Thursday, July 31, 2014

July Foodie Pen Pals Reveal

I was writing another post, but time just snuck up on me...



The Lean Green Bean

So it's time once again for free food in the mail!

I had taken a few months off of the food trade. There were many other obligations and lately the local post office hasn't been too up to snuff when it comes to packages, so a few got lost or way delayed in the mail. (And I'm not the only one in the neighborhood feeling that pain). 

But I figured I'd give it another shot. 

This month I was matched with Ilona from New Jersey. On the plus side, an "almost local" make for easier to deliver packages. On the not so plus side, Ilona's wasn't going to be so impressed with NYC local delicacies she can get with a short drive across the river. So I put together a few odds and ends from the neighborhood. And even though Ilona's all about recipes, I weighed my package more on the snack side. You can check out her site for details of what I sent.

But what did Ilona send me? 


It was another caffeinated delight of a package! There was coffee beans (called Americadoodle flavor - have yet to try that), Coffee Rio caramels (lasted about 2 days), J Morgan's vanilla sea salt caramels (lasted less than two days), Haribo juicy gummis (shared with many and gone fast), a Pamela's Whenever bar, and the piece de delices, Vintage Bee creamed honey with spiced apple.


You can't see my other hand is sticky with honey already...

This stuff was AWE-some! I tried to parse it out, but it did not last more than a week. It ended up in a few desserts, but mostly it was just eaten out of the jar. I'm thinking I will have to buy some of this in bulk and use it in my honey cookie recipe for upcoming Rosh Hashana.

So thank you, Ilona, for getting me back on the FPP track.

If you're interested in joining the free food in the mail brigade, find out more details here.


Sunday, July 20, 2014

Hitching a ride on names

For many years, I had heard about Marcella Hazan's famous tomato sauce recipe: an incredibly simple idea with what looks like not enough ingredients that somehow becomes something magical. Crushed tomatoes, butter and an onion, cooked for about 40 min. That's it.

I've talked before about not following recipes to the letter, but I do like to try them out correctly on the first go, before I decide what I can do to tweak them to my taste. So I made Marcella's recipe as it was written.

Oh. My. God.

There are some creations of masters with which you do not tamper! It was pretty amazing both in its simplicity and it's final complex taste. My only concession is that the end product does not always end up on pasta. I use it on veggies, meats and on occasion, just plain toast.

Heinz - Woman with tomato shap... Digital ID: 1675405. New York Public Library
Mmm...funny shaped tomatoes! via NYPL Digital Gallery


I don't see it as an everyday sauce. (that's a lotta butter for my everyday Streamlined lifestyle!) And sometimes I do want different flavors and textures, but then what I am making is not Marcella's sauce.

And doing a brief search around the internet, you see quite a few photoshopped versions of the sauce, but there's also a few where someone decides to "modernize it just a bit." Perhaps "veganizing" or "paleo-ing" it up. 

And a lot of those "modernizations" usually include substituting butter with olive oil and perhaps adding garlic, basil, hot peppers, etc.

Which means you're making ANOTHER SAUCE!  

There's nothing wrong with making other sauces. I myself love garlic and basil in tomatoes, or chilis, or fish sauce or assorted vinegars and curries, but I can't stretch that to say I'm making a"modified" Marcella sauce. The whole purpose of it is that it really is just those three ingedients. 

And all those other recipe bloggers ...you're just using name recognition to try to get some more attention. I find this ironic as more and more folks are trying to find "food authenticity" and yet you're completely changing something while claiming this provenance. 

Harsh? Yeah, but we see that even more so in the fitness world. Yoga has been reiterated so many ways that it's become impossible to know what is considered that form of exercise. Pilates has gained so many "improvements" that I can only wonder that the canterkerous old boxer would probably smack all these modern practitioners. 

But the biggest shift I see is taking all these exercise regimens and making them more ... comfortable. Basically creating a spa environment for what should probably be just a sweaty time. 

Take this recent article about a new CrossFit studio in NYC. I'm not a huge fan of CrossFit; I have far too many leg and hip injuries and, as I've said before, I'm not too big on team exercise classes or events. So, not putting it down, but it's not for me. And what I do like about it is that it's about movement and exercise taken to a rather basic form. 

But here's a studio looking to "deliver the luxury-level amenities to the CrossFit community" by adding yoga, spa treatments and the like.

So is this still CrossFit? Isn't this really ... a spa & gym? It seems to me that they're just taking the name and using it as a marketing ploy. 

Or is it that people just don't like exercise to be basic and dirty? They need pampering along with a name exercise?

The spa, Central Park. Digital ID: 800960. New York Public Library
Do they have pull up bars at this spa? Or is just hot yoga? via NYPL Digital Gallery
I get that people need a push. This study shows that overweight subjects found exercise less pleasurable the more they had to exert during the exercise. And that, of course, led to less adherence to the exercise regime.

But is claiming a name making it more palatable? I don't think you'll get more intense exercise out of added facials and rubdowns. 

Exercise is still hard. And calling something that it's not is merely pasting glitter on the same idea. Trying to make yourself popular without actually BEING the thing in question is just bad form.

I'll just wait for butter to be included in my pilates workout, then.




References:

Ekkekakis, P., and E. Lind. “Exercise Does Not Feel the Same When You Are Overweight: The Impact of Self-Selected and Imposed Intensity on Affect and Exertion.” International Journal of Obesity 30, no. 4 (2006): 652–60. doi:10.1038/sj.ijo.0803052.


“Is ‘CrossFit Chic’ Coming to New York City?” Well+Good NYC. Accessed July 16, 2014. http://wellandgood.com/2014/07/07/is-crossfit-chic-coming-to-new-york-city/.

Tuesday, July 8, 2014

The Illiteracy of Life

"Whaddaya mean 'illiterate'? My father and mother were married right here in the city hall!"- Dorothy McNulty (aka Penny Singleton) in After the Thin Man.

Ah, I love that movie.

There's a strong movement in many professions about literacy or one's knowledge about a certain subject. Certainly in my own profession of librarianship (or more often academic librarianship), there's a constant push for information literacy. Some professional library organizations like the Association of College and Research Libraries (or ACRL) spend an awful lot manpower on it. And virtually every academic library has to partake in this exercise.

To weigh over on the Librarian side of the Streamlined Ska persona, I have some serious issues with how information literacy is thrown en masse as THE answer to successful students navigating the ever changing resources in front of them. I'm more of a fan of developing critical thinking skills among library users and less of a specified learning objective. If I base technical proficiency for librarians based on when I was in Library School, well then, it probably hasn't changed much. I don't think being technically savvy is the answer to successful research. It's part of it, but just enabling one key phrase is not going to get youngsters to understand how to formulate a question in order to find an answer that might be more than just parroting their favorite website.

That's my very small nutshell. I would suggest reading Lane Wilkinson's take on ACRL's attempt to recast info lit in terms of threshold concepts to see a larger timeline and set of resources as to part of this argument.

"But what has this to do with food and weight maintenance," you ask? Well, we're now in the age of trying to teach food literacy. (I mean "we" in the sense of us all, although librarians did stick their nose in it, too.)

And it's very similar to info lit: If we teach the basic tenant of this subject to someone, they will better prepared to make an informed decision about their food intake. And a recent literature review of food literacy programs geared at adolescents shows ... that few of these initiatives show a positive impact on dietary choices. Even though the need is still there. Whomp-whomp.

And yet if you look at the 19 studies reviewed in this paper, they all had different learning outcomes. While they were all about getting a better understanding of healthy eating, there was not overriding method or exercise.

So we have librarians trying to agree on a set way of determining outcomes and we then have ... well, I was going to say "Dietitians and Nutritionists have many ways to determine outcomes," but that's not entirely true.

It seems a lot of people feel they can teach you to eat better and be more healthy, even without a professional accreditation. Information literacy still tends to stay in the Academic wheelhouse, and usually with the librarians. For food it's not always the professionals. Sort of in the same way as "Why do I need a library? It's all online." Anyone can write a cookbook.

Man, people are stupid.

Still, getting back to actual research in food literacy, I'm thinking the reason it's so difficult to tackle this in a uniform matter is that most people have very different concepts not only of food, but of themselves. It's one thing to say, "I prefer searching Lexis-Nexis to Westlaw." It's another to say, "I only eat vegetables that look and feel and taste this way," such as in this study from the Netherlands.  (Although as a long time former employee of a Dutch company, I rarely found any Dutch who liked their veggies raw or crunchy!)

Het spijt me, maar het is waar!

And let's look at this study about perceived body fat. While gender made a huge difference in results, it seems very few folks were correct in estimating their own body fat percentage nor were they satisfied with their current body fat.

So here we are studying ways to get folks to make better choices when they already cannot perceive themselves correctly nor do they prefer the taste and texture of healthier foods. How do you change that? How do you teach someone to make lifelong decisions that may often go against their internal make up? Is it the same as teaching a freshman how to better prepare a research question?

At this point, I suppose I could make a grand conclusion summarizing how once again the librarian and dietitian groups need to come together to create some universal moment of literacy. But I'm not, because I don't really think that'll work this time. Not that we shouldn't play together, but not like this.

Instead I really think we need to move into the idea of critical thinking. It's not if you're an expert on a subject. It's that you know enough to try to question WHY something might work for you, information or food-wise. And it opens up your mind to finding out more in order to make an informed decision that works for you.

I always say that's what makes a good librarian anyway. Perhaps that's also why the Streamlined Ska life has been manageable, as well!

ETA: I will say that most of my career OUTSIDE of academia, we never worried about this stuff. It was always just critical thinking.  

References:


Bongoni, R., R. Verkerk, M. Dekker, and L. P. A. Steenbekkers. “Consumer Behaviour towards Vegetables: A Study on Domestic Processing of Broccoli and Carrots by Dutch Households.” Journal of Human Nutrition and Dietetics, June 1, 2014, n/a–n/a. doi:10.1111/jhn.12245.

Brooks, Natalie, and Andrea Begley. “Adolescent Food Literacy Programmes: A Review of the Literature.” Nutrition & Dietetics, December 1, 2013, n/a–n/a. doi:10.1111/1747-0080.12096.

Campisi, J., K. E. Finn, Y. Bravo, J. Arnold, M. Benjamin, M. Sukiennik, S. Shakya, and D. Fontaine. “Sex and Age-Related Differences in Perceived, Desired and Measured Percentage Body Fat among Adults.” Journal of Human Nutrition and Dietetics, June 2014, n/a–n/a. doi:10.1111/jhn.12252.

“Information Literacy Resources.” Accessed July 8, 2014. http://www.ala.org/acrl/issues/infolit.

“The Problem with Threshold Concepts.” Sense & Reference. Accessed July 8, 2014. http://senseandreference.wordpress.com/2014/06/19/the-problem-with-threshold-concepts/.

Yang, Sharon Q., and Min Chou. “Promoting and Teaching Information Literacy on the Internet: Surveying the Web Sites of 264 Academic Libraries in North America.” Journal of Web Librarianship 8, no. 1 (2014): 88–104. doi:10.1080/19322909.2014.855586.

Tuesday, June 24, 2014

A Pinch of Oz

So, almost a year after getting my "Dear John" letter from my trainer, I finally bit the bullet. No, I didn't get a new trainer ... yet but I did decide to return to the bigger, more expensive gym where I first met him. And you really do get what you pay for:


Via the NYPL Digital Collections


Perhaps it's the initial giddiness of these first two weeks back in the old place (although the actual gym moved down the block, but it's still the same chain as before). The sheer happiness of finding fully equipped weight rooms, working squat racks, TRX bands, a decent amount of working cardio machines and even the semblance of regular cleaning so there's not a patina of mystery stains after using any stretching/abs/floor areas. Maybe that will wear off in a bit, but for now I can see the difference in my workout already. And that has had a positive effect on my food intake, as well.

Of course, there are a few of the regular flies in the health ointment. That huge cabinet of supplements still stands near the main entrance and the hard sell has begun. My last trainer had a reflex flinch every time we passed by that cabinet after our first session when I ripped him a new one and said if he ever tried to sell me one pill, our sessions were over. Harsh? Yes, but it worked!

But now the push is back. They even offered a welcome back goodie bag of the stuff (I declined). 

If you're running a place that pushes exercise and even nutrition as hard work (no judgements, and fun, but hard work) , why are you also then selling this "easy boost"? (It's rhetorical, I know why.)

I know this is a business model. I know this is a way to make some extra funds. But I see it as a mixed message. And yet, it's not like it's the only place trying to sell us a "cheating way to win."

I get sent lots of library links, cute tattoo videos, and of course, many links about nutrition and weight loss from a variety of my friends. Most of these are out on the usual social media memes, so I often receive them again and again.

And then Dr. Oz happened this past week. So I got a loooooot of links about it.

While I'm not surprised at the results of the hearing or the backlash around it, it does raise the question: If everyone supposedly thought Dr. Oz was a quack about these supplements, why did he still sell so many of them? My "professionals-of-another-degree-mother," the Registered Dietitians, have been weighing in on Oz's claims for quite some time, a lot of it critical towards the man. (Although there are some who use his show as their own PR sounding board). You think having some credential might be taken into account.

Yet we still all want to believe that something will be a "miracle," especially when it comes to our health and weight. One study a few years back showed that the majority of people surveyed did believe that dietary supplements would help in obesity. The numbers were higher for people who were overweight or obese. Yet results, especially those from evidence-based research, show that the efficacy and safety of these supplements is still unknown, and even the ones from "natural ingredients" have not been shown in any positive results of dieting individuals.

And these are often the same people who "eat clean" or deny certain basic food groups. They'll still take a mystery concoction that is "magic"? Is it ethical to promise a miracle, especially if you have a few initials after your name and a global audience?

There's nothing wrong with having faith that you can achieve whatever you want for your body in terms of being healthier. But I'd rather do it on my own belief that "mystery miracles" are not part of the equation.

via The Smithsonian Collection

Yeah ... no.

References:


Laddu, Deepika, Caitlin Dow, Melanie Hingle, Cynthia Thomson, and Scott Going. “A Review of Evidence-Based Strategies to Treat Obesity in Adults.” Nutrition in Clinical Practice 26, no. 5 (October 1, 2011): 512–25. doi:10.1177/0884533611418335.

Pillitteri, Janine L., Saul Shiffman, Jeffrey M. Rohay, Andrea M. Harkins, Steven L. Burton, and Thomas A. Wadden. “Use of Dietary Supplements for Weight Loss in the United States: Results of a National Survey.” Obesity 16, no. 4 (April 1, 2008): 790–96. doi:10.1038/oby.2007.136.


 


Sunday, June 15, 2014

Sometimes a swift kick...

Definition of a bad day:


Via Getty Images


It's been a frustrating week or so, even if this is the farthest the NY Rangers have come in 20 years. Still, not the way you want to spend a weekend, seeing this happen.

But if anything, it's sort of become my new "clickable moment" or perhaps a re-ignition of my old one. It's time to take stock of what I'm doing and smack myself in the tuchas to get back on it. In a way, the past few months have been filled with a quite a few "on hold" plans and events, all unresolved, which admittedly took away from my laser-like focus of the Streamlined Ska Librarian lifestyle. And now they've all ended in a somewhat disappointing way. So, the Rangers loss is sort of the symbolic culmination of all that stuff.

You can see my blog entries dropped off, too. And while I can say that my food choices weren't always great, it was definitely the drop in intense exercise that really dragged me down. And a lot of that was due to the very cheap gym to which I belong. The final straw was going three days with some missing dumbbells, thereby preventing a decent workout. (It's hard to do chest presses with only one weight .. and the bench presses were not there). Oh, and the fact that there was no airflow in this basement gym, which led to mold and mildew growth. And the boxing bag broke. Hat trick of gym hell. 

It was time to go.

So I've bitten the bullet and rejoined the expensive gym. It is a financial sacrifice? Yes. Do I think it's worth it? Most definitely.

As I've said many times before, I know what I need to stay in Streamlined mode. And that, sadly, does cost something. Or at least  it requires more of a real gym. Some other life amenities will have to go, but that's ok, I'm willing to make that decision.

As I said in previous posts, exercise makes me happy...the inability to do said exercise does not. I have become a picky gym bunny. Who knew?

Well, I did, actually.

And already, I just feel better. Because I know I will be the intense happy guy I can be, the guy who didn't get a chance to really appear for the past 6 months. And I also know, I'm doing it for me. Not because I'm back in Retro Ska Librarian body, cuz I'm not there yet, but rather because I can see Retro mindset creeping up if I don't.And that ain't good

It brings to mind a recent post from RD Aaron Flores. (Always a dietitian work into the posts!) I'm not going to say I agree with everything he says, but the mindset is there. You have to comfortable knowing what works for you and be happy in your journey to get where you want to go health-wise.

And my taking stock meant that swift kick is upon me.

No scholarly references this time, just a shout out the Rangers. You still inspire me.

Wednesday, June 11, 2014

"Stop Saying Wheee!"

I do not know why but for someone who is very good at group activities and following rules, I've always felt really uncomfortable at enforced "enjoyment events." Summer camp sing-a-longs, any solstice drum circle and especially group exercise classes where they shout at you to enjoy yourself. They creep me all out. 

Look, I know spin classes and laughing yoga work for many people, but I just don't like them. I don't need to be told when to say "Wheee!"

(This blog entry's title actually comes from a scene from here. It's very apt to this topic).

"But, Mr. Streamlined Ska Librarian," you say, "If I enjoy it, won't I do it more?" Why, yes, small handful of blog readers, you probably will. I think it's sort of obvious that one tends to do any activity more often if one enjoys it. 


via
Maybe I'd have this same expression during my cardio if I had those fabulous heels to work out in. Wheee, indeed.

However, there might be another reason why enjoyable exercise works towards weight loss or weight maintenance. A recent study showed that subjects who were told they were doing a physical activity "for fun" as opposed to "for exercise", ate less afterwards. There was less of a reward aspect to their physical activity. ("I ran 60 minutes on the treadmill, so I can have 2 donuts!")

And I do find that fascinating. Especially when another recent study shows that we consistently misunderstand what is meant by "moderate exercise." And we're only misunderstanding it in one direction.

So at least if we're not getting enough vigorous exercise, we're probably eating less to compensate if we enjoy that exercise.

I do enjoy running, even if it means having to get through those initial 10 minutes of my brain saying, "You can stop now!" Once I get going, I'm very happy. I also enjoy boxing very much and yes, even heavy weight lifting.

But it doesn't mean I don't get bored with the routines and I rarely consider weight lifting to be "just for fun." However, I still like it more than many group exercise instruction. I feel less uncomfortable, which makes it more enjoyable. But I also know that it's work. I'm doing this for a reason. And being Streamlined does make me happier and more comfortable with myself. 

And sometimes you just need to be comfortable and satisfied to get towards happiness. Yet another study shows the relationship between obesity and subjective well-being. Not surprisingly, there seems to be a inverse relationship, and women suffer from low satisfaction due to obesity far more than men. But they also mention one interesting hypothesis from their results:

"Our findings demonstrate that where obesity is more prevalent, the difference in life satisfaction between the obese and nonobese is smaller for women and almost nonexistent for men. The same relationship is likely to exist over time: the emotional cost and advantage of obesity and nonobesity, respectively, may be decreasing as the prevalence of obesity increases. If future research finds evidence for this trend over time, it would offer additional insight into the causes of the exponential growth in obesity over the past 30 years: a cyclical process in which the emotional cost of obesity declines, resulting in greater prevalence, resulting in fewer emotional costs."

In other words, if we all get fat, we'll have less options to which to compare! Yay, now we can make fun of you for being bald!

But, even if we're all moving towards an inevitable obese society, it still doesn't mean you can't have fun being active in some way. And if that makes life better, then it's probably something we should all do in some way. 

Just don't say Wheee. Nobody says wheee. Nobody.



References:


Canning, Karissa L., Ruth E. Brown, Veronica K. Jamnik, Art Salmon, Chris I. Ardern, and Jennifer L. Kuk. “Individuals Underestimate Moderate and Vigorous Intensity Physical Activity.” PLoS ONE 9, no. 5 (May 16, 2014): e97927. doi:10.1371/journal.pone.0097927.

Wadsworth, Tim, and Philip M. Pendergast. “Obesity (Sometimes) Matters The Importance of Context in the Relationship between Obesity and Life Satisfaction.” Journal of Health and Social Behavior 55, no. 2 (June 1, 2014): 196–214. doi:10.1177/0022146514533347.

Werle, Carolina O. C., Brian Wansink, and Collin R. Payne. “Is It Fun or Exercise? The Framing of Physical Activity Biases Subsequent Snacking.” Marketing Letters, May 15, 2014, 1–12. doi:10.1007/s11002-014-9301-6.

Sunday, June 1, 2014

That diet is bananas!

First, if I may:




LET'S GO RANGERS!!!!! WHOOOP!! WE WANT THE CUP! 

OK, now where were we...

A browse through some of my recent cookbooks acquisitions brought this little ditty to light:


via The Buffet Cookbook
 
This is not something met with my usual lip smacking culinary fantasy. However, it seems this was a fairly common recipe in mid-century cookbooks. And I was intrigued. Instead of getting immediately creative, I followed the recipe pretty much to the letter (except I halved it). The result?




Ummmm...no. Granted, my dinner guest thought it was delicious. I thought it tasted like, well, bananas mashed into beef. Blerk.

This might have been good with some sort of curry or jerk spice. Something tangy-spicy to interact with the bananas.

To me, it was a failure. Even if the blog reviews of this recipe were saying it was amazing.You can't believe everything you read.

Which is why this particular article in the NY Times made me a little nervous, at least by it's headline. Men losing 11 pounds in only 4 days? If you look at the full study, overweight men were given severe caloric restriction (360 cal/day!) combined with intense exercise, then continuing increase exercise for another week. And surprise, these men lost a lot weight. And they seemed to have kept it off after a year. But even the scientists confirmed that this needs more observation and it may not be ideal for those without the initiative.
But also, there was a only a handful of men in the study, so this cannot be considered a universal solution, just yet.

Also, looking at it in perspective, when I started my Streamlined lifestyle change, I worked out with my first trainer that if I cut my intake to 2700 cal/day, but increased my exercise, I could maintain my goal of a one lb. of weight loss per week.

Now that was already a huge calorie drop for me. Doing a quick and dirty calorie count on Retro Ska Librarian meals, I was probably taking in 4000-6000 cal/day. Way more than any recommended daily allowance. So coming down to 2700 was already a shift, never mind that it also meant I should be engaging in "intensive exercise" at least 5 days a week (otherwise weight loss would have been only do to even less calories).  I cannot imagine handling 360 cal/day. That's not even a bagel or a beer.

So while this is an eyebrow raising study, do we see it fitting into a healthy lifestyle change? I'm sure someone will try to bank on that! 

"The Danish Starvation Diet! Eat like a Little Mermaid!"

But what makes it more difficult could be our overall diet. A brief written for JAMA has two doctors saying it is the way we store fuel in fat cells that can actually prevent us form properly losing weight. Coming back to the theory that it's not how much you eat, but what you eat. 

I'm not sure how I feel about this theory, and it is just that at the moment, a theory. Taken at it's basics, yes, it is healthier when you count calories to try to eat healthier foods (I suppose 2700 cal/day of frosting tubs would have not have been very smart of me to do).

But will this idea throw more people into the arms of "quick fix" diets and pills, as they feel they are "doomed" by their fat cells? Frank Bruni, fellow former pudgy guy, does see it as a problem that we all fall into:

"And the vogue for painstakingly tailored eating regimens and dieting techniques is to some extent a distraction from that, a dangerous one, because it promotes the idea that basic nature and fundamental biology can somehow be gamed, cheated, transcended."


There is no cheat. There is no extreme way of doing this. And I can no longer buy into any special diet.

It is highly possible that my fat cells have been so overworked that weight loss for me might be harder. But I did do it, without denying myself anything out of the ordinary. However, maybe those "trigger" foods are what these doctors are talking about.  I don't know, I just know what worked and it wasn't advertised on TV.

In any case, there is no easy answer. Never was. Never will be. You want a miracle, look at those beautiful NY Rangers! It took 20 years, but they finally hit their goal! (OK, ouch...)

 
References:


4 Days, 11 Pounds. (n.d.). Well. Retrieved May 23, 2014, from http://well.blogs.nytimes.com/2014/05/22/4-days-11-pounds/


Bruni, Frank. “Diet Lures and Diet Lies.” The New York Times, May 26, 2014. http://www.nytimes.com/2014/05/27/opinion/bruni-diet-lures-and-diet-lies.html.


Calbet, J. a. L., Ponce-González, J. G., Pérez-Suárez, I., de la Calle Herrero, J., & Holmberg, H.-C. (2014). A time-efficient reduction of fat mass in 4 days with exercise and caloric restriction. Scandinavian Journal of Medicine & Science in Sports, n/a–n/a. doi:10.1111/sms.12194

Ludwig DS, & Friedman MI. (2014). Increasing adiposity: Consequence or cause of overeating? JAMA. doi:10.1001/jama.2014.4133