Dispelling nutrition myths, ranting, and occasionally, raving


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How to end hallway medicine

End hallway medicine: ban hallways

There’s been a lot of talk about “hallway medicine” (i.e. patients receiving treatment in hospital hallways due to hospital overcrowding) in Ontario over the past couple of years. A recent report from the Premier’s Council on Improving Healthcare and Ending Hallway Medicine provided recommendations to the government on how to improve the current situation. The key findings from the report were as follows:

    1. Patients and families are having difficulty navigating the health care system and are waiting too long for care. This has a negative impact on their own health and on provider and caregiver well-being.  
    2. The system is facing capacity pressures today, and it does not have the appropriate mix of services, beds, or digital tools to be ready for the projected increase in complex care needs and capacity pressures in the short and long-term. 

Following the release of the report I saw a number of articles and heard several radio interviews, all of which featured emergency room doctors and occasionally nurses. Undoubtedly they have experience which can contribute the the discussion. However, I was frustrated by what I saw as the glaring absence of input from public health. I think that perhaps everyone thinks that the problem lies within the hospitals and therefore the solution can be found there too, even if it’s the suggestion from ER doctors that more home care supports are needed. However, while not an immediate solution to the problem, I think that we need to look further upstream for real long-term solutions. Adding more beds, increasing home care, and improving system navigation for patients are all important but they don’t address the reasons why so many people are ending up in the hospitals in the first place. If we can prevent the need for emergency care then we can reduce the number of people in need of hospital beds.

I was pleased to see that alPHa (Association of Local Public Health Agencies) submitted a response to the report to the government highlighting the important role of public health in improving healthcare and ending hallway medicine. I was also pleased to see OPHA (Ontario Public Health Association) submit a letter to the Minister of Finance advocating for health promotion and chronic disease prevention measures that would help to end hallway medicine. Has anyone seen anything about this in the news though? I haven’t heard any public health officials or representatives publicly advocating for the important role of public health in ending hallway medicine. Public health needs to do better at getting their messages to the public. If people don’t know about what public health does to prevent injuries and chronic disease, reduce infectious disease, and advocate for the social determinants of health then how can we expect them to support these initiatives or even to recognize how these things contribute to the demand for healthcare services?

In addition to the importance of public health in ending hallway medicine I’d like to see more effort to connect with those who are likely most in-the-know about patient concerns: reception staff. Yes, doctors, nurses, other allied health professionals, and patients can all contribute important insights but who speaks to everyone seeking care? Who hears the complaints and concerns that people may not feel comfortable voicing to doctors? Who is at the first point of interaction with the public? Reception staff. I’m sure that they could contribute a great deal of valuable information to the consultation on ending hallway medicine.

If the government truly wants to end hallway medicine they need to consider the reasons that people need healthcare and the impact that their cuts (and decisions) in other areas is going to have on the demand for hospital services. Hallway medicine is not happening in a vacuum. Cuts to social assistance, ending the basic income pilot, cutting support for cycling infrastructure, reducing funding to the Trillium fund, reducing oversight for meat processing facilities, cuts to mental health funding, ending minimum sick days and reducing employee protections, cancelling the planned raise for the minimum wage, increasing accessibility and affordability of alcohol, and on and on, are all going to result in an increased burden on the healthcare system and our hospital hallways are only going to become more crowded.


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What obesity and homosexuality have in common

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A couple of weeks ago I was listening to an episode of Radiolab on which they shared an episode of the short podcast series Unerased titled: Dr Davison and the Gay Cure. They were talking about the former perception of homosexuality as a disorder and the rise of conversion therapy. As I was listening what they were saying really struck a chord with me. I found myself thinking “this is exactly how people are going to think about weight loss counselling one day”.

On the podcast, they were saying, essentially, it doesn’t matter if people come to us wanting to change. What does it actually mean to help them? “The problem that these people are asking us to solve is a problem we created. That we labeled as a problem.” Even if we could effect certain changes, there is the more important question as to whether we should… It makes no difference how successful the treatment is, it is immoral.” And I was like “YES, this exact same thing could be said about weight loss treatment!”

This belief in relation to homosexuality was considered to be fringe and most people weren’t in support of it initially. This parallels the Health at Every Size/body diversity/weight acceptance movement. There is a lot of push-back from people in the medical community and the general public when it’s suggested that weight is not a condition that needs to be treated. Just as with the acceptance of homosexuality as a normal state, there were a few outspoken pioneers leading the movement and with time, it became more accepted by the mainstream. I feel that this is beginning to happen now with weight. More of us RDs who were always taught that “overweight” and “obesity” are unhealthy are coming to realize that people can be healthy at many different sizes.

Of course, there are still hold-outs and there is still conversion therapy happening in some places. Similarly, there will likely continue to be hold-outs who believe that only thin people can be healthy and that BMI is indicative of health. However, I’m hopeful that we’re reaching a turning point and that one day the medical community will agree that weight is not a “problem” and that weight loss treatments are unethical.


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Are calories an enemy?

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I would like to propose that we stop demonizing calories. All too often I see products promoted as “low-calorie” or “calorie-free”. I hear jokes about things like it’s okay to eat a broken cookie because the calories all leak out. Consuming as few calories as possible is considered virtuous. This despite the fact that we need calories to live.

Just in case you need a quick refresher on calories, despite what many people will have you believe, a calorie is a calorie. The definition of a calorie is, “the heat energy required to raise the temperature of one kilogram (rather than a gram) of water by one degree Celsius”. Calories provide us with energy. Energy to get through each day but also energy for your body’s systems and cells to function. Without a source of calories you will die.

So, why do we think that calories are bad and something to avoid? Because we’ve learned that excess calories, those we don’t use up, are often stored by our bodies for later use in the form of fat. And fat is bad because our society has rather arbitrarily decided that being thin is more attractive. Regardless of your body shape or size though your body still needs calories to function.

Wouldn’t it be wonderful if we lived in a world and mental space where instead of choosing 100 calorie snacks or avoiding foods because they contain “too many calories” we could look at food as a pleasurable way to nourish our bodies? Not just to think of food as fuel but as an essential component of self-care. Calories are not the enemy, they are vital to life.


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What does “healthy” look like?

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A little while ago I wrote about the importance of representation and how the health care industry is failing at it. Of course, it’s not quite as simple as saying “we’re going to use more diverse images in our marketing and materials”. Most organizations don’t take their own photos. Instead, most use stock photography sites from which staff select images. It’s not just health care that has a problem, it’s all media, and it’s the sites from which we source our images.

So many of the images I come across on the stock photo site we use at work are problematic. I’m not going to name the site because it really doesn’t matter which one it is, they’re all the same. Search the word “healthy” and you’ll likely come up with a lot of smiling, slim, glowing, youthful white people outdoors wearing athletic clothing or eating salad. Of course there might be one older person, a black person, and a “normal” (i.e. not model thin) person in the mix but these are the exceptions that prove the rule. Fitness returns more of the same, minus the salad shots. On the other hand, when you search “fat” you come back with a bunch of headless torsos clutching their bellies, larger people drooling over fries, large people looking miserable, and a few “good” fat people engaging in physical activity – again, the exceptions that prove the rule. Then there’s the images of “healthy choices” in which the ubiquitous glowing youthful white woman is weighing a doughnut in one hand and an apple in the other as if this is all that healthy eating is about. Or how about the images of large women kicking “junk food” solidly away? How virtuous. Or the woman literally taking a pair of scissors to her stomach? Horrifying.

All these images do is serve to reinforce the popular beliefs that we hold around body size, health, and personal responsibility. To reinforce the stigma against larger bodies and the false assumption that smaller bodies are always healthy bodies and the result of healthy personal choices. It takes a lot of effort and consideration for people to choose images from these stock photo sites that don’t contribute to stereotypes. It’s worth that extra effort though to show that all bodies are good bodies and that your organization is for everyone, not just people who look a certain way.


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To keto or not to keto

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I feel like there’s one thing missing from a lot of the discussion about the keto diet (and similar extreme diets, really). Everyone talks a lot about whether or not it “works” with proponents on both sides, research supporting both sides, arguing that it does or doesn’t work for weight loss. The problem with this is the assumption that weight loss is the most important feature of a good diet. It’s not. You can lose weight eating lots of things that are not going to provide you with the nutrients you need. Weight loss is not the most important thing for health, despite what the media, the “wellness” industry, society, and even many health care professionals have lead us to believe.

Just because you feel good on a ketogenic diet and are losing weight doesn’t mean that it’s a good idea. As a dietitian, this is something that I really struggle with. It’s our job to support people. We can tell them that keto is a difficult diet to follow, that it may not be advisable, but when it comes down to it, they decide if it’s something they want to pursue or not. And if they do decide to pursue it, we can’t say “well, good luck, I wash my hands of you”. We have to help them undertake it in as healthy a way as possible. Which kind of blows my mind (and makes me glad that I don’t work in a counselling role) because if someone came to us with an eating disorder we wouldn’t support them in that. How can it be ethical for us to support people in following a diet that may cause them harm?

A little history of keto: the ketogenic diet originated as a treatment for epilepsy in children in the 1920s. It was intended to mimic the effects of fasting through the generation of ketones. In recent years this concept has caught on with people desiring to lose weight. After all, if ketones are produced during fasting, then if a specific diet can promote the production of ketones, it may also lead to weight loss. Not illogical. In some children with epilepsy who do not experience a reduction in seizures with medications, the ketogenic diet can be an effective treatment. However, there are potential side-effects.

A few long-term studies (1, 2) have looked at the effects of the ketogenic diet in children and have found such side-effects as: kidney stones, slowed growth, dyslipidemia, and fractures. There are also short-term risks (2, 3, 4) associated with the diet in children with epilepsy including: acidosis, hypoglycemia, gastrointestinal distress (including vomiting, constipation, diarrhoea, and abdominal pain) dehydration, hypoproteinemia, and lethargy. All of these studies have found low long-term adherence among children. There are many reasons for this: some children see improvement in symptoms, even after discontinuing the diet, others find it difficult to adhere to the diet, for some it’s not effective.

Of course, adults who wish to lose weight are not the same as children who have epilepsy. It’s hard to say if slowed growth in children would have a similar counterpart in an adult. However, many of the short-term side effects may be seen in adults, as may some of the other long-term side effects. In addition, there is potential for nutrient deficiencies when following such a restricted diet. Unfortunately, we don’t have research into the long-term effects of a ketogenic diet on adults using it for weight loss. We have some short-term studies that primarily look at it from the standpoint of whether or not it’s an effective weight loss diet. Maybe it’s perfectly safe, but maybe it’s not. Given that the vast majority of people who lose weight on the diet end up regaining it, and often more, is it really worth taking that risk? By following a keto diet you’re basically enrolling yourself in an uncontrolled experiment.

I think it would be interesting to know what the long-term effects of a ketogenic diet for weight loss are in adults. What I’d really like to know though is why we have become so obsessed with being thin that we are willing to adopt disordered eating habits at the expense of other aspects of our health and well-being. Why is it when we talk about a diet “working” we de facto mean weight loss? Why have we come to value weight loss over every other indicator of health? Why can’t we just value ourselves enough to properly nourish our bodies?