatory for the clustering of obesity in social networks. That folks whose lifestyles may be more conducive to obesity, may well gravitate towards one another, and/or that people living in geographically/socially similar environments, environments that may contribute to the risk of obesity, together share increased risks and outcomes.Statistical arguments aside (frankly they're way over my head and I couldn't begin to venture a guess who's right and who's wrong), what was most fascinating to me was Lyons' discussion of his paper's publication. If Lyons' hypothesis is correct, his paper's a big deal. It refutes one of the most widely publicized studies of the decade, one that's translated itself into millions of dollars of grants, countless news stories, and even a book that's been published in 20 different languages. So what happened when he tried to publish it? The New England Journal of Medicine and the BMJ rejected it outright, without peer review. JAMA, the Lancet and the Proc. Nat. Acad. Sci. all rejected it next, this time because they have policies of not publishing critiques of articles they themselves didn't publish. Next Lyons submitted his paper to a statistics journal. The journal, Stat. Sci., did send it out for peer review. 2 of the 3 referees recommended publication without revision, and the 3rd, clearly not an obesity researcher, stated that while they agreed with Lyons' conclusions, that the subject was not important enough to warrant publication. Stat. Sci.'s editors agreed with reviewer number 3, and rejected the paper.Eventually Lyons' work was published in the journal Statistics, Politics, and Policy, whose impact factor's rates at 0.857. Contrast that with the impact factor of 50 that the New England Journal of Medicine enjoys.The entire experience has led Lyons to use his paper as a call to action to establish a journal whose subject matter is made up solely of study critiques. Were such a journal available, it would create a venue for publication of important criticisms, further protect the public from bad statistical analyses, and potentially serve as an incentive for researchers to double check their work.All in all, even if you're not a statistician, Lyons' paper is worth a sober read and reflection, and here's something else to chew on - the journalists who were originally all over Christakis' and Fowler's work? I'd bet every last penny I've got that not a single one of them were skilled enough in statistical analysis to analyze it. Really, why should they have been? They're journalists, not statisticians. No, instead they smelled a good story, and ran with it. Those same journalists who shouted from the rooftops that obesity's contagious? I'm betting the vast majority of them are going to be silent on this one, yet wouldn't re-reporting be the socially responsible, ethical, and journalistic right thing to do? Now I know that plenty of reporters read this blog. Would love to hear from you. Am I off base?Lyons, R. (2011). The Spread of Evidence-Poor Medicine via Flawed Social-Network Analysis Statistics, Politics, and Policy, 2 (1) DOI: 10.2202/2151-7509.1024

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Lyons, R. (2011) The Spread of Evidence-Poor Medicine via Flawed Social-Network Analysis. Statistics, Politics, and Policy, 2(1). DOI: 10.2202/2151-7509.1024

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