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I have been asked to comment on the American Medical Association’s resolution to stop using the BMI as the sole criterion for diagnosing obesity [To find this resolution, click on CCSPH Report(s) #07: Support Removal of BMI as a Standard Measure in Medicine and Recognizing Culturally-Diverse and Varied Presentations of Eating Disorders].

The BMI—Body Mass Index—defined as weight in kilograms divided by height in meters squared—is a quick way to categorize the relationship of weight to height and does a better job of identifying people with excessive body fat than most other simple and inexpensive measures.

Unfortunately, not everyone demonstrates a close correlation of BMI to body fat and those who don’t may well find themselves discriminated against in the health care system.

The BMI is also an imperfect measure of health risk:

The current BMI classification system is also misleading regarding the effects of body fat mass on mortality rates. Numerous comorbidities, lifestyle issues, gender, ethnicities, medically significant familial-determined mortality effectors, duration of time one spends in certain BMI categories, and the expected accumulation of fat with aging are likely to significantly affect interpretation of BMI data, particularly in regard to morbidity and mortality rates…[This report] outlines the harms and benefits to using BMI and points out that BMI is inaccurate in measuring body fat in multiple groups because it does not account for the heterogeneity across race/ethnic groups, sexes, and age-span.

The resolution recommends:

(1) greater emphasis in physician educational programs on the risk differences among ethnic and age within and between demographic groups at varying
levels of adiposity, BMI, body composition, and waist circumference and the importance  of monitoring these waist circumference in all individuals with BMIs below 35 kg/m2;

(2) additional research on the efficacy of screening for overweight and obesity, using different indicators, in improving various clinical outcomes across populations, including morbidity, mortality, mental health, and prevention of further weight gain; and

(3) more research on the efficacy of screening and interventions by physicians to promote healthy lifestyle behaviors, including healthy diets and regular physical activity, in all of their patients to improve health and minimize disease risks.

My translation: Keep using the BMI as an indicator, but also pay attention to body composition and waist circumference as better measures of body fat.

The AMA is not minimizing the importance of excess body fat as a disease risk factor.  It is saying that only using the BMI to evaluate the risk itself risks stigmatizing patients, especially those of non-majority race, ethnicity, and gender conformation.

This resolution ought to further sensitize physicians to such issues.  If it does, it could not come a better time.

Resources

• Stat News on the resolution
• Ancel Keys et al’s original paper on the BMI: Indices of relative weight and obesity.

I am putting the Keys’ paper into this discussion to demonstrate that Keys was quite well aware of the strengths and weaknesses of the BMI, which was intended mainly to identify groups and populations at risk of undernutrition.

Guided by the criteria of correlation with height (lowest is best) and to measures of body fatness (highest is best), the ponderal index is the poorest of the relative weight indices studied.  The ratio of weight to height squared, here termed the body mass index, is slightly better in these respects than the simple ratio of weight to height. The body mass index seems preferable over other indices of relative weight on these grounds as well as on the simplicity of the calculation and, in contrast to percentage of average weight, the applicability to all populations at all times.

Last week, I attended and spoke at the UNICEF-WHO Global Congress on Implementation of the International Code of Marketing of Breast-Milk Substitutes at WHO headquarters in Geneva.

The meeting was attended by more than 400 government, health, and advocacy representatives from more than 100 countries.  Representatives of infant formula companies were not invited to participate.

Its purpose was to encourage governments to promote and enforce the International Code, which nearly all U.N. member states ratified and committed to in 1981 (the U.S. was a long-standing holdout).

This meant they would control inappropriate marketing of infant formulas by banning advertising to people who are pregnant or nursing, gifts of formula samples, and doing anything to make formula appear superior to breastfeeding.

The logic of the Congress:

• Breastfeeding is the superior method for feeding human babies.
• Successful breastfeeding requires support from families, society, and government.
• It is quite easy to undermine confidence in the ability to breastfeed.
• Formula companies do all they can to undermine confidence in breastfeeding.
• Formula companies’ main goal is to sell more formula.
• Formula companies promote their products as normal and superior.
• Breastfeeding is easier when formula marketing is controlled.y

I talked about the food industry “playbook”—strategies and tactics used by industries (tobacco, chemical, drug, alcohol, and food as well as infant formula) to cast doubt on unfavorable research, fund their own research, and lobby against public health recommendations (photo: Arum Gupta).

Many country representatives discussed the effects of the playbook in their areas, and what they are trying to do to stop formula companies from using  the playbook to get around the Code.

The general consensus:  Formula companies should NOT be allowed to:

• Advertise or market products in violation of the Code.
• Participate in public health policymaking.
• Partner with relevant government agencies or non-governmental groups.

Obviously, formula companies are not happy with such recommendations.  If you would like to see an example of the playbook in action, take a look at the response  from the International Special Dietary Foods Industries.

It was exciting to be with so many people who cared so deeply about this issue.

Resources

• WHO Breastfeeding page
• WHO International Code FAQ
• The Global Breastfeeding Collective

Oxygen nanobubbles?  Oxygen in little tiny bubbles?

For this gem I am indebted to an item I read in NutraIngredients-Europe:

Oxygen nanobubble drink found to enhance athletic performance, study suggestsA new study finds the consumption of an oxygen nanobubble beverage significantly improves the time-to-completion of maximal and submaximal exercises performed by male cyclists…. Read more

I went right to the article.

The study: A Double-Blind, Randomized, Placebo-Controlled Pilot Study examining an Oxygen Nanobubble Beverage for 16.1-km Time Trial and Repeated Sprint Cycling Performance.  Journal of Dietary Supplements. https://doi.org/10.1080/19390211.2023.2203738.

The concept: Athletes need oxygen and water.  Therefore, oxygen-supplemented water should improve performance.

The result: As comparied to placebo, Althletes who consumed the oxygen-nanobubble beverage demonstrated significantly improved performance.

The conclusion:  “An oxygen-nanobubble beverage improves performance during submaximal and repeated sprint cycling, therefore may provide a practical and effective ergogenic aid for competitive cyclists.”

Guess who funded this: “This study was funded by Avrox Technologies Ltd, Harrogate, North Yorkshire, HG3 3SZ. Avrox Technologies provided the experimental beverages but had no role in study design, data storage, analysis and interpretation.

I wondered what the placebo was and whether study subjects could distinguish the drinks.  The beverages:

were supplied by Avrox Technologies in 500 mL individually sealed bottles and consisted of the same solution containing water, glycerol, glycyrrhizin, lecithin and citric acid. Both beverages have similar organoleptic properties, including taste, aroma, and texture. Previous investigations have indicated that the oxygen nanobubble drink consists of a suspension of lecithin vesicles with a modal diameter of ∼100 nm and concentration 7 × 1012 particles/ml.

The authors deal with my question in their discussion of the study’s limitations:

we did not evaluate the success of our double-blind design, therefore, changes in performance might be somewhat attributed to participants’ expectancy of positive outcomes from their belief that they successfully identified the O₂ beverage…Whilst there were no notable differences in taste, texture or appearance of the O₂ and PLA [not spelled out in the study but must refer to the placebo] beverages, we should have assessed blinding via treatment allocation questionnaires to determine whether participant biases influenced results.

Yes, you should have.

I also wonder whether club soda or Pellegrino might have the same benefit?  Or giving water a good shake?

I am not a big fan of the MyPlate food guide.

• It was created without doing consumer research to find out how well people understand it.
• Pie charts are harder to understand than pyramids (the old pyramid, despite its flaws, conveyed the what-you-should-eat messages much better).
• The Protein section makes no nutritional sense; grains and dairy are also excellent sources of protein, and beans, which are high in protein, are vegetables.

Never mind.  We have to live with it.

It appeared in 2010.  Now the USDA is trying to sell it, and with a catchy music video no less.

Will this sell kids on eating their veggies?

I hope the USDA has an evaluation in the works.

This has not been a good year for artificial sweeteners.

The World Health Organization says don’t use them for weight control and don’t give them to children.

The recommendation is based on the findings of a systematic review of the available evidence which suggests that use of NSS does not confer any long-term benefit in reducing body fat in adults or children. Results of the review also suggest that there may be potential undesirable effects from long-term use of NSS, such as an increased risk of type 2 diabetes, cardiovascular diseases, and mortality in adults.

US Right to Know says: Aspartame: Decades of science point to serious health risks  

• Dozens of studies have linked the artificial sweetener aspartame to serious health problems, including cancer, cardiovascular disease, Alzheimer’s disease, seizures, stroke and dementia, as well as negative effects such as intestinal dysbiosis, mood disorders, headaches and migraines.
• Evidence also links aspartame to weight gain, increased appetite and obesity-related diseases.

Poisoned: The Dirty Truth About Your Food, a Netflix documentary about food safety in the U.S., premiered at the Tribeca Film Festival and I got to go.

It’s based on the book by Jeff Benedict about the Jack in the Box E. coli O157:H7 poisonings in 1993, and features Bill Marler, the lawyer who represented the families of kids who got sick or died from eating undercooked hanburgers contaminated with that especially toxic form of E. coli.  

I got to go to the premier because I’m in it—one of the many talking heads.

From left to right: Alexa Ginsburg, Associate Producer; Kristen Lazure, Producer; Bill Marler, food safety lawyer and Poisoned star; Ross Dinerstein, Producer; Jeff Benedict, Author of Poisoned; Christine Haughney, Journalist; Sarah Sorscher, CSPI; Me; Darin Detwiler, father of boy who died from eating a Jack in the Box hamburger and food safety advocate; Stephanie Soechtig, Director.

My interview for this was so long ago—prepandemic?—that I had forgotten all about it.  I may be prejudiced but I think the film is terrific.

It really lays out what’s wrong with our food safety system and what needs to be done to fix it.  I thought I knew this stuff pretty well—see my book Safe Food: The Politics of Food Safety—but I learned a lot from it, partly because the photography is so well done.

Some images are unforgettable (spoiler alert):

• The children hooked up to tubes in hospitals.
• Their grieving parents.
• Vast confined animal feeding operations (CAFOs) right next to fields of vegetables.
• Representatives of the USDA and FDA: “the US has the safest food supply in the world.”
• Bill Marler saying that he no longer has cases of people sick from eating hamburger since the USDA declared E. coli O157:H7 an adulterant.

It’s really worth seeing.

While waiting for Netflix to schedule it, Marler explains how you can see it on Tribeca at Home.

At Home Virtual Screenings will take place June 19 – July 2

• WAYS TO WATCH:
  • Browser: watch.tribecafilm.com
    • Members can use their login credentials (email & password) to access the At Home portal.
    • Single ticket holders can redeem their 9-digit voucher code for their screening. This code can be found in the confirmation email.
  • App: “Tribeca At Home”/ Available on Apple TV, Fire TV, Roku
  • TV:
    • Download the OTT app for Apple TV (Gen4 and above), Fire TV, or Roku
    • Chromecast [3rd generation or later Chromecast stick] from a computer using the Chrome browser or an Android device to your TV.
    • Airplay from a computer, iPhone or iPad to your Apple TV (Gen 4 and above) or to any Smart TV bearing the “AirPlay” badge.
    • Connect your laptop to your TV via HDMI, VGA, or DVI cables.
  • Computer:
    • PCs running Windows 7+ [Browsers: Google Chrome, Firefox, Microsoft Edge, Opera]
    • Intel-based Macs running macOS 10.12+  [Browsers: Google Chrome, Firefox, Safari, Opera]
    • *Internet Explorer is not supported
  • iPhone / iPad / Android:
    • Android: use Chrome on Android 6.0 or later
    • iPhone/iPad: use Safari on iOS 11.2 or later

It will get to Netflix evenually.  Watch out for it.

This article in Feed & Grain caught my attention: Cargill intends to sell its poultry business in China to private equity firm DCP Capital, according to reports.

Cargill is the tenth largest broiler producer in the world; it was responsible for the slaughter of an astonishing 625 million broilers last year, of which 49 million were in China.

You don’t hear much about Cargill because it is not publicly traded.  It is family held, but huge:  155,000 employees, annual revenues of more than $134 billion.

It makes that money from food oils, ingredients, grains, oilseeds, cotton, animal feed, and financial services.

According to this article,

Cargill in 2013 inaugurated its integrated poultry operation in Lai’an, Anhui, China, which included every stage of the supply chain: breeding, raising, feed production, hatching, slaughtering and processing…The company also opened a new US$48 million poultry complex in Chuzhou, Anhui, in 2019. That operation included breeding, raising, feed production, hatching and primary and further processing capabilities.

Now, Cargill is selling off its Chinese enterprises to venture capital.

Cargill must think it best to get out of China.

The venture capital company must think money can still be made there.

This, it seems to me, is an example of what is happening to the global food supply.

It is no longer about making sure that people have enough to eat and do not go hungry.

Food is about making money for investors.

That means keeping costs as low as possible, regardless of the effects on health or the environment.

Christina Leffel, a public health nutritionist in Florida, sent this one, which with both find amusing.

The study: Effects of Adding Lean Red Meat to a U.S.-Style Healthy Vegetarian Dietary Pattern on Gut Microbiota and Cardiovascular Risk Factors in Young Adults: a Crossover Randomized Controlled Trial – The Journal of Nutrition.  VOLUME 153, ISSUE 5, P1439-1452, MAY 2023, https://doi.org/10.1016/j.tjnut.2023.03.013

Method:  19 participants consumed 3 study diets in random order: 1) healthy lacto-ovo vegetarian diet (LOV); 2) LOV plus 3 ounces/d of cooked unprocessed lean red meat (URM); and 3) LOV plus 3 ounces/d of cooked processed lean red meat (PRM). Measures: Fecal and fasting blood samples.

Results: The addition of unprocessed or processed lean red meats to a LOV HDP did not influence short-term changes in bacterial taxonomic composition.  When the data from all three diets were combined, “changes in some bacteria were associated with improvements in TC, LDL-C, triglycerides, and HDL-C concentrations, and TC/HDL-C ratio.”

Conclusions:  Healthy young adults who adopt an HDP that may be vegetarian or omnivorous, including lean red meat, experience short-term changes in gut microbial composition, which associate with improvements in multiple lipid-related cardiovascular risk factors.

Funding: “The study was cofunded by the Pork Checkoff, North Dakota Beef Commission, Beef Checkoff, and Foundation for Meat and Poultry Research and Education. The supporting sources had no role in study design; collection, analysis, and interpretation of data; writing of the report; or submission of the report for publication.

Author disclosures: “During the time this review was conducted, WWC received funding for research grants, travel or honoraria for scientific presentations, or consulting services from the following organizations: U.S. National Institutes of Health, U.S. Department of Agriculture (Hatch Funding), Pork Checkoff, National Pork Board, Beef Checkoff, North Dakota Beef Commission, National Cattlemen’s Beef Association, Foundation for Meat and Poultry Research and Education, American Egg Board, Whey Protein Research Consortium, National Dairy Council, Barilla Group, Mushroom Council, and the National Chicken Council. Additionally, SRL received funding for research grants, travel or honoraria for scientific presentations, or consulting services from the following organizations: U.S. National Institutes of Health, U.S. Department of Agriculture, National Science Foundation, Showalter Research Trust, Grain Foods Foundation, CP Kelco US, OLIPOP, Inc, Council for Responsible Nutrition. YW, T-WLC, MT, and CMC declare no conflict of interest. The funder and these other organizations had no role in the design and conduct of the study, analysis, interpretation of the results, and writing of the manuscript.”

Comment: This is yet another industry-funded study in which the funder claims no role–a statement that always makes me laugh.  That’s what they all say, despite much evidence that the funding influence in such situations can be considerable, although unrecognized.  For details, see my book, Unsavory Truth: How Food Companies Skew the Science of What We Eat.

The meat industry, apparently, is trying to convince vegetarians that they can eat any kind of meat they want and not affect their cardiovascular risk.  This, of course, contradicts tons of other evidence, including associations with cancer risk.  These risks may not be mediated through the microbiome, however.  What this study says is that if you are worried about the risks of meat, you don’t have to worry that it changes your microbiome much, at least under the conditions of this study.