How exercise in old age prevents the immune system from declining

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lab testing with Norman Lazarus Image caption Professor Norman Lazarus, aged 82, has the immune system of a 20 year old

Doing lots of exercise in older age can prevent the immune system from declining and protect people against infections, scientists say.

They followed 125 long-distance cyclists, some now in their 80s, and found they had the immune systems of 20-year-olds.

Prof Norman Lazarus, 82, of King's College London, who took part in and co-authored the research, said: "If exercise was a pill, everyone would be taking it.

"It has wide-ranging benefits for the body, the mind, for our muscles and our immune system."

The research was published in the journal Aging Cell.

Prof Janet Lord, director of the Institute of Inflammation and Ageing, at the University of Birmingham, and co-author of the research, said: "The immune system declines by about 2-3% a year from our 20s, which is why older people are more susceptible to infections, conditions like rheumatoid arthritis and, potentially, cancer.

"Because the cyclists have the immune system of a 20-year-old rather than a 70- or 80-year-old, it means they have added protection against all these issues."

The researchers looked at markers in the blood for T-cells, which help the immune system respond to new infections.

These are produced in the thymus, a gland in the chest, which normally shrinks in size in adulthood.

'Out of puff'

They found that the endurance cyclists were producing the same level of T-cells as adults in their 20s, whereas a group of inactive older adults were producing very few.

The researchers believe that being physically active in old age will help people respond better to vaccines, and so be better protected against infections such as flu.

Steve Harridge, co-author and professor of physiology at King's College London, said: "Being sedentary goes against evolution because humans are designed to be physically active.

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Media captionOne elderly cyclist said he had the body fat of a 19-year-old

"You don't need to be a competitive athlete to reap the benefits - or be an endurance cyclist - anything which gets you moving and a little bit out of puff will help."

Prof Harridge and Prof Lazarus believe that highly physically active older people represent the perfect group in which to analyse the true effects of biological ageing.

A separate paper in Aging Cell found that the cyclists did not lose muscle mass or strength, and did not see an increase in body fat - which are usually associated with ageing.

I met a dozen of the cyclists, on a morning ride in Surrey. Despite the bitter cold, they were universally cheerful, and clearly used to riding in all weathers.

They are members of Audax, a long-distance cycling organisation that organises events ranging from 100km to 300km.

The older members - in their 80s - say they do only the "short" 100km (62-mile) rides, but this is still highly impressive.

So why do they do it?

Pam Jones, 79, told me: "I do it for my health, because it's sociable, and because I enjoy the freedom it gives you."

Brian Matkins, 82, said: "One of the first results I got from the medical study was I was told my body fat was comparable to that of a 19-year-old."

Aged just 64, Jim Woods, is a comparative youngster in the group. He averages 100 miles a week on his bike, with more during the summer.

He said: "I cycle for a sense of wellbeing and to enjoy our wonderful countryside."

Cycling 60 miles or more may not be your idea of fun, but these riders have found something that gives them pleasure, which is a key reason why they continue.

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Yes, bacon really is killing us

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There was a little cafe I used to go to that did the best bacon sandwiches. They came in a soft and pillowy white bap. The bacon, thick-cut from a local butcher, was midway between crispy and chewy. Ketchup and HP sauce were served in miniature jars with the sandwich, so you could dab on the exact amount you liked. That was all there was to it: just bread and bacon and sauce. Eating one of these sandwiches, as I did every few weeks, with a cup of strong coffee, felt like an uncomplicated pleasure.

And then, all of a sudden, the bacon sandwich stopped being quite so comforting. For a few weeks in October 2015, half the people I knew were talking about the news that eating bacon was now a proven cause of cancer. You couldn’t miss the story: it was splashed large in every newspaper and all over the web. As one journalist wrote in Wired, “Perhaps no two words together are more likely to set the internet aflame than BACON and CANCER.” The BBC website announced, matter-of-factly, that “Processed meats do cause cancer”, while the Sun went with “Banger out of Order” and “Killer in the Kitchen”.

The source of the story was an announcement from the World Health Organization that “processed meats” were now classified as a group 1 carcinogen, meaning scientists were certain that there was “sufficient” evidence that they caused cancer, particularly colon cancer. The warning applied not just to British bacon but to Italian salami, Spanish chorizo, German bratwurst and myriad other foods.

Health scares are ten-a-penny, but this one was very hard to ignore. The WHO announcement came on advice from 22 cancer experts from 10 countries, who reviewed more than 400 studies on processed meat covering epidemiological data from hundreds of thousands of people. It was now possible to say that “eat less processed meat”, much like “eat more vegetables”, had become one of the very few absolutely incontrovertible pieces of evidence-based diet advice – not simply another high-profile nutrition fad. As every news report highlighted, processed meat was now in a group of 120 proven carcinogens, alongside alcohol, asbestos and tobacco – leading to a great many headlines blaring that bacon was as deadly as smoking.

The WHO advised that consuming 50g of processed meat a day – equivalent to just a couple of rashers of bacon or one hotdog – would raise the risk of getting bowel cancer by 18% over a lifetime. (Eating larger amounts raises your risk more.) Learning that your own risk of cancer has increased from something like 5% to something like 6% may not be frightening enough to put you off bacon sandwiches for ever. But learning that consumption of processed meat causes an additional 34,000 worldwide cancer deaths a year is much more chilling. According to Cancer Research UK, if no one ate processed or red meat in Britain, there would be 8,800 fewer cases of cancer. (That is four times the number of people killed annually on Britain’s roads.)

The news felt especially shocking because both ham and bacon are quintessentially British foods. Nearly a quarter of the adult population in Britain eats a ham sandwich for lunch on any given day, according to data from 2012 gathered by researchers Luke Yates and Alan Warde. To many consumers, bacon is not just a food; it is a repository of childhood memories, a totem of home. Surveys indicate that the smell of frying bacon is one of our favourite scents in the UK, along with cut grass and fresh bread. To be told that bacon had given millions of people cancer was a bit like finding out your granny had been secretly sprinkling arsenic on your morning toast.

Vegetarians might point out that the bacon sandwich should never have been seen as comforting. It is certainly no comfort for the pigs, most of whom are kept in squalid, cramped conditions. But for the rest of us, it was alarming to be told that these beloved foods might be contributing to thousands of needless human deaths. In the weeks following news of the WHO report, sales of bacon and sausages fell dramatically. British supermarkets reported a £3m drop in sales in just a fortnight. (“It was very detrimental,” said Kirsty Adams, the product developer for meat at Marks and Spencer.)

But just when it looked as if this may be #Bacongeddon (one of many agonised bacon-related hashtags trending in October 2015), a second wave of stories flooded in. Their message was: panic over. For one thing, the analogy between bacon and smoking was misleading. Smoking tobacco and eating processed meat are both dangerous, but not on the same scale. To put it in context, around 86% of lung cancers are linked to smoking, whereas it seems that just 21% of bowel cancers can be attributed to eating processed or red meat. A few weeks after publishing the report, the WHO issued a clarification insisting it was not telling consumers to stop eating processed meat.

Meanwhile, the meat industry was busily insisting that there was nothing to see here. The North American Meat Institute, an industry lobby group, called the report “dramatic and alarmist overreach”. A whole tranche of articles insisted in a commonsense tone that it would be premature and foolish to ditch our meaty fry-ups just because of a little cancer scare.

Nearly three years on, it feels like business as usual for processed meats. Many of us seem to have got over our initial sense of alarm. Sales of bacon in the UK are buoyant, having risen 5% in the two years up to mid-2016. When I interviewed a product developer for Sainsbury’s supermarket last year, she said that one of the quickest ways to get British consumers to try a new product now was to add chorizo to it.

And yet the evidence linking bacon to cancer is stronger than ever. In January, a new large-scale study using data from 262,195 British women suggested that consuming just 9g of bacon a day – less than a rasher – could significantly raise the risk of developing breast cancer later in life. The study’s lead author, Jill Pell from the Institute of Health and Wellbeing at Glasgow University, told me that while it can be counterproductive to push for total abstinence, the scientific evidence suggests “it would be misleading” for health authorities to set any safe dose for processed meat “other than zero”.

The real scandal of bacon, however, is that it didn’t have to be anything like so damaging to our health. The part of the story we haven’t been told – including by the WHO – is that there were always other ways to manufacture these products that would make them significantly less carcinogenic. The fact that this is so little known is tribute to the power of the meat industry, which has for the past 40 years been engaged in a campaign of cover-ups and misdirection to rival the dirty tricks of Big Tobacco.


How do you choose a pack of bacon in a shop, assuming you are a meat eater? First, you opt for either the crispy fat of streaky or the leanness of back. Then you decide between smoked or unsmoked – each version has its passionate defenders (I am of the unsmoked persuasion). Maybe you seek out a packet made from free-range or organic meat, or maybe your budget is squeezed and you search for any bacon on special offer. Either way, before you put the pack in your basket, you have one last look, to check if the meat is pink enough.

Since we eat with our eyes, the main way we judge the quality of cured meats is pinkness. Yet it is this very colour that we should be suspicious of, as the French journalist Guillaume Coudray explains in a book published in France last year called Cochonneries, a word that means both “piggeries” and “rubbish” or “junk food”. The subtitle is “How Charcuterie Became a Poison”. Cochonneries reads like a crime novel, in which the processed meat industry is the perpetrator and ordinary consumers are the victims.

The pinkness of bacon – or cooked ham, or salami – is a sign that it has been treated with chemicals, more specifically with nitrates and nitrites. It is the use of these chemicals that is widely believed to be the reason why “processed meat” is much more carcinogenic than unprocessed meat. Coudray argues that we should speak not of “processed meat” but “nitro-meat”.

Prosciutto di Parma has been produced without nitrates since 1993. Photograph: Stefano Rellandini/Reuters

“Pure insane crazy madness” is how Coudray described the continuing use of nitrates and nitrites in processed meats, in an email to me. The madness, in his view, is that it is possible to make bacon and ham in ways that would be less carcinogenic. The most basic way to cure any meat is to salt it – either with a dry salt rub or a wet brine – and to wait for time to do the rest. Coudray notes that ham and bacon manufacturers claim this old-fashioned way of curing isn’t safe. But the real reason they reject it is cost: it takes much longer for processed meats to develop their flavour this way, which cuts into profits.

There is much confusion about what “processed meat” actually means, a confusion encouraged by the bacon industry, which benefits from us thinking there is no difference between a freshly minced lamb kofta and a pizza smothered in nitrate-cured pepperoni. Technically, processed meat means pork or beef that has been salted and cured, with or without smoking. A fresh pound of beef mince isn’t processed. A hard stick of cured salami is.

The health risk of bacon is largely to do with two food additives: potassium nitrate (also known as saltpetre) and sodium nitrite. It is these that give salamis, bacons and cooked hams their alluring pink colour. Saltpetre – sometimes called sal prunella – has been used in some recipes for salted meats since ancient times. As Jane Grigson explains in Charcuterie and French Pork Cookery, saltpetre was traditionally used when brining hams to give them “an attractive rosy appearance when otherwise it would be a murky greyish brown”.

In earlier centuries, bacon-makers who used saltpetre did not understand that it converts to nitrite as the meat cures. It is this nitrite that allows the bacteria responsible for cured flavour to emerge quicker, by inhibiting the growth of other bacteria. But in the early 20th century, the meat industry found that the production of cured meats could be streamlined by adding sodium nitrite to the pork in pure form. In trade journals of the 1960s, the firms who sold nitrite powders to ham-makers spoke quite openly about how the main advantage was to increase profit margins by speeding up production. One French brand of sodium nitrite from the 60s was called Vitorose or “quick-pink”.

Nitro-chemicals have been less of a boon to consumers. In and of themselves, these chemicals are not carcinogenic. After all, nitrate is naturally present in many green vegetables, including celery and spinach, something that bacon manufacturers often jubilantly point out. As one British bacon-maker told me, “There’s nitrate in lettuce and no one is telling us not to eat that!”

But something different happens when nitrates are used in meat processing. When nitrates interact with certain components in red meat (haem iron, amines and amides), they form N-nitroso compounds, which cause cancer. The best known of these compounds is nitrosamine. This, as Guillaume Coudray explained to me in an email, is known to be “carcinogenic even at a very low dose”. Any time someone eats bacon, ham or other processed meat, their gut receives a dose of nitrosamines, which damage the cells in the lining of the bowel, and can lead to cancer.

You would not know it from the way bacon is sold, but scientists have known nitrosamines are carcinogenic for a very long time. More than 60 years ago, in 1956, two British researchers called Peter Magee and John Barnes found that when rats were fed dimethyl nitrosamine, they developed malignant liver tumours. By the 1970s, animal studies showed that small, repeated doses of nitrosamines and nitrosamides – exactly the kind of regular dose a person might have when eating a daily breakfast of bacon – were found to cause tumours in many organs including the liver, stomach, oesophagus, intestines, bladder, brain, lungs and kidneys.

Just because something is a carcinogen in rats and other mammals does not mean it will cause cancer in humans, but as far back as 1976, cancer scientist William Lijinsky argued that “we must assume” that these N-nitroso compounds found in meats such as bacon were also “carcinogens for man”. In the years since, researchers have gathered a massive body of evidence to lend weight to that assumption. In 1994, to take just one paper among hundreds on nitrosamines and cancer, two American epidemiologists found that eating hotdogs one or more times a week was associated with higher rates of childhood brain cancer, particularly for children who also had few vitamins in their diets.

In 1993, Parma ham producers in Italy made a collective decision to remove nitrates from their products and revert to using only salt, as in the old days. For the past 25 years, no nitrates or nitrites have been used in any Prosciutto di Parma. Even without nitrate or nitrite, the Parma ham stays a deep rosy-pink colour. We now know that the colour in Parma ham is totally harmless, a result of the enzyme reactions during the ham’s 18-month ageing process.

Slow-cured, nitrate-free, artisan hams are one thing, but what about mass-market meats? Eighteen months would be “a long time to wait on hotdogs”, as the food science expert Harold McGee comments. But there have always been recipes for nitrate-free bacon using nothing but salt and herbs. John Gower of Quiet Waters Farm, a pork producer who advises many British manufacturers of cured meats, confirms that nitrate is not a necessary ingredient in bacon: “It’s generally accepted that solid muscle products, as opposed to chopped meat products like salami, don’t require the addition of nitrate for safety reasons.”

Bacon is proof, if it were needed, that we cling to old comforts long after they have been proven harmful. The attachment of producers to nitrates in bacon is mostly “cultural”, says Gower. Bacon cured by traditional methods without nitrates and nitrites will lack what Gower calls that “hard-to-define tang, that delicious almost metallic taste” that makes bacon taste of bacon to British consumers. Bacon without nitrates, says Gower, is nothing but “salt pork”.

Given the harm of “nitro-meat” has been known for so long, the obvious question is why more has not been done to protect us from it. Corinna Hawkes, a professor of Food Policy at City University in London, has been predicting for years that processed meats will be “the next sugar” – a food so harmful that there will be demands for government agencies to step in and protect us. Some day soon, Hawkes believes, consumers will finally wake up to the clear links between cancer and processed meat and say “Why didn’t someone tell me about this?”


The most amazing thing about the bacon panic of 2015 was that it took so long for official public health advice to turn against processed meat. It could have happened 40 years earlier. The only time that the processed meat industry has looked seriously vulnerable was during the 1970s, a decade that saw the so-called “war on nitrates” in the US. In an era of Ralph Nader-style consumer activism, there was a gathering mood in favour of protecting shoppers against bacon – which one prominent public health scientist called “the most dangerous food in the supermarket”. In 1973, Leo Freedman, the chief toxicologist of the US Food and Drug Administration, confirmed to the New York Times that “nitrosamines are a carcinogen for humans” although he also mentioned that he liked bacon “as well as anybody”.

The US meat industry realised it had to act fast to protect bacon against the cancer charge. The first attempts to fight back were simply to ridicule the scientists for over-reacting. In a 1975 article titled “Factual look at bacon scare”, Farmers Weekly insisted that a medium-weight man would have to consume more than 11 tonnes of bacon every single day to run the faintest risk of cancer. This was an outrageous fabrication.

But soon the meat lobby came up with a cleverer form of diversion. The AMI – the American Meat Institute – started to make the argument that the nitrate was only there for the consumer’s own safety, to ward off botulism – a potentially fatal toxin sometimes produced by poorly preserved foods. The scientific director of the AMI argued that a single cup of botulism would be enough to wipe out every human on the planet. So, far from harming lives, bacon was actually saving them.

In 1977, the FDA and the US Department of Agriculture gave the meat industry three months to prove that nitrate and nitrite in bacon caused no harm. “Without a satisfactory response,” Coudray writes, “these additives would have to be replaced 36 months later with non-carcinogenic methods.” The meat industry could not prove that nitrosamines were not carcinogenic – because it was already known that they were. Instead, the argument was made that nitrates and nitrites were utterly essential for the making of bacon, because without them bacon would cause thousands of deaths from botulism. In 1978, in response to the FDA’s challenge, Richard Lyng, director of the AMI, argued that nitrites are to processed meat “as yeast is to bread”.

The meat industry’s tactics in defending bacon have been “right out of the tobacco industry’s playbook”, according to Marion Nestle, professor of nutrition and food studies at New York University. The first move is: attack the science. By the 1980s, the AMI was financing a group of scientists based at the University of Wisconsin. These meat researchers published a stream of articles casting doubt on the harmfulness of nitrates and exaggerating the risk from botulism of non-nitrated hams.

Does making ham without nitrite lead to botulism? If so, it is a little strange that in the 25 years that Parma ham has been made without nitrites, there has not been a single case of botulism associated with it. Almost all the cases of botulism from preserved food – which are extremely rare – have been the result of imperfectly preserved vegetables, such as bottled green beans, peas and mushrooms. The botulism argument was a smokescreen. The more that consumers could be made to feel that the harmfulness of nitrate and nitrite in bacon and ham was still a matter of debate, the more they could be encouraged to calm down and keep buying bacon.

A bacon sandwich at a diner in Michigan. Photograph: Molly Riley/Reuters

The botulism pretext was very effective. The AMI managed to get the FDA to keep delaying its three-month ultimatum on nitrites until a new FDA commissioner was appointed in 1980 – one more sympathetic to hotdogs. The nitrite ban was shelved. The only concession the industry had made was to limit the percentage of nitrites added to processed meat and to agree to add vitamin C, which would supposedly mitigate the formation of nitrosamines, although it does nothing to prevent the formation of another known carcinogen, nitrosyl-haem.

Over the years, the messages challenging the dangers of bacon have become ever more outlandish. An explainer article by the Meat Science and Muscle Biology lab at the University of Wisconsin argues that sodium nitrite is in fact “critical for maintaining human health by controlling blood pressure, preventing memory loss, and accelerating wound healing”. A French meat industry website, info-nitrites.fr, argues that the use of the “right dose” of nitrites in ham guarantees “healthy and safe” products, and insists that ham is an excellent food for children.

The bacon lobby has also found surprising allies among the natural foods brigade. Type “nitrate cancer bacon” into Google, and you will find a number of healthy eating articles, some of them written by advocates of the “Paleo” diet, arguing that bacon is actually a much-maligned health food. The writers often mention that vegetables are the primary source of nitrates, and that human saliva is high in nitrite. One widely shared article claims that giving up bacon would be as absurd as attempting to stop swallowing. Out of the mass of stuff on the internet defending the healthiness of bacon, it can be hard to tell which writers have fallen under the sway of the meat lobby, and which are simply clueless “nutrition experts” who don’t know any better.

Either way, this misinformation has the potential to make thousands of people unwell. The mystifying part is why the rest of us have been so willing to accept the cover-up.


Our deepening knowledge of its harm has done very little to damage the comforting cultural associations of bacon. While I was researching this article, I felt a rising disgust at the repeated dishonesty of the processed meat industry. I thought about hospital wards and the horrible pain and indignity of bowel cancer. But then I remembered being in the kitchen with my father as a child on a Sunday morning, watching him fry bacon. When all the bacon was cooked, he would take a few squares of bread and fry them in the meaty fat until they had soaked up all its goodness.

In theory, our habit of eating salted and cured meats should have died out as soon as home refrigerators became widespread in the mid-20th century. But tastes in food are seldom rational, and millions of us are still hooked on the salty, smoky, umami savour of sizzling bacon.

We are sentimental about bacon in a way we never were with cigarettes, and this stops us from thinking straight. The widespread willingness to forgive pink, nitrated bacon for causing cancer illustrates how torn we feel when something beloved in our culture is proven to be detrimental to health. Our brains can’t cope with the horrid feeling that bacon is not what we thought it was, and so we turn our anger outwards to the health gurus warning us of its hazards. The reaction of many consumers to the WHO report of 2015 was: hands off my bacon!

In 2010, the EU considered banning the use of nitrates in organic meats. Perhaps surprisingly, the British organic bacon industry vigorously opposed the proposed nitrates ban. Richard Jacobs, the late chief executive of Organic Farmers & Growers, an industry body, said that prohibiting nitrate and nitrite would have meant the “collapse” of a growing market for organic bacon.

Organic bacon produced with nitrates sounds like a contradiction in terms, given that most consumers of organic food buy it out of concerns for food safety. Having gone to the trouble of rearing pigs using free-range methods and giving them only organic feed, why would you then cure the meat in ways that make it carcinogenic? In Denmark, all organic bacon is nitrate-free. But the UK organic industry insisted that British shoppers would be unlikely to accept bacon that was ‘“greyish”.

Then again, the slowness of consumers to lose our faith in pink bacon may partly be a response to the confusing way that the health message has been communicated to us. When it comes to processed meat, we have been misled not just by wild exaggerations of the food industry but by the caution of science.

On the WHO website, the harmfulness of nitrite-treated meats is explained so opaquely you could miss it altogether. In the middle of a paragraph on “what makes red meat and processed meat increase the risk of cancer”, it says: “For instance, carcinogenic chemicals that form during meat processing include N-nitroso compounds.” What this means, in plain English, is that nitrites make bacon more carcinogenic. But instead of spelling this out, the WHO moves swiftly on to the question of how both red and processed meats might cause cancer, after adding that “it is not yet fully understood how cancer risk is increased”.

The typical British sausage does not fall into the ‘processed meat’ category. Photograph: Julian Smith/AAP

This caution has kept us as consumers unnecessarily in the dark. Consider sausages. For years, I believed that the unhealthiest part in a cooked English breakfast was the sausage, rather than the bacon. Before I started to research this article, I’d have sworn that sausages fell squarely into the “processed meat” category. They are wrongly listed as such on the NHS website.

But the average British sausage – as opposed to a hard sausage like a French saucisson – is not cured, being made of nothing but fresh meat, breadcrumbs, herbs, salt and E223, a preservative that is non-carcinogenic. After much questioning, two expert spokespeople for the US National Cancer Institute confirmed to me that “one might consider” fresh sausages to be “red meat” and not processed meat, and thus only a “probable” carcinogen. (To me, the fact that most sausages are not processed meat was deeply cheering, and set me dancing around the kitchen with glee thinking about toad in the hole.)

In general, if you ask a cancer scientist to distinguish between the risks of eating different types of meat, they become understandably cagey. The two experts at the National Cancer Institute told me that meats containing nitrites and nitrates have “consistently been associated with increased risk of colon cancer” in human studies. But they added that “it is difficult to separate nitrosamines from other possible carcinogens that may be present in processed meats like bacon”. These other suspects include haem iron – a substance that is abundant in all red meat, processed or not – and heterocyclic amines: chemicals that form in meat during cooking. A piece of crispy, overcooked bacon will contain multiple carcinogens, and not all are due to the nitrates.

The problem with this reasoning, as I see it, is that it can’t account for why processed meat is so much more closely linked to cancer than cooked red meat. For that, there remains no plausible explanation except for nitrates and nitrites. But looking for clear confirmation of this in the data is tricky, given that humans do not eat in labs under clinical observation.

Most of what we know about processed meat and cancer in humans comes from epidemiology – the study of disease across whole populations. But epidemiologists do not ask the kind of detailed questions about food that the people who eat that food may like answers to. The epidemiological data – based on surveys of what people eat – is now devastatingly clear that diets high in “processed meats” lead to a higher incidence of cancer. But it can’t tell us how or why or which meats are the best or worst. As Corinna Hawkes of City University comments, “The researchers don’t ask you if you are eating artisanal charcuterie from the local Italian deli or the cheapest hotdogs on the planet.”

I would love to see data comparing the cancer risk of eating nitrate-free Parma ham with that of traditional bacon, but no epidemiologist has yet done such a study. The closest anyone has come was a French study from 2015, which found that consumption of nitrosylated haem iron – as found in processed meats – had a more direct association with colon cancer than the haem iron that is present in fresh red meat.

It may be possible that epidemiologists have not asked people more detailed questions about what kind of processed meats they eat because they assume there is no mass-market alternative to bacon made without nitrates or nitrites. But this is about to change.


The technology now exists to make the pink meats we love in a less damaging form, which raises the question of why the old kind is still so freely sold. Ever since the “war on nitrates” of the 1970s, US consumers have been more savvy about nitrates than those in Europe, and there is a lot of “nitrate-free bacon” on the market. The trouble, as Jill Pell remarks, is that most of the bacon labelled as nitrate-free in the US “isn’t nitrate-free”. It’s made with nitrates taken from celery extract, which may be natural, but produces exactly the same N-nitroso compounds in the meat. Under EU regulation, this bacon would not be allowed to be labelled “nitrate-free”.

“It’s the worst con I’ve ever seen in my entire life,” says Denis Lynn, the chair of Finnebrogue Artisan, a Northern Irish company that makes sausages for many UK supermarkets, including Marks & Spencer. For years, Lynn had been hoping to diversify into bacon and ham but, he says, “I wasn’t going to do it until we found a way to do it without nitrates.”

When Lynn heard about a new process, developed in Spain, for making perfectly pink, nitrate-free bacon, he assumed it was another blind alley. In 2009, Juan de Dios Hernandez Canovas, a food scientist and the head of the food tech company Prosur, found that if he added certain fruit extracts to fresh pork, it stayed pink for a surprisingly long time.

In January 2018, Finnebrogue used this technology to launch genuinely nitrate-free bacon and ham in the UK. It is sold in Sainsbury’s and Waitrose as “Naked Bacon” and “Naked Ham”, and in M&S as “made without nitrites”. Kirsty Adams, who oversaw its launch at M&S, explains that “it’s not really cured”. It’s more like a fresh salted pork injected with a fruit and vegetable extract, and is more perishable than an old-fashioned flitch of bacon – but that doesn’t matter, given that it is kept in a fridge. Because it is quick to produce, this is much more “economically viable” to make than some of the other nitrate-free options, such as slow-cured Parma ham. The bacon currently sells in Waitrose for £3 a pack, which is not the cheapest, but not prohibitive either.

I tried some of the Finnebrogue bacon from M&S. The back bacon tasted pleasant and mild, with a slight fruitiness. It didn’t have the toothsome texture or smoky depth of a rasher of butcher’s dry-cured bacon, but I’d happily buy it again as an alternative to “nitro-meat”. None of my family noticed the difference in a spaghetti amatriciana.

Nitrite-free bacon still sounds a bit fancy and niche, but there shouldn’t be anything niche about the desire to eat food that doesn’t raise your risk of cancer. Lynn says that when he first approached Prosur about the fruit extract, he asked how much they had sold to the other big bacon manufacturers during the two years they had been offering it in the UK. The answer was none. “None of the big guys wanted to take it,” claims Lynn. “They said: ‘It will make our other processed meats look dodgy’”.

But it also remains to be seen how much consumer demand there will be for nitrite- or nitrate-free bacon. For all the noise about bacon and cancer, it isn’t easy to disentangle at a personal level just what kind of risk we are at when we eat a bacon sandwich. OK, so 34,000 people may die each year because of processed meat in their diet, but the odds are that it won’t be you. I asked a series of cancer scientists whether they personally ate processed meat, and they all gave slightly different answers. Jill Pell said she was mostly vegetarian and ate processed meats very rarely. But when I asked Fabrice Pierre, a French expert on colon cancer and meat, if he eats ham, he replied: “Yes, of course. But with vegetables at the same meal.” (Pierre’s research at the Toxalim lab has shown him that some of the carcinogenic effects of ham can be offset by eating vegetables.)

Our endless doubt and confusion about what we should be eating have been a gift to the bacon industry. The cover-up about the harm of meat cured with nitrates and nitrites has been helped along by the scepticism many of us feel about all diet advice. At the height of the great bacon scare of 2015, lots of intelligent voices were saying that it was safe to ignore the new classification of processed meats as carcinogenic, because you can’t trust anything these nutritionists say. Meanwhile, millions of consumers of ham and bacon, many of them children, are left unprotected. Perhaps the most extraordinary thing about this controversy is how little public outrage it has generated. Despite everything, most of us still treat bacon as a dear old friend.

In an ideal world, we would all be eating diets lower in meat, processed or otherwise, for the sake of sustainability and animal welfare as much as health. But in the world we actually live in, processed meats are still a normal, staple protein for millions of people who can’t afford to swap a value pack of frying bacon for a few slivers of Prosciutto di Parma. Around half of all meat eaten in developed countries is now processed, according to researcher John Kearney, making it a far more universal habit than smoking.

The real victims in all this are not people like me who enjoy the occasional bacon-on-sourdough in a hipster cafe. The people who will be worst affected are those – many on low incomes – for whom the cancer risk from bacon is compounded by other risk factors such as eating low-fibre diets with few vegetables or wholegrains. In his book, Coudray points out that in coming years, millions more poor consumers will be affected by preventable colon cancer, as westernised processed meats conquer the developing world.

Last month, Michele Rivasi, a French MEP, launched a campaign – in collaboration with Coudray – demanding a ban of nitrites from all meat products across Europe. Given how vigorously the bacon industry has fought its corner thus far, a total ban on nitrites looks unlikely.

But there are other things that could be done about the risk of nitrites and nitrates in bacon, short of an absolute veto. Better information would be a start. As Corinna Hawkes points out, it is “surprising” that there hasn’t been more of an effort from government to inform people about the risks of eating ham and bacon, perhaps through warning labels on processed meats. But where is the British politician brave enough to cast doubt on bacon?

• Follow the Long Read on Twitter at @gdnlongread, or sign up to the long read weekly email here.



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20 Years of Scalzi.com

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Today’s a day some some personal significance: 20 years ago today I secured the “scalzi.com” domain, making it my permanent home on the Web and on the Internet. To some extent it happened out of necessity — I was about to be laid off from AOL and all my email addresses there were about to be discontinued, so I needed to get an email address — but in a larger sense I decided that I needed an online home that I couldn’t suddenly get kicked out of, at the whims of someone else. So long as I paid the domain and ISP fees on an annual basis, I had a place to call my own.

And so it has been this last double decade. AOL is reduced to a tiny sliver of what it once was, Friendster and Myspace and LiveJournal (not to mention AngelFire or Geocities) are similarly gone or greatly reduced, and all manner of sites that existed in the long-lost days of 1998 are now only accessible via the Internet Archive. And yet, here’s scalzi.com, still plugging along. There are of course older sites out there, but in the increasingly thin segment of personal web sites, not all that many.

I’ll note that today is not the 20th anniversary of Whatever, the blog; that comes in September. It took me about six months to get my act together on that score. Instead what was here was collections of writing from when I was at AOL and, before then, at the Fresno Bee — basically a lot of writing samples I could point people to if they wanted to hire me. It worked, inasmuch as I was soon hired to write music and video game reviews, although I never did go back to working as a full-time employee for anyone else.

Lots of good things have come from having this site out there, including selling Old Man’s War, which started me on my way to becoming a full-time novelist. I’ve told that story before and so I don’t think I need to go into great detail about it again right now. Nevertheless one thing I will repeat now and as often as people need to hear it is that especially for creative people having your own domain is really important. Other sites are highly contingent: they come and go, and they may also arbitrarily decide who gets to see your stuff and who doesn’t (see: Facebook, and its annoying tendency not to show everything you post to everyone who follows you).

Even if you have a large following elsewhere, you should always have a place to call your own, that you are in control of, not someone else. So when Facebook and Twitter and Instagram and Snapchat are dead and buried — and they will be — people can still find you. And email you! There’s something to be said for having the same email address for 20 years.

So: Hooray, 20 years. Scalzi.com is definitely not going anywhere anytime soon. I suspect it’ll be here as long as I am here, and then, probably, well after that.



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New trailers: Fahrenheit 451, Wreck-It Ralph 2, and more

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Normally I might take this time to tell you what I thought of Paul Thomas Anderson’s Phantom Thread, which I saw last weekend, but people apparently have very strong feelings about this film and feelings about what your reaction to it says about you. I don’t want you to know! Phantom Thread reactions are the new astrological signs.

Luckily for astrological signs and everyone who has one, movies will continue to be released.

Check out six trailers from the week below.

Wreck-It Ralph 2

In the sequel to Wreck-It Ralph, Ralph Breaks the Internet: Wreck-It Ralph 2, Ralph and Vanellope von Schweetz escape their arcade game yet again, and “go to the internet.” If you’re into family-friendly internet references in film form, this is the sequel for you.

It’s in theaters on Thanksgiving.

Fahrenheit 451

HBO’s adaptation of Ray Bradbury’s 1953 novel stars Michael B. Jordan as Guy Montag, a firefighter who becomes disillusioned with his government-sanctioned book-burning job.

The movie premieres this spring on HBO.

The Week Of

About a year ago, Netflix inked a deal with Adam Sandler to produce four more of his movies, in addition to 2015’s The Ridiculous 6 and 2016’s The Do Over. The Week Of, about two families meeting before their kids get married, is Sandler’s latest feature for the streaming service. It stars Chris Rock, Steve Buscemi, and Rachel Dratch alongside Sandler.

It arrives April 27th on Netflix.

Thoroughbreds

Thoroughbreds looks like a decently campy evil rich teens movie. It stars Anya Taylor-Joy and Olivia Cooke as Lily and Amanda, who plot to kill Lily’s father (Paul Sparks).

It’s in theaters March 9th.

Yellowstone

Yellowstone is a series starring Kevin Costner about a family that owns the largest ranch in the US. If that doesn’t tell you enough about it, this quote from the trailer should: “All men are bad, but some of us try real hard to be good.”

It premieres on June 20th on the Paramount Network.

Cobra Kai

YouTube Red’s upcoming series is a sequel to 1984’s Karate Kid. In it, Ralph Macchio and William Zabka revive their old characters more than three decades later. This trailer only teases Zabka as Johnny Lawrence, who now runs his own karate studio.

It’ll be out sometime this year.



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Skillful Service Is Born of a Quiet Heart

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Wise intention and skillful service need to be nourished by periods of quiet and prayer. Every great tradition includes some from of the Sabbath. In the West we inherited the blessing of the Christian and Jewish Sabbath. Muslims have Friday as their holy day, and likewise Hindus and Buddhists renew their vows of simplicity on full moon, new moon, and quarter moon days. When I was young, Massachusetts had Sabbath “Blue Laws” requiring all forms of business to stop on Sundays. But now, one generation later, we have twenty-four-hour supermarkets and twenty-four-hour banking, seven days a week; our consumer society has claimed the right to operate without constraint. This is a recipe for burnout.

A spirit of service to one another and to ourselves grows out of different soil- out of moments of remembering, moments of prayer and blessing. If we pay attention to the cycle of our breath and the beating of our heart, there is a tiny and necessary pause between each. To beat for our whole life, the heart must restore itself in the stillness before each new beat. Spiritual maturity also requires such periods of Sabbath, where we step out of commercial time into that which is timeless.

We need to become the sanctuary we seek. This can begin with a Sabbath day or a daily period of meditation and prayer. Sometimes it may require creating regular periods of silence where we work. It can mean reassessing our lifestyle, moving toward voluntary simplicity, spending time in nature, attending periodic retreats. It may mean turning off CNN and turning on Mozart. In time of difficulty or conflict, it may mean taking a breath, settling the heart, listening silently to our deepest intention. In these moments we remember our heart’s task on earth. A Christian contemplative teacher recalls:

I had lived many years in a small protected community. Then it came to me that it was time to go back to society to serve. I began an integration, going back and forth. I worked at an AIDS hospice and crisis center. Once a month I would return to my community, my heart longing for silence.I would stand in line when the gift of food was presented, and feel how each thing there, even the most ordinary, was held in a holy way. This is actually how it is all the time; this is the mystery of grace. I knew it wasn’t just the prayer or meditation that was important. It was the silence, stopping and taking a breath, opening the heart, seeing that the whole planet, and everything on it, is holy. I want to bring the beauty with me to everyone I touch. So I return to silence regularly. I know if I can stop and remember this, life will fulfill its promise to me.

From moments of stillness, the most skillful way to love and serve becomes clear. By stopping to listen we connect with one another, and true community is born.

This excerpt is taken from the book, “After the Ecstasy, the Laundry: How the Heart Grows Wise on the Spiritual Path

 



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What Parents Need to Know About Juuling 

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One of the biggest topics right now in high school parent newsletters everywhere is the Juul. It’s a popular e-cigarette system that looks a lot like a USB flash drive—you may have seen one in your teenager’s room, figuring it contains an essay on The Great Gatsby. Based on Twitter and Instagram posts with the hashtag #doit4juul, students are “juuling” wherever, whenever—in school bathrooms, in libraries and under their desks in class. They’re getting away with it because the device is discreet, the “cloud” can be hidden in a sleeve, and the vapor smells sweet and fruity, unlike cigarette smoke. Among teens, e-cigarettes are more popular than traditional cigarettes, and the Juul brand is currently king.

School administrators are trying to crack down on juuling. One Miami counselor confiscates two Juuls per week. A district in Pennsylvania has banned actual flash drives on campuses in an attempt to get rid of the confusion. A principal in D.C. felt the Juul problem was becoming so bad that he took doors off the bathroom stalls.

Here is what parents need to know about the e-cig of the moment:

What Does It Look Like?

The Juul consists of a long, slim vaporizer and disposable “pods” of nicotine juice. The pods come in flavors such as mango, creme brulee and cucumber. Some call the Juul the “iPhone of vapes” because of its sleek and minimalistic design. It charges on a laptop or other USB port.

How Does It Work?

The device heats the nicotine juice to create vapor, which is inhaled by the user.

Who Is It Intended For?

Juul describes itself as “a mission-driven company seeking to eliminate cigarettes by providing a true alternative for adult smokers.” The company states on its website that Juul is “not appropriate or intended for youth, former smokers, or never smokers.” To purchase Juul products on the official website, JUULvapor.com, you must be 21 and go through an age verification process. In stores, you must be of the legal age to buy a tobacco or nicotine product in your state. But teens are finding ways to get them, such as using fake IDs, buying them on unregulated websites or knowing of a lax gas station attendant.

What Does It Feel Like to Juul?

One anonymous 15-year-old describes it like this:

The first time was in the lunchroom. Everyone else was hitting it and I was like “alright, I want to try that.” I guess I knew there was nicotine in it, but I had no idea that it had so much. When I hit it for the first time it was, like, really crazy. I felt a really big buzz off of barely anything.

It hurt my throat more than anything else I’ve done. I hit it and coughed immediately. At first it was just fun and it was something that you could do anywhere. It’s so easy. Then it just became something I was doing nonstop, but I still felt a buzz. Now, I go crazy if I don’t have it. I don’t even feel a buzz anymore.

Jack Waxman, a high school senior in New York who’s working to spread awareness about the dangers of teenage Juul usage, says he’s seen friends all go down the same path: First, they’re attracted by the “fun flavors” and enticed by the head-rush. But then, after using the Juul for a while, they feel no rush at all. “They use the device to make their body feel normal again, just like any smoker,” Waxman says. He’s seen people “struggle to make it thirty minutes without taking a hit.”

How Much Nicotine Does It Contain?

Each pod has about the same amount of nicotine as a pack of cigarettes, or 200 puffs. Specifically, the nicotine concentration is 59 mg/mL per pod, which can be more than double that of other vaping products. It gives users a strong, fast punch.

How Dangerous Is the Juul for Those Underage?

For adults, vaping is generally believed to be a healthier alternative to cigarettes because it doesn’t burn tobacco and release carcinogens. (Under FDA regulations, Juul “cannot and does not make any claims that its products are less harmful or safer than cigarettes.”)

But no e-cigarette product should ever be considered “safe,” especially not for those underage. Teenage brains are still developing, so they’re uniquely vulnerable to addiction. Nicotine is very addictive, and exposure to nicotine in adolescence has been shown to have long-term impacts on brain development. It may affect teens’ behavior, concentration, memory and their ability to learn.

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There are other health concerns for young people who vape. According to a study published in the American Journal of Respiratory and Critical Care, adolescents who use e-cigarettes are twice as likely to suffer respiratory symptoms such as a persistent cough, bronchitis, congestion and phlegm as those who don’t. And there’s some evidence that shows teen vapers are more likely to take up smoking tobacco cigarettes than non-vapers.

Also, a lot of teenagers have no idea what’s in their vape. In a study sponsored by the National Institute on Drug Abuse, when high schoolers were asked what they believed was in the last product they vaped, most said “just flavoring.” As for the Juul, some teens are filling the pods with other substances, which is even more dangerous.

How Can You Tell if Your Teen Is Juuling?

Signs of general e-cigarette use include increased thirst (the propylene glycol in the devices can cause dry mouth), a new sensitivity to caffeine and possible nosebleeds.

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It’s important to start a conversation with your teens about e-cigarettes, whether you suspect they are using them on not. With the Juul, you might open with a general, nonthreatening question—“Hey, I just read about this thing. What have you heard about it?”—and see what they say. Explain the serious health risks of e-cigarettes (remember phlegm, nosebleeds, lung problems, a messed-up brain, and addiction, just to name a handful). If your son or daughter is vaping, let them know that you do not approve, and work with them to replace the unhealthy behavior with a positive one. E-cigarettes contain more than fun, fruity flavors, and when teenagers use them, there may be lasting consequences.



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Can Minnesota Wild fans predict the future, or do they not know how to count?

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To be fair to Minnesota Wild fans, Tuesday night's tilt with the St. Louis Blues was a high-flying affair, and it may have been tough to keep tabs on all 11 goals scored in the game. Their squad poured it on Blues goaltenders Jake Allen and Carter Hutton, finding the back of the net eight times, including this goal-of-the-year candidate from Mikael Granlund:

Turns out this Granlund goal that made it 3-1 was his second of the night thanks to a stat correction that credited him with the Wild's second goal, which was originally given to veteran Eric Staal, who went on to net his first almost halfway into the second period. Apparently, those inside the arena weren't notified that it was Staal's first, so when he scored his second in the third period, fans rained down their hats onto the ice prematurely, thinking Staal had just earned his 14th career hat trick.

But then, miraculously, Staal delivered with an actual third goal three minutes later, finishing off a five point night and earning the rare, never-before-seen double-hat toss, but more importantly raising the question: can Minnesota Wild fans predict the future, or do they not know how to count?

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This really comes down to whether or not the PA announcer notified the fans that the goal had been given to Granlund. Judging by the second hat toss, he must have, right? Or these damn Minnesotans just love to waste a good hat. And that was "Wednesday's Worthless Debate" at The Loop, something I just made up.



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Is Keto the Cure for Type II Diabetes?

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Type II diabetes is one of America's most ubiquitous—and expensive—chronic diseases. Patients often require a suite of pharmaceutical products to manage high blood glucose levels, and the complications that arise over the long term, ranging from loss of vision and limbs to kidney failure and coronary artery disease, strain the resources of patients, their families, and the health care system.

The financial strain on insurance companies, employers, and Medicaid and Medicare is even more enormous. A 2013 study in the American Journal of Preventive Medicine put the lifetime direct medical costs for type II diabetes treatment at $124,000 for patients diagnosed in middle age. With nearly 30 million Americans affected by the disease, the American Diabetes Association estimates the national cost of direct diabetes care to be roughly $176 billion per year.

But unlike type I diabetes, which is an autoimmune disorder that destroys insulin-producing cells in the pancreas, type II diabetes is a lifestyle disease, and thus reversible. Over time, people with type-II diabetes can be made more receptive to their own insulin, which in turn allows their bodies to effectively clear glucose from the blood without insulin medication. The trick for the vast majority of type II patients is as simple as losing weight. ("The relationship between obesity and diabetes is of such interdependence that the term 'diabesity' has been coined," two diabetes researchers wrote in 2005.)

But that "trick" is actually pretty hard. Permanent weight loss without bariatric surgery is practically impossible at the population level. A 2014 study by Kaiser Permanente that looked at incidents of non-surgical diabetes remission in 122,781 patients found that it basically doesn't happen. The most commonly cited number among obesity researchers, meanwhile, is five percent—only five percent of people who lose weight without surgery will succeed in keeping it off over the long term.

Now Virta Health, a Silicon Valley startup, has developed a lifestyle modification system that can reverse the markers of type II diabetes. In a study published this month, Virta researchers found that over the course of a year, they were able to achieve remission of symptoms and a cessation of several pharmaceutical products in nearly two hundred patients using a "novel metabolic and continuous remote care model."

Virta uses a combination of the ketogenic diet—which involves moderate fat and protein intake combined with very low carbohydrate intake—and frequent remote contact with a physician and a health coach to help patients change their lifestyle and lower their body weight, their blood glucose, and their HbA1c (a biomarker for diabetes). In its December study, 94 percent of patients in the control arm of the trial were able either to cease using insulin or to radically lower their insulin dose, and all of the patients in the control arm were able to stop using a class of antidiabetic drugs called sulfonylureas, which increase the amount of insulin released by the pancreas. The control group meanwhile, increased its insulin use over the course of that same year.

At $370 a month, Virta's model isn't cheap, but it's cheaper over the course of a year than the suite of drug therapies many type II patients require. And if Virta's model is scalable, the long-term savings on dialysis, hospital stays, and management of diabetic foot ulcers could be massive. Already, the company has partnered with Purdue University and Nielsen to offer the Virta system as a covered health benefit to employees with type II diabetes. The company's stated goal is to reverse diabetes in 100 million people by 2025.

I recently spoke to James McCarter, Virta's head of research, about the company's treatment model and the broader landscape of type II diabetes care. McCarter received his A.B. in biology from Princeton, and he got his M.D. and a PhD in genetics from Washington University in St. Louis, where he's an adjunct professor at the medical school. Our conversation has been edited for length and clarity.

Reason: Every doctor recommends lifestyle modification as the first course of treatment for patients with type-II diabetes and pre-diabetes. Yet most patients end up on metformin and eventually insulin and some other pharmaceutical products. Physicians seem jaded about lifestyle modification as a viable treatment. Do they have good reasons to be jaded?

James McCarter: I think endocrinologists and primary care doctors have reason to be jaded, in that they've seen lifestyle modification fail so many times. The conventional advice of "eat less and exercise more" has been shown to not work. People can do caloric restriction for a while, but you know what happens when you calorically restrict without any overall strategy other than just eating less? You get hungry. Exercise, and you get hungry. You can battle that hunger and craving for a while, but eventually it's going to come back. What's generally seen with most lifestyle interventions is that people will lose five pounds and gain it back over the course of a year.

Exercise is great for overall fitness and something that I believe in strongly in terms of maintenance of overall health. But it's not a good strategy for weight loss.

Reason: So instead, type II diabetes patients and their doctors end up treating symptoms instead of trying to reverse the disease itself.

McCarter: I think that's right, and I think to your point about physicians being jaded, they've seen that lifestyle modification only works in a minority of people. They're not surprised when a patient comes back three months, six months, or a year later and the disease has progressed.

Reason: If one of the problems with lifestyle modification is that only a tiny fraction of patients can self-motivate or self-direct an effective change, what does the Virta model do differently? How do you help the patient who can't pull off lifestyle modification?

McCarter: If you look at a large study that was done by Kaiser a number of years ago, they saw that their remission rate of type II diabetes was well under 1 percent. We're seeing well over 50 percent. So what's causing that 50-times improvement in our results? It really comes down to two things. Let's talk first about the physiology and then we'll talk about the behavior change.

First of all, using nutritional ketosis as an underlying part of the physiology approach has a tremendous impact on people's ability to succeed in getting glycemic control, which is reduction in medications, improvement in metabolic health, and reduction in weight.

The reason for that is that unlike a willpower approach, where you're just trying to force yourself to eat less, using nutritional ketosis allows you to tap into body fat for fuel. That means you have incoming energy from your body fat storage and from dietary fat. As a result, people will naturally tend to eat fewer calories because they are satiated.

We ask people everyday, "Tell us on a four-point scale how you feel about your hunger, cravings, mood, and energy. What we see is that as people achieve nutritional ketosis, energy and mood go up, hunger and cravings go down.

In effect, the physiology of ketosis is providing you with a tail wind. It's making the whole process much easier.

Reason: Various kinds of diets can work for almost everyone for at least a little while. How do you make those new eating habits stick?

McCarter: The other part of our model is the coaching. The number of people who can just read a diet book and implement its recommendations without any monitoring or coaching is small. What we're doing with Virta is we're providing five things: We're providing a physician with telemedicine for medication management; a health coach with an ongoing, one-on-one daily relationship who consults on nutrition and behavior change; education that's provided online; biometric feedback; and an online community.

Essentially, we're providing a whole support environment that allows people to understand what they're doing and why.

Reason: Is there a calorie deficit? It seems like there would have to be for weight loss, but I'm also guessing that it would be a small one because you seem to be very skeptical of crash diets or excessive calorie restriction. Or does keto somehow defy the claim that calories out need to exceed calories in?

McCarter: Rather than measuring calories, what we're doing is having people monitor their approximate macronutrients. Roughly how many carbohydrates am I having on a daily basis? How much protein am I having on a daily basis? It's a low-carbohydrate, moderate-protein diet.

What we have people do instead of an elaborate food diary is measure daily blood beta hydroxybutyrate. That's one of the ketone bodies, and by seeing an elevation in beta hydroxybutyrate, we're able to say, "Oh, you're actually in nutritional ketosis which means you're burning fat for fuel which is what we want to achieve."

It doesn't mean you have a caloric deficit necessarily, but at least you're getting your diet and other aspects of your lifestyle correct in a way that supports nutritional ketosis. And we're looking at glucose as well. That way we can say on a daily basis, are you on track or off track?

Now, calories still do matter. What generally happens, even though we are not asking people to count calories, is that because they are feeling satiety in their meals at an earlier point, they're creating a deficit. Rather than having a second or third helping, they're saying after one helping, "Gosh, I feel you know, adequately full." They are generally eating less, especially in the first six months.

Reason: So instead of having the goal be "I will eat 500 fewer calories today than my body needs," patients are focused on getting the macro ratio roughly right and checking their efforts against the ketone blood test?

McCarter: Right, and it's going to be a different journey for everyone. Some people just get it right out of the gate. Other people will take quite a few weeks or even months before they really figure out exactly how to do this. One of the key things we've found is a need for individualization. We want this to work not just for the quantified self-optimizer, but for somebody who has had diabetes for 10 or 20 years, who is on insulin or other potent diabetes drugs they want to stop taking. It has to work for somebody who is a stay-at-home parent, for a business traveler, for somebody working the night shift. It has to work for different ethnic cuisines; it has to work for different dietary restrictions.

That's what both our software and our health coaches aim to do. Make changes that work for specific individuals.

Reason: Where do you think the rest of the medical community is on the utility of a low carbohydrate diet for weight loss? In the realm of nutrition science, the debate over dietary fat still seems pretty contentious.

McCarter: Conventional wisdom has shifted somewhat. Many physicians would describe it as effective for weight loss, but most would say that it is a short-term measure that is not sustainable. Many do worry about dietary fat. There is a growing movement that counters the status-quo. While the number of physicians that recommend a sustained low carb approach for weight loss and metabolic health is still limited (low single digit percentage?), it is growing rapidly. For instance, the international petition we started for Dr. Tim Noakes last week has garnered nearly 35,000 signatures, including many physicians and medical professionals. [Editor: Tim Noakes is a South African physician who pioneered early research into the low-carb, high-fat diet as a treatment for type II diabetes. The Health Professions Council of South Africa is attempting to revoke Noakes' medical license because he recommended to a woman that she transition her baby to such a diet when the child finished breastfeeding.]

We find that when we start taking care of a patient, their primary care doctor, who often begins as a skeptic, quickly converts to a supporter based on the results we obtain and the supporting scientific literature we provide.

Reason: It seems like the ability to do a lot of this coaching and guidance remotely is what's going to make this model scalable for Virta and anybody else that wants to help large numbers of people make lifestyle modifications. Because if everybody needed to check in with someone who lived where they lived, this seems like a thing that could maybe only go so far.

Jim: You're exactly right. It doesn't work without technology and it doesn't work without the ability to provide what we call continuous remote care. We actually tested that in our clinical trial. Of the 262 people with type II diabetes that were in the intervention arm, half received everything remotely—the physician, the health coach, the education, all of it.

The other half received all the remote stuff but also came to an in-person classroom setting with 10 to 20 other people and a health coach at our clinic. Initially, it was once a week, and then less frequently over time. The outcomes between the in-person group and the remote-only group were statistically indistinguishable.

Reason: Most of my own weight loss was self-directed, but I recently signed up for a remote coaching service with daily lessons as a way to get better about my eating habits, and I noticed that the combination of check-ins with a real person and daily lessons on a website is strangely compelling for reasons that aren't entirely related to the content. I feel watched, but not in a bad way.

Jim: That's part of the reason we structured Virta the way we did, with an actual one-on-one relationship with a coach. There are prior clinical studies that have shown that when you have this coaching relationship, as opposed to entirely automated or entirely self-directed program, people will do better.

Reason: What do you make of the fact that some patients in your trial couldn't come off of metformin? Does that mean some aspects of type II diabetes are not actually reversible? That it could take longer to reverse the symptom that metformin treats?

Jim: Let me talk you through the medications a little bit and address Metformin as part of that. The first thing I should say is that medication reduction is symptomatic of an overall improvement in metabolic health.

Of all the medications for type II diabetes, there are things that can be done right away and there are things that take more time. First off, we want to avoid hypoglycemic events, which is low blood sugar. If you're on potent hypoglycemic medications, which are medications like sulfonylureas and insulin that lower your blood sugar, and then you go on a carbohydrate-restricted diet, that's going to drive you toward low blood sugar levels. So what we try to do early on is very aggressively remove sulfonylurea. Fully everyone in our trial were off that within the first three months.

After that, we're aggressively titrating the insulin downwards, so that about half of the insulin was gone by three months and another nearly half of patients had it reduced. Ninety-four percent of people in the intervention group were able to either reduce or eliminate their insulin use.

But the one that we generally will leave alone and not aggressively reduce is metformin. The reasons for that are that it is generally well-tolerated, it's generally inexpensive, and there's a growing body of evidence that it's effective in prediabetes. The American Diabetes Association now recommends metformin for people with prediabetes to prevent progression to diabetes, and there is also emerging evidence that it may have some other benefits, including longevity benefits.

That's the rationale to leave metformin in place if it's well-tolerated. Our definition for having reversed diabetes is that patients have glycemic control, which means they've lowered their hemoglobin A1C lower than 6.5, which is the diabetes threshold, without medications like insulin and sulfonylureas.

Reason: Chronic diseases require decades of expensive treatment, which means effective lifestyle modification could save payers—be they insurance companies, patients, or employers—thousands of dollars a year per person. Can you talk a little about Virta's disruption potential and what kind of blowback that might attract?

McCarter: There's plenty of work to be done, so I'm not worried about what's going to happen to many of the incumbent players. For instance, there are not enough endocrinologists to take care of all the people with type II diabetes in the United States. If Virta is successful over time, maybe this allows endocrinologists, who are incredibly well-trained, to concentrate on more challenging diseases, like type I diabetes and other extremely challenging endocrine disorders.

As for the pharmaceutical industry, there's plenty of disease out there to be handled. There are also people for whom the types of behavior change we're advocating are not a fit for them. It's not as if we're going to get 100 percent adoption. The industry is going to be disrupted over time, but it will adjust.

Reason: So it's overly dramatic to say that one thing will work for everyone, or that an effective new treatment option will crater incumbents overnight?

McCarter: To get a sense of how industries adapt, it helps to look back at the late 1970s, which is when the dietary recommendations for low-fat foods came out. You can see that within about five years, the food industry rolled out something like 100,000 products where they just removed fat and put in sugar and starch. That probably didn't do consumers any favors, but it showed the speed with which industry can respond.

Reason: The food industry seems to be changing again right now. I've noticed with delight that a ton of products now advertise their protein content on the package, the same way they used to advertise their low-fat content.

McCarter: Yeah, people are focusing on protein. In the coming five years, I think you're going to see a return to the idea that fats can be beneficial. As opposed to saying something is low-fat, I think you're going to see things that advertise as being high-fat.

Reason: That still feels far away to me, but maybe not that far. The number of products and recipes that incorporate chia and coconut and almonds has increased quite a bit. Those are all very fatty, delicious, and thus satiating things. It seems like the next logical step for manufacturers is being more explicit about why they think these products are good for us.

McCarter: There was actually a report from Credit Suisse a couple of years ago, maybe two years ago now, where they basically predicted all of this. It was kind of an industry direction report suggesting that fat was a marketing tool.

Reason: A health care tool potentially being scalable and scaling a health care tool are two different issues. How does Virta scale?

McCarter: On the commercial side of things, our goal is to make this available and affordable to everyone over time. To begin to break through, we've been concentrating on employers. Self-insured employers are on the hook for the costs. What we can do is we can go to that employer and say, "Hey, work with us to have your folks with type II diabetes join the Virta Clinic and turn that around." We put a fair amount of the fee structure at risk. It's outcomes-based, so if we don't succeed in reversing type II diabetes, we don't get paid.

Reason: Does Virta currently have a way to follow study participants past the 12-month mark? The Kaiser study you mentioned covers a pretty long time horizon, and I know obesity researchers like to point out that weight regain gets likelier with each passing year.

McCarter: Absolutely. The Virta-IUH trial (see clinicaltrials.gov listing) was originally designed for two years and has recently been extended to five years. You can read the description on our blog. We will be publishing two-year and five-year outcomes. We are also following our commercial patients long-term, with more to come on that in a few months. The longterm view is super important.



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Woman Arrested for Cop Killing Her Child, Google Bans Sale of Sex Pistols Merchandise, Oakland Tips Off Locals to ICE Raid Plans: A.M. Links

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  • A Baton Rouge baby was killed after a local cop caused a car crash. The child's mother has since been arrested for negligent homicide—the same charge the cop who triggered the crash faces—for allegedly having failed to properly adjust the child's car seat straps for her height.
  • In a shocking and rare example of Oakland authorities doing something right, Mayor Libby Schaaf warned residents that Immigration and Customs Enforcement (ICE) would be conducting raids on Tuesday night, a move which ICE has blamed for some deportees being able to elude the agency.
  • Google has stopped advertising shopping results for "pistols," which turns out to be bad news for a certain 70s punk band.

  • An Alabama whistleblower was arrested on dubious charges just a few days after criticizing Etowah County Sheriff Todd Entrekin in a news article.
  • "People who came from where I did, and who were given the thoughts I was given, should know that the future can be different from the past," writes Quinn Norton, who was recently hired and then fired from The New York Times editorial board after an internet uproar over old comments she had made online and her friendship with an infamous neo-Nazi.
  • Phoebe Maltz Bovy and Katie Herzog have an interesting chat on social-media dysfunction, cultural taboos, and "trying to be less of an asshole on Twitter":

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