It’s All in the Labeling or How to Get Your Child to Eat His Veggies

In a study recently published in JAMA Internal Medicine, researchers from Stanford University have shown what restauranteurs have known for years- describe your dishes in an indulgent manner and patrons will be enticed to buy. Image result for types of zucchini

Researchers performed the study at the University’s cafeteria, with a total of 27,933 diners (undergraduate students, graduate students, and staff) over the 2016 autumn academic calendar.

Each day, one featured vegetable dish was randomly labeled in one of four ways: basic, healthy restrictive, healthy positive, or indulgent. For example, butternut squash could be “butternut squash” (basic), “butternut squash with no added sugar” (healthy restrictive), “antioxidant-rich butternut squash” (healthy positive), or “twisted garlic-ginger butternut squash wedges” (indulgent). The kicker was that all meals looked and tasted the same and there was no difference in how they were served.

The researchers found that labeling the vegetables in an indulgent way significantly increased not only the selection of the vegetable, but the amount consumed as well. Vegetables labeled indulgently were chosen 25% (p=.04) more often than basic, 41% (p=.001) more often than healthy restrictive, and 35% (p=.01) more often than healthy positive. Similarly, indulgent labeling increased the amount consumed by 23% (p=.03) compared to basic, 33% (p=.004) compared to healthy restrictive, and 16% (NS) compared to healthy positive. There was no significant differences amongst basic, healthy restrictive and healthy positive groups for either outcome.

It’s seems a better strategy to speak of healthy foods in an indulgent manner, focusing on taste and flavors. Instead of “eat your zucchini,” you can try “who wants the slow-cooked garlicky heirloom zucchini with freshly chopped tarragon?”


Get off your butt, or Add 10 minutes for health

According to the World Health Organization (WHO), the minimal weekly level of leisure time exercise for adults is 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity. Most studies had examined the benefits of such exercise spread across 3 or more days per week.

In a study of over 55,000 adults, Lee et al evaluated the benefits of running on mortality. The participants had a mean age of 44 and mean follow-up of 15 years. Runners had a 30% lower all-cause mortality and 45% lower cardiovascular disease (CVD) mortality compared to non-runners. Runners lived on average 3 years longer. Of interest, running distance, time, frequency and pace did not significantly affect the mortality. Even running slowly (< 6 minutes/mile) 1-2 times per week for a total time of < 51 minutes was associated with mortality benefit. In fact, 5-10 minutes every day at slow speeds had mortality benefit.

In a more recent;y published study, researchers in England found that “weekend warrior” mode for just 1 or 2 sessions per week lowered all-cause mortality risk, CVD mortality risk and cancer mortality risk. There were almost 64,000 adult respondents, all over age 40, during 561,159 person-years of follow-up. The mean age was 58.6 years.

Participants were divided into four groups: (1) “Inactive” (no reported moderate or vigorous activity); (2) “Insufficiently active” (< 150 minutes moderate or < 75 minutes vigorous activity weekly); (3) “Regularly active” (meeting WHO recommendations with ≥ 150 minutes moderate or ≥ 75 minutes vigorous activity weekly over ≥ 3 sessions); or (4) “Weekend warrior” (≥ 150 minutes moderate or ≥ 75 minutes vigorous activity weekly but over only 1-2 sessions). Of the total participants, 62.8% were “inactive,” 22.4% were “insufficiently active,” 11.1% were “regularly active,” and 3.7% were “weekend warriors.” The BMI was similar for all groups. Occupational and domestic physical activity were not included. Weekend warriors were equally likely to exercise in 1 versus 2 sessions. Weekend warriors were more likely to be men and, as expected, tended to have more vigorous level of activity.

Compared the Inactive group (1), there was a significant reduction of all-cause mortality (30%), CVD death (40%), and cancer death risk (18%) amongst the Weekend warriors. There were similar risk reductions for group 2 and group 3 compared to group 1. Thus, even just 1 or 2 days of moderate to vigorous activity or exercise is sufficient to reduce risks for all-cause mortality, CVD mortality, and cancer mortality. Although men tended to  be “weekend warriors,” there was similar benefit for women.

What do these studies tell us? Even “insufficient” levels of activity or “weekend warrior” mode are associated with lower risks for all-cause mortality, CVD death, and cancer death compared to those adults who get no moderate to vigorous activity. In fact, just 5-10 minutes every day at slow speeds had mortality benefit.

Watching Too Much TV Could Kill You

In the Nurses’ Health Study, researchers had found a significantly increased risk (2.3) for pulmonary embolism (PE) for those who sat for >40 hours per week compared to those who spent < 10 hours sitting per week.

In a study recently published in the American Heart Association’s journal Circulation, researchers analyzing data from the Japanese Collaborative Cohort Study, involving >86,000 participants followed for more than 19 years, found that watching television for 5 or more hours per day increased the risk of death from PE 2.5-fold and watching TV for 2.5-4.9 hours daily had a 1.7-fold increase of PE death. These results were controlled for such factors as obesity, diabetes mellitus, hypertension, smoking, sports activity, age and sex. The risks could actually have been even higher since deaths from PE are likely underreported given the difficulty in diagnosis.

Sitting and watching TV for more than 5 hours per day significantly increased the risk of dying from blood clots. The current study participants were queried before computers, tablets and smartphones became such popular sources of entertainment, leading to the question as to whether sitting and watching these would be associated with the same or similar risk.

Prolonged sitting has been associated with venous stasis, a potential mechanism for development of deep venous thrombosis (DVT) and subsequent PE. Perhaps analogous to long airplane travel, it is best to get up frequently and to exercise and stretch your legs while binge-watching.

Traveling with COPD

For patients with chronic obstructive pulmonary disease (COPD), traveling can be challenging or problematic. Because of difficulty breathing, many COPDers may curtail traveling altogether, or limit vacations to places close to home. With advance planning and preparation, you can enjoy your travels. Sometimes COPD support groups can provide helpful advise.

Prepare:                                                                                                                                         1. Medications- Most importantly, do not pack your medication in checked baggage; keep them all with you in your carry-on. Keep any dose(s) that you need to take during your flight in a separate pill dispenser and give yourself a reminder so you won’t forget. Keep a copy of your medication list with you when you travel. Many smart phones have a health app that can be accessed without a password in case of emergencies and you should make sure to have your updated medication information entered. In addition, take a close up photo of each prescription bottle, making sure to include prescriber and the drug name, dose, and frequency. Don’t forget your inhalers!
2. Air Quality-  Poor air quality can make breathing difficult for patients with COPD. Check the air quality of the place(s) you are traveling to before you go. You can learn more here.                                                                                                                                                         3. Oxygen- See below and plan ahead. Be sure to have an adequate supply and be prepared for the unexpected. Consider bringing extra supplies in case of malfunction and speak with your DME/oxygen company before you go to get names and locations of suppliers along your route. Don’t travel without it.
4. Doctors- In addition to having a written list of your doctors and phone numbers, have a list of names and locations of doctors or hospitals at your destination(s). Your own doctor may be able to offer a referral or advise. Talk to your doctor about a COPD Action Plan.

Airplane Travel:                                                                                                                          1. Plan AheadMake sure you call your airline in advance to learn their policy and procedures for traveling with personal medical oxygen/equipment. You might consider calling airlines before purchasing your tickets, as some airline companies might more or less difficult to work with than others. Talk with your doctor because at altitude your oxygen needs are going to change and a COPDer who does not need oxygen normally at sea level may need it for air travel.                                                                                                    2. Medical Documents- Some airlines require documents from your physician or proof of current medical prescription for oxygen.                                                                                    3. Arrive Early at the Airport- Some airlines require early check-in and there may be hiccups that need extra time to fix. Personal medical oxygen and other respiratory-related equipment are permitted through TSA security but you be sure to find out more here.       4. Oxygen Arrangements- Many airlines will not let you bring your own equipment into the cabin, but instead require that you use their oxygen while in flight. Plan ahead and confirm that you will have a supply of oxygen awaiting at your destination. Your DME/oxygen supplier can often help, including arranging for a concentrator.                      5. DVT Prophylaxis- With airplane seats so cramped lately, there is a risk of developing deep venous thrombosis (DVT) otherwise known as blood clots. For someone with COPD, these can be especially serious. For long distance traveling, you can help prevent DVT by getting up occasionally and walking around, exercising your calf muscles and stretching your legs while you are seated, and selecting an aisle seat when possible. You might speak with your physician about compression stockings or preventative medications.

Bus or Train Travel:                                                                                                                      1. Plan Ahead- In most cases, patients with medical oxygen may take their own oxygen aboard but be sure to review the bus/train line’s policies and procedures well in advance of travel.                                                                                                                                                         2. Air Quality- Don’t forget to confirm that your accommodations are smoke-free.

Traveling by Cruise Line:                                                                                                        1. Plan Ahead- Most cruise lines are well-equipped to help customers with special needs, such as oxygen equipment, wheelchairs, respiratory equipment, etc but make sure you inform your cruise line well in advance of travel to advise them of your needs and to confirm procedures. More information can be found here.                                                         2. Medical Documents- Some cruise line require documents from your physician, such as medical history, medication list in case any need to be replaced, and copy of your oxygen prescription.                                                                                                                             3. Oxygen Arrangements- Most cruise lines will assist you but you may need to arrange for your oxygen tanks or concentrator to be delivered to the ship prior to departure. Your DME/oxygen supplier can often help.

Car Travel:                                                                                                                                    1. Plan Ahead- Get information on hospitals and doctors on your route, in case of emergency. Ask your doctors.                                                                                                       2. Oxygen- Position your oxygen tank upright next to you, preferably secured. If you have extra tanks, don’t leave them in the trunk.                                                                         3. No smoking- Make sure no one smokes while in the car with you.                                 4. Pace Yourself- Be prepared to rest along the way and consider making shorter driving segments each day.                                                                                                                 5. Air Quality- Check the air quality of the places along your route. Avoid exhaust fumes and allergens by keeping the windows closed and the recirculating air conditioning on.

Choosing a Place to Stay:                                                                                                         1. Smoke-Free- Select a smoke-free hotel, or at a minimum ask for a non-smoking room. If you are staying with friends or relatives who smoke, ask them for your health to do so outdoors.                                                                                                                                          2. Reduce Odors and Allergens- Ask your hotel if they have special rooms with reduced allergens and use unscented cleaning products. If you are staying with family or friends, be sure to ask them not to burn incense or scented candles.

Visiting Places:                                                                                                                            1. Zoos and Animal Parks- If you have an allergic component, best to avoid exposure.
2. Swimming Pools- Chlorine and other chemicals used to clean pools can be irritating to the lungs, especially with COPD. Be sure the area is well ventilated, and you may want to avoid indoor pools.                                                                                                                           3. Camping- Campfire smoke can be very irritating and make COPD symptoms worse. Don’t sit too close and remain upwind.                                                                                            4. Outdoors- Be aware of the air quality, including smog, fumes, particulates and pollens. Don’t get over-heated and take rests in an indoors air-conditioned location. Make sure you have your rescue inhaler medication with you.



Danger of Reliance on Placebo Effect

With asthma patients, giving an inhaled bronchodilator medication, like albuterol, can result in a rapid improvement in airflow that can be objectively measured using spirometry testing. This testing can be repeated over a short period of time, thus making asthma an excellent model for assessing a “placebo effect” (benefit resulting from simulated treatment or the experience of care).

In a randomized, double-blind, cross-over study published in the New England Journal of Medicine, Wechsler et al compared 4 intervention arms in asthmatic patients:

  1. Active medication—double-blinded albuterol inhaler
  2. Placebo #1—double-blinded inert inhaler
  3. Placebo #2—single-blinded sham acupuncture
  4. No intervention at all

Only those asthmatics with documented FEV1 bronchodilator responsiveness (of at least 12%) were enrolled and each study subject received each of the four interventions three times.

The authors looked at objective evidence of airflow improvement by measuring spirometry, as well as self-reported subjective improvement, and here is what they found:

  1. Albuterol produced a significant improvement in FEV1 (20.1%), as compared to only about 7% with each of the other three interventions (p<0.001). There was no statistical difference in airflow improvement among either placebo arm or the “nothing” arm.
  2. Patients’ subjective report of improvement did not significantly differ between the albuterol inhaler (50%), placebo inhaler (45%), or sham acupuncture (46%), but all three were significantly better than no intervention (21%)(p<0.001).
  3. In an assessment of treatment credibility (percent of subjects’ subjective belief they had received an active treatment), sham acupuncture (85%) was statistically “more credible”(p<0.005) than either albuterol inhaler (73%) or placebo inhaler (66%).

For the objective testing, there was a powerful medication effect, but no placebo effect. For the subjective outcome, the placebo effects were equivalent to the active medication effect, and all were better than no intervention. Placebos offered no objective bronchodilator effect beyond no intervention of any kind. Incredibly, subjective improvement for placebo was similar to active drug, even though active drug had 3 times the bronchodilator effect and placebo was no better than no intervention.

In this well designed study, with the inclusion of a “no intervention” arm, the authors are able to demonstrate that placebos are primarily detectable in subjective outcomes, and that studies reporting only subjective results should be interpreted with extreme caution.

Don’t trust the “snake oil” study if it relies on subjective results, rather than objective measurements.