Sugar given Carte Blanche to cause panic

When you (by which I mean, the average person) thinks about something as being “addictive”, I think we mean that the substance or activity in question is particularly likely to cause you to develop some combination of dependence, tolerance, cravings and withdrawal symptoms.

You’d also, if addicted, go to significant lengths to obtain the thing that you are addicted to. On a trivial end of this spectrum, people who smoke cigarettes might walk out into a cold and rainy evening to go and purchase cigarettes, instead of staying under the duvet like any sensible (i.e., non-addicted) person would.

When you think of addiction, in other words, I’d guess that you typically don’t mean that you know this fellow, George, who has become so obsessed with playing Minecraft that you describe Minecraft as addictive, as opposed to acknowledging that people can become “addicted” to Minecraft.

sugarThe distinction is important, and points to one of the significant problems in discourse around sugar “addiction”, as recently portrayed on the South African current affairs show, Carte Blanche. It’s important because the things we like are rewarding at the level of the brain, in that they result in dopamine release – but this does not necessarily mean that they are addictive in the stronger sense that we tend to reserve for things that you can’t help but find rewarding.

In other words, there’s almost zero chance of my becoming addicted to running, because I don’t like doing it, and tend not to do it. But there’s a significant chance – and a similar chance to your chance – of my becoming addicted to heroin, if either of us were to try it.

We’re using the word “addictive” in a very broad sense when we describe the Internet, exercise, and sugar as addictive. In fact, the sense in which it’s being used is broad enough as to mostly lose its meaning, by contrast to the strong sense in which certain substances are very likely to result in the sorts of reactions mentioned above, for many people.

Most of us exercise, use sugar or the Internet, and have sex quite unproblematically (in terms of addiction, Beavis). More of us use things like heroin or cocaine unproblematically than the standard sorts of addiction panics claim also, but that’s a story for another day. The point I’m making here is quite simply that any claim that sugar is “addictive” is using the word “addictive” in a misleading and hyperbolic way.

Long-term addiction is the exception, not the rule – we suffer from a confirmation bias here in the sense that we don’t get to hear about the people who live with addictions that are largely under control and remitting (in other words, most of them). We hear about the horror-stories, of people struggling with a demon, and (sometimes) heroically fighting it off.

And, as the cases and science detailed in Johann Hari’s Chasing the Scream persuasively suggest, the primary vehicle we have for escaping addiction is to give ourselves a sense of purpose and above all, agency – and agency is last thing that panics around things like sugar addiction have time for. Instead, the narrative is all about you being a victim of conspiracy.

You can watch the Carte Blanche insert yourself, in which you’ll be told that “sugar may be as addictive as nicotine and hard drugs”, that sugar can “hijack the brain” and so forth. But what you’ll mostly see is three self-described (and apparently self-diagnosed) sugar addicts telling you how addictive it is.

Their primary scientific resource, Prof. Nicole Avena, doesn’t even herself support the strong addiction claim, saying “a little bit of sugar won’t hurt you. It’s not a bad thing in general, it’s just the way we are consuming it is a bad thing”. The “we” is perhaps too broad there, in the sense that many of us who aren’t on LCHF-type diets have been restricting added sugars for our entire lives already, given that warnings about refined sugars have been a staple of dietary advice for quite some time now.

Nevertheless, I’d agree that people are eating too much sugar. And, people who are prone to compulsive behaviour might well find themselves becoming “addicted” to sugar – and you wouldn’t be surprised to find (as you do in one of the three cases presented in the show) that these people can become “addicted” or even addicted to a range of things over the course of their lives.

The problem, in short, might be with their lives and their circumstances – at least in large part – rather than in the substances or activities. We should not be surprised that our brains find food rewarding, and that we seek it out. We’d be surprised if it was any other way. But if we can (typically, as with most consumers of sugar) control the impulse to eat too much of it, then addicts need to shoulder a large portion of the responsibility themselves, and not hand it over to sugar.

But, say some (and as presented at 2m21s in the video, with an unfortunate reference to quack-central Natural News), studies prove that sugar is more addictive than cocaine. Unfortunately, studies prove what you want them to, depending on which studies you read, and which you ignore.

Plus, of course, how attentively you read them can be an issue – as I’ve noted before, Avena and others are far more circumspect and tentative than they are presented to be by the media and vested interests. Her own oft-cited paper is full of scare-quotes for the word “addiction”, and stresses that “whether or not it is a good idea to call this a “food addiction” in people is both a scientific and societal question that has yet to be answered.”

The hyperbole in blogs and online news sources, never mind repositories of the worst sorts of pseudoscience like Natural News, don’t help resolve these issues. Neither do personal anecdotes, regardless of our compassion for people who struggle with compulsive behaviour of various sorts. Movies like Fed Up are of little use also, in that they simply populate the scaremongering filter-bubble with cherry-picked and misrepresented data.

If you want to read about why the Lenoir et. al. study quoted in Natural News doesn’t resolve my doubts about sugar addiction, not to mention comparing rat data to human experience – especially given the fact that psychological rather than physiological factors seem most relevant to addiction – I’d recommend reading this Scicurious post closely.

That post points out that there’s perhaps a vast difference between the self-administration of drugs in humans compared with rats, who can’t reason about their choices like we can. It also notes that the study doesn’t measure a progressive ratio – in other words, it doesn’t tell us what the rat prefers when it really has to work to get its reward. When things get tough, will it prefer sugar, or will it quit trying?

We don’t yet have good human data for sugar addiction. What we do seem to have is limited evidence for “eating addiction“, but as I’ve stressed above, an addictive behaviour is not the same thing as an addictive substance. People who are addicted to eating might well find foods – including sugar – deeply rewarding, but it’s premature to blame the sugar itself.

To conclude: there’s no problem with saying we find sugar rewarding. Of course we do, as we would exercise and so forth. To say it’s addictive makes a far stronger claim, and that claim is the suggestion that it’s a sinister substance that’s out to get you, rather than something you’re free to enjoy in moderation, just as you can alcohol or any other drug, depending on the legislation where you live, and your own personal risk-tolerance.

One thing I’m quite concerned about, though, and have noted before, is that it seems quite likely to me that your risk-tolerance can only be compromised through being treated like a perpetual victim – and that believing your food is out to kill you seems a wholehearted embracing of that victimhood.

Roundup – 2015 LCHF Summit #OMHealth #LCHF2015

In news that came as a surprise to some us who are here, myself included (thanks to the generosity of the organiser, Karen Thomson), critics of Noakes and the low carbohydrate, high fat diet are apparently “boycotting” the Old Mutual Health Convention, that wraps up today.

The convention took place over 4 days – the first 3 operating as a professional event, with healthcare practitioners earning continuing professional development (CPD) points for attending, and the last day defined as a public event.

There are also a number of skeptical dieticians here, as well as a few GP’s that I know to be critical, after having discussed this issue with them at various talks over the past few years. But what I suspect Noakes and Thomson thinks proves the boycott point is that none of the 15 critics who were invited to participate in a debate accepted the invitation to do so.

I’ve explained why I would not have done so in a previous post – and can also tell you that I was part of email correspondence with 5 of those who were invited, who (thanks to the choice of debate topic) thought the invitation in bad faith, given how much it stacked the deck against them.

Anyway – enough back-story. I mention these things mostly to make the point that there’s lots of room for “eye of the beholder” interpretations of reality here, and crucially, also for subjective interpretations of evidence.

This is not because the evidence itself is subjective, but more because what you are exposed to (and crucially, what you are not exposed to), cannot help but frame your interpretation of things. If you construct a case that only represents one point of view, it’s little surprise to find that point of view emerging with credit.

To highlight some positives from the conference right off the bat – the catering has been very good, and the organisation (excepting the schedule not consistently allowing for questions, discussed below) exemplary. So, well done to all – there have been 400+ people here every day, and having organised this sort of thing myself in the past, congratulations are well-deserved.

(One peculiar thing about the catering that some of you will find amusing, though, is that no sugar was provided with coffee/tea – in fact, waitstaff had to – nervously, I’d imagine – tell delegates that sugar was verboten. This strikes me as bizarrely paternalistic, and also arguably evidence of some serious groupthink, in that even if sugar is addictive (it’s not) rather than “addictive”, we can surely trust adults to give themselves a small maintenance dose every now and then.)

Which brings me to my first general critique – if you want a conference to be viewed as an objective overview of current science, giving equal (or at least substantial) airtime to critics seems a good idea (whether via a fair debate topic, or via giving them opportunity to make presentations).

A related point – opportunity even for questions from the audience has been irregular and often non-existent. At the very least, a programme on a controversial topic like this (if academic/scientific objectivity is a goal) should include dedicated time for questions.

So, the event is framed in such a way that sympathetic folks will get to hear more about something they are already (at least somewhat) committed to, and – unfortunately – that folks who view authority uncritically (as in, here’s yet another “expert” defending LCHF) will get the impression that LCHF is the dominant view.

You might think it should be the dominant view, sure. But I mention this to note that when people ask me (as quite a few have, including one rather abrasive journalist) whether I’ve been persuaded by being here, I have to keep reminding them that persuasion occurs – or should occur – after you’ve heard the best articulation of competing points of view, and then conclude that one is stronger.

Having said that, I’ve independently exposed myself to various points of view and arguments on the mainstream or consensus side, so do have some ability to weigh these up against what I’ve heard here. Others might not have had the same opportunity, which is why – if I was one of the speakers here – I’d have made sure to emphasise that what’s being presented here is not obvious, inescapably true and so forth.

So, if you want to know about the current state of research into LCHF, this is certainly the place to be. If you want to know about the current state of research into diet and health, not so much.

But it has been useful to me, both in terms of understanding their arguments better, but also in terms of noticing (a) they don’t agree with each other about everything; and that (b) Prof. Noakes is arguably on the extreme end of commitment to various propositions, with other voices emerging as more convincing in consequence (because dogma is antithetical to good science).

These points are both important – (a) because it suggests that some of the LCHF proponents are avoiding dogma, and wanting to nudge us towards a different diet direction, rather than call for revolution; and (b) because this is what I’ve been saying all along – I don’t necessarily disagree with everything Prof. Noakes says, but I do think he says it in very unhelpful ways. (Unhelpful in terms of persuading those who are skeptical, I mean – his approach is spot-on in terms of motivating the flock, via catchphrases, conspiracies and the like.)

So, hearing the arguments expressed in a less hyperbolic way than South Africans have typically been exposed to has been very useful. It’s like hearing about Jesus from a religious studies professor versus from Errol Naidoo or Pat Robertson, if you get my meaning.

For example, at least one speaker (and others in conversation) used the phrase “low carb, healthy fat” (healthy, instead of high, for the H in LCHF). My primary concerns – and the concern of consensus guidelines at present, has been about the extreme stance that a person like Prof. Noakes takes on these matters – not only limiting carbs, but limiting them severely; not just being unafraid of certain fats, but embracing those fats as well as saturated fat.

If we limit refined carbs, and eat more healthy fats, then we’re in the territory of the Mediterranean diet, which is pretty much how I’ve eaten for the last 8 years in any case, and also what my reading suggests is the diet recommended by most experts.

But the problem remains that even those who spoke of “healthy fat” peppered their speech with talk of addiction, or the evil 1977 McGovern report which led to the dietary guidelines that have “made us sick”, and various other tropes from the LCHF playbook.

No amount of repetition seems to make this point stick, but the dietary guidelines in question never told us to eat lots of refined carbs, and in fact cautioned against sugar – but we never followed them. They did tell us to limit fat and be careful of cholesterol, yes, but they have since caught up with science (policy inescapably lags behind science, given committees, consultation and the like).

CarbSane_2015-Feb-21

And sure, I’m sympathetic to the point that “big food” added sugar to compensate for less fat – but that’s a a separate point in that it explains (in part) why we ended up eating too much sugar, but also tells you that we didn’t follow the guidelines, albeit not entirely because of informed choice.

It’s possible, in short, that we wouldn’t be in the state we’re in in terms of obesity and/or non-communicable diseases if we had followed the guidelines then, or start following the guidelines now. The burden of proof, in other words, is still on people who want to propose an alternative to guidelines based on the totality of evidence.

Anne Childers repeated this misleading claim about the guidelines, showing us a graph of NHANES data, according to her showing that Americans complied with those guidelines (in that carbs were up, fat was down, yet obesity increased).

livinlowcarbman_2015-Feb-20

But that shows us nothing of the sort, in the guidelines were not “increase carbs in general”, and folk ended up (whether via the evil Big Sugar or not) eating far too many of the wrong sorts of carbs. They didn’t eat the fruits and whole grains they were supposed to, and they ate far too many of the refined grains and desserts, while guzzling plenty of soda.

This sort of misrepresentation (misleading, even if not mendacious) was not uncommon. Consider Gary Taubes, who in his talk repeated the claim made in Why We Get Fat: And What to Do About It, that “Weight loss achieved in clinical trials of calorie restricted diets are so small as to be clinically insignificant.”

As evidence for this claim, he cites a Cochrane Collaboration report (since withdrawn, simply because the evidence and analysis is now out of date) where the abstract concludes as follows:

The review suggests that fat-restricted diets are no better than calorie restricted diets in achieving long term weight loss in overweight or obese people. Overall, participants lost slightly more weight on the control diets but this was not significantly different from the weight loss achieved through dietary fat restriction and was so small as to be clinically insignificant.

Read the abstract for yourself, or the full report if you have access, but it tells us that the weight loss in the “low fat group was -5.08 kg (95% CI -5.9 to -4.3 kg) and in the control group was -6.5 kg, (95% CI -7.3 to -5.7 kg)”. So, people did lose weight in the calorie-restricted diet, and the “clinically insignificant” from the Cochrane report refers to the difference between the two diets, not weight-loss in a calorie-restricted diet.

As you might expect, many speakers retreaded the line about this all being the fault of Ancel Keys and his allegedly manipulated data (cherry-picking 6 data points instead of the full 22 he had access to, when arguing that heart disease correlated positively with fat intake). But as others have argued in detail, the correlation remains if you include the full 22 countries, and the fact that everybody plagiarises Gary Taubes in saying otherwise doesn’t make it more true.

We also heard some odd contradictions between speakers – Christine Cronau wanted us to believe that fibre “tears holes in our bowel walls” and was to be avoided, Dr. Jason Fung thought fibre was cardio-protective and in general good. During a rare question session, Dr. Eric Westman explained the contradiction as being attributable to “different philosophies”, which hardly seems a compelling answer in matters of physiology.

Dr. Aseem Malhotra gave a talk of two distinct halves – the first half great, on innumeracy, false positives, over-prescription of drugs and the like. But he also engaged in some conspiracy theorising around funding sources for research, and repeated the question-begging narrative about the dietary guidelines. More weird, perhaps, is that his arguments all seem to support the Mediterranean diet, and then his conclusion veered off into the LCHF direction (maybe he’s being paid off by Big Cauliflower? (I joke, of course.)).

The prize for most bizarre statement must go to Dr. Robert Cywes, who told us that “Two hours after a high carb meal, you have effectively swollen your brain and caused concussion”. As The Doctor remarked, those poor Italians must be in a state of perpetual concussion!

On the final (public) day, Dr. Aseem Malhotra was the highlight, in focusing (in quite sober tones) on the consequences of overconsumption of sugar, and how easily you can consume too much without noticing it. My respect for him was undiminished, and possibly enhanced, over the two presentations he gave here.

The main disappointment on the final day was to hear “The Diet Doctor”, Andreas Eenfeldt, repeat the falsehood that Sweden’s SBU has shown that LCHF is the “best” diet. As I’ve written before, and as Slipp Digby has extensively catalogued, they said nothing of the sort. Their report discussed diets for obesity – not everyone – and even so, found LCHF superior only on a time horizon of 6 months or less.

Even the SBU authors have made this clear, after LCHF advocates started trumpeting the (false) claim, so it’s rather disturbing to see Dr. Eenfeldt take advantage of a primed-to-be-receptive audience in this way. I’d have hoped that misrepresentation was incompatible with the LCHF understanding of primum non nocere – first, do no harm. But perhaps Eenfeldt is simply misinformed.

[Edit: The above portions have been struck out because Dr. Eenfeldt contests that he said this. Given that I make a rather impolite accusation towards him here, it’s only correct that I be sure of whether it’s justified. I can only do that when the recording comes out. So at present, this was a regrettable failure of decorum, for which I apologise.]

Prof. Noakes wrapped proceedings up, first discussing causation. I’ve written enough about him, so will just say: no, calling your success story anecdotes Black Swans neither makes them good examples of Black Swans, nor makes them more than anecdotes. They were uncontrolled experiments, so we have no way of knowing cause-effect worked the way you claim it did. Saying that it proves your case begs the question. But he was charming, as usual.

Two final points before concluding: for a medical conference (on the first 3 days – the final day was for the public), with continuing professional development (CPD) points on offer, it was a tad disappointing to hear two purely autobiographical talks on the first day. But this again speaks to the purpose of the conference, as indicated above – it was constructed filter-bubble, rather than a general investigation of the issues.

Second, Old Mutual were careful to distance themselves from the LCHF diet and movement itself, despite apparently throwing buckets of money at it. I’m not sure if this is a winnable game to play (in terms of public impression of them being supportive), but there were three mentions of this not being a show of scientific support by Old Mutual in the first half-hour of the conference.

They argued that they merely wanted to facilitate the debate, help create the space for discussion, and bring information to South Africans. Credit to them for that, as these are worthy goals, but I can’t help thinking that they should then have insisted on the programme being more balanced. In the absence of that, they can’t blame people for thinking they’ve offered an endorsement.

Others can pick over the details once the talks are on the web, as I’m told they will eventually be. But to summarise, I heard plenty that further convinced me that refined sugars are (in general) bad, and that (certain) fats are not a problem. I better understand the arguments for why this is the case. So, I’m pleased to have been here, and feel like I’ve learned plenty.

A last point: I’ve enjoyed having more personal contact with some folks who I’ve previously debated or encountered on social media, notably Karen Thomson and Dr. Gail Ashford, both of whom are pro-LCHF. Thanks to you both for the civil and often fruitful engagements we had over the past four days.

[Edit: I spoke with John Maytham on CapeTalk567 for a few minutes towards the end of day 2. The podcast of that conversation is embedded below.]

Big Food, Big Babies: moral panics and the business of eating

Earlier this year, Owen Frisby (the chairperson of SAAFoST) invited me to give a presentation at the 25th Congress of the Nutrition Society of South Africa. While the majority of speakers at the congress were dieticians and others working in medical science, my focus – as in previous posts and columns – was on poor critical reasoning and hyperbole in science writing, and the negative consequences this might have for public understanding of science. If you care to, you can read the text of my presentation below.


 

I’m speaking to you today not as a scientist, but as a philosopher – mostly focused on philosophy of science and critical thinking – and as a columnist for various publications, most regularly the Daily Maverick.

It’s been said that the philosophy of science is as useful to scientists as ornithology is to birds, so instead of speaking on that topic, I’ll focus on how issues related to health and nutrition are presented to the public, and whether those who do scientific work and try to communicate it to the public are getting their message across. Also, I want to look at whether it’s the right message at all.

There’s no question that, for most of us, health is important. This doesn’t however mean it needs to be treated as a good that always trumps all other goods. It’s entirely possible, and possibly even rational, for an individual to sometimes prioritize goods other than health.

If pursuing such goods comes at a cost to the health of others (for example, second-hand smoke), or at a cost to public welfare in terms of increasing the costs of healthcare for all the rest of us, we can also be excused for wanting to regulate such choices, or to at least disincentivise them in some way.

But one thing that I think is often missed when health is treated as our only or our primary interest is the effect that debates on nutrition, or science more generally, might have on the public’s ability to think critically about evidence and the scientific process.

Our health is a topic that lends itself to over-reaction, panics, and sometimes, the rise of what might appear to be cults, complete with prophets that can lead us from the wilderness of confusion, so long as you trust and obey.

The fact that we mostly do tend to regard our health as a good in itself, and a very important one at that, can lead to our being susceptible to discarding nuanced – and more accurate – understandings of the scientific process and its conclusions in favour of misleading headlines and hyperbole.

So as a starting point, one of the things I hope to persuade you of – seeing as many of you are communicating science in one way or another – is that one of the important lessons healthcare professionals, scientists, and science writers can teach others, including the public and government policy makers, is that things are often uncertain.

We might have very good reason to believe something, yet not feel entitled to claim that we are sure of it. This attitude of epistemic prudence is a reminder and demonstration to laypersons that (in the words of Dara o’ Briain) “science knows it doesn’t know everything – else it would stop”.

The point is, claiming certainty, or adopting a dogmatic stance, not only forecloses debate, but more importantly puts science in the same realm as pseudoscience. Homeopaths confuse the public with unfalsifiable claims, astrologers likewise, and these things waste people’s time, money – and occasionally – lives. It’s the fact that we embrace questions, and doubt, that makes the scientific method superior.

To put it another way, being right often starts with embracing the possibility that you might be wrong.

By contrast, the tone of much popular discourse, including coverage of important scientific fields in newspapers and on social media, proceeds as if things can be known, for certain.

This leads to absurd contestations where things are “proved” and then “disproved” with each new bestseller, and where apparent “authorities” rise and are then quickly forgotten as our attention shifts to the next sensation.

This infantilises the public – not only in treating them as if they are unable to make choices for themselves, but also more literally, in helping to ensure that they can’t make choices for themselves, through misleading them and teaching them to believe in simplified versions of the truth.

Let’s start with a very clear message, as captured in this quotation from the “Bellagio Declaration” of 2013, subtitled “Countering Big Food’s Undermining of Healthy Food Policies”.

The influence of Big Food in preventing public policy initiatives was clearly outlined by Dr Margaret Chan, Director-General of WHO (June 2013):

‘Research has documented these tactics well. They include front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt. Tactics also include gifts, grants, and contributions to worthy causes that cast these industries as respectable corporate citizens in the eyes of politicians and the public. They include arguments that place the responsibility for harm to health on individuals, and portray government actions as interference in personal liberties and free choice.’

This statement might have come out of a North Korean government press office. It’s infused with hysteria, paranoid thinking, conspiracies, and the evasion of personal responsibility in favour of placing blame elsewhere. And this is why I chose the title I did – big food has turned us into big babies, no longer capable of looking after ourselves.

To very briefly focus on some complex issues that the statement above ignores in favour of promoting paranoia: first, “these tactics” assumes there is a consensus around what the tactics are, and that they are already known to be evil.

“Industry-funded research” is spoken of as if it’s axiomatic that funding has to corrupt, which isn’t necessarily the case. And even if it tends to be, more often than not, the research can still stand or fall on its own merits, and we can’t dismiss it without looking at the evidence.

The “tactic” whereby “they” “cast these industries as respectable corporate citizens” again implies that they cannot possibly be respectable corporate citizens, and also assumes that we are already in agreement as to what a corporation’s responsibilities are in this regard.

Most importantly, consider the way in which personal responsibility is framed: it simply doesn’t exist, in that it’s someone else’s fault that you’re sick and overweight, never yours.

Arguments that “place the responsibility on individuals” are presented as suspect, so instead of reflecting on your own contribution to your problems, you’re encouraged to find a scapegoat – or better yet, let government do it for you, ignoring those idiots who think the state is interfering with “liberties and free choice”.

In summary, conspiratorial thinking is presented matter-of-factly, and thus normalized, in the course of this hyperbolic statement. And given the statement is from an “authority”, we’re primed to grant it our attention and (perhaps) trust.

But for me, this sort of fearmongering indicates that the World Health Organisation is perhaps less concerned with our cognitive health than with other forms of wellbeing. This statement is effectively bullying, rather than persuading the public – and if you teach people that they can’t think for themselves, you shouldn’t be surprised to find that they stop being able to.

And if you’re primed to spot a pattern involving malice and conspiracy, malice and conspiracy there will be. Eli Pariser’s concept of the “filter bubble” articulates this point well – if you go looking for evidence of Bigfoot on a cryptozoology website, you’ll find it. Chances are you’ll end up believing in the Loch Ness monster too, simply because the community creates a self-supporting web of “evidence”.

When these tendencies are expressed in the form of conspiracies, the situation becomes even more absurd, in that being unable to prove your theory to the doubters is taken as confirmatory evidence that the theory is true – the mainstream folk are simply hiding “the truth” so as not to be embarrassed or exposed.

You are all familiar with the language that becomes common in these sorts of situations, but perhaps that familiarity has made us somewhat less vigilant than we should be. Perhaps we should still take note, and be suspicious, when someone replaces argument with summary terms and slogans like big pharma, big ag, GMOs, organic and FairTrade.

These terms serve as triggers for fear or hope – in general, for reinforcing our biases. They describe folk who are doing these things to us, while we helplessly eat what we are told.

I don’t mean to suggest that these labels don’t refer to some real problems – it’s more that the labels take the place of argument, assume both the presence and magnitude of problems, and encourage us to stop thinking.

Thinking is a good in itself – healthcare choices are just one area where we need to make decisions, and rational decisions are only possible if we are thinking things through.

A sound relationship to evidence, reasoning, and the role of authorities in guiding us towards conclusions is a general virtue. Our failure to cultivate such a relationship won’t only impact choices related to health. Becoming lazy in making any category of choices means tolerating sloppy thinking, which is bad for our health in a different sort of way.

From a macro sort of perspective, here’s something that should give us pause for thought. Even though conversations around diet often involve fear, judgement, hyperbole, panic and so forth, consider:

Food isn’t moral. It’s not immoral, either. It’s morally neutral.

What should we then say about so-called “addictive” foodstuffs? The first thing to remember is the point Paracelsus made in the 15th century – “the dose makes the poison”.

sugar

While there might be no safe number of cigarettes to smoke, there will be a dosage of carbohydrates, or sugar, that’s unproblematic in all but the most rare cases.

Let’s look more closely at “sugar addiction”, and addiction in general. Two papers are typically cited as evidence for sugar being addictive, at least in the popular media. But what they mostly reveal is that science journalists no longer read or understand the journals, and that the public – and some professionals – are far too trusting when it comes to the sensational headlines that convey elements of those studies to us.

First, the Avena study, published in Neuroscience & Biobehavioral Reviews in 2007:

Food is not ordinarily like a substance of abuse, but intermittent bingeing and deprivation changes that. Based on the observed behavioral and neurochemical similarities between the effects of intermittent sugar access and drugs of abuse, we suggest that sugar, as common as it is, nonetheless meets the criteria for a substance of abuse and may be “addictive” for some individuals when consumed in a “binge-like” manner. This conclusion is reinforced by the changes in limbic system neurochemistry that are similar for the drugs and for sugar.

Pause there – who might be inclined to consume in a “binge-like” fashion? Perhaps someone with a pre-existing impulse control disorder, who happens to latch on to sugar? In other words, the reverse inference from the bingeing to the sugar might get the causal direction entirely back-to-front. We’ll get back to the neurochemistry later, but also, notice the scare-quotes – the author is hedging her bets, with the text only weakly supportive of any claim to sugar addiction, at least if “addiction” is taken to mean what it normally does.

It is not clear from this animal model if intermittent sugar access can result in neglect of social activities as required by the definition of dependency in the DSM-IV-TR (American Psychiatric Association, 2000). Nor is it known whether rats will continue to self-administer sugar despite physical obstacles, such as enduring pain to obtain sugar, as some rats do for cocaine (Deroche-Gamonet et al., 2004).

Nonetheless, the extensive series of experiments revealing similarities between sugar-induced and drug-induced behavior and neurochemistry lends credence to the concept of “sugar addiction”.

In other words (to get to the gist of the first two sentences above), there are some fairly typical features of what we normally understand as addiction that are missing here – but we’ll call it addiction in any case.

As I’ll argue in a moment, our common understanding of addiction is itself flawed, but I pause here just to note that the rats are supposedly “addicted”, but don’t fit the DSM definition of dependency – in other words, we’re using words rather liberally.

One is perhaps reminded of a line from Lewis Carrol’s “Through the looking glass”, where Humpty Dumpty said: “When I use a word, it means just what I choose it to mean—neither more nor less.”

Then, there’s Johnson & Kenny’s paper in Nature Neuroscience (2010), on junk food and addiction (also conducted on rats):

Notably, it is unclear whether deficits in rewards processing are constitutive and precede obesity, or whether excessive consumption of palatable food can drive reward dysfunction and thereby contribute to diet-induced obesity.

As in the Avena study, we don’t know whether an impulse control disorder is simply being expressed – rather than discovered as an effect resulting from the junk food – in this experiment.

Common hedonic mechanisms may underlie obesity and drug addiction.

Yes, if you grow to like something (or find it rewarding), you’ll seek it out. This does not mean the thing is innately addictive. In fact, Hebebrand’s recently published paper in Neuroscience & Biobehavioral Reviews concludes that if anything, “eating addiction” rather than “food addiction” best captures what’s going on when people compulsively over-eat. The food is an expression, not a cause of the impulse control disorder.

Both of these studies use brain imaging to support their conclusions. I worked for five years as part of a multi-disciplinary team investigating disordered gambling, also with the help of fMRI data, and in that time I got to read enough of the literature on fMRI to know just how misleading it can be, especially as presented outside of the lab.

As Sally Satel (who works as a psychiatrist in a methadone clinic) puts it, brain scanning is “a perfect storm of seduction”, promising “great revelations and great objectivity”. More to the point of my presentation today, it offers the possibility of eliminating your responsibility for what’s wrong with you – we can say, “it wasn’t me, it was my brain!”

Many of you will know this image, but before I go on to talk more generally about addiction, here’s an indication of just how misleading fMRI can be:

fmri-salmonThe short explanation of why this image is interesting is that it neatly summarises why you can’t reach firm conclusions from fMRI data. This fish is in fact dead, yet the scanner showed signs of brain activity.

fMRI data are suggestive, and weakly so at that, in that they reflect neural correlates of various stimuli, but nothing of the perceived and subjective mental responses to those stimuli.

In slightly more detail: Increased blood flow and a boost in oxygen are treated as proxies for increased activation of neurons, and from there we induce to what those neurons are doing. We compare that data to a baseline, and subtract the one from the other, averaging out over the many data points of all participants in a study, with software filtering out background noise and creating these seductive images.

But our experimental conditions are imperfect – think of the difficulties of creating appropriate baseline tests, for one – and large sample sizes cost a lot of money. Add to that the fact that our brains can process the same stimuli in different regions – no one specific area can reliably be said to perform the same task for all of us – and it should be clear that it’s far too soon to reach definitive conclusions from fMRI data.

The philosophical problem is one of reverse inference – we reason backward from neural activation to subjective experience. But if identified brain structures rarely perform single tasks, one-to-one mapping between activation in a region and a mental state is very speculative.

The images that get the attention in the media ignore these complexities. As we know, headlines don’t have space for subtleties, and furthermore, novel and exciting claims get our attention. If your fMRI scans can be said to show that sugar is “more addictive than cocaine”, you’re guaranteed some prime media attention, and who can blame you for trying to capitalize on that?

To quote Satel, we can’t tell – yet – “whether fMRI scans indicate an impulse that is irresistible, or one that simply hasn’t been resisted”. But it’s easier to make choices when you believe that there’s a choice to make, rather than a forced one, such that an “addiction” narrative might support.

To put it another way, diminished expectations of agency can lead to diminished agency – if you’re not aware of your choices, it’s more difficult to make choices.

Furthermore, addiction – and here I mean what we more commonly think of as addiction, like with heroin – retains elements of being a voluntary behaviour. It might be more difficult to make certain choices, in certain circumstances, but it’s still possible, and you’re more in control than you might think.

Yes, we see increased dopaminergic action (limbic/reward system) – where expectation is mediated by something known to be an addictive substance, or a correlate of an addiction. But we can’t conclude from this that all volition is lost, or that the addictive substance has “hijacked the brain”.

When we speak of things “changing the brain” in what Satel refers to as the “brain disease” model, we not only frame our choices as being all-or-nothing (sugar is toxic!), we also overstate the significance of changes to the brain in general.

This is because we’re changing our brains all the time, and we like the fact that we can do so. When you learn to play chess, or learn a language, you’re “changing the brain” too.

And what’s forgotten in this “brain-disease model” is how much we can tweak our behaviour – even our most compulsive behaviour – through using our past experience as a guide to influencing our futures through sanctions, incentives, and adjusting the contingent facts of our day-to-day lives.

Addiction – even of the most acute kind – is a behaviour whose course can be altered by the application of sanctions or incentives. Satel describes the brain level of analysis as subject to neurocentrism – the notion that the brain is inevitably the best level at which to explain behaviour.

The neurocentric position is held to be more authentic, more true, and holding more predictive value. And while some brain disorders – Alzheimer’s, for example – can be interpreted in light of this sort of model, addiction is far more complex.

For addiction, the neurocentric view implies that the solution is always a medical one. And yes, methadone does work (for withdrawal), but can obscure other remedies. Here’s a detail that might surprise you – in the majority of cases, people quit on their own, usually by their early 30’s. But we suffer from a confirmation bias here, in hearing about the cases that don’t quit, because these cases are often dramatic, and tragic.

Addiction is also a remitting condition – and in chronic cases, addicts also tend to have depression, anxiety and other confounders. What this means is that there are various options for intervention, and the psychological and environmental tweaks that might help addicts are frequently overlooked in favour of the brain-level explanation.

nixon

Here’s a great example from history. In 1971, there was an epidemic of heroin use in SE Asia among US soldiers. Nixon panicked, and launched Operation Golden Flow. You couldn’t board a plane back to the US unless you tested clear (after having a few weeks to clean up). In July, an estimated 15% of soldiers were using heroin regularly, but two months later, all but 4.5% tested clear. In follow-up studies, 3 years later, only 12% of those who had dependence had re-experienced addiction.

The addicts who are in control of their dependencies also adopt self-binding strategies. One of the books I recommend most strongly for understanding how volition works is George Ainslie’s “Breakdown of Will”, in which he speaks of “Bright Lines” as ways to hack the brain, given that we know in advance which weaknesses we’re susceptible to.

Motivation, in short, can make a huge impact. And the brain level is not YET the level at which our interventions are the most useful. Addiction and impulse control issues are a human drama, occurring in a context.

But the problem is that we like stories, and the media feed that liking. Sensationalist stories gain traction via our confirmation bias, and our cognitive dissonance – not being able to reconcile the complicated version of events with the sensationalist one – results in the backfire effect, where we double-down on our existing beliefs and shut out dissenting views.

What this adds up to is hysteria and moral panics, with little tolerance for nuance.

Worse of all, sometimes people who work in science contribute to our illiteracy by cherry-picking data, by presenting science as settled when it’s actually contested. This might sell books and gain a following, but at the expense of our critical thinking skills.

One clear lesson here is that we have a responsibility to be prudent with advice, and to reinforce the character of scientific enquiry in how we operate.

Set this more complex snapshot of addiction against the version currently gaining traction in South African and international media, and it should be clear that a word like “addiction” is being exploited for political and marketing purposes. The intent might be sound, even noble, but is it necessary to mislead, or can the message get through without the hyperbole?

We need to factor in the cost to our critical thinking abilities, as an at least part offset against the purported health benefits. Physical health does not necessarily trump these other considerations.

bantingWe should also be concerned with the costs all of us bear. An establishment in Hout Bay called Harmony Clinic now offers an 8 week online program for R 2 500, as well as a more expensive 28 day inpatient programme, to cure you of your “sugar addiction”.

They also run a “Sugar & Carb Addicts Anonymous” group – and the thing that makes this more troubling than simply being a middle-class moral panic is first the amount of breathless media coverage it gets – usually uncritically – but also the fact that the programme has now been recognized by Discovery Health – which means we are all paying for quackery.

To briefly touch on some other examples of how popular culture can be nudged into believing some very controversial claims about health, consider the rise of the idea of “real food”, or the “real meal revolution”, which inserts panic regarding GMOs and soy products into dietary advice that can (and should) itself be the subject of critical interrogation, some of which I’m pleased to see happening at this congress.

Leaving details of any particular diet to one side, I’d want to simply pause and ask “What is real food?” Does golden rice, genetically engineered and holding the promise of saving the 670 000 children who die of Vitamin A deficiency every year count? Or what of the founder of the Green Revolution, Norman Borlaug, a biologist who invented high-yielding wheat that is credited with saving a billion lives?

One sometimes gets the sense that some of these concerns are what folk on social media ironically refer to as “middle-class problems” – for people who are struggling to simply stay alive, you won’t get much sympathy for your GMO-skepticism, or for scaring them with nonsense fears around vaccines and autism.

Here’s another middle-class problem: FairTrade – which is by and large an exploitative cartel. Growers are paid very little for Fair Trade coffee, and consumers pay more for it. But growers sign up for fear of being frozen out, thanks to the marketing clout FairTrade has. So it’s either sell something at a lower profit, or sell nothing – which sounds quite a lot like a protection racket, but good luck convincing a hippie of that.

As London’s SOAS reported in their study of FairTrade:

What did surprise us is how wages are typically lower, and on the whole conditions worse, for workers in areas with Fairtrade organisations than for those in other areas.

Likewise with “organic” food – organic farms are currently 80% as productive as conventional ones, so immediately, we need more space to farm in, and more people willing to be farmers.

Science is also unable to support claims that organic food is safer or healthier. In the meanwhile, who pays the price for our affectations? The less well-resourced farmers, who can’t get by without the pesticides and so forth, because they have to concern themselves with yield above all else.

They also can’t afford the extra staff, and organic farming is more time and labour intensive, results in more spoilage, and at the end of the day, less profit.

The lesson might be: when you’re struck with a noble sentiment, try to ensure it’s not being funded by poor people, who don’t have the luxury of choice.

quinoaAlso, organically reared cows burp twice as much methane as conventionally reared cattle – and methane is 20 times more powerful a greenhouse gas than CO2 is. So future generations might be a little less than pleased at your organic food fixation.

Again, as with FairTrade, there are various cartels controlling organic certification, in a process that results not only in various confusing standards, but also creates a market for regulatory bodies to interfere with choice.

We end up with something like a religion, as in the potential need for separate bread slicers!

bread_signIt’s rarely true that people can’t think for themselves – if we allow them to. As I hope I successfully conveyed earlier, even addicts have all sorts of lucid periods, figuring out coping strategies for themselves.

Furthermore, the things we’re attracted to – even drugs – serve a purpose in our lives, and we need to understand that in our responses too. We’re inclined towards thinking that one model of health is compulsory for all of us – but self-harm on your definitions does not always need to be pathologised.

The problem with these panics, and with “science” and science reporting being infused with scaremongering, is that the state will turn to paternalism. Some things – that are always unhealthy – deserve serious nudging. But as I mentioned earlier, there is a safe level of sugar, wheat and so forth, and diets shouldn’t be medicalised all the time – it’s food first, rather than medicine. And food should be fun.

When nudges are appropriate, for example through taxes, or increased healthcare premiums for smokers, the most important question is simply whether they work or not – food should not become a moral battleground.

As you know, South Africa is now talking about a sugar tax. There are reasons for pessimism, and for thinking this a moralistic move rather than a pragmatic one. Alchohol taxes here are not very effective, and cigarette taxes haven’t increased the fiscus greatly, thanks to cross-border smuggling.

But even in more coherent economies, results are poor. Bloomberg’s soda tax didn’t work, and created perverse incentives such as people simply buying two sodas. Denmark’s “fat tax” lasted only a year- but in the meanwhile, authorities said the tax had inflated food prices and put Danish jobs at risk. The Danish tax ministry has also said it was cancelling its plans to introduce a tax on sugar.

I’m arguing that we are able to take responsibility for our choices, but have been trained into doubting that, and now need someone to blame for our poor choices. Even if there is more unhealthy food available than ever before, we’re eating more of it than ever before too – and that’s our fault.

On top of that, we’re moving less too, spending all our time in cars, in front of televisions or computer screens, perhaps reading about how the evil food producers are making tasty food.

There’s no reason to think it’s a conspiracy – they are making the food that we ask for. We’ve taken 3 decades to reach our current levels of obesity – and now that we cotton on to the fact that many of us need to learn new habits, and in general simply eat less, why not give that message a little time to sink in, instead of rushing to legislate/medicalise?

A short-term reaction involves panicking, and governments telling us what to do, perhaps gaining some revenue through taxing the things we’re told have made us sick. A longer-term – but more sustainable – solution involves education, teaching people to think critically about evidence, and encouraging them to take responsibility for their choices.

Yes, of course non-communicable diseases are a problem – but we’re still living longer than ever before, which means the story is on the whole positive, rather than catastrophic. This is something that’s easy to forget when only focusing on the panics.

Advertising might well be a contributing factor to buying unhealthy food – but it’s parents who buy the food, not the kids, and parents can understand the risks if they choose to. Meanwhile, we can’t blame companies for making their products attractive – that is, after all, their job. Of course food is engineered for our pleasure. Would we want it any other way?

We have no compelling reason to doubt that the food market – and “unreal” food, whatever that might mean – can’t develop into being healthier. And to some extent, our interests and those of the food producers are aligned – after all, the longer we live, the more product we buy!

Nuance in these debates is sacrificed for hyperbole, and slacktivism replaces activism in the field of education in critical reasoning about science. In the world of social media and short attention spans, we overstate the value of our own experiences, and generalise from them to universal truths.

But a collection of anecdotes does not equal data, but that’s difficult to remember when temperatures run as hot as they do.

The democratization of knowledge via the Internet has brought real boons to society. But it can also make us forget that real scientific breakthroughs happen in journals, not in bestselling cookbooks. And you hear about them on the news, not on the Dr Oz show.

It’s our job to fight for nuance, and to demonstrate, partly through showing that we’re willing to embrace uncertainty, what the value of the scientific method is, and why our best-evidenced conclusions should be preferred to conspiracies and folk wisdom.

And we devalue our scientific currency, or credibility, when we assert certainty – and we do the political cause of science harm, in teaching people that there are easy answers.

Our worth as scientists or science communicators is not vested in conclusions, but in the manner in which we reach conclusions. It’s not about merely being right. Being right – if we are right – is the end product of a process and a method, not an excuse for some sanctimonious hectoring, or dietary evangelism.

Sometimes we need to remind ourselves of what that method looks like, and the steps in that process, to maximize our chances of reaching the correct conclusion. Focusing simply on the conclusions rather than the method can make us forget how often – and how easily – we can get things wrong.

As Oscar Wilde had it, “the truth is rarely pure and never simple”.

I have a drug problem

addictionAnd that problem is stigma. Addiction is a biological mechanism, where the desire for a certain stimulus is reinforced through (among other mechanisms) a dopamine “hit” in the nucleus accumbens. It’s a chronic brain “disease” of sorts, influencing your reward system and your motivations. Despite this, many folk continue to think and talk about it primarily as a moral failing, or – on another end of the spectrum of unhelpful interventions – dilute the significance of addiction by using the term to refer to the fact that we enjoy certain foods as evidence of “sugar addiction” or “carbohydrate addiction”.

As Salon puts it in a piece on why addiction carries such a stigma, “the idea that those with addictive disorders are weak, deserving of their fate and less worthy of care is so inextricably tied to our zeitgeist that it’s impossible to separate addiction from shame and guilt”. And that shame and guilt, in turn can sometimes stop people from seeking out treatment while there’s still time to do so.

In Cape Town, we have a significant drug problem – from tik and its association with poverty and gangsterism, to the alcohol abuse that helps to fuel road death statistics. Besides taking responsibility for your own substance-use and (perhaps) abuse, there is one other simple thing we can all consider doing to contribute to alleviating Cape Town’s drug problem. Even if each individual contribution is slight, the collective contribution could be significant.

That contribution is in helping to end the stigma, thereby encouraging people to seek treatment and support. A wider public understanding of what addiction is can remind us to not be unnecessarily judgmental, nor to be overly simplistic about it in referring to social media or sugar addictions as if they are in the same league as a tik addiction. We can also inform ourselves about what the Government is doing (which includes a rapidly-expanding outpatient programme for opiate detox, an emergency helpline, and a significant annual spend on treatment and rehab.

This post was part of a City of Cape Town substance abuse awareness campaign.

If you’d like to add your voice to the Cape Town community and help deal with the substance abuse problem that affects the city, you are invited to share your own story. Post your story of how drug abuse affected your life in The City of Cape Town, and share it on Twitter by using the hashtag #ihaveadrugproblem. If you or someone you know needs help with substance abuse, phone the free 24hr helpline on 0800 435 748.

“Addicted” to hyperbole

Some of you might have noticed that recent blog posts here have earned me some antagonism from defenders of the low-carb, high fat (LCHF) diet. In their defence, they of course think that I’m being needlessly antagonistic, especially towards someone (Prof. Tim Noakes) who they think of as doing pioneering – and very important – work in nutrition.

I’d like to try and approach the topic from a slightly different angle here, in the hopes of illustrating what I mean when I say that my criticisms are premised on a concern for exaggerating the quality and consequences of data, in a context of great uncertainty. In the same way as my language and arguments around religion have tempered significantly over the past 3 or so years, in science I’m equally concerned with the example we set as to how to think, where the claims we make should be proportional to the quality and amount of evidence we have.

A comment on one of my previous posts led me to this blog post by Prof. Grant Schofield, in which he responds to a press release from health professionals in New Zealand, decrying low-carb high-fat advocacy. Schofield’s post seems happy to embrace nuance and to acknowledge the limitations in what we can know right now about the long-term effects of LCHF diets, and is to me a great example of how to argue for an outlier position in a way that lures people into serious consideration of your case, rather than giving the impression that you’re being asked to join a religious cult.

As I wrote earlier in the week, the language of science should embrace uncertainty. We should not offer people dogma, both because it dumbs down the process of scientific reasoning, and second (an extension of the first, though) because it encourages people to think in terms of false dichotomies or other poorly defined and crude categories. What’s right is often about nuance, and doesn’t fit in a tweet or headline – and those of us who know better should not encourage a simplistic “X is right/wrong/healthy/good/bad”, especially when we know that’s what the market wants to hear.

The Doctor just tweeted a link to a great piece about “food fearmongering” that makes this point via examples of diet advice and promotions for books and movies about diet that are almost comical in their hyperbole. Food, basically, is trying to kill you – and unfortunately, you’re also addicted to it.

Until fairly recently, I was involved with a multi-disciplinary research team working in the field of pathological gambling, and as a result got to spend five years working with leading international addiction scholars, neuropsychologists, clinicians in the field of addiction, and so forth. In national prevalence studies and other research, I also got to spend a fair bit of time with people who describe themselves as addicts.

The simple takeaway, if I were to distill five years into one sentence, is that addiction is complex, and not a word to be used glibly. Today, anything we happen to like is often described as addictive, and people will talk about “brain scans show that area X lights up” when you eat a Snickers bar, while not thinking that perhaps area X happens to light up when you do stuff you enjoy. Or, that people who are inclined to addiction will find things to get addicted to, but that this doesn’t always mean that the thing in question is intrinsically addictive.

Today, people are variously addicted to sex, love, the Internet, cocaine, carbohydrates, sugar, crystal meth and so forth. But using the same word to describe all these things is profoundly misleading, and is also potentially insulting to people who suffer from the sort of unambiguous addiction that costs you your savings, your family, your health and so forth. To put a mild lack of self-control alongside heroin seems somewhat glib.

Cocaine, for example, often has no physical withdrawal effects. Psychotherapist Marty Klein says that, in 31 years of practice in the field, he’s never seen “sex addiction”, and describes it as a myth. Internet addiction was invented as a hoax in 1995, when Dr Ivan Goldberg took the diagnostic criteria for pathological gambling and adapted them to the Internet.

Internet addiction wasn’t included in the 2013 revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) – not even in the “Conditions for Further Study” chapter, that highlights things thought worthy of continued attention. “Internet gaming disorder” can be found in “Conditions for Further Study”, and “gambling disorder” does appear, in a new category for “behavioral addictions”. As I say, it’s complex.

Then, as I’ve written in the past, we might even want to be wary of treating the DSM as authoritative, perhaps especially with regard to the class of behavioural addictions, accused of making a “mental disorder of everything we like to do a lot”. My point is simply that this one word, “addiction”, is being made to do a lot of work – and a term that broad can sometimes appear rather meaningless in consequence.

It’s of course not meaningless for people who do suffer with an addiction of their own. The question I’m asking here: if we start speaking of anything that people struggle with as an “addiction”, what are the consequences of that? I fear that we’re not only encouraging shoddy thinking about addiction (and science, in general), but we’re also encouraging victimhood in that my lack of self-control can now simply be ascribed to the fact that I’ve been snared by the evil Internet, or the seductive candy bar.

And finally, there’s the danger of insensitivity – almost insult – to people who struggle with addictions that destroy lives. While being badgered by a LCHF devotee on Twitter, I was asked “do you have ANY experience with addiction that is not related to some scientific study? So much more to it than that.” In other words, I was being asked if I was an addict.

Now, this was Twitter, so you might say that this sort of thing comes with the territory. But what if I was an addict, really struggling with something, perhaps have just lost a job, or a spouse, or somesuch? Might one not think the question rude, crude, inappropriate – even indefensible? (Regardless, of course, of whether it was relevant or not, in that I was being asked “never mind the data, but do you have an anecdote?”)

I’d certainly think it inappropriate, perhaps even “triggering“, in the contemporary language of social justice. When it comes from someone who works at an addiction clinic, of all places, I’d be even more convinced.

And in this case, that’s exactly where it came from – a person offering treatment for “sugar and carbohydrate addiction”. The field of addiction – and addicts themselves – could do with us being a little more careful about the language we employ, and the categories we use to describe the things we enjoy.