Monthly Archives: January 2016

How hormones help us sleep

I return turn to today after a week in Tasmania, refreshed and ready to go! Sleep problems are often hormonal, and if not, then some of the hormones I use may help viz  Melatonin, Progesterone, Oestrogen and a Testosterone. Talk to me about them when next you see me, if insomnia bothers you.

Chemical messengers: how hormones help us sleep

September 9, 2015 2.45pm AEST

The activities we do during the day – from having a fight with a partner to using our iPhones at night – also affect our hormone levels and, in turn, our quality of sleep. Jan Faukner/Shutterstock

Disclosure statement

Jo Abbott does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.

Partners

Swinburne University of Technology provides funding as a member of The Conversation AU.

When it comes to motives for getting a good night’s sleep we don’t usually think about our body’s hormones. But sleep allows many of our hormones to replenish so we have the optimal energy, immunity, appetite and coping ability to face the day’s highs and lows.

The activities we do during the day – from having a fight with a partner, using our iPhones at night, running in a race, to travelling overseas – also affect our hormone levels and, in turn, our quality of sleep.

For both men and women, changes in our levels of sex hormones can affect how well we sleep. These differences also change with age.

Understanding the connections between hormones and sleep may help ximprove your own sleep and well-being.

What are hormones?

Our body’s hormones are like chemical messages in the bloodstream which cause a change in a particular cell or organ and surrounding tissues. The hormone adrenaline, for example, is produced by the adrenal glands (on top of the kidneys) and helps prepare the body’s “fight or flight” response during times of stress.

Hormones control many of the body’s processes, including growth, development, reproduction, responding to stress, metabolism and energy balance.

Hormones are linked with sleep in a number of ways.

Hormones affect sleep through our stress levels

Some hormones, such as adrenaline, make us feel more alert and prepared for action. This then makes it hard for us to go to sleep. To prevent this effect it’s best to do relaxing activities before bedtime, rather than stressful work tasks or intense exercise.

When stress is long lasting, adrenocorticotrophic hormone within the pituitary gland (attached to the base of the brain) triggers the release of cortisone and cortisol from the adrenal glands.

Levels of adrenocorticotrophic hormone tend be higher in people with insomnia than in good sleepers. This suggests that excessive arousal and ongoing stressors contribute to the insomnia.

Elite athletes can have difficulty getting to sleep because they tend to have high levels of cortisol throughout the day, including in the evening.

Hormones released during sleep boost our immune system and make us hungry

Sleep is a time when several of the body’s hormones are released into the bloodstream. These include growth hormone, which is essential for growth and tissue repair, including in adults.

Sleep helps to balance our appetite by maintaining optimal levels of the hormones ghrelin and leptin. So, when we get less sleep than normal we may feel an urge to eat more.

Sleep also controls levels of the hormones insulin and cortisol so that we wake up hungry, prompting us to eat breakfast, and we are prepared for facing daytime stress.

If we get less sleep than normal our levels of prolactin may get out of balance and we can end up with a weakened immune system, difficulty concentrating and carbohydrate cravings during the day.

Hormones stop us from having to get up in the night to go to the bathroom

Changes in hormonal levels during sleep, including higher levels of aldosterone and antidiuretic hormone, prevent us from needing to go to the toilet. In children, while the hormonal system is still developing, bedwetting may be partly influenced by low levels of antidiuretic hormone.

Hormones make us feel sleepy at night

Hormone levels also influence the timing of when we feel sleepy and awake – our body clock or sleep-wake cycle. The hormone melatonin is released with darkness and tells our body it’s time to sleep. This is why being around too much bright light before bed can affect our sleep as it can stop the release of melatonin. It’s also why it can be hard for night-time shift workers to sleep during the day.

While artificial melatonin is available, taking the wrong dosage and at the wrong time of day can make things worse, so it’s best used with the guidance of a medical doctor.

Hormones give us a wake-up call in the morning

Levels of the hormone cortisol dip at bedtime and increase during the night, peaking just before waking. This acts like a wake-up signal, turning on our appetite and energy.

When we travel long distances our body’s sleep-wake cycle takes a while to adjust. So increased cortisol levels and hunger may occur at inappropriate times of the day.

For women, changes in sex hormones affect sleep

The relationship between hormones and the sleep-wake cycle in women is further influenced by the menstrual cycle. Just before a woman’s period, hormonal changes, including the sudden drop in levels of progesterone, affect the body’s temperature control, which in turn can reduce the amount of “REM” sleep. This is the stage of sleep when most of our dreams occur.

For women with severe premenstrual symptoms reduced levels of melatonin before bedtime just before their menstrual period can cause poor sleep, including night-time awakenings or daytime sleepiness.

Changes in hormone levels also contribute to sleeping difficulties during pregnancy. Increased progesterone levels can cause daytime sleepiness, particularly in the first trimester. High levels of oestrogen and progesterone during pregnancy can also cause nasal swelling and lead to snoring.

During menopause, low levels of oestrogen may contribute to sleeping difficulties. Changes in hormone levels mean that body temperature is less stable and there may be increases in adrenaline levels, both of which can affect sleep.

The loss of oestrogen causes body fat to move more to the stomach area, which increases the chances of women having snoring and sleep apnoea.

For men, testosterone levels affect sleep

For men, levels of testosterone are highest during sleep and require at least three hours sleep to reach this peak. Low levels of testosterone in men, which can occur with sleep deprivation, ageing and physical problems, have been associated with a reduction in sleep efficiency and changes to the stages of sleep men experience.

Testosterone can be taken as a drug but abuse of it can lead to other sleep problems.

Hormones influence our dreams

Finally, as we sleep, our hormones, including levels of oxytocin and cortisol, may influence the content of our dreams.

By doing things to promote good sleep, such as reducing stress, engaging in relaxing evening routines before bed, going to bed and getting up at regular times, or seeking professional help for sleeping difficulties, we can facilitate the replenishing activities of our hormones that help us make the most of our day and optimise our well-being.

This article is part of an occasional series, Chemical Messengers, on hormones and the body. Stay tuned for other articles on hunger, mood and sexual desire.

5 Food Year’s Resolutions for 2016

5 Food Year’s Resolutions for 2016

January 8, 2016 8.01am AEDT

Flickr CC / Thomas Rousing, CC BY-SA

As 2015 closes, it is easy to feel daunted by the future – even overwhelmed. In a year that saw the world pass the historic 400PPM of atmospheric carbon for the first time in a long time, and with global temperature records seeming to be broken on a now regular basis, it is easy to feel alarmed by the mounting climate ‘canary’.

For those of us in global health, things at first seem less dire. Over the past decades we have made much progress on reducing poverty, infection and hunger – to the point that in 2015 less than 800 million of us went hungry each day. A number that is still too high, but one that reflects the enormous gains made over the recent decades. In stark contrast though and of growing concern to doctors, governments and international organisations alike, a staggering 1.9 billion people on this planet now wake up each day overweight – and half a billion obese.

Finally, as I talked with colleagues and peers throughout the world in 2015, I got a sense that the third big concern on people’s minds is a lack of community thinking and connection in societies. A breakdown in the fabric that binds us together. The very interpersonal connection and trust that will be needed to find the combined vision and fortitude to overcome our great climate and health threats.

festival21

With all this in mind, last year I led a small group of young, pro bono Melbournians to fundraise, organise and stage a massive public festival about our future. Instead of focusing on the doom and gloom, we looked beyond problems and welcomed more that 4000 people on 11 December to the largest convention space in Australia to discuss and rethink the path we are all on. Using something we love yet at the foundations of many of our greatest challenges, we began to turn what have become the biggest conversation killers – climate change, obesity, social connection – into new conversations for change.Centred around food and our food systems, the festival had a simple message – let’s come together and rethink who we are and where we are going, through food. Food systems are a major driver (if not the major driver) of climate emissions; they’re a major challenge and opportunity for our health; and they’re a fabulous way to reconnect societies across borders, cultures and political viewpoints.

We all need to eat – and we are what we eat.

If you didn’t make it to festival21, I want to share with you just five take home messages for your New Year’s resolution. Simple things we can all do to unlock the potential on our dining plates and create a better future for us, and our planet, through food.

1. Eat with your neighbours

Do you remember being young and having that wonderful older friend next door who would bring cakes and biscuits? That someone who you would join for dinner or a cuppa after school? It’s time to revive this tradition.

Nayran at festival21

Imagine if everyone in our city had dinner with one of their neighbours this month. The potential impact on social isolation for the elderly, or community mental health, or even community safety and security would be enormous.Nayran Tabiei explained how this simple act of kindness and connection could unlock so many added benefits. Why not extend a neighbourly invitation in 2016 and open your door to something better?

2. Buy food, not products

Navigating the food landscape to decipher what is healthy, sustainable and affordable is not always simple, but speakers like Joost Bakker, Madelaine Scott and Keith of The Digger’s Club suggested three easy rules for toasting to a better future.

First, buy local, fresh and in season. These are often the cheapest foods in the supermarket and in abundance. They will usually have travelled less miles to your plate and if you stick to a diet based on fruits and vegetables in season – it can be affordable, convenient, healthy and delicious.

Madelaine’s Eggs

Second, is to buy food and not products. Inspired by the 2014 Dietary Guidelines of Brazil, the message is to buy things that are in their natural, complete state and make these the staple of your meals. Add products and condiments (like salt and oil) to taste, but base your meals on things with one ingredient – food.Finally, Madelaine a 20-year old organic egg farmer called on everyone to rethink their sourcing of meat and eggs: eat less but always eat quality. Buying fresh eggs and meat from farmers like Madelaine may cost a little more, but the quality and sustainability of the food reflects this price. Finding great suppliers and enjoying an infrequent and appreciated meat meal is likely best for your health, and certainly best for the planet.

To learn more about Joost or Madelaine, or to order your fresh, free range eggs and meat, head to their websites. Join Digger’s Club today and begin growing your own fresh food.

3. Eat Mindfully – and eat with others

We often eat a chocolate bar or down a morning coffee with little or no thought to the time and energy that went into delivering that mouthful. The army of hands that touched the coffee bean before it was picked, dried, shipped and roasted. The thousands of kilometres from the cocoa farms in Africa or the refineries in Europe before it met with an entire day’s work for some generous Jersey. The attention and technology that went into growing the nuts, drying them, shelling them. If we stop and think for a moment how much work goes into every mouthful, we might slow down a little. We might eat a little less. We might not waste so much.

In addition, science suggests that if we eat with others we eat more slowly and in some ways eat more healthily. Switch off the phone, put away the laptop and engage with those at your table.

To learn more, head to Smiling Mind.

4. Waste not

festival21

One in three mouthfuls of food worldwide will go to waste, and in countries like Australia, the UK and the USA, much of that waste lies with the consumer. In 2016, make this the year of less waste.Learn to pickle and preserve when foods are in season, cheap and abundant.

Make a list when you go shopping so that you don’t buy more than you need, or things you don’t want.

Finally, cook from scratch and learn to adapt recipes to what you have in your cupboard, rather than what you have in your cupboard for each recipe.

To learn more, go to Preserving The Italian Way or Jamie’s Ministry of Food.

5. Let food be thy litmus

Finally, food is not just about what and how we eat, it is also a great litmus test for how our societies are tracking. Inequality in access to food and the quality of the food we eat often reflects the social and economic inequalities in our communities. Google what a food desert is and find out how you can tackle this problem in your community. Support great organisations who are reusing food and reducing waste, or using food to tackle poverty.

Julian Burnside and Erik Jensen at festival21

To learn more, head to OzHarvest, SecondBite, Feast of Merit or Stephanie Alexander’s Kitchen Garden Foundation.

HNY

As a new year begins, don’t feel overwhelmed or numbed by the challenges we face as a global community. It is OK to feel worried, but use this to mobilise action. Rethink what and how you eat, and the structures and policies which afford food to those around you.

Use something you love to make that urgently needed impact on the issues we find hard to address.

Have a happy and safe 2016.

Bon appétit to us all.

Measuring up: this year, aim for fitness over fat loss for long-term success


Measuring up: this year, aim for fitness over fat loss for long-term success

January 5, 2016 6.15am AEDT

Disclosure statement

Simon Rosenbaum is funded by a Society for Mental Health Research Early Career Fellowship. He is a National Director of Exercise and Sports Science Australia.

Partners

UNSW Australia provides funding as a member of The Conversation AU.

 

Getting fit and losing weight are consistently among the top New Year’s resolutions, and January is the boom period for the billion-dollar gym industry. While any attempt to incorporate more exercise into our lives should be welcomed, it’s time to rethink the reasons for joining the gym. And, in particular, the way we measure success when it comes to exercise.

Weight loss is one of the most common reasons why people start an exercise program, linking sweating it out with reduced fat. Sadly, they’re setting themselves up to fail because there’s good evidence that exercise in the absence of dietary modification is not all that effective for weight loss. In other words, “you can’t outrun a bad diet.”

In fact, the idea that exercise will lead to weight loss is potentially dangerous because it acts as a disincentive for people who stick to their exercise goals to only find the scales haven’t turned in their favour – and throw in the towel.

A better measure

Research published a few months ago shows the likelihood of an obese man achieving normal weight without surgery is one in 210. And the chances are only a little better for women, at one in 124. Among those who manage to lose significant weight (at least 5% of bodyweight), at least half will regain it within two years.

Weight loss is very important for improving health and reducing risk of chronic disease. But when focusing on the reasons people should be physically active and engage in regular exercise, fitness, as opposed to fatness is a better focus.

Exercise can directly improve fitness independent of changes in weight. And it may be protective of developing chronic diseases, such as type 2 diabetes, even for people who are overweight or obese. But the importance of trying to lose weight through broad lifestyle change shouldn’t be ignored.

A recent study of over 1.3 million Swedish men found that when it comes to risk of dying early, high fitness isn’t protective for people who are obese. But it showed fitness was an important factor nonetheless and didn’t measure other key health outcomes. Most importantly, improving fitness is a tangible and achievable outcome, so it’s more motivating.

Poor fitness is a modifiable factor associated with heart disease. Other benefits people may gain from exercise, apart from weight loss, include improved mental health, improved sleep and reduced risk of conditions, such as Alzheimer’s and dementia.

Helpful hints

Joining a gym may work for some, but it’s not the only way of getting the benefits of regular exercise. Here are some practical tips to get moving.

You can’t outrun a bad diet. liebeslakritze/Flickr, CC BY-SA

1. Avoid a “all-or-nothing” mentality and remember that every bit of time spent exercising instead of being sedentary counts.

When you’re in the habit of exercising regularly, it’s easier to keep going and find the motivation to continue. But when you’ve been inactive for a while, such as over the holiday season, it’s often difficult to overcome the mindset of feeling overwhelmed and out of touch with exercising. This often leaves people feeling unsure about where to begin.

To avoid feeling lost, try setting some realistic, and achievable goals that can be written down and achieved every day. Plan for the worse-case scenario (such as those extra long lunches). Even one set of squats, five minutes of yoga, or a brief walk around the block may be enough to avoid the build-up of post-holiday exercise fear.

2. Seek help getting active, especially if you have a chronic or complex medical conditions. Australia has one of the most progressive physical activity referral schemes in the world, which means people with chronic conditions can be referred to accredited exercise physiologists or physiotherapists to receive individualised exercise programs.

If weight loss is your primary aim, seek help from an accredited practising dietitian to help modify your diet.

3. When it comes to exercise, forget the scales and focus on moving more and sitting less. Wearable technology can help with monitoring and goal setting.

Use other ways of measuring progress, such as how breathless you feel after walking up that set of stairs or how much easier it is to carry the groceries, as well.

4. Don’t forget resistance training (muscle building exercise). Working muscles is not only for young men; it has considerable benefits for men and women of all ages.

Most importantly, the best exercise program is the one that’s realistic for your situation, enjoyable and progressively more challenging. And it’s not necessarily one limited to the gym.

Why now is the best time to go on a diet, or the science of post-holiday weight loss


Why now is the best time to go on a diet, or the science of post-holiday weight loss

January 5, 2016 6.15am AEDT

Disclosure statement

Amanda Salis (publishing as Sainsbury) receives funding from the National Health & Medical Research Council (NHMRC) of Australia, in the form of research project grants and a Senior Research Fellowship. She is the author of The Don’t Go Hungry Diet (Bantam, Australia and New Zealand, 2007) and Don’t Go Hungry for Life (Bantam, Australia and New Zealand, 2011) and owns shares in a company (Zuman International Pty Ltd) that sells these books

Partners

University of Sydney provides funding as a member of The Conversation AU.

If you – or someone you care about – are embarking on post-holiday weight loss, understanding the body’s physiological responses to excess kilojoule intake could give you the edge for a successful New Year’s resolution.

Weight loss is never easy, but the first days to weeks are easier than what’s to come. That’s because whenever you consume more kilojoules than your body burns – think big, festive feasts and then sitting around for hours with your friends or relatives – your body activates a series of physiological processes that actually help you to reverse excess. I call these physiological processes the “fat brake”, because they put the brakes on fat gain.

The most obvious sign of your fat brake is a reduction in your drive to eat. So in the aftermath of holiday overeating, if you’re attentive to your body’s hunger and satiety signals, you may not feel as drawn to as abundant or as rich foods. To make the most of this effect, it’s important to not eat when you’re not hungry – even if that means eating less than a weight-loss diet’s allowance.

Get jiggy with it

In addition to reducing your drive to eat, the fat brake can also increase your propensity to be physically active, the amount of energy you use when you are active, or both. These also help to allay fat accumulation.

This effect of the fat brake means the start of a new year is an excellent opportunity to get into physical activity (but be gentle with your body if you’re just starting out). By the time the fat brake wears off, you could be on your way to active new habits.

After a period of excess, our bodies put brake on our drive to eat. Let Ideas Compete/Flickr, CC BY-NC-ND

As well as decreasing the drive to eat and stimulating the amount of energy expended on physical activity, some but not all studies show that excess energy intake – such as over the holiday period – leads to an increase in the amount of energy the body burns while at rest. This is known as your “resting energy expenditure” or “resting metabolic rate”, and the change in it also helps to reverse holiday excesses.

To get a sense of whether your fat brake has activated your resting energy expenditure, consider how much you’re wearing now compared to before the holidays. If you wear lighter clothing or use fewer bed coverings than before festive feasting began, then your resting energy expenditure has likely increased. That’s because body temperature is directly related to resting energy expenditure.

Look for the waterfall

If you follow your fat brake’s lead by eating less and being active this New Year, then your body will burn off your holiday excesses very efficiently. This will contribute to rapid weight loss, not only due to the loss of fat, but also due to the loss of glycogen.

Whenever you eat more than your immediate needs, such as during the festive season, your body converts some of that food into glucose (a simple sugar) and then into glycogen. This is stored in your muscles and liver to tide you over in times when you’re eating less. Your body can store about half a kilo of glycogen in total. Remaining excesses are stored as fat.

The interesting thing about glycogen is that it holds roughly three times its weight in water. So when you embark on a weight-loss plan, your body uses up its stored glycogen in the first few days, and the water that was packaged with it (easily a litre) is released. Much of it ends up as urine.

The festive season often involves large meals followed by lots of sitting around. praline3001/Flickr, CC BY-NC-ND

So if you notice that you need to relieve yourself more often than usual in the post-holiday period, it’s a sign that you could be on the right track because your body is using up glycogen.

Fast and furious

With the fat brake reducing your appetite and increasing energy expenditure, and your body using up glycogen, weight loss in the immediate post-holiday period can be the fastest it will ever be – up to several kilos per week. And this can be extremely motivating.

A common misconception is that fast weight loss is bad. Indeed, it is not uncommon to hear recommendations to limit weight loss to half to one kilo per week or less.

But, new research shows that fast weight loss does not result in faster weight regain than gradual weight loss. This is all the more reason to try your hardest with post-holiday weight-loss efforts – to make the most of your body’s natural physiology (the fat brake), which is actually helping you to rapidly reverse holiday weight gain.

Beware the speed hump

Once you’ve been losing weight for a while, your body will recognise you are no longer in energy excess, and your fat brake will deactivate. This – and the fact that you will have depleted your body’s glycogen stores by then – will contribute to an increase in your drive to eat and a reduction in your rate of weight loss.

When the fat brake switches off is different for different people; it’s dependent on many factors including how much excess weight you’re carrying, how long you’ve been carrying it for, how much weight you’ve lost, and your genes. For most people, it will likely occur within a couple of weeks (around mid-January), when many people abandon their New Year’s resolution to lose weight.

Be alert but not alarmed about the imminent increase in the amount of effort you’ll need to exert to keep losing weight. Accepting this, and the falling rate of weight loss, could mean the difference between giving up your New Year’s resolution, and powering over the mid-January speed hump towards a noticeable outcome.

The best time to lose weight is right after holidays filled with excess consumption. Alan Cleaver/Flickr, CC BY-SA

But be warned – research suggests the fat brake doesn’t stay activated forever, even if you don’t lose any weight. If you don’t act on your body’s signals by eating less and moving more now, it may come to accept the holiday excess as part of the status quo, and you could be stuck with those holiday kilos for the whole year and beyond.

The best weight-loss tip is to act now to reverse energy excess, while your fat brake is activated and the window of opportunity is still open.

One way to help maintain motivation for weight loss is to participate in a clinical weight loss trial. You can locate such trials around the world by clicking here. My team is currently seeking people living in the Sydney metropolitan area for clinical weight loss trials. For more information, please register your interest here, or e-mail us.

New Research on Obesity

Expert alert – precision medicine and obesity

Mayo Clinic, 05/20/2015

Mayo Clinic researchers have identified five sub–categories of obesity in an effort to determine the most effective, individual treatments. Researchers found that an individual with obesity will eat around 150 calories more than a normal weight individual to feel full. Researchers also found the stomachs of patients with obesity empty faster and are larger. Obese individuals also had a lower level of a hormone that signals fullness than normal weight individuals. Based on these findings, researchers identified the following obesity sub–classifications:

  • Abnormal satiety – difficulty feeling full (20%)
  • Larger stomach (14%)
  • Behavior component (13%)
  • Stomach empties faster (13%)
  • Others (26%)

Using obesity sub–classification, physicians will be able to prescribe the most effective treatment. For example, patients with a larger stomach might be good surgical candidates, and patients with behavioral issues may benefit from counseling or anti–anxiety medications. In this initial study, researchers compared the efficacy of a satiety medication, a medication which helps patients feel full, to a placebo. When this satiety medication is normally prescribed, weight is reduced by 3 pounds per week. Using the sub–classification method, the same satiety medication could be prescribed to patients who had difficulty feeling full. In the study, these patients reduced weight by 6 pounds per week. This research was published recently in Gastroenterology.

Eat food, not nutrients: why healthy diets need a broad approach

Eat food, not nutrients: why healthy diets need a broad approach

August 14, 2015 6.30am AEST

We need to stop fussing over macronutrients and think about foods. Eugenia Loli/Flickr, CC BY-NC

In a paper published today in the journal Cell Metabolism, researchers found that when 30% of a day’s kilojoules were restricted by cutting fats (diets with a higher intake of carbohydrates), participants in their study lost more body fat compared to when the same amount of energy was restricted by cutting carbs (diets with a higher intake of fat).

This study used a type of meticulous metabolic research, which is expensive and unsuited to lengthy periods, but valuable for exploring the physiology of reducing equal dietary contributions from fat or carbohydrate. But like much dietary analysis, it may be shining a light on the wrong issues altogether.

The good, the bad and the ugly

The most important aspect of any diet is that it should be practical and healthy enough to follow for the rest of your life. There’s no magic bullet for weight loss. While some people claim they find it easier to cut out foods high in carbohydrates, others find it easier to avoid high-fat foods.

If you need to lose weight, cutting down is what helps. But few people can stick to any extreme diet for life, so what you substitute is just as important as what you cut out – especially for long-term health.

Choices based only on macronutrients (foods required in large amounts in the diet, such as fats, carbohydrates and protein) miss important aspects of many foods and open the diet to imbalance. Carbohydrate foods, for instance, include nutritionally worthy choices – such as legumes, wholegrains, fruits, milk and yoghurt – but also a huge range of items high in sugar or refined starches with little or no nutritional attributes. “Cutting carbs” doesn’t distinguish between the good and bad foods in this category.

This may not be the best way to get your daily ration of fruit. Adrian Scottow/Flickr, CC BY-SA

The same thing happens with fats. Sources of unsaturated fat – such as nuts, seeds, avocado or extra virgin olive oil – have proven health benefits. But there’s no evidence for any benefits of lard, dripping, cream, fast foods or any of the fatty snack foods that account for much of our saturated fat intake. And no long-term study shows sustained weight loss or other health benefits from a diet high in saturated fats.

Some foods are more even problematic. Most fast foods are high in saturated fat and salt, and lack dietary fibre. And they’re not only largely devoid of vegetables (apart from the odd gherkin), but often displace meals that would have contained vegetables.

Biscuits, cakes, pastries, many desserts and confectionery provide a double whammy with high levels of unhealthy fats as well as sugar and refined starches. Make that a triple whammy because most lack any nutritional virtue as well.

From bad to worse

Assumptions based on macronutrients are simply too gross to be meaningful. This is apparent in so-called meta-analyses based on a mixture of cohort and case-control studies that use different methods and time frames relating to what people eat, and fail to report all aspects of the diet.

One review, for instance, claimed that saturated fat was unrelated to cardiovascular disease. But it ignored the adverse impacts of the foods that had replaced saturated fats and provided no information about the foods that provided saturated fat in the first instance.

Worse still, such analyses are prone to many errors. A long check of every reference used in that meta-analysis showed that the conclusion would have differed if 25 studies had either not been omitted or had been reported correctly (sadly, it’s paywalled).

Another recent review also failed to show any clear association between higher saturated fat intake and all-cause mortality, heart disease, ischaemic stroke or type 2 diabetes, although the authors were unable to confidently rule out increased risk for heart disease deaths. They also noted that the certainty of associations between saturated fat and all outcomes was “very low”, which means we don’t yet understand the association between saturated fats and disease.

Not all dairy products are created equal. Samir Rahamtalla/Flickr, CC BY-NC-ND

Hopefully, further research will distinguish between food sources of saturated fats; they are not all equal. There’s already good evidence that processed meats can have more deleterious effects than fresh meat. And that fermented dairy products, such as yoghurt and cheese, may also have health benefits and are distinctly different for heart health risk compared to butter.

Swapping saturated fat for sugar or refined starches is worse than useless for preventing cardiovascular disease. But please direct criticism of foods where fat has been replaced by sugar at the food industry. Dietary guidelines have always recommended limiting sugar as well as saturated fat.

A sorry state of affairs

Unfortunately, in most developed countries, sugar consumption remains high while intakes of vegetables, legumes, fruits, nuts and wholegrains are low. And while macronutrient intakes in countries such as Australia may look fine (31% of energy from fat and 44% from carbs), problems remain with the kinds and amounts of foods we consume.

Junk food and drinks were once consumed only as an occasional treat, but they now contribute significant portions of both adult and children’s diets – in Australia, 35% of adults’ and 41% of childrens’ energy intake. Confectionery and starchy, fatty, savoury snack food intake have also increased significantly.

It really is time to focus on foods instead of wasting time on macronutrients. Australia’s Dietary Guidelines have made this change, as has the new simple Swedish equivalent, which emphasises sustainable choices. Norway and 20 European countries also take a food focus and the number one point in Brazil’s enlightened guidelines is that diet is more than the intake of nutrients.

Consider the dozens of studies on Mediterranean diets, including randomised trials, where the fat and carbohydrate content vary but the health value depends on particular foods: extra virgin olive oil, nuts, vegetables, fruits, grains and legumes and a low intake of highly processed products. The take-home message from these is that we need to stop fussing over macronutrients and think about foods.

Australians are undergoing unnecessary surgery – here’s what we can do about it

I am back at work this week. I hope you had a healthy and restful holiday season. I will continue to keep you informed of the major developments in health and hormones, on my regular blog. I pick and choose from a range of sources, making sure it is accurate and from trustworthy.

Australians are undergoing unnecessary surgery – here’s what we can do about it

August 17, 2015 6.27am AEST

Ineffective care exposes patients to complications and side-effects and waste precious health care resources. Jim Young/Reuters

Yet while many clinicians believe there is a problem, the policy response has been limited. It is often hard to isolate treatment choices that are inappropriate. A choice that is wrong in one case may be right in another.

To avoid ineffective treatments, we need a new way to identify and reduce questionable care. A new Grattan Institute report shows how to do it.

Warning signs

The report follows up two clues that treatment choices are sometimes wrong.

The first is geographic variation. In 2010-11, there were 1.3 tonsillectomies for every 1,000 people in Western Sydney. Along the Great South Coast in Victoria (the area around Warrnambool), the rate is 7.4 (these rates are adjusted for age and sex). It seems unlikely that variation this large is just a matter or people in some areas being sicker or more willing to go under the knife.

But while geographic variation is troubling, it is inconclusive. Some of it can be explained by factors such as how sick people are, but not all of it.

It is also hard to tell if over-servicing or under-servicing is the problem. Are people in areas with high rates of surgery getting too much, or are people elsewhere getting too little?

Finally, variation is typically measured among regions. That can make it hard to tell which providers are behind it. For all these reasons, years of debate and commentary about clinical variation has resulted in little policy action.

Public and private hospitals should be given time to examine their own practices. ChameleonsEye/Shutterstock

The second clue that alerts us questionable care is the use of treatments we know are ineffective for certain types of patients. Clinical research has uncovered hundreds of treatments that don’t work for certain types of patients. These treatments have been targeted for reduction or removal. Australian medical colleges have recently listed treatments that should be questioned in discussions between doctors and their patients.

Like clinical variation, ineffective care has been widely discussed but still persists. It is very hard to find treatments that are always wrong and efforts to shift treatment choices are sometimes met with indifference, resistance or gaming.

For instance, powerful evidence shows that a certain type of arthroscopy – inserting a tube to remove tissue – won’t help people with knee osteoarthritis. But it still happens at least 800 times a year in Australian hospitals.

What should be done?

The first step to address the problem is to provide better information. Clinicians cannot keep track of all the evidence published each year. Much of the guidance that summarise the evidence is flawed. We recommend that a body such as the Australian Commission on Safety and Quality in Health Care develop and publish clear guidance about which procedures should be avoided.

The second step is to monitor whether this guidance translates into practice. To show how this can be done, we measured how often hospitals provide five examples of do-not-do treatments. They are treatments that evidence, and usually government bodies, say should not be given to certain types of patient:

  • Vertebroplasty for osteoporotic spinal fractures: surgery to fill a backbone (vertebrae) with cement
  • Arthroscopic debridement for osteoarthritis of the knee: inserting a tube to remove tissue
  • Laparoscopic uterine nerve ablation for chronic pelvic pain: surgery to destroy a ligament that contains nerve fibres
  • Removing healthy ovaries during a hysterectomy
  • Hyperbaric oxygen therapy (breathing pure oxygen in a pressurised room) for a range of conditions including osteomyelitis (inflammation of the bone), cancer, and non-diabetic wounds and ulcers.

Our analysis combines the two big clues about questionable care: variation and ineffective care. It looks at treatments that we know are ineffective and identifies hospitals that are furthest from normal clinical practices.

This exposes outliers with troubling patterns of care. While many hospitals never provide the do-not-do treatments, some outlier hospitals provide them at more than ten times the average rate.

Some public hospitals give do-not-do treatments far more often than average

Grattan Institute

The Australian Commission on Safety and Quality in Health Care should report these results to hospitals, states and health insurers. Clinicians should know when they are out of step with the evidence and their peers.

But that won’t always be enough. When high rates of do-not-do procedures persist, states and insurers must take action. In theory, these treatments should never happen, but in practice they might sometimes be needed. For this reason, we recommend a cautious approach that uses data to drive expert clinical evaluation.

Public and private hospitals should be given time to examine their own practices. If after a year they still perform a do-not-do procedure at an above-average rate, the state government should initiate a clinical review of the hospital’s practices. Then doctors who perform the procedures can explain why to their peers.

The hospital’s practices may turn out to be justifiable. But if they aren’t, there should be consequences: states and insurers should start withholding funding for the do-not-do procedure.

Our report provides a proof-of-concept for this approach. Many more do-not-do treatments can be measured, including those that should be not be performed but not routinely (our report looks at a further three examples in this category).

For years there have been concerns that patients are getting the wrong treatment. Our Questionable Care report shows how to stop it.