Verdant Nation

The Workplace ECO Committee

noreply@blogger.com (Anonymous) — Thu, 27 Feb 2014 01:22:00 +0000

I'm a member of the ECO Committee at my work. We try to come up with ways that we as employees and our employer alike can be more conscious of and therefore mitigate the negative impact we have on our environment. There's a few initiatives that we run, based on industry best-practices. These include:

encouraging recycling and composting by staff => using signage to promote proper garbage sorting (what's really garbage, recyclable, and compostable) and providing relevant bins;
sorting of garbage by maintenance staff;
running educational and awareness-raising campaigns using print and electronic media;
organizing agency-wide events such as Spring Clean-up Day, guest speakers, etc.;
working with management to improve certain policies (e.g., all computers are set up to always print double-sided, buy materials that are earth-friendly whenever possible).

Our organization even has solar panels and a complex computer system to manage electricity use - after a few years, we are running a surplus, which can be sold back to the grid. This system can even calculate the C02 emissions that are saved.

I am happy to say that my organization does quite a lot for the environment. This will eventually come full circle and positively impact human health. We on the committee are always grappling with ways in which we can improve as individuals and as an organization. I've recently been tossing three ideas around in my head.

The first is to encourage staff to bring in reusable containers and coffee mugs to use when buying lunch/hot drinks. This will reduce packaging, such as styrofoam that is recycled or thrown away. It necessitates staff remembering to bring these things in. I don't have great faith in memory unless we have adequate awareness-raising and incentive programs, at least at the outset.

The second is to create a green roof. We have lots of space on the roof and it is flat. I am guessing, however, that this will require quite an investment by the organization, in terms of buying materials and maintenance costs. I'm not entirely certain if it is structurally possible either.

The last is a bit more contentious. The organization is not located downtown and many staff live in suburban or rural areas, which makes taking the car the only feasible option. One idea to reduce driving is to encourage people to park further away from work, and walk, say 10-20 min the rest of the way. This would involve identifying areas where staff are allowed to park for the entire day, without penalty from the City or other organizations. This is an idea that has come up in the child active transportation literature. I'm just not sure that it will be feasible without changing at least the organizational culture towards driving, and recognizing that this does not have to be an all or nothing endeavor - one or two days a week would be something!

Recently at a committee meeting, it was brought up that we don't always tangibly know how certain interventions translate into say C02 emissions savings (other than our electrical system). We've been basing our initiatives on best-practices, but yes, this is important to know. Especially in terms of where we divert most of our efforts. I plan to research this; something that is certainly out of my domain of expertise. Please, business/environmental/sustainability people, show me the way to the relevant science literature!

If you don't already have one, think about organizing an ECO (or green or whatever) committee in your place of work. It's about reducing impact on the environment, but ultimately it's about improving human health. You already do it a home, why not help your workplace and fellow co-workers?

The science of scientific reporting - we suck at communicating our results to the public

noreply@blogger.com (Anonymous) — Tue, 17 Sep 2013 01:58:00 +0000

One of my favourite PhD comics is "The Science News Cycle." I think it adequately portrays one of science's fundamental flaws, communicating research findings to Joe Public. Or, in the case of the comic, grandma.

Knowledge exchange. Even the phrase is jargon. As researchers, we don't do it very well. We write up our research for the scientific community with the ultimate goal of publishing articles in scientific journals, and of course, eventually the Lancet or The New England Journal of Medicine. Although, most of us PhDs and post-docs are happy to have publications, period.

Each discipline has its own jargon. You need to speak and of course understand the jargon to get published. But what about cross-disciplinary endeavours? Can we understand each other? It's a resounding no. Take me for example. For topics related to but outside my domain of expertise, I often have difficulty reading and fully understanding what is being communicated to me (I had a PhD last time I checked). Statistical papers are my number one nemesis. I often come across papers with complex formulas derived from first principles, when all I am looking for is a more detailed "applied" understanding of the method. So, even within academia we speak foreign languages, it is no wonder Joe Public has a hard time.

You may be familiar with the quote: "Data is not the plural of anecdote," from Roger Brinner. Based on my training and experience, you cannot plan programs or develop policy based on an anecdote, or an n of 1. But all too often, journalists reduce research to anecdotes, a story of how Sally used shark-fin soup to cure cancer and now lives life to the fullest with her three-legged, rescued cat named Jesus. Journalists do this because it's catchy, simple to understand, and brings the story to the reader or listener at a personal level; plays on emotions and perhaps, past experiences. Vincent Lam, award winning author and emergency medicine doctor, recently spoke about the importance of a narrative to a room full of Queen's University medical students, emphasising that telling a story can make you a better doctor. Anecdotes break through the jargon. But all too often, messages get twisted or misunderstood anyway.

I don't claim to know how to do this. I don't know how to report research results responsibly AND make them interesting AND catchy AND easy to understand. It's something I struggle with as an epidemiologist and public health researcher, especially with a topic as complicated as obesity.

Obesity is not a behaviour like smoking. One of its main contributors is diet, but unlike smoking, we can't quit eating. It's complex. Take, for example, the work the Foresight Group has done to characterize obesity as a complex, adaptive system (CAS), complete with feedback loops.

A CAS is defined as being: "composed of many heterogeneous pieces interacting with each other in subtle or non-linear ways that strongly influence the overall behaviour of the system" (SCPHRP, 2011)

I think this CAS perspective is important, but its incredibly messy. How in the world can we talk tangibly about this to the public?

When considering obesity as a CAS, two basic principles also need to be underlined (SCPHRP, 2011):
1) Single interventions probably won't work on their own
2) Many small changes may lead to cumulative improvements

So, what does this mean? Reporting the results of single studies, then reducing them to anecdotes probably won't help in making things clearer. In fact, I think this is what we're doing when we do that:

Cartoon by Jim Borgman, first published by the Cincinnati Inquirer and King Features Syndicate 1997 Apr 27; Forum section: 1 and reprinted in the New York Times, 27 April 1997, E4.

Perhaps we need a new field - a degree that comprises an undergrad, masters, and PhD, which merges epidemiology, population health, and journalism/communication, and miraculously turns people into Dr. David Katz. Maybe we should stop making a big deal out of single studies? Open access journals are increasing and researchers are also paying traditional publishers to have their articles be made open access, so I doubt this is feasible. What are your thoughts? Should we only be reporting the results of well conducted systematic reviews and some how developing them into short narratives? How should we be reporting complex aetiological and intervention population health research that engages the public?

Government Office for Science (2007). Tackling Obesities: Future Choices – Project Report 2nd Edition FORESIGHT Programme

Tips for safely commuting by bike

noreply@blogger.com (Anonymous) — Sat, 06 Apr 2013 01:15:00 +0000

I am sharing a modified presentation that I did some time ago for my old Toastmasters club in Ottawa. I am passionate about active transportation and cycling in particular, and promote it as often as I can. This presentation is based on a blog post in Bicycling Magazine (hopefully it's okay that I used it and modified it a bit :S) set to one of my favourite songs by Queen (again, hopefully this isn't a copyright issue but I thought the song was too perfect to pass up, we'll see if I have to take it down at a later date).

Do the right thing Tim Hortons

noreply@blogger.com (Anonymous) — Sun, 03 Mar 2013 16:33:00 +0000

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It's that time of year again, yes it's "Roll up the Rim to Win" at Tim Hortons. For anyone who is unaware of this phenomenon, Tim Horton's is a Canadian coffee institution (I have no idea why, but I still buy it) and Roll up the Rim to Win is a marketing ploy to get us to buy more coffee. Every time we buy a coffee, we're essentially playing the lottery, to win anything from donuts to a BBQ or even a car. I believe that Americans are also subjected to this chaos, but I'm not sure how much Tim Hortons has infiltrated our southerly neighbours. In Canada, having a Tim Hortons is more important than having a hospital, police department, or grocery store.

Consumer marketing. It's everywhere. That's not my problem for once. The problem I have is that I and many others make a concerted effort to reduce garbage in landfills by bringing in our own travel mugs. This initiative totally dissuades anyone from doing any good. The other day, I brought in my mug, got it filled, but was given an empty cup anyway, to "roll up". I paused for a minute. Do I say, "nah, just keep the cup," thereby allowing the server to keep it for herself or give to the next guy for free and he/she happens to win the Rav4? I couldn't take that chance (I live in a capitalist society after all), so I took the cup, rolled up the rim, won a coffee, saved the rim and threw the rest of the cup out. That totally defeats the purpose of bringing in my own mug - now when I go for a coffee break at work, I don't bring my own mug. Tim Horton's you are undermining me!

The take-home message for Tim Hortons is that they should be environmentally responsible and devise a secondary way to roll up the rim for those who bring in their own mugs. A colleague at work suggested "spinning a wheel." I like that idea, or even providing a mini rim (the thing you keep anyway if you win) so that you don't end up throwing out the entire cup! Do it Tim Hortons, do the right thing.

On Obesity Panacea: Measuring change in child weight status in relation to local environmental factors

noreply@blogger.com (Anonymous) — Sat, 12 Jan 2013 18:30:00 +0000

Just recently a colleague and friend of mine, Travis Saunders, asked me to guest post on his blog: Obesity Panacea - a highly cited obesity blog, hosted by the Public Library of Science Blog Network. The post highlights a portion of my PhD work investigating how change in child weight status relates to local environmental factors. You can access the post here. The papers on which my post focus on can be found below.

Carter MA, Dubois L, Tremblay MS, & Taljaard M (2012). The Influence of Place on Weight Gain during Early Childhood: A Population-Based, Longitudinal Study. Journal of urban health : bulletin of the New York Academy of Medicine PMID: 22806452

Carter MA, Dubois L, Tremblay MS, Taljaard M, & Jones BL (2012). Trajectories of childhood weight gain: the relative importance of local environment versus individual social and early life factors. PloS one, 7 (10) PMID: 23077545

The precautionary principal in the garden of obesogens

noreply@blogger.com (Anonymous) — Wed, 21 Nov 2012 03:38:00 +0000

Creative Commons image

Today's post is a follow-up to the previous post on the pervasiveness of environmental contaminants and pollutants and the potential link to obesity, particularly in utero. As I left off, much research remains to be conducted to definitively link specific industrial chemicals (known endocrine disruptors), which are highly prevalent in our society, to obesity.

The precautionary principal is used to protect public health and has various interpretations. In general, it says that complete evidence of harm does not have to exist before steps can be taken to protect members of society from harm (Weir et al, 2010). In this post, I'd like to discuss a Canadian-specific framework for applying the precautionary principal in relation to suspected obesogens, public health, environmental health, and our overall North American lifestyle.

Historically, there has been a general failure in North America and Europe to determine potential negative public health and environmental effects from industrial chemicals before manufacture and widespread use (Wordsworth et al, 2007). This likely explains why every person or animal that has ever been tested has had detectable levels of endocrine-disruptors in their bodies.

"An analysis by the Environmental Protection Agency in 1998 found that, of the 3,000 chemicals that are used in the highest volumes in the United States (3), forty-three per cent had no testing data at all that would establish their basic toxicity. Only 7 per cent had a full set of safety tests (4). For chemicals used in lower volumes, even less information was available (5)." (Wordsworth et al, 2007).

The European Union is no better. And we Canadians don't have a lot to be proud of either:

More recently, in September 2006 the Canadian government concluded one of the most extensive reviews of substances ever undertaken. The government identified more than 4,000 suspect chemicals in Canada with the potential to be persistent, bioaccumulative and “inherently toxic” (8)." (Wordsworth et al, 2007).

Does this mean that the precautionary principal is not relevant? If the link between certain endocrine-disruptors and obesity is found to be causal, is it already too late? I think it's a no to both, but truly unfortunate to have to put ourselves in this situation in the first place. Applying the principal, particularly when it has to do with the environmental sector and public health, is far from straightforward, as you will see.

Weir et al (2010) propose a framework for applying the precautionary principal in Canada (10 Guiding Questions). There are two parts. The first assesses the degree of certainty to which the relationship between a risk (in this case certain chemicals) and harm (obesity and other potential health outcomes) can be considered causal. They use Sir Bradford Hill's 9 criteria for causation. Anybody with an epidemiology background should know what these are. I'm not going to list them here, simply because they're not really necessary for what I am going to talk about. What I am interested about is the second part, the remaining 9 questions, and Weir et al's discussion.

2. Is the harm associated with the suspected exposure serious?
3. Is the suspected exposure widespread?
4. Is there an observed increase in the incidence of the suspected harm that is temporally associated with increased exposure?
5. Is the harm associated with the suspected exposure difficult to treat or reverse?
6. What are the economic and non-economic costs and benefits of action and non-action?
7. Are the proposed control measures proportional to the level of risk? Are the economic costs of removing the exposure minimal? Are the health and societal costs of removing the exposure minimal?
8. Are comparable situations being treated similarly according to a standard of practice?
9. Is the level of the protective measures consistent with equivalent areas in
which scientific data are available?
10. If precautionary measures are adopted, is there any new evidence to reduce the level of uncertainty about harm and benefit?

Going by these questions, yes obesity is serious and yes exposure is widespread. I would say that at this point, #4 can only be answered in animal studies. Obesity has been difficult to treat and reverse and it has multiple determinants. Number 6 and 7 are where it starts to get tricky. Because obesity has multiple determinants (i.e. is complex) and because of lack of evidence, it's hard to say whether decreased use of these chemicals would result in less obesity and related diseases and therefore lower healthcare costs and other indirect costs like absenteeism/presenteeism.

Weir et al contend that the appropriateness of applying the precautionary principal increases "when the economic and social costs of removing the exposure are small relative to the suspected harm." These chemicals no doubt make life easier for us - are we willing to give up a certain level of convenience to live without them, at least until adequate replacement substances are found (I have faith in technology to remedy this gap rather quickly)? Are we willing to knowingly gamble with our economy? I could answer for myself, but I'm sure that many others would disagree, some with valid points.

At the same time, Weir et al add that appropriateness of applying the principal increases "when the health costs of removing the exposure are minimal; and when, in addition to the uncertain harms, there are known health, economic or social harms caused by the exposure." I can't see health costs associated with removing obesogens; worse case, procedures with medical equipment made with obesogens are no longer possible until replacement substances are found. Obesogens also have known negative impacts on the environment and suspected health impacts that go beyond obesity. I am unaware of comparable situations that could be used to address #8 (that doesn't mean there aren't any), and we're not even close to answering #9 and #10 yet.

This is only the tip of the iceberg. Based on this quick run-through, I hope you grasp the complexity of this problem. What do you think? Is it too late to apply the precautionary principal? Is applying the principal even relevant for obesity, or worth the potential negative social and economic effects? Is not applying it worth further environmental damage?

Weir E, Schabas R, Wilson K, & Mackie C (2010). A Canadian framework for applying the precautionary principle to public health issues. Canadian journal of public health. Revue canadienne de sante publique, 101 (5), 396-8 PMID: 21214055

Pervasiveness of environmental contaminants: what does this mean for obesity?

noreply@blogger.com (Anonymous) — Sat, 20 Oct 2012 02:09:00 +0000

Everybody knows that obesity results from energy in being greater than energy out, right? Okay, we know that it's a lot more complex than that, but what if obesity could arise separate from this? We're pretty wedded to the idea that diet and physical activity are major risk factors, so it may be a little disconcerting to learn that a new body of research suggests that being exposed to "obesogens," chemicals in the environment (usually man-made), may program us to be fat. In this first post, I will provide a very basic overview of obesogens, leaning heavily on two reports. In the second post of this two-part series, I will discuss what this means in terms of the precautionary principal versus level of evidence.

CBC (the Canadian Broadcasting Company) aired a documentary earlier this year that discussed the puzzling results of scientists researching endocrine-disrupting chemicals. Their original projects were not about fat, but their lab animals turned out to be unusually heavy after being exposed to these chemicals. The documentary can be accessed here. You can have a sneak-peek by viewing the trailer below.

We know that fat tissue acts like an endocrine organ. Since endocrine-disrupting chemicals include a wide variety of substances it is difficult to generalize mechanisms of actions. The Endocrine Society gives the following broad definition (Diamanti-Kandarakis et al, 2009):

"An endocrine-disrupting substance is a compound, either natural or synthetic, which through environmental or inappropriate developmental exposures alters the hormonal and homeostatic systems that enable the organism to communicate with and respond to its environment."

In general though, it is thought that obesogens mimic hormones, which can increase the size of fat cells, increase the number of fat cells or negatively affect appetite, metabolism, and/or food preferences (Holtcamp, 2012). Much of the evidence to date has been from animal studies, but there are many epidemiological studies linking exposures of 15-20 chemicals during fetal and infant development to infant and child weight status (Holtcamp, 2012). Take for instance, smoking during pregnancy - there is fairly persuasive epidemiological evidence linking this to obesity in children (Oken et al, 2008). There is also some evidence for an effect of endocrine-disrupting chemicals on adult weight status; however this is a burgeoning area of research that is need of more studies (Tang-Péronard et al, 2011).

Obesogens (those in addition to the byproducts of smoking) are found everywhere - in industrial solvents/s and their byproducts (PCBs), plastics (BPA), plasticizers (phthalates) in PVC, organotins, pesticides (atrazine, DDE), surfactants used to reduce friction (PFOA), and pharmaceutical agents (DES) (Diamanti-Kandarakis et al, 2009)(Holtcamp, 2012). We are exposed to these chemicals by drinking contaminated water, eating contaminated food, breathing contaminated air, or coming into contact with contaminated soil. In industrial areas, chemicals can leach into the soil and contaminate the ground water, and may bio accumulate in both humans and animals. The web of contamination is so complex that areas considered "prestine"and remote from the original site that produced the chemical, have been found with levels of the chemical (Diamanti-Kandarakis et al, 2009). Many of these obesogens are also found in items we may or may not use every day. Examples include: medical devices, some canned foods, cash register receipts, designer handbags, items made of Gore-tex(TM), wallpaper, vinyl blinds, tile, and vacuum cleaner dust, air fresheners, laundry products, personal care products, items with Scotchgard(TM) (e.g. carpets, furniture, and mattresses), non-stick cook-ware, and microwaveable food items. There are also potential dietary obesogens including phytoestrogens (soy) (Diamanti-Kandarakis et al, 2009) and MSG (monosodium glutamate) (Holtcamp, 2012).

Many endocrine-disruptors demonstrate an inverted U-shaped dose-response association. This means that with medium "doses" of the chemical, obesity risk increases. But at low and high doses, the risk decreases. This likely depends on the chemical and other factors as some endocrine-disruptors have been found to increase risk at very low or very high levels. Estimating the level of exposure that leads to a negative outcome is complex in a living, human population. It depends on sex, age at exposure, length of exposure, the mix of chemicals one is exposed to, and innate lag between exposure and effect (Diamanti-Kandarakis et al, 2009), to name a few.

The link between these chemicals and obesity can only be considered exploratory and hypothesis-generating at this point. Nonetheless, endocrine-disruptors can be detected in all animals and humans (Diamanti-Kandarakis et al, 2009). Some researchers link this to the fact that even individuals on the low end of the BMI distribution are increasing in weight (hinting that obesogens may be the cause of everyone increasing weight on a population scale). I'm not so sure that this link can be made given the drastic change in our food system and our increasingly sedentary lifestyle. I'll delve more into what this may mean in the next post.

Holtcamp, W. (2012). Obesogens: An Environmental Link to Obesity Environmental Health Perspectives, 120 (2) DOI: 10.1289/ehp.120-a62

Is cooking the silver bullet to the obesity epidemic?

noreply@blogger.com (Anonymous) — Wed, 06 Jun 2012 14:24:00 +0000

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Many writers (e.g. Mark Bittman), journalists, researchers, scientists, and celebrity chefs (e.g Jamie Oliver), believe that if people cooked more, obesity wouldn't be such a big issue. While I agree with this observation generally and feel that it could probably be good for the environment too, I don't think it is something that on its own could ever be effective in our capitalist society.

First, how can cooking our own meals help the obesity epidemic? Meals and snacks eaten outside of the home generally have more calories than those made in the home. Simplistically, if you consume more calories than you expend on a regular basis, you're going to gain weight. There is also some evidence that eating more frequently outside of the home is related to an increased body weight. Preparing your own meals also cuts down on packaging, particularly if you eat a lot of fast food, which is better for the environment. And preparing your own meals means just that - as Yoni Freedhoff recently commented, nuking something doesn't count.

Cooking is a skill. It requires time. I've frequently heard that cooking skills have been on the decline (although I can't give a you specific source for that). I'd guess, because they're not necessary anymore (abundance of prepared, tasty food), and perhaps due in part (please feminists don't hate me) to the emergence of the two-working-parent family; the housewife social norm is disappearing. People, therefore, need to be taught how to cook; and to cook food that tastes at least as good as what could be bought pre-made. Where and how would this happen? Sure,we can get at kids in schools, but what about their parents? Adults are a less captive audience. Second, people don't feel like they have time. They're stressed. Everyone is. But, this is particularly tough for people on lower incomes, trying to make ends meet. They know the value of healthy eating but lack time and resources. Thus, sometimes being able to get prepared foods for relatively cheap is valued much more highly than cooking skills and being able to cook one's own meals. Some people can't even afford places to live that have enough room for cooking equipment anyway. Given the current state of global economic affairs, I imagine, that these scenarios will only become more frequent.

If we want to people to cook more, it's not simply a matter of setting up social marketing campaigns and saying "hey you guys, you should cook more." There needs to be education programs in schools, the workplace, and the community, as well as changes in policies to support those trying to get by (minimum living supplement, housing and energy subsidies, etc.), workplace policies that are family friendly, egalitarian, and aim to reduce stress, etc. To his credit, I believe Bittman does allude to these nuances in his new book. So these are the first prerequisites (or 'upstream' factors) for being able to cook more in our society.

Second, social norms need to change. Bittman and others have also suggested this - that valuing cooking and eating needs to become the societal norm. In North America, I'd say we value eating. We can get incredibly good tasting food pretty much anywhere, but we eat it 'on the run'. What we don't value anymore is appreciating the food, and the social aspects of eating - that social interaction when cooking and eating with family/friends. Changing this norm runs hand in hand with the incredible convenience of our society; being exposed to such an abundance of food that's ready made for us. I find it mind boggling the amount of 'stuff', not even just food, that is available for consumption. Take Walmart for example. Everything is convenient and available to us at very little cost. I'm not even sure that we knowingly value the convenience of having someone else prepare our meals - it's just something that we take for granted - it just is. Cooking is an effort and if we don't feel like doing it, we know we can get prepared food easily elsewhere. I didn't feel like cooking the other day, so opted to get sushi take-out instead. That took all of 5 min. And I do it more than I care to admit...

I doubt that in a capitalist society like ours, decreasing the number of products out there for consumption is a viable option. I don't think that taking away convenience would work either (aside from some sort of environmental or man-made catastrophe). So, if both stay, there is really no incentive to cook. Sure, some efforts may have some sort of impact. But the reality is that we have pre-made food all around us, all the time. Plus, we'd need to have the prerequisites in place that I talked about above. This may be difficult given that many in society do not value collectivism, and oppose government intervention (read: the 'nanny' state). What could work in the mean time?

I don't mean to say here that people should not cook - because I'm not saying that. We need to cook more, absolutely, but I'm skeptical about it having an impact on the obesity epidemic. Prepared food needs to change (e.g. fast food meals, pre-made meals in grocery stores). It needs to become healthier, with smaller portion sizes. Meals need to have more veggies and legumes; there needs to be more options with less meat. Prepared food needs to have taste that rivals its unhealthy competitors (with less salt); and it needs to preserve the convenience factor to be competitive. Packaging should also be biodegradable and we should use less of it. We should also strive to produce food locally, mostly to support local farmers, but also for other reasons that might be debated (read: environmental). Marketing of these healthier foods needs to be creative to maximize dollars spent, as for example, McDonald's marketing budget exceeds many countries' GDP.

I'm drawn to Portland, Oregon as an example of what could happen elsewhere in North America, to rival the dominant fast food chains and pre-made meals sold in grocery stores. Portland is considered a world-class city for street food. City policies allow local vendors to set up shop on semi permanent pods in private parking lots. Food is cheap, and there are over 700 food carts; therefore, lots of variety to chose from. Street food vendors are popular with the workers at lunchtime, tourists, and the after bar crowd. Food carts also promote sustainability and walkability, but in many cities, zoning and public health policies limit their proliferation. Vancouver is moving slowly to allow more street vendors to operate within its borders. In Ottawa, it's non-existent, save for examples like the Stone Soup Foodworks Truck, a mobile food vendor selling soups, sandwiches, salads, and tacos made from local, organic producers. Throughout most of the school year this truck can be found on the campus of the University of Ottawa, but it also frequents events throughout the city. There has been an attempt by the broader community in Ottawa to try and start a street food movement - but it doesn't look to have gained enough steam at this point to provide much sway to city officials.

Street food in Portland, Oregon (CC image)

Best case scenario is that wide sweeping social reform would make us less worried about income, and transform our time-use, allowing for more time to cook real food. We'd be able to acquire cooking skills throughout the life course, and social norms would change; knowledge of and respect for where our food comes from, cooking and eating, and the social interaction when cooking and eating would become highly valued in our society (particularly North American society). Because I envision that this will be difficult, I think that in the mean time, the content of prepared food needs to fundamentally change and that street vendors could be a more sustainable way to combat traditional fast food.

What are your thoughts? Agree? Disagree? Would love to hear them.

Lachat, C., Nago, E., Verstraeten, R., Roberfroid, D., Van Camp, J., & Kolsteren, P. (2012). Eating out of home and its association with dietary intake: a systematic review of the evidence Obesity Reviews, 13 (4), 329-346 DOI: 10.1111/j.1467-789X.2011.00953.x

Bezerra, I., Curioni, C., & Sichieri, R. (2012). Association between eating out of home and body weight Nutrition Reviews, 70 (2), 65-79 DOI: 10.1111/j.1753-4887.2011.00459.x

Troy LM, Miller EA, & Olson S (2011). Hunger and Obesity: Understanding a Food Insecurity Paradigm: Workshop Summary Institute of Medicine

Does a randomized social experiment shed light on the link between neighborhoods and obesity?

noreply@blogger.com (Anonymous) — Mon, 30 Apr 2012 19:48:00 +0000

cc image: ZoL87 on Flickr

Determining the potential for residential characteristics to influence the development of obesity is a difficult endeavor. There are a multitude of reasons for this, but one I want to focus on is the research design of the study. Most research in this area has been cross-sectional (looking at one point in time only). The problem with these studies is that we have no idea what came first, the neighborhood characteristic or obesity. There is also the issue of self-selection. Certain people may prefer to live in certain types of neighborhoods for a variety of reasons that may be related to weight; thus it’s not the neighbourhood characteristic(s) per se that explains the association with weight status, it’s something else that we haven’t measured. Longitudinal studies are better but tend to be based on cohort studies where the main intent was not to examine neighbourhood level effects. This means that the researcher has to use whatever information has been collected, and usually this gives an incomplete picture. Plus, there’s the attrition issue. People get fed up after a while, and some drop out of the study. This decreases power to detect significant differences and can introduce bias if dropout is in some way related to the outcome.

So, imagine my surprise when I learned about a randomized social experiment with obesity as the outcome. Randomization balances the exposure [neighbourhood characteristic(s)] on known and unknown confounders, and rectifies the issue of temporality. Randomized controlled trials are the gold-standard in clinical epidemiology, but for ethical and economic reasons, are usually not feasible in social epidemiology (randomizing people to smoke, for instance, would never fly).

The study, published by Jens Ludwig and crew in the New England Journal of Medicine, was based on the Moving to Opportunity for Fair Housing Program, conducted by the US Department of Housing and Urban Development (HUD). The basic premise of this experiment was to determine how best to provide housing for those in need. Briefly, 4498 families with children living in public/project housing in high poverty neighbourhoods in Baltimore, Boston, Chicago, Los Angeles, or New York, were randomly allocated to one of three groups in the years 1994-1998 (one quarter of those eligible):

1. The MTO low poverty voucher group which received rental vouchers usable only in low-poverty areas (where < 10% of residents were poor), along with counseling and assistance in the search to find a private rental unit (n = 1788)

2. The traditional voucher group, which received rental vouchers where there were no restrictions on where the family could relocate, as well as support ordinarily given to families by local public housing authorities (n =1312)

3. The control group, which received no vouchers but remained eligible for public/project housing and other social programs, otherwise the status quo (n=1398)

For the most part, families were headed by African-American or Hispanic single mothers. From 2008-2010, health outcomes of female adults (usually the family head) were measured and included height, weight, and level of glycated hemoglobin.

Now, not all families moved or used the vouchers. The study used an intent-to-treat analysis which analyzes individuals based on groups to which they were assigned. This is the least biased and most conservative way to analyze a study like this. So even though a family may have been assigned to the MTO group but did not move to a low poverty neighbourhood, they would still be analyzed as part of the MTO group.

In the MTO group, 48% used the vouchers, in contrast to 63% in the traditional group. All groups were comparable at baseline in terms of 57 characteristics including age, race/ethnicity, marital status, employment, education, and federal assistance, for example. One year after randomization, the neighbourhood poverty rate was significantly lower in the MTO group, but this difference attenuated (still remained significant) at 5 and 10 y, as families in the control group moved to lower poverty areas on their own. Additionally, the proportion of women that said they felt safe/very safe in their neighbourhood, and the proportion that said neighbourhood adults would intervene in youth anti-social activity (defined as collective efficacy) were significantly higher in the MTO compared to the control group at 4-7 y and 10-15 y post-randomization. These same significant differences were seen for the traditional versus the control group, although there was no difference in collective efficacy at 10-15 y.

At 10-15 y of follow-up, after adjustment for baseline characteristics and allocation procedures, the prevalence in each category of extreme obesity was significantly lower in the MTO group (BMI ≥ 35 = 31.1%, and BMI ≥ 40 = 14.4%) compared to the control group (BMI ≥ 35 = 35.5%, and BMI ≥ 40 = 17.7%). There was no difference in obesity defined as BMI ≥ 30. The prevalence of elevated glycated hemoglobin was also lower in the MTO versus the control group (16.3% versus 20%). Differences were in the same direction but not significant between the traditional versus the control group.

This study was interesting to me mainly because of its design. Yes, significant differences were found, and interestingly, even with such low compliance. But there are some important things to keep in mind when interpreting the results of this study:

=> Significant differences were for severe obesity, not for overweight or obesity in general.

=> No baseline data was available for BMI or glycated hemoglobin so changes could not be assessed (the authors state that this should not affect internal validity, which I tend to agree with, especially if they found no significant differences in 57 baseline characteristics).

=> Allocation of participants and data collection procedures were extremely complicated; in many cases information was not collected from participants (even though they were eligible and appeared not to have refused), or they were randomly excluded. Perhaps because of word limits, reasons for treatment of participants during these processes were not clear to me.

=> Only one quarter of those eligible actually applied to be randomized.

=> I am wondering if exposure to environments after the initial move (e.g. subsequent moves) may have confounded associations. But I can’t really work out why this would be different across groups, given randomization, unless attrition was higher in one group versus another. Attrition is an issue in longitudinal study designs in general, but doesn’t appear to be an issue in this study (although, in light of what I said in the previous paragraph, I have trouble following calculation of response rates). I think the issue of multiple moves, and duration of time spent in each neighbourhood, warranted more of a discussion in the actual paper (some descriptive measures of neighbourhood characteristics were weighted by time spent in each neighbourhood, but I don’t think the main analysis accounted for this).

=> Is it the change in environment characteristics (and which ones are important), or just the move itself that is responsible for significant differences? Even though there were no significant differences between the MTO (had to move to a low poverty area) and the traditional group (who had no restrictions of where to move) in terms of the health outcomes, the authors say that differences approached significance for glycated hemoglobin, which they say, suggests that a change in the environment is important. I’m not sure if the results they are referring to can really support this assertion. It’s also evident that the traditional group moved to more affluent areas anyway so a comparison of the two groups in this regard may be moot.

=> This is a high-poverty, minority sample that examined adult women only. Although it may have higher relative internal validity for a social study, it lacks external validity or “generalizability” to other population subgroups.

- To expand a little on the high-poverty issue, I hypothesize that lower income individuals are more tied to their residential neighbourhoods (less mobile) than more affluent people (due largely to lack of access to a car). Thus, they accrue more exposure time than more affluent people. In this vein, I think residential environments are less important for more affluent individuals compared to those who are worse off. I also think that context in the US is likely not generalizable to the Canadian context (e.g. ghettoization based on racial segregation and poverty).

=> There is evidence that MTO families moved to areas lower in poverty but similar in racial distribution. These new areas still had more poverty than the country average.

=> Neighbourhoods themselves are not static entities, but were treated as such in this study. Some research has indicated that when change is considered, disadvantage is the same in the MTO versus the control group

=> Even though neighbourhood cohesion and safety were not outcomes, they are potential reasons for why significant differences were seen. However, the measures employed in the study were based on single items, which I find hard to accept that they accurately captured what they were supposed to measure.

=> Finally, this study was based on individuals as the unit of allocation and analysis, not neighborhoods. Thus, this was not a study of a neighbourhood-level intervention. Population interventions such as those for neighbourhoods are generally more cost-effective than those targeted to individuals. A discussion of the two in regards to the MTO study is provided by Sampson (2008).

All in all, the MTO is, and I’ll quote Sampson, “a major contribution to the long tradition of experimental social science.” There are certainly methodological issues with it, but I think that the NEJM study provides fairly strong evidence that small decreases in neighbourhood poverty can decrease prevalence of diabetes and extreme obesity in a highly disadvantaged population.

Ludwig J, Sanbonmatsu L, Gennetian L, Adam E, Duncan GJ, Katz LF, Kessler RC, Kling JR, Lindau ST, Whitaker RC, & McDade TW (2011). Neighborhoods, obesity, and diabetes--a randomized social experiment. The New England journal of medicine, 365 (16), 1509-19 PMID: 22010917

Would you pay for child slave labour-free chocolate bars?

noreply@blogger.com (Anonymous) — Wed, 15 Feb 2012 04:10:00 +0000

CC Image: cocoa beans

Today is Valentine’s Day, the day of chocolate treats. But have you ever considered where your chocolate comes from? Like, at the beginning of the supply chain, with cocoa beans? Neither had I, until a few days ago. Now, my appetite for chocolate has substantially diminished, especially knowing that most of the chocolate I have eaten to date has likely not been child slave labour-free.

The chocolate industry is a multi-billion dollar global industry including key players such as Nestle and Hershey. The world loves chocolate. Our waistlines may be a testament to that.

About 60% of the world’s cocoa beans are grown in the poor West African countries of the Ivory Coast and Ghana. We depend on these countries for our chocolate, but these governments depend on cocoa for the revenue they provide in taxes. The locals depend on cocoa, simply to put food on the table.

Such inequity has led to one of the worst forms of child labour. Children are trafficked in these two countries, working long hours harvesting cocoa beans, often with dangerous equipment like machetes, with little food, no school, and no pay. Money goes to their traffickers, who are often family members who desperately need the money.

This grave problem is highlighted in an eye-opening documentary that was recently aired on the CBC (available only for another month). A BBC journalist bravely goes undercover in these poor countries to determine for himself the extent of child slave labour, as well as what the world’s cocoa companies are doing to remedy both child trafficking, and inequities leading to trafficking (it turns out unsurprisingly, not nearly enough).

The journalist also poses as a cocoa bean buyer and makes some chocolate of his own: a chocolate bar made with 100% child labour, clearly marked and all. Would you buy it after seeing this? Probably not; all of those interviewed were appalled. But would you pay more for child slave labour-free chocolate?

This demonstrates clearly that things we do on one side of the world can have far reaching effects. Our demand for chocolate in the West fuels child labour. Not knowing is one reason for inaction, but now we know; meaning that now there are no excuses for not demanding and paying more for child slave labour-free chocolate. The next step will be a labeling issue, like Fair trade coffee, allowing us to recognize the more socially responsible companies.

Global health should be everybody’s problem.

We shouldn't be giving cooking the finger

noreply@blogger.com (Anonymous) — Thu, 26 Jan 2012 21:10:00 +0000

Happy New Year and all that jazz. The last few months have been a bit hectic for a variety of reasons, some of which I'd like to forget :) I am going to try to post on a more or less two-post per month schedule, but am also trying to finish this damn PhD, and now am teaching! We'll see how it goes...

Today's post is more of a pet-peeve of mine.

There is some evidence to show that eating out of home is related to consuming more energy and more energy from fat; results that appear to be more consistent among adults than children. Presumably, 'out of home' means eating prepared meals at fast food or sit-down restaurants. The authors of this review, however, indicate that the definition of 'out of home' was context-dependent. That's important to keep in mind, but for the sake of my argument, let's just say that eating out more often, compared to cooking your own meals, is related to consuming more calories and can plausibly be related to obesity. Also, I would imagine that if we cooked for ourselves or family-members more often, we'd be eating substantially less salt and waste less food and packaging.

Now, I am an advocate of eating more home-cooked meals, as are many of my colleagues; however, the problem is much more nuanced than simply blaming people and telling them they need to cook more. One such nuance is marketing...I absolutely hate this marketing campaign by Boston Pizza: Finger cooking and giving cooking the finger...It's admittedly funny and catchy, but makes me angry and sad all at the same time, and also suggests that males might be incompetent (as pointed out by a male friend of mine).

I enjoy watching Jim Treliving on CBC's Dragon's Den. He's certainly nicer than Kevin O'Leary. From their dealings I get that it's all about making money. The more successful a marketing campaign, the better it is for the company. But this particular campaign crosses the line for me Jim. I don't even watch TV that often and I see it all the time. I've never seen a restaurant or fast food company actively target a social norm in this way. We need to make cooking at home easier, cheaper, more convenient, and stop marketing campaigns like this. Otherwise, cooking, along with the skills that go with it, will go the way of the woolly mammoth.

Be back soon - short hiatus

noreply@blogger.com (Anonymous) — Fri, 18 Nov 2011 20:10:00 +0000

Sorry for being MIA. I am taking a short break from blogging due to school. I hope to be back in the new year (or hopefully sooner).

~Megan

Graduate school roundtable

noreply@blogger.com (Anonymous) — Mon, 31 Oct 2011 14:27:00 +0000

I am a part of a blog roundtable on graduate school, chaired by my colleague Atif Kukaswadia on his blog: Mr Epidemiology. The first post introduced the panel. Today's post asks us why we decided on grad school. A series of questions will be answered by us throughout the month of November. If interested, you can subscribe to Atif's feed. The dates that particular questions with their answers will be posted are outlined at the bottom of the first post. This will be particularly useful for those of you undecided about whether to go to grad school or not, and those that have decided but are nervous/unsure of what to expect. Others may also find it entertaining. Enjoy!

Am I single-handedly perpetuating the negative effects of food insecurity?

noreply@blogger.com (Anonymous) — Thu, 13 Oct 2011 21:11:00 +0000

CC Image: Franco Folini

Now I am not generally one to give money to a pan-handler. If I do give something, it’s generally a snack (usually healthy) if I have one on me. This has been met with different responses: scorn, indifference or thankfulness. I have offered a few times to go and buy something to eat or drink but have never been take up on the offer, until today. I regret though, that I may have contributed to, not helped the problem of food insecurity.

Today, I had walked to an appointment along Dalhousie Street in Ottawa (for those of you who know where that is) and was on my way back to work, when I stopped to grab something from my purse and rearrange my things. I was soon confronted by a shabbily dressed young man. Since I was stopped, kneeling over my bag, I was his captive audience. He proceeded to tell me all of his problems, from being kicked out of the shelter down the street because of a fist fight, to not having enough to eat. He also assured me that spending money on drugs was not an issue because he doesn’t use them. I was waiting for him to ask me if I could give him money, but that didn’t seem to surface from the avalanche of words spewing from his mouth. I interjected, “can I buy you something to eat?” He replied with “oh yes, yes, please, I’m so hungry.”

At this point I should maybe provide a little background on food insecurity. The prevailing definition of food security is “a situation that exists when all people, at all times, have physical, social, and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life.” Food security and insecurity are on opposite ends of a continuum. Food insecurity has different stages of severity starting with not being able to buy and eat what one would like. This gets at issues of quality including variety, safety, nutrient content, and the caveat that foods must last and not go to waste. The next stage involves a decrease in quantity which might or might not be accompanied by hunger. Finally, the most severe stage is the complete absence of food intake (going completely without).

Food security is a basic human right, but from the 2007-2008 Canadian Community Health Survey, 7.7% (961,000) of Canadian households were food insecure. And keep in mind this is for people with a fixed address, unlike homeless people and those in shelters, so the number is likely higher. I imagine this figure will only climb as our (Canadian) income gap rises and worldwide economic problems deepen; unless of course, our social policies change, but that’s a discussion for another day.

Remember that a key part of food security covers quality – we should have access to healthy, nutritious food. Being food insecure is related to decreased quality of foods consumed and nutrient inadequacies, which makes intuitive sense.

I regret that although I was providing food in principle, it was not of the nutritious variety. We went to the nearest restaurant, Garlic Corner, and I said to the guy “get what you like, I’ll pay for it.” He hummed and hawed, something about wanting breakfast down the street because “these guys don’t serve it past noon, and they are really, really slow.” Then it was he didn’t eat meat but didn’t want any of the vegetarian options. Either the choices at Garlic Corner were not healthy enough (which is partially true) or he wanted money instead, of which I am guessing the latter. Anyway, I told him that I had no cash, so he settled on a Nanaimo cake thing and a red bull. All crap. I mulled all of this over on the remaining walk back to the office. What have I done here? Propagated the problem? Should have I stipulated what he order, ordered it for him, went to a better restaurant, what?

What do you think? I tried to help out a fellow human in need, but did I really? Even if I had stipulated what he had ordered, it would have been denigrating. The other alternative would have been to ignore him, pack-up my things and continue on as if I had not seen or heard him. While I have ignored street people in the past, I am growing increasingly uncomfortable with it, trying now to at least acknowledge them as people when I walk by – a smile, node, or hello. I don’t mind providing snacks here and there but I’d almost rather do nothing if it means that the another red bull or Nanaimo cake gets sold and consumed. At the same time, it's food, pretty good tasting food at that. I would imagine that it's pretty hard to be concerned about nutrition when there are so many other problems to deal with. That is the problem.

Pilgrim A, Barker M, Jackson A, Ntani G, Crozier S, Inskip H, Godfrey K, Cooper C, Robinson S, & SWS Study Group (2011). Does living in a food insecure household impact on the diets and body composition of young children? Findings from the Southampton Women's Survey Journal of Epidemiology and Community Health, June 7 : 10.1136/jech.2010.125476

Kirkpatrick SI, & Tarasuk V (2008). Food insecurity is associated with nutrient inadequacies among Canadian adults and adolescents. The Journal of nutrition, 138 (3), 604-12 PMID: 18287374

Evaluating urban planning initiatives to increase active transportation

noreply@blogger.com (Anonymous) — Fri, 30 Sep 2011 17:22:00 +0000

Ottawa Sun: Laurier St. bike lane in Ottawa (ON), Canada

Urban planning and epidemiology need to become better friends. Rigorous epidemiological studies that assess the health impacts of urban planning interventions are desperately needed. These studies can more reliably tell us what works and what doesn’t, and therefore where best to put our hard-earned tax dollars. I’m not sure why they are lacking. Money? Time? I guess they are all good excuses. But in the grand scheme of things, I would settle for even just a simple before-after study – something that I think is more than feasible.

Ottawa recently implemented a segregated bike lane pilot project on Laurier Street, running from Bronson to Elgin Streets. The lanes are blocked off from traffic with concrete curbs, plastic poles, parked cars and planter boxes. New road markings (including those gross green boxes) and signs tell cyclists where they should be. Most on-street parking has been removed and some bylaws have even changed, such as no right turns on a red light, which protect cyclists from absent-minded motorists. The project is part of the City of Ottawa’s plan to become a greener and more sustainable city.

All of this is great news for cyclists (and environmentalists), even though it has received some grumblings from residents and merchants on Laurier Street who have lost parking spots as a result. Since the lanes were open on July 10, 2011, almost 117,000 people have used them (that is, passed a counter at Laurier and Metcalf). Wow, that sounds like a lot of people…but wait a sec…How many cyclists used Laurier before? Maybe the same number of people used Laurier last year from July 10^th to September 28^th, 2010. So this number really tells us nothing. We have no idea what the ‘success’ of the pilot project is defined as either. Is it a certain percentage increase in the number of users, fewer accidents, more commerce, increase in physical activity, etc.? The main points I am trying to make here are that the city could have at least placed a counter in the same location BEFORE they implemented the project, as well as determined significant outcomes a priori and communicated those to the public. I don’t think it would have been that much more costly.

I’d like to highlight that this would be something that is needed in the very least. These types of designs that use counters to count the number of users before and after are not robust against bias and cannot capture all that we would really like to examine. Here are a few examples why:

We can only count users and not individuals so likely we are double, triple counting, etc. Perhaps increase in usage is only by those people that already cycle on the road
If counters are electronic, I'm not sure if they can discriminate between cyclists and people that shouldn't be using the lane (such as skateboarders, motorized scooters, etc.)
We cannot determine impact on the health outcomes of individuals living nearby, such as increased physical activity or decreased obesity
Increase/decrease of cycling on Laurier could actually be due to other factors that we have not accounted for or reflect only secular trends (not due to the new lane)

I have had a very hard time finding an urban planning intervention with the intent of increasing active transportation/physical activity, or decreasing obesity, that has been well conducted. There is also the added caveat of residents actually knowing about the change to their environment. For example, if they don’t know about a new bike lane, trail system, or park how can they use them?

A study by Evenson et al (2005) perhaps is a basic model to follow– with, of course, some upgrades (e.g. addition of a control group). They set out to determine if a new rail trail built in Durham North Carolina (US) significantly increased time spent in leisure activity, moderate and vigorous physical activity, and active transportation of residents living nearby.

Participants 18 years or older living within 2 miles of the trail were randomly recruited to participate in two telephone surveys conducted before and after introduction of the trail (n = 366). Questions were largely based on the Centers for Disease Control and Prevention’s Behavioural Risk Factor Surveillance System. The researchers did not find that the new trail had any effect on the outcomes they looked at. There were some issues with the study which may explain why they did not find anything. Some examples include:

The after measurement occurred just 2 months after the trail opened – this may not have been a sufficient amount of time (e.g. residents may still not have known about it). In fact, 38% of respondents said they weren’t aware of the trail [Correction - this should be 11.3%, 38 was the n]

The after measurements occurred in November, whereas the before measurements occurred in summer and early fall. In Canada at least, we tend to be outside less as the winter approaches versus in the summer
Low response and retention rates. The people who responded were likely not representative of the population (they already had high baseline rates of activity). What were the people who didn’t respond like?

There are some other issues that I won’t get into but I think it’s a basic study that could easily be implemented by urban planners, with the help of public health professionals or universities with epidemiology or program evaluation departments (to increase the study’s robustness which is very important)! Who knows, maybe the City of Ottawa has done all of this and we just don't know about it - I'll give them the benefit of the doubt. Regardless, I truly think this is a worthwhile and necessary transdisciplinary endeavour that will benefit society as a whole. And don't get me wrong, I am for increasing biking infrastructure. I just want to make sure we can quantify its benefits and that we do it in the best possible way.

Evenson, K., Herring, A., & Huston, S. (2005). Evaluating change in physical activity with the building of a multi-use trail American Journal of Preventive Medicine, 28 (2), 177-185 DOI: 10.1016/j.amepre.2004.10.020

Behavioral economics - a way to fight Big Food?

noreply@blogger.com (Anonymous) — Thu, 22 Sep 2011 03:13:00 +0000

Eating that double-fudge brownie or entire bag of chips ultimately comes down to individual choice. However, it is becoming more and more apparent that we are not really free to choose – our choices arise from opportunities or barriers that are structured in large part by the places in which we live, work, play, or go to school. The abundance of ultra-processed, energy –dense, nutrient-poor foods that are readily available, heavily marketed, cheap, and tasty, presents a large barrier to many of us in terms of following a healthy diet. How can we counteract this to make healthier foods like fruits and vegetables the more attractive option? I’ve been thinking about this a lot lately, wondering if the only way is to make these foods just as convenient to consume, such as in healthy prepackaged meals, and somehow find the means to heavily market them in the same way as Big Food.

Behavioral economics may be a simpler way – changing the layout of cafeterias, stores, and restaurants to subtly influence people to make the healthy decision.

Smarter lunchrooms is an initiative out of the Behavioral Economics and Nutrition Center at Cornell University concerned with doing exactly this. Their philosophy is that draconian school food policies, like banning junk food from cafeterias, don’t work. Often children will skip lunch, bring in their own snacks, or head to a fast food restaurant. Principal investigators Brian Wansink and David Just think that ‘nudging students toward making better choices on their own, by changing the way their options are presented’ is a better option. I tend to agree.

Although the epidemiologic evidence doesn’t look like it’s strong (most studies appear to be case studies or before-after and I’m not entirely sure of the methodology), I think the results of some of these interventions are worth discussing, especially since most of these are low cost and low effort for the school to implement. Hopefully some larger scale, well designed randomized controlled trials are on the horizon (us epidemiologists can only dream). Here are a few examples from Wansink & Just, as well as their colleagues (virtually verbatim from their website):

Putting nutritious foods like broccoli at the start of the cafeteria line, rather than in the middle, increased sales by 10-15%
Switching apples and oranges from a stainless steel pan to a fruit bowl more than doubled fruit sales
Giving healthy food choices more descriptive names like ‘creamy corn’ rather than ‘corn’ increased sales by 27%
Moving the chocolate milk behind the plain milk led students to buy more plain milk
Putting the salad bar in front of the check-out register nearly tripled sales of salads
When cafeteria staff asked students if they wanted a salad, salad sales increased by a third
Requiring that desserts such as cookies be paid for in cash (not with lunch tickets or debit cards) led students to buy 71% more fruit and 55% fewer desserts
Keeping ice cream in a freezer with a closed, opaque lid significantly reduced ice cream sales

I think that something like this could in some way be translated to other shared dining spaces such as cafeterias in workplaces, hospitals, and universities, to name a few. Google has actually shown us that it is feasible. Now whether its employees are healthier for it, I'm not sure if it has, or will ever be formally evaluated. Too bad..Seems like a waste of a good intervention study.

Just D.R.,, & Wansink B (2009). Smarter Lunchrooms: Using Behavioral Economics to Improve Meal Selection Choices:The Magazine of Food, Farm, and Resource Issues, 24 (3)

Are tightly-knit communities best for obesity prevention?

noreply@blogger.com (Anonymous) — Thu, 01 Sep 2011 19:56:00 +0000

I am re-posting a guest-post that I wrote in June for my friend and colleague, Travis Saunders, on his blog: 'Obesity Panacea'. I was too lazy then to put the whole thing up on my own blog...Alas, I've come back to it as potential thesis material, so have decided to take the two minutes to format it. You can also view the original post here.

I am hoping that researchers and the public at large are starting to get past the ‘blame the victim’ perspective of obesity. True, choice and preference obviously have something to do with it, but we as individuals live and interact in complex environments. Behaviours like sedentarism and eating junk food may be natural responses to opportunities and barriers that are structured by the places in which we live, work, play, or go to school. And not everyone is likely to be equally affected - protected or prone depending on things such as genes, age, sex, socioeconomic status, cultural upbringing, and the like. We need to consider the context in which people live their lives. If not, obesity prevention and treatment efforts are akin to throwing people back into the fire.

Humans, by nature, are social animals, so one such contextual factor that has garnered a lot of attention in the field of place and health is social capital. It refers to networks of social relationships that people have and the associated norms of <warranted> trust and reciprocity (gift giving with the expectation of receiving) (1). Social capital can work at the individual level, but also through collective or group-level mechanisms (2). These group-level workings may be most relevant for the development of obesity, since buying and eating food , as well as being physically active, often (but obviously not always) take place in shared spaces, such as neighbourhoods.

There is already a vast literature demonstrating an association between low collective social capital and adverse health outcomes such as delayed child development, child and adolescent behaviour problems, stress and isolation, violent crime, and increased mortality (3). A newer body of research is emerging now, suggesting that low collective social capital may be related to obesity and even related diseases such as hypertension (4).

Social capital in a collective or community context is often referred to as ‘collective efficacy,’ which is used to describe a number of social processes that may affect health (5). In short, it is the social cohesion (connectedness/togetherness) among neighbours (or members of a community) combined with their willingness to intervene on behalf of the common good.

Okay, so how can that translate into obesity? I’ll try to spare you the jargon as much as I can while still conveying the meaning of these pathways (one of the main criticisms of this area of research is that words and phrases describing concepts, and the meaning of these concepts are not consistently applied). Also, keep in mind that these pathways can interact and overlap.

Creative Commons Image

Informal social control

Neighbourhoods that are more cohesive informally enforce social norms (e.g. obeying the law), which may decrease anti-social behaviours such as graffiti, vandalism, illegal dumping, drug-dealing, violence etc (5). By informally it is meant that residents are willing to intervene when they see someone breaking social ‘rules’. This can have an impact on the physical aspect of neighbourhoods, making them more or less aesthetic, as well as on the perception of safety (6, 7). Both may influence resident’s decisions to be active outside (or decisions to let their kids be active outside), as well as decisions by certain groups of people and organizations to move into or out of the neighbourhood (8). For example, a specialized grocery store relocates out of the neighbourhood to a ‘better’ or ‘safer’ location. Neighbourhood residents therefore, no longer have access to this service. Another example is calling the SPCA to complain about a certain neighbor (me) letting their dog poop on one’s property and not cleaning it up. In my defense, that dog poop was from winter – I had no idea Jax went over there to do his business, and the snow covered it up! As a result of this we bought a retractable leash and no longer let Jax off-leash in the backyard (to his chagrin). Maybe now our neighbours do not hesitate as much to let their little girl play in the backyard.

Trustworthiness

Somewhat related to social control is how much residents feel that they can depend on their neighbours, and how dependable neighbours actually are. In a more cohesive neighbouhood this mutual trust is high (9). Parents may feel better about and consequently let their child play outside more often when they know there are other people around to look out for the well-being of the child.

Collective action

Increasing the social connectivity of a neighbourhood facilitates coordinated action (9). Highly cohesive neighbourhoods may have more power to influence physical and social changes within the neighbourhood itself, at higher levels of social organization, such as at municipal and regional levels (I blogged about something similar in a recent post). For example, if neighbourhood members deem that being in a food desert is a problem they may have the collective might to bring about policies that allow farmers markets to locate within the community, thereby improving the accessibility of healthier foods. Another excellent example of this is DIY streets – an initiative to increase pedestrian and cyclist safety, which has also increased (full circle) a sense of community between neighbours on a street in London, England.

Social contagion

“The Chameleon Effect” is a phenomenon that operates at the level of our unconscious – merely perceiving certain behaviours makes us more likely to engage in those behaviours (10). In a more connected community, when we see/hear about people being active outside, or say ordering from an organic food basket, we may be more likely to engage in those behaviours (11). And this may lead to those behaviours becoming a social norm, which thus further reinforces those behaviours. I use the term ‘social contagion’ perhaps loosely, as the spreading of normative and stable healthy behaviours is likely not a fast process.

Richness and density of social ties

In some sense this operates more at the individual level but is relevant to discuss here. The more connections an individual has within the neighbourhood the more access they have to health relevant resources (12). Thus, a person who is isolated within the neighbourhood may not know about easily accessible (and perhaps free) services or amenities such as parks, new grocery stores, etc., or be exposed to health promotion initiatives that are local in scope. Having rich social interactions on a daily basis may also increase well-being and reduce stress. Individuals prone to isolation (like seniors) may benefit from living in a community with high social interaction – neighbours may periodically check in on and provide support, and a recent study has found that seniors living in areas with high social cohesion are less likely to die from stroke (13)

Stress

Again, this functions more at the individual level but can result, at least in some part, from a lack of collective efficacy at the community level. More physical and social neighbourhood disorder may illicit psychological distress <either warranted or unwarranted> (6). Chronic stress has been shown to have direct effects on metabolism and has been linked to obesity (14, 15). Eating may also be used as a coping strategy (15, 16) – I do this to self-medicate before a big presentation.

A few thoughts...

There are certainly some caveats in social capital research, particularly at the group-level (I won’t go into them all but you can read about them in a series of articles published by the International Journal of Epidemiology, called the Social Capital Debate). The literature posits an influence of community social capital on physical activity, healthy eating, and obesity, but it may itself be influenced either by the behaviours themselves (e.g. more people meet outside during a jog), the built environment (e.g. interesting and safe places to walk to), or broader factors such as policies and global social norms. And certainly, the fact that most of this research has been cross-sectional does not help any to untangle the mess. Social capital can also be a bad thing, such as gangs or perpetuating unhealthy behaviours.

So, if we increase community social capital, will that decrease obesity? And how do we increase community social capital? Good questions, I don’t think we have satisfactory answers yet, unfortunately. A discussion for another day perhaps…

References

Szreter, S. (2004). Health by association? Social capital, social theory, and the political economy of public health International Journal of Epidemiology, 33 (4), 650-667 DOI: 10.1093/ije/dyh013

Google: dedicated to keeping employees healthy and happy and reducing its ecological footprint

noreply@blogger.com (Anonymous) — Mon, 29 Aug 2011 15:28:00 +0000

As regular readers and/or Twitter followers are likely well aware, I’m not exactly 100% pro-capitalism. So it may come as a bit of surprise that today’s post gushes over one particular money-making machine: Google.

Now, Google has skeletons in the closet like any other business, but a lot of what I’ve read depicts it as a company vested in keeping employees healthy and happy, and dedicated to reducing its ecological footprint. It's business model demonstrates that companies can be sustainable while also profitable; two concepts that I think a lot of libertarians believe are mutually exclusive. Please check out the videos and articles below for a few examples of how socially responsible this company is.

The Atlantic: Marion Nestle
What Google's Famous Cafeterias Can Teach Us About Health

Good (Environment): Sarah Laskow
Google's Newest Clean Energy Project: Solar Leasing

I think Google's biggest downfall is that it may have plans for world domination...Given these examples, do you think this is a bad thing?

Safety and biking infrastructure - segregated vs marked bike lanes

noreply@blogger.com (Anonymous) — Tue, 23 Aug 2011 18:57:00 +0000

Hopefully I will be back to a more or less regular blog posting schedule now that I am back from my trip overseas. I went to Dublin (Ireland) and Edinburgh (Scotland) for a few weeks of vacation and a couple days of conferencing. I was lucky enough to get to do some biking both inside and outside of the city (the city being Edinburgh). Today’s post is more of a reflection on biking culture and infrastructure in Ireland and Scotland versus here in Canada. I was only there for a short while so I am sure locals will have much more insight than I; don’t be afraid to let me know if I’ve got something wrong.

Both Dublin and Edinburgh appear to make extensive use of on-street bike lanes. These are generally shared with bus lanes and are often painted red, which makes them impossible to miss by motorists. I noticed continuity of markings and signage (i.e. I as a cyclist knew where I was supposed to be at most times) and priority for cyclists (e.g. areas allocated for cyclists in front of motorists at intersections – see picture below). Bike lanes also continued on more rural roads, along with pedestrian islands to slow traffic, which you don’t see here in Canada. Even though streets were busy and I had to ride on the opposite side of the road I did not feel scared to be on the road, perhaps because motorists are more cyclist-savvy and no one yells or honks at you.

On-street marked bike lanes in Dublin, Ireland

The infrastructure in these cities has made me wonder if on-street marked bike lanes are the way to go. Don’t get me wrong, I am not against segregated lanes, but on-street marked lanes would likely be cheaper, more direct, and make fewer people angry (e.g. merchants who lose parking spaces). Changing our cycling culture requires, at the very least, making friends not enemies (I'll talk about this in an upcoming post).

I’m just not sure if on-street marked lanes are safer for the average person and I doubt that parents would be more willing to let their children commute anywhere on them versus segregated lanes or a sidewalk. At the same time, some segregated bike lanes can be dangerous because motorists can’t see you. For example, in Hull, there is a National Capital Commission off-road pathway that crosses three roundabouts; it is blocked to traffic by a wall until you have to cross each roundabout. Motorists coming into and out of the roundabout are looking for other cars and often nothing else. Cyclists are quicker than pedestrians and may appear out of nowhere to motorists. I have had a few close calls. Being on the street makes you seen and forces motorists to more or less treat you like a car. This is why I cycle on the road in this area, even with motorists motioning to me in some sort of code that I think means I should be using the ‘perfectly good bike lane’ beside me.

I think therefore that a comparison of segregated and on-street marked bike lane safety is beside the point (the evidence shows that both may be beneficial compared to unmodified road ways, and that the sidewalk is the worst). I guess the appeal of segregated lanes is that they may induce feelings of safety, whether real or imagined which could motivate people to actively commute. My point is that we may want to investigate more wide-spread use of on-street marked bike lanes that are highly visible as in Dublin and Edinburgh, and/or with buffer zones as in New York City (see picture below), as these could improve both real and imagined safety in the same way, improve route directness, be more cost-effective, and piss fewer people off.

A buffer zone in NYC

Reynolds, C., Harris, M., Teschke, K., Cripton, P., & Winters, M. (2009). The impact of transportation infrastructure on bicycling injuries and crashes: a review of the literature Environmental Health, 8 (1) DOI: 10.1186/1476-069X-8-47

Urban agriculture - where's the evidence?

noreply@blogger.com (Anonymous) — Mon, 25 Jul 2011 17:04:00 +0000

Creative Commons Image: City Farm in Chicago, US

One potential way to combat the obesity epidemic and environmental degradation all in the same go is urban agriculture. I’ve been thinking a lot about this lately, wondering if it is feasible in climates like New York City and Toronto, if it can actually generate enough food to continuously feed a city, and of course, also improve diet quality at a population-level.

Urban agriculture refers to agricultural practices (usually intensive) within and around cities that compete for resources such as land, water, energy, and labour – but produce food, plant and animal-based pharmaceuticals, fibre, and fuel that benefit the local population (crops and animal husbandry included). This can occur at the micro and meso scales of cities – e.g. using vacant lots, backyards, street verges, green roofs and walls, balconies, community gardens, urban parks, and individual collective garden allotments. Larger scale practices can include commercial farms, nurseries, and greenhouses, which would likely operate in peri-urban areas and be private/corporate, for-profit entities.

There are a number of other potential benefits for UA, aside from food, food security, and pollution/land degradation that I hadn’t initially thought about. These include:

Employment and income
Personal skill development
Social interaction/community or social capital-building
Increased well-being
Highest productive use of land (with respect to vacant lots)
Diversified industry base
Light, odour, and noise abatement/absorption

I was surprised to read in a recent journal article that in developed countries like Australia, UA is responsible for 15% of state vegetable and fruit production. And that in Sydney, UA accounts for 1% of land area but contributes $1 billion in agriculture produce. Those are interesting numbers, but I still feel skeptical; this is Australia after all, where temperatures rarely fall below freezing. And I imagine that most of this occurs at the macro, not the micro or meso scales.

Most research on UA in terms of any type of outcome, not just health (e.g. environmental, social, and economic) has been in the form of case studies, with no real quantification of its benefits. It is difficult to build an argument for this practice with no hard evidence. At the same time, it has the potential to positively affect many different aspects of society, not just health. For this reason, I think UA is worthwhile.

I don’t, on the other hand, believe that farming at the micro and meso scales of cities (involving individuals and communities), especially in northern North America, can continuously feed local residents. Farming is time-intensive, and requires certain knowledge and skills. And to feed families year-round in North America, would require up-front investment for equipment like greenhouses. This is not compatible in a culture that breeds convenience and instant gratification, where for example, we don’t seem to have enough time to clean out reusable containers for our drinks, so instead buy crates of water bottled in plastic that can be thrown out or recycled.

This may be different if UA at the micro/meso level is a social business, or a private/corporate entity. An example is the Science Barge in New York City, a 1300-square-foot greenhouse that floats on the Hudson River. It is a sustainable urban farm powered by solar, wind, and biofuel and irrigated by rainwater and purified river water. Fresh fruits and vegetables are grown using recirculating hydroponics and aquaponics. And surprisingly, despite floating on the river, is a prototype for a sustainable roof-top garden (more information on the Science Barge can be found here).

Another example is Gotham Greens, a roof-top greenhouse in Brooklyn, NY that grows vegetables and herbs for local restaurants and retailers using sustainable methods. They expect to produce 80 tons of produce yearly, and employ residents in nearby communities.

Gotham Greens greenhouses

Macro-level UA in urban fringes using sustainable methods has potential, but right now is often more costly or harder to access than buying produce at supermarkets like Loblaws or Metro. Government policies (e.g. zoning) and community initiatives that support local farms will be needed to make buying local economically feasible and physically accessible to everyone. An example of this support is Equiterre, a Montreal-based organization that maintains a directory of Community Supported Agriculture (CSA) farms that must be local and organic, serving primarily low-income sharers (clients that share the risk of farming). The organization connects potential sharers with CSA farms, and coordinates drop-off points that increase accessibility for sharers, while at the same time minimizing transport time and cost to the farms. CSA produce prices are cheaper than what you would find in a supermarket, and the average farm is family run and has between 30-80 sharers.

In terms of improving diet quality, many questions about UA in developed countries remain – can individuals and communities do it to feed themselves year-round? My guess is no. Is it economically feasible for social businesses, and for-profit private/corporate entities in urban and peri-urban areas? If so, will it be socially equitable and improve diet quality at the population-level? Given UA’s potential to benefit many different areas of society, I believe it is a worthwhile pursuit irrespective of scientific evidence. That being said, if further investment (time, money, policies, etc,) is to be made in UA, rigourous trans-disciplinary studies need to be conducted to quantify its benefits.

Pearson, L., Pearson, L., & Pearson, C. (2010). Sustainable urban agriculture: stocktake and opportunities International Journal of Agricultural Sustainability, 8 (1), 7-19 DOI: 10.3763/ijas.2009.0468

Some musings on sustainability and obesity: focusing on BOTH physical activity & diet needed

noreply@blogger.com (Anonymous) — Tue, 12 Jul 2011 14:41:00 +0000

There is no disputing that diet and physical inactivity are contributors to the obesity epidemic. A recent debate involving Drs Yoni Freedhoff and Bob Ross showed that both are important (I don’t think there was consensus in the audience as to who won). What I want to highlight in this post is that, from a sustainability perspective (see my previous post for a definition), it is a moot point to argue over the relative importance of each.

Our food system has changed dramatically over the last few decades. We can get tasty, energy dense, often nutrient-poor foods anywhere, for very little money. And we’re constantly bombarded with advertisements to buy and eat these foods. What’s more is that we have almost completely engineered physical activity out of our daily life. For instance, most jobs nowadays require sitting for 8 hours (I am sitting as I write this), escalators and elevators do the climbing for us and are easily accessible, and we live far from where we work, play, or go to school so often must rely on the car, which involves more sitting.

I think there is a consensus developing among obesity researchers and health professionals that obesity (or diabetes or other related diseases) is not entirely the fault of the individual. In my opinion, unhealthy behaviours are a natural response to our “obesogenic” environment, which increase a person’s risk of developing obesity. So then why do we expect that prevention or treatment efforts targeted at the individual will be effective and maintained over the long-term? To fix our deranged food system and culture of sitting requires interventions at higher levels of social organization, including changes stemming from the local community, municipal, provincial, and national governments, as well as the global community.

In the last 10 years there has been a boom the number of scientific studies examining how our environments, beyond the household, are associated with obesity. The majority of these studies have been observational, with a cross-sectional design, and have looked at things like how street infrastructure, fast food restaurant density, and socioeconomic-level of residential neighbourhoods relate to obesity among adults. Children have been less studied in this regard, as well as other types of environmental exposures, such as social interactions, and other types of areas, such as those around workplaces and schools (since these are likely not in one's residential neighbourhood). Perhaps because of the complexity involved, even fewer studies have examined how specific policies and programs may influence physical activity, diet, and obesity at higher levels of social organization (you can find an example here).

Certainly more studies are needed given the weaknesses in the current literature, as well as the dearth of information in some areas. But I would like to put forward another argument. Increasing the “walkability” and “liveability” of our shared spaces - *may* decrease obesity but will likely help to decrease green house gas emissions. Making it easier for us to get and cook wholesome foods (namely fruits and veggies) that are free of pesticides, antibiotics, and other chemicals, and harder to get meat, as well as processed foods *could* decrease obesity, but could also help to reduce land degradation, pollution of our water sources, and climate change. All of these things are good for our health in ways other than on our waistline.

My argument is that if there is a focus on sustainability, which these changes imply, population and environmental health should follow. We need to focus on BOTH the diet and physical activity side in order to not only combat obesity, but a myriad of environmental problems and related health ailments like diabetes and asthma. These changes are complex, don’t happen overnight, and may bring with them a whole set of new problems (the potential problem of denser living leading to a decrease in indoor air quality immediately comes to mind as an example).

Nonetheless, I think we need to move towards rigorously implementing and evaluating interventions that increase sustainability – looking to see if they a) improve the environment, b) reduce obesity, or improve lifestyle behaviours, and c) that they do not negatively impact health in other ways (a post for another day).

Feng J, Glass TA, Curriero FC, Stewart WF, & Schwartz BS (2010). The built environment and obesity: a systematic review of the epidemiologic evidence. Health & place, 16 (2), 175-90 PMID: 19880341

Increasing fruit & veggie intake - the why and the how

noreply@blogger.com (Anonymous) — Tue, 28 Jun 2011 17:33:00 +0000

Creative Commons Image

Today’s post focuses on why you should eat yer fruits and vegetables, and how it may be possible to get more of us to do so.

At a population level, the evidence for increasing fruit and vegetable (F&V) consumption and decreasing obesity isn’t super strong [1]. But I still think that it’s at the heart of how to make a healthy population – coupled of course, with decreasing intake of crappy, energy dense, nutrient poor snack foods and sugar-sweetened beverages, as well as growing food in sustainable ways (e.g. sans pesticides). For instance, insufficient intake of F&Vs is estimated to be responsible for around 14% of gastrointestinal cancer deaths, about 11% of ischemic heart disease deaths and about 9% of stroke deaths worldwide [2]. They may even be able to make our immune systems healthier and decrease common communicable diseases [3].

Fruits and vegetables have seemingly magical properties – they are abundant in vitamins and trace minerals, often are high in fibre, and are low in calories. But we don’t get enough of them – even in developed countries. Just to give you an idea, in 2004, only 30% of Canadian children (aged 4- 8 y) and 50% of adults met dietary recommendations for F&V intake [4]. More concerning is that children aged 4-18 years obtained a higher percentage of their calories (22.3%) from foods that are not recommended in the Canadian Food Guide (food high in sugar, fat and salt and low in nutrients) than from F&Vs (13.9%) [4].

How can we increase intake? I think it’s all about making F&Vs easier to buy and prepare. This means that they are easily accessible, cheap, and offered in healthy, ready-to-eat meals (not only as whole foods).

Grocery stores have been identified as potential means to increase F&V intake – through their influence on availability, access, pricing, promotion and information on the health properties of F&Vs [5]. Churches, childcare centres and the broader community may also represent effective settings to implement environmental initiatives.

According to Glanz & colleagues:

"Policy and environmental approaches may have greater impact [on F&V consumption] because they influence the overall environment, reach many people, and are less costly and more enduring than clinical, individually oriented, or small-group educational interventions"

Unfortunately, the evidence for effectiveness in increasing F&V intake through these means is not strong (and even lacking with regard to obesity). But I don’t think that should be a deterring factor, especially given how difficult it is to actually implement an evaluation in this type of setting, let alone a rigorous one.

There have been some innovative environmental initiatives that I have come across recently, which show great promise, but have not been formally evaluated (hopefully in some way soon). Descriptions and links can be found below:

The New Haven Health Corner Store (US) – member corner stores add healthier choices to the aisles of chips, soda and salty snacks, such as fresh produce and low-fat dairy products. Stores also have added advertising (including an easy to identify logo) and giveaways to increase awareness among consumers about healthier choices. The website highlights a study of why it might be important to target corner stores

Fruixi (Canada) – Mobile F&V bike carts operated by young volunteers around Montreal parks (kind of like getting street meat). All F&Vs sold are from local producers and at prices less than what you would have to pay in grocery stores. Fruixis will soon be available around University of Montreal affiliated hospitals. Unfortunately, the service is not available in winter.

Fresh Moves Mobile Product Market (US) – A great idea – retrofitting a bus to become a one-aisle produce market for underserved communities in Chicago. Conventional as well as organic and local produce are available at affordable prices.

A healthy (for-profit) street food business called KeBal (Jakarta, Indonesia) – Targeted to children aged 5 years and under with branding, advertising, and health promotion initiatives. The menu was created by nutritionists and menu items are made from non-processed, whole foods. This is an interesting concept that could be translated to children and adults in developed countries.

Food Oasis, a virtual food market – a platform that works through consumers text messaging to communicate their individual needs. These messages go to a central system, where these small orders are aggregated by suppliers into economically-viable groups. Suppliers, including corner stores, local farmers or large grocery chains, can negotiate with consumers to agree on a price and central neighborhood delivery location (e.g., churches, day care centers, employment centers). This platform is still in preliminary stages of development.

Other environmental interventions that deserve further thought and investigation include making high calorie, nutrient poor foods harder to find and the display of fruits and vegetables more appealing and easier to access. A great example of this can be found here. Glanz and Yaroch also recommend establishing farm stands at large sports events; “cross-promotions” (e.g. bananas sold with cereal) and promotion of pre-packaged foods (including frozen) with high F&V content in grocery stores; as well as F&V sold in convenience stores as ready-to-eat or ready-to-heat food dishes.

Fruits and vegetables are good for us and we need to eat more of them. Environmental interventions can make the healthy choice the easier choice. For these initiatives to work they have to make F&Vs easier to choose over crappy food – so this means that they have to be convenient, at least the same price, easy to access, and tasty. And one intervention may not make a dent in our diets or our waistlines - this will require environmental interventions in multiple settings, making evaluation a tall, but necessary order.

References

[1]Ledoux TA, Hingle MD, & Baranowski T (2011). Relationship of fruit and vegetable intake with adiposity: a systematic review. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 (5) PMID: 20633234
http://cals.arizona.edu/nutrition/sites/cals.arizona.edu.nutrition/files/pubs/Hingle-Relationship.pdf

[2] Mathers C, Stevens G, Mascarenhas M, for the World Health Organization. Global Health Risks: Mortality and burden of disease attributable to selected major risks. http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf . 2009. Geneva, Switzerland, WHO.

[3] Villamor E, Fawzi WW: Effects of vitamin a supplementation on immune responses and correlation with clinical outcomes. Clin Microbiol Rev 2005, 18: 446-464.

[4] Garriguet D: Canadian's eating habits. Health Reports 2007, 18: 17-32. http://www.statcan.gc.ca/pub/82-620-m/82-620-m2006002-eng.pdf

[5] Glanz K & Yaroch AL. Strategies for increasing fruit and vegetable intake in grocery stores and communities: policy, pricing, and environmental change. Preventive Medicine. 2004; 39: S75-80 http://www.med.upenn.edu/nems/docs/Glanz_Yaroch_2004.pdf

Why should we become more engaged in civil society? For health, that's why!

noreply@blogger.com (Anonymous) — Wed, 25 May 2011 17:01:00 +0000

I am an intense believer in the social determinants of health and looking at health problems through a social-ecological lens (i.e. determinants of health exist at multiple social levels of influence and are not just attributable to the individual or to the healthcare system). I think this is why I’ve also gotten incredibly interested in politics – from this perspective, government policies can influence population and environmental health. An interesting social determinant of health, social capital, has made me realize how we as individuals can collectively make a difference in shaping the quality of our shared spaces, and potentially overall community health – through influencing policies and working with government.

Social capital, a concept originating from the work of Robert Putnam, among others, embodies the norms of reciprocity (gift giving with the expectation of receiving), social and civic participation and trust in society. Another, complimentary view is that social capital refers to the network of social relationships that provide access to resources. Regardless of the definition, when you have more of these things you have more social capital (sometimes called cohesion). Although both definitions are relevant, I am speaking more to the former definition in the discussion that follows.

Richard Wilkinson was the first to introduce social capital to studies on health. He found that societies that are more socially cohesive, with smaller income gaps (more egalitarian) have higher life expectancies and lower infant mortality rates. Other authors have found that societies with higher levels of income inequality and lower social cohesion have higher levels of crime and violence and higher mortality rates. At a more local level, it has been found that residents who are more involved in the community tend to be happier where they live, regardless of the physical quality of their homes. Some studies have even found that as the level of social cohesion in an area increases, the prevalence of obesity decreases.

Social capital is complex – these studies show how it may influence health. An obvious explanation is that it improves the quality of our immediate social and physical environments, as well as society at large. One caveat is that social capital itself can be shaped by many different factors operating at many different levels of social organization (e.g. at the neighbourhood/community, region, province, and country level), which thus impacts the quality of our spaces. Social capital therefore, is not a one-way street, rather an intricate web of interaction.

Open space in question, complete with dog

My plan is to add to social capital and hopefully improve the quality of my neighbourhood, by becoming more civically engaged. I’ve read a lot lately about how greenspace can potentially be beneficial for mental and physical health, and how it is also good for the environment (I have blogged a bit about this too). I enjoy being outdoors in natural areas – it makes me happy – and I also have a dog, with no back-yard. Unfortunately there are no dog parks or interesting greenspaces within walking distance of my home. I often take my dog to an open space close by. It’s a piece of land that separates two suburban neighbourhoods, with trees and a man-made marsh that was constructed to deal with street water runoff. Other neighbourhood residents also bring their dogs, kids toboggan down the banks of the marsh in the winter, and residents of houses bordering the space often use it as their personal dumping ground (a pet-peeve of mine discussed in a previous post). There is no landscaping and the space is never maintained.

Neighbours like to use it as their own personal dump

I would really like to have this space converted into a dog-friendly park (that is maintained), with perhaps a community composter (since everyone dumps their s**t anyway), and even a community vegetable garden. Although, my partner brought to my attention that probably dog parks and food don’t mix – I’ll have to think the vegetable garden through a little bit more…

I really had no idea how to go about making this happen until I read an interesting post on the City of Gatineau’s website:

“Ville de Gatineau is revising its land use and development plan. Would you care to share your thoughts about how your neighbourhood or the city should develop? This is the time! This revision will extend over three years, with meetings scheduled to start this spring!”

This first meeting for my area is this June the 6^th. I plan to go to see how I can voice my ideas and connect with others who may share my view and/or be able to help me. This will be the first time (other than voting in various elections) that I am involved in the running of my community. I’ll keep you updated as to how this pans out. And I urge everyone else to do the same. Finally, I will not be a hypocrite, especially with respect to my own research!

Leal C, & Chaix B (2011). The influence of geographic life environments on cardiometabolic risk factors: a systematic review, a methodological assessment and a research agenda. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 (3), 217-30 PMID: 20202135

Home cookin', leftovers, and your health

noreply@blogger.com (Anonymous) — Mon, 09 May 2011 20:43:00 +0000

CC image: Kathleen Franklin

Home cooking is where it’s at. In my view, getting people to cook at home with wholesome foods is one way to combat the obesity epidemic. And of course, home cooked meals *can* taste great; that’s chef-dependent of course. Foods prepared outside of the home are higher in calories, fat, and sodium, and a recent meta-analysis found that children and adolescents who eat shared family meals at least 3 times per week are less likely to be overweight or eat unhealthy foods than children who eat fewer shared meals. There are two main problems with home cooking, aside from the multitude of barriers to actually being able to cook (e.g. time/work schedule, knowledge and skills). Rather, these are outcomes of cooking that I will discuss based on a recent experience.

First, we waste a whole lot o’ food. Research in the UK has shown that 2.2 million tonnes of food is thrown away due to cooking, preparing, or serving too much. That’s just food that we’ve managed to work with – it doesn’t include fresh produce, meats/fish, dairy, etc. In the US, 30% of all food is thrown away each year.

All of this waste is obviously costly, as we’re paying for food that we don’t eat. In the case of the US, this amounts to US$48.3 billion! But food waste is also harmful to the environment. Rotting food releases methane, one of the most potent greenhouse gases. A UK research group estimates that if food were not left to rot in landfills, this would be the greenhouse gas equivalent of removing 1 in 5 cars from the road. And we can’t forget all of the fertilizers, pesticides, and energy going into growing/raising food that we just toss into the trash.

Okay, home cooking is great but waste is bad. What do we do? Eating your leftovers is one way to get the best of both worlds. Hang on though, leftovers need to be handled and stored properly in order to avoid illness. I have a dietetics bachelor’s degree but am the worst for food safety (probably because more often than not I don’t get sick). I’m the one that leaves the ham sandwich in the car in 30 degree weather (that’s Celsius) all day and then eats it unperturbed on the way home from work. Or leaves a defrosting tenderloin on the top shelf in the fridge or even out on the counter for the entire day (both no-no’s).

But the other day, I did get sick – not badly mind but enough to make me realize that food safety does matter if I want to avoid having to take a day off of work. My significant other thought he was doing a service (which he was) by bringing home leftovers from a conference at work. It was some sort of pasta with a béchamel sauce and chicken. We reheated it in the microwave at home and ate about half of what was brought home. The next day, we both could not stray too far from the toilet…This was no coincidence – same symptoms and the pasta was the only thing we had in common for the previous 24 hours. We threw the rest of it out.

So what went wrong? I can’t say for sure because there are so many things that could have happened, but I’ll touch on a few here. It’s hard for bacteria to grow in foods that are held at temperatures less than 4°C (40°F) or more than 60°C (140°F) – in between is called the ‘danger zone’. When serving prepared hot foods, like this pasta dish, it is imperative that the food be above 60°C. Additionally, time is a factor. Food left out for more than 2 hours is more prone to bacterial contamination. Perhaps the pasta was held in this danger zone – something that caterers should know to avoid, or not thrown out after 2 hours. My partner may have also taken the pasta and unknowingly left it out for too long. Reheating the pasta at home didn’t seem to do anything. The Canadian Food Inspection Agency (CFIA) recommends reheating leftovers to 75°C – maybe we didn’t hit that mark.

When other people make your food there is always the possibility that they didn’t adequately wash their hands, or use clean serving utensils or pots/containers. That’s something out of your control but you can ensure that you do these things when you make your own food.

Other ways to deal with leftovers to prevent illness:

Put hot leftovers in shallow containers and place immediately in the fridge. Really hot items can be left out for a bit then put in the fridge after the steam stops. Leave lids off or wrap loosely until food becomes fridge temperature (to avoid explosions)
A great way to keep leftovers is to freeze them
Eat leftovers left in the fridge (as opposed to the freezer) within 2 to 3 days
Throw out uneaten leftovers - i.e. once reheated, don’t keep the left over leftovers
Thaw frozen leftovers in the fridge or microwave. This is something I need to think about doing – I always thaw my soup at room temperature
Never refreeze thawed leftovers – they should be eaten or thrown out
When reheating leftovers, stop the microwave half-way through and stir the dish in order to ensure even heat distribution (we didn’t do this with the pasta dish)
The CFIA recommends using a digital thermometer to check food temperatures but I don’t really see this as something that I would do let alone the general public. Maybe… if I get sick again….
And finally, when in doubt, throw it out!

The more we cook at home, the better for our health. But sometimes we cook too much. Instead of throwing out food, which is bad for the environment and our pocketbooks, think ‘leftovers for lunch’ and perhaps even for a second dinner. But be mindful of how you handle, store, defrost, thaw, and reheat leftovers.

Other great resources include:

The Food Safety Network http://www.foodsafetynetwork.ca/aspx/public/default.aspx

United States Department of Agriculture: Food Safety and Inspection Service http://www.fsis.usda.gov/factsheets/safe_food_handling_fact_sheets/index.asp

Love Food Hate Waste: tips for reducing household food waste http://www.lovefoodhatewaste.com/

Hammons AJ, & Fiese BH (2011). Is Frequency of Shared Family Meals Related to the Nutritional Health of Children and Adolescents? Pediatrics PMID: 21536618

Quested T, & Johnson H (2009). Household Food and Drink Waste in the UK WRAP

Part 2 Building Design: Fooling people into taking the stairs

noreply@blogger.com (Anonymous) — Tue, 03 May 2011 00:51:00 +0000

I just got back from a conference in Montreal – one on obesity at that. The hotel, the location for the conference, held sessions on floors 1-4 and on sub floors below the lobby – ample opportunity to use the stairs. There were two main problems: 1) the stairs were confusing – you’d get up to one floor but then couldn’t find the next set of stairs to the next floor and have to walk quite a distance to get to them; and 2) there were escalators in between these floors in plain sight from the main floor lobby, somewhat easy to navigate, and were a brilliant, flashy gold colour. I, more often than not, took the flashy-fancy escalators.

In my last post, I reflected on how easy it is to be physically inactive nowadays and went on to discuss point-of-decision prompts as a way to get people to use the stairs instead of escalators or elevators. These prompts appear promising, but what if buildings are not designed to make taking the stairs easier or enjoyable, such as was the case at the obesity conference? To answer this, in today’s post I will discuss the recommendations provided by New York City’s Active Design Guidelines to make buildings enjoyable places to walk – and some instances make walking the more convenient form of transportation. The guidelines were developed based on the best available evidence in the literature, as well as on current best practices in architecture and design. So keep in mind that even though these are recommendations there is no guarantee that they’ll work to increase physical activity. At the same time however, they have direct synergies with sustainability, such as decreasing electricity and building material use (so, in my opinion, are at least worth considering).

There are three main categories of building design recommendations that I’ll touch on in my discussion below: 1) Elevators and escalators; 2) stairs; and 3) supportive design elements. I think that the more recommendations implemented, the more likely that building design will be successful at increasing the physical activity levels of its users.

Design of elevators and escalators

Mechanized options for travel between floors should be designed to be hard to find, or at least less prominent (not the case for the escalators at my conference). Decreasing their speed can make them less efficient than walking, and save on electricity. Installing the minimum number of elevators required by building codes could also decrease efficiency by increasing volume of users. Other ways to make elevators less efficient than walking include programming them to:

Be skip-stop (they don’t stop on every floor so you have to get out and walk up a floor);

Open at each floor (this may not make sense in buildings with 30+ floors);

Open and close very slowly (which is beneficial for persons with disabilities)

Design of stairs

Stairs should be the main attraction. They should be visible from the lobby and elevators, and always located close to building occupants (i.e. office areas). One way to draw attention to them is to put the lobby of the building on the second floor, accessible from the ground floor via a grand staircase, with elevators accessible only at the lobby (meaning people have to use the stairs to access the elevators). Point-of-decision prompts can also help (as I discussed in Part I). A great example of making stairs interesting -maybe a bit extreme and perhaps not sustainable, but cool nonetheless- is the piano stairs:

Additionally, stairs should:

Open to and be accessible at each floor (no locked doors);

Be seen – if stairwells are a must they should be transparent;

Receive large amounts of natural light;

Be well ventilated

Canadian Museum of Nature, Ottawa (ON): CC images Michelle Hotchin

In order to improve the overall experience, stairs themselves should be designed for comfort, aesthetics, safety, and ease of maintenance. Art and articulated and unique stair composition can increase interest. Balustrades, handrails and landings can provide architectural points of interest, especially for grand staircases. Floor finishes should be slip resistant and colour or textural contrasts can be used to increase safety. Step height should be comfortable for small children (i.e. not too high), and staircases should be wide enough for groups traveling in opposite directions to safely pass. Finally, stairs should be easy to maintain. Long lasting materials should be chosen that are easy to clean and discourage vandalism or graffiti.

Cooper Union New Academic Building, New York, NY: CC images

Supportive design elements

There are some things that can be included in building design that make being physically active easier and more enjoyable. Change rooms and showering facilities are big ones for me. My work building currently does not have one. I figured it would be quite easy to add a shower – one for men and one for women and no need for change rooms as our washrooms are so large. No dice though, my request was immediately shut down by my organization – citing no money. Always the excuse. I plan to press the issue. Bike parking and storage are also important. In NYC, several laws have been enacted that mandate certain buildings and facilities provide bicycle parking or other accommodation for cyclists. Storage can also prevent damage to building interiors when bikes are brought inside, and also prevent nasty notes from being sent to you when you forget your bike lock.

Design of building exteriors should also have the pedestrian/cyclist in mind and interestingly can influence building users and non-users alike. Here are a few examples that can enliven, and improve the comfort/convenience and safety of the streetscape:

Reducing set-backs (space between the road and building) and providing multiple entry points

Adding awnings or canopies (to provide shelter from the weather)

Porches, stoops, and terraces can add to the social environment and provide ‘eyes on the street’

Paying attention to nearby parks, open spaces and public gathering areas so that the building does not adversely affect them (e.g. minimizing the cast of building’s shadow, and the potential for creating unpleasant wind conditions)

Building in New Orleans (LA): CC image

The design of public buildings (including point-of-choice prompts) has the potential to not only increase physical activity, but also to vastly improve the quality of our shared spaces. Perhaps residential spaces could also be designed to promote physical activity and reduce sedentary behaviour. The hard part is that people generally choose what they live in and where they live. It is my hope that more and more researchers examine how design of our spaces (from houses to cities) may influence not only obesity but overall health, with high quality epidemiological methods - something that is currently lacking.

Bloomberg MR, Burney D, Farley T, Sadik-Khan J, & Burden A (2010). Active Design Guidelines: Promoting Physical Activity and Health in Design City of New York