Quick hits - New Year's Resolutions, a (hopefully final) word on masks, and OTC fish oil
I don’t have one big topic for you today, just a few quick hits about things I’ve been contemplating recently.
As always, you can reply directly to this message with questions or comments.
New Year’s Resolutions fail for simple and predictable reasons
I can’t tell you how many patients I’ve seen in the last month that mention something to me about how their New Year’s resolution is to get back into shape now that the holidays (or the pandemic) are over.
Let’s leave aside the fact that bringing up your plan to start a New Year’s resolution a few weeks into the year suggests a low probability of success - after all, the best day to start is today - and spend a few minutes on why most people who lose weight eventually gain it back.
Most New Year’s resolutions are destined to fail for the same 3 predictable reasons that most diets fail:
There’s no plan for success. Hope is not a plan.
Relying on willpower rather than a change to the environment.
Viewing the resolution or diet as means of getting to a destination and then being able to stop.
We can look to the National Weight Control Registry of people who have long term success (>5 years) in maintaining weight loss tend to see how this plays out.
Almost all of them (98% to be exact) modify their food intake and 94% increase their physical activity, mostly by walking.
You can read a list of the studies looking at the NWCR here, and the most wild part of it is how boring the findings are - less sugary beverages, more walking, better sleep, long term changes in diet.
Note what’s absent here: the people who were successful didn’t do keto, go plant-based, start doing CrossFit, or start intermittent fasting.
They picked a strategy, changed their environment, and didn’t revert back to their old ways when the number on the scale reached their goal.
Masks don’t really work if you actually look at the data on their use
I started out at the beginning of the pandemic very much a believer in the importance of masking.
After the DANMASK study in Denmark showed that masking didn’t work across the population, I wrote a newsletter on why I wasn’t persuaded by the results and why I was still bullish on masking.
After the cluster randomized trial in Bangladesh, I wrote about why it made me think that masking over age 60 was really important.
But now the Cochrane Collaboration has a review of the evidence on masking, and it’s pretty unimpressive:
If you look at the sum total of the evidence, masking doesn’t seem to prevent Covid, flu, or respiratory illness.
Now, you can certainly discuss the caveats in data interpretation here - compliance with masking is low, asymptomatic transmission is real - and cite studies about the physics of how viruses spread through respiratory droplets, but we aren’t mannequins who wear masks perfectly 24 hours a day.
In real life, people take their masks off to each lunch and socialize outside of masked spaces with nothing covering their faces. They pull their masks down to take a deep breath or because not everyone’s hearing is all that great and we use lip reading and facial expressions to communicate.
When an intervention doesn’t show a benefit in actual clinical trials in the real world, it doesn’t really matter how elegant the mechanism of action is.
No one should start prescribing permafibrate to lower triglycerides after the PROMINENT trial showed that it didn’t reduce heart attacks.
And I think it’s equally hard to argue that that population-wide masking does anything to slow the spread of Covid with all the data that we have showing that it doesn’t.
When you’re making policy, you should be honest about what the data show. And when it comes to masks, the data shows that they don’t do anything.
But before you jump on me for this data interpretation - one quick caveat
What applies to the population doesn’t necessarily apply to an individual. Someone at individually high risk might benefit from wearing an N95 mask to protect themselves - but that’s a very different statement than suggesting population wide masking makes any difference.
Over the counter fish oil is probably a waste of money
When I wrote about fish oil in this newsletter a few months ago, I discussed over the counter fish oil in a neutral way - I wrote that it’s probably fine to take, as long as you buy from reputable sources.
As I’ve read and thought more here, I think that’s probably the wrong advice, and I’ve updated my conversations with patients accordingly.
Fish oil is mostly polyunsaturated fatty acids, which are less stable than most other fat sources. They’re prone to oxidation, and over the counter fish oil supplements have significant oxidative damage when tested.
A fair number of them also contain more saturated fat than suggested by labeling.
And the gamble here just isn’t the right thing.
If I’m going to recommend to my patients that they spend their money on something to reduce their heart disease risk, I’m going to need to see much better data on OTC fish oil than exists.
I need to see not only that’s it’s more effective in reducing heart disease risk, but I also need to see better proof it’s not harmful.
Because I no longer believe it to be an intervention that might help but might be neutral - I think that there’s real risk in actually making things worse.