Friday, December 27, 2013

One a Day Keeps Nothing Away

Vitamin use is ubiquitous in Canada.  50% of women and 35% of men take a daily vitamin or mineral supplement.  They are so commonly used that few question their necessity.

James Lind was an 18th century Scottish physician tasked with finding a cure for scurvy, a greater threat to the Royal Navy than enemy arms.  Instead of relying on anecdotes as his colleagues did, he conducted the first known clinical trial.  Citrus fruit was so obviously effective that supply of lemon juice was made mandatory on all British ships.

It took 100 years to discover that vitamin C in citrus fruits is what cures scurvy, but Lind’s rational approach nonetheless identified the best treatment and saved lives.  

Contrast this with the approach taken by Linus Pauling and his countless followers.

Pauling was an American scientist who won the Nobel Prize in Chemistry and the Nobel Peace Prize.  Then he met Irwin Stone.

Stone convinced Pauling, just by saying so, that if he took 3000 mg of vitamin C daily, he would live a long life.  Pauling was so excited about vitamin C he increased his daily dose to 200 times the daily limit and published a book about it. Shortly after, 50 million Americans were following along.  

He eventually promoted other vitamins to prevent and treat every disease known to modern medicine, including cancer.  His pronouncements became so outrageous that he lost his scientific credibility.

The public didn’t notice and the use of vitamin supplements grew unabated.

Pauling based his treatment on anecdote, Lind based his on evidence.  

Who was right?

Vitamin C is useless in treating colds.  It may slightly reduce the duration of colds if used daily, but not the number of colds.  

As for multivitamins, there is no currently available evidence that daily use in the general population has any impact on reducing cancer, cardiovascular disease, or mortality.  

Beta-carotene, selenium, and vitamins A, C and E warrant special mention.  Not only do they have no impact in preventing disease but there is reasonable evidence that beta-carotene and vitamin E may actually increase risk of death.  

“There is no scientific basis for recommending vitamin-mineral supplements to the healthy population.”-Dr. Benjamin Caballero, MD.


4.  Offit PA. Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine. New York:HarperCollins; 2013.

9.  http://www.ccjm.org/content/77/10/656

Friday, December 13, 2013

Something's Fishy Here

First published in the December 6, 2013 issue of The Vault Magazine.  

If you research ice cream sales and drownings in swimming pools, you will find they are correlated.  That is, as ice cream sales increase, so too do drownings in swimming pools, and vice versa.  To say that ice cream causes people to drown is of course absurd.  More likely, heat waves cause both variables to increase.

This logical fallacy is common in population studies.  Researchers look at large groups of people and analyze their lifestyles.  They then look at the health of this population and try to determine if certain lifestyle factors are associated with poor (or positive) health outcomes.  

When they find relationships it often leads to pronouncements of causation which quickly spread. 

The ubiquity of omega-3 fatty acids is testament to the problems this can cause.  

Omega-3 fatty acids (AKA omega-3s, EPA, DHA, fish oil, etc.) occur most commonly in fish.  They represent a $25 billion global market, mostly in infant formula, fortified foods, and supplements. 

From this one would think the evidence is conclusive that they improve health.  

Sadly, this is not the case. 

It all started in the 1970s when Danish researchers looked at Greenlandic Eskimos, a population with extraordinarily low rates of heart disease.  Their diet consisted almost entirely of marine animals and their blood showed massive levels of omega-3s.  

Assuming correlation equals causation, they attributed the low rates of heart disease to the high rates of omega 3s.

The notion spread.  Study after study showed that high rates of fish consumption correlated with lower risk of heart disease.  

Today omega 3s appear in every form imaginable, from pills to yogourt.  They are promoted for infant development, intelligence, autism, ADHD, heart disease, Alzheimer’s and more.  

Dr. Oz says they are 1 of 5 "critical" supplements every woman should take, and good for "just about every single part of your body".  

To determine causality, researchers conducted randomized controlled trials, the gold standard in medical research, on omega 3 supplements.  

The Cochrane Collaboration reviewed many of these studies and the conclusions are clear.  

There is simply NO evidence that supplementation with omega-3 fatty acids causes any of the health benefits attributed to them.

Populations with high fish consumption have lower rates of heart disease than those with low fish consumption.  

This does not mean fish consumption causes low rates of heart disease.  

It is likely just one component of an overall healthier lifestyle.

To think that in the infinitely complex interaction between lifestyle and health that ONE chemical component of ONE food group is responsible for this effect is a leap of faith. 

To take that one ingredient and put it into every food and supplement we consume and think we will reap healthy rewards stretches the boundaries of reason.  


It’s a shortcut to health that rarely works.  

Next time: What multivitamins and the Nobel Prize have in common.  


References

1.  http://mnstats.morris.umn.edu/introstat/public/instruction/causation.html
2.  http://www.innovation.research.wvu.edu/r/download/158952
3.  http://www.sciencedirect.com/science/article/pii/S0140673671916588
4.  http://www.isodisnatura.ca/history_of_omega-3s.htm
5.  http://content.onlinejacc.org/article.aspx?articleid=1117937
6.  http://www.doctoroz.com/videos/daily-dose-omega-3
7.  http://www.ncbi.nlm.nih.gov/pubmed/22968891
8.  http://www.ncbi.nlm.nih.gov/pubmed/23814120

Friday, November 29, 2013

The Cholesterol Conundrum

Originally published in The Vault Magazine, November 22, 2013.

On November 12, the American College of Cardiology and the American Heart Association released an update to their clinical guidelines for the management of high cholesterol.  Amid all the ensuing controversy and debate, the most remarkable facet of the guidelines was forgotten.

Previous guidelines promoted measurement of cholesterol and frequent monitoring for the purposes of “getting to target”.  Start treatment, measure cholesterol, adjust treatment if it needs to go lower, and repeat.  

The new guidelines suggest these numbers be almost entirely abandoned in clinical practice.  If a patient has excessive heart disease risk and it has not been ameliorated by lifestyle changes, they suggest you take a statin (eg. LipitorTM and CrestorTM) and be done with it.  The cholesterol measurement only remains important for determining risk. 

It’s about time.  These targets were always arbitrary.  They have no scientific underpinning and led to excessive treatment including unnecessarily high doses and use of drugs that have no proven benefits beyond lowering cholesterol.  

Wait a minute.  If a drug lowers cholesterol, isn’t that good for you?  

Not exactly.  And herein lies the public interest in this issue.  

Cholesterol is a “surrogate marker”.  If studies show lower cholesterol correlates with lower heart disease risk, then a drug developer might look at the impact of their treatment on cholesterol and assume any reductions in this number translate into reductions in heart disease.  Measuring heart attacks, strokes, and deaths in your research takes time and money.  Measuring cholesterol does not.

If A=B and B=C, in medicine at least, A does not always equal C.  

For example, many cholesterol drugs on the market reduce bad cholesterol but only statins are known to reduce heart disease.  

Not convinced?

Torcetrapib was a drug being developed by Pfizer which showed great promise as the next “blockbuster drug”.  Early small studies showed the drug raised good cholesterol by 60-100%.  This should, by extension, mean it reduces heart disease.

Shortly after, Pfizer’s large clinical trials were stopped early because the drug increased risk of death by 60%.  

Why should you care?  

Because the media, TV doctors, and internet snake oil marketers LOVE surrogate markers.

Dr. Oz’s most popular recommendation of the year has undoubtedly been raspberry ketones for weight loss.

Too bad they’re useless.

His website quotes all sorts of research on the topic to lend it credibility but it is useless for everything but hypothesis generation.  All the studies he quotes were done on animals or in test tubes and they studied things like markers of metabolic rate and fat metabolism.  

Not a SINGLE piece of research shows raspberry ketones do ANYTHING useful in humans, let alone cause them to lose body weight or body fat.  

THAT is why you need to know about surrogate markers and why from now on, you will know to ignore practically everything Dr. Oz says.  

Unless by some miracle he starts promoting products based on high quality medical research conducted on humans.


I can dream.

Next time: Why some would argue that ice cream causes swimming pool drownings.

Other Resources
A hilarious video on surrogate markers from my friend and colleague, James McCormack, PharmD.

References
1.  http://newsroom.heart.org/news/acc-aha-publish-new-guideline-for-management-of-blood-cholesterol
2.  http://www.theglobeandmail.com/life/health-and-fitness/health/us-heart-guidelines-may-threaten-new-class-of-cholesterol-drugs/article15413756/
3.  http://en.wikipedia.org/wiki/Torcetrapib
4.  http://www.nejm.org/doi/full/10.1056/NEJMp078020
5.  http://www.ncbi.nlm.nih.gov/pubmed/15071125
6.  http://www.ncbi.nlm.nih.gov/pubmed/16326978
7.  http://www.doctoroz.com/videos/rasberry-ketone-what-science-says

Wednesday, November 20, 2013

The Problem with Origins


I was directed to this "enlightening" image by a Facebook friend.  I don't take umbrage with her sharing it with me.  I believe she only meant to guide me toward the origin of the word Pharmakeia.  However, after looking at the link, I have to take umbrage with the suggestion inherent in the text of the image.

Instead of writing a giant tirade of a comment on Facebook, I thought I would post it here.

The origin of the word pharmakis in Ancient Greek did indeed mean "witch".  This makes sense as much of the origin of pharmacy came from experts in botany and translating that into medicinal uses.  Many early chemists were considered "witches" by the medical establishment at the time, which is funny given that the docs thought disease was caused by unbalanced humours in the body and treated everything under the sun with blood letting.

And yes, they were seen as potions and witchcraft, but only because the science hadn't caught up to their use.  Use of pharmacologic substances was much more advanced in the Arabic world early on than it was in Europe.  It is there that pharmacology as a science originated.  Meanwhile in the "modern" world of Europe, because the drugs they used were not understood, those making them were considered witches, sorcerers, and poisoners.  All drugs are really just poisons brought to a dose tolerable by the human body.  Anyone suggesting that this means pharmacists are poisoning everyone doesn't understand science.

As the science of pharmacy evolved, it always remained connected to medicine.  It is only recently that it evolved into an independent profession, and, in turn, it evolved into a more clinical profession than one focussed solely on drugs.  The word "pharmacy" today means something very different than it did even 25 years ago, let alone in the Middle Ages or Ancient Greece.

If we are going to take the word literally, the original practitioners that were labelled this way practiced something more similar to modern herbalists and "natural" practitioners.  If homeopathy, for example, actually worked, it would only be through witchcraft, given that there is no detectable active compound in homeopathic substances.

As well, the word "physician" comes from "healer", "sage" and even "physicist".  "Doctor" comes from the word meaning "teacher".  That doesn't mean they teach kids in classrooms about how to prove String Theory.

More etymology fun.  "Sycophant" originates from "showing the fig".  Figure that out.  Or "clue".  Originates from "ball of thread".

The point is that the origins of words are meaningless without historical context and evolution.

The poster of the image above sells essential oils for a living.  She actually promotes essential oils for weight loss.  Essential oils have absolutely no scientific evidence whatsoever of effectiveness, no less for weight loss.

I'm not going to comment on her use of Bible quotes to deride and debase modern medical science.  If she wants to believe that using products that have no scientific evidence to support their use means she has "knowledge", she can go on thinking that.

Or MAYBE, just MAYBE, she is making those arguments because, gee, I don't know, she sells essential oils through her website?  And yes, I know I'm a pharmacist, before someone points out the obvious and says I also have a financial interest in promoting drugs as safe.

Too bad I spend more time talking people OUT of taking drugs (which, no matter what way you slice it, "natural" products are also considered; as a dietitian once said "If you get it from food, it is a vitamin.  If you get it in a bottle, it's a drug.").

And that the majority of problems associated with medication use are due to inappropriate use or prescribing.  Roughly 7.5% of hospital admissions in Canada are due to adverse drug reactions.  Roughly 40% of those adverse drug reactions are considered preventable.

But none were likely due to natural products, right?  Wrong.  Natural products cause serious reactions too.  Unless you think that hepatotoxicity leading to market withdrawal is not serious.  Sadly, many of them go unnoticed because, despite appearances, they are poorly regulated and there is very little in the way of formal pharmacovigilance monitoring programs.

If someone wants to go back to the time before modern medicine, they can be my guest.  But I'd rather revel in the advances of modern medicine that have expanded the human lifespan.  It has not been universal by any means, but we are getting somewhere.  Estimates range from roughly half of the 7.5 years gained in life expectancy since 1950 being due to medical care to 25 of the 30 years gained since the early 1900s being due to public health measures (vaccines, improvements in sanitation, etc.).  And yes, some of these things, like pasteurization (this is a really good article; check it out), were discovered by scientists and not necessarily "medical" practitioners, but the scientific method underpins the discovery, as it does medicine, so the argument still stands.

Natural does not mean safe.  Synthetic does not mean dangerous.  I wonder if proponents of this notion would be willing to part with all of the other synthetic products in their lives?  Or if they knew some essential oils were extracted with solvents like methanol and hexane? Or if they knew stevia is manufactured using a chemical extraction process and marketed by such major players as Cargill?

If worshiping modern technology means that I adhere to the scientific method and refuse to condone anything that has yet to be proven effective or has actually been proven completely useless, than a witch I am.  Or warlock I guess.

Friday, November 15, 2013

The Cause and Effects of Health and Disease

First published in The Vault Magazine, November 15, 2013

This is the first in a series of articles that will run in The Vault.  As part of the agreement with the editors, I will not publish the article on my blog until 1 week after publication in The Vault.  Feel free to comment on the blog or send comments to the e-mail below.  Enjoy!

In 1853, a cholera outbreak struck a neighbourhood in London.  A bright physician named Dr. John Snow questioned the prevailing wisdom and was certain the disease spread through some mechanism other than “foul air.”

Through a meticulous and systematic investigation, he traced the source of the outbreak to the Broad Street water pump, into which had been leaking human excrement.  The pump handle was removed and, shortly thereafter, the local outbreak ended.

This proved Snow’s theory.

After Snow’s death, Louis Pasteur demonstrated the germ theory of disease and Robert Koch isolatedVibrio cholerae, the responsible bacteria.

For his methodology in isolating the source of an illness, Dr. Snow is widely considered the father of epidemiology, the study of the patterns, causes, and effects of health and disease.

The study of health and illness has since expanded and for even the most obscure clinical query, there are usually numerous researchers who have looked at it.  This poses a problem though.

If ten researchers study the same problem, but five get one result and the other five the opposite, who is correct?

Archie Cochrane, a medical researcher, had the solution.  He created a group that would later become the Cochrane Collaboration.  Their first project collected all the studies that had ever been done on giving drugs called corticosteroids to women in premature labour and brought all the data together to provide the best answer.

Doing this, they found this simple intervention cut in half the risk of infants dying from the complications of prematurity.

Because no one had systematically reviewed the research until that point, many infants needlessly died because clinicians were unaware of an effective intervention.

That is the power of clinical epidemiology.

That is what this column is about, but not in an esoteric way.

I want to look at the questions that matter to you, but with an eye to the evidence.

No myths.  No miracles.  Just the real deal.

Questions like:

What is the least effective but most commonly used method to lose weight?

Does anything Dr. Oz recommends actually work?

Are multivitamins necessary for healthy people?

Is the shingles vaccine effective?  Is it necessary?

All questions are fair game so long as they are not of a specific personal nature. I cannot treat you through this column, only educate you and do some good old-fashioned myth busting.

Along the way you’ll learn about tricks drug companies and researchers play, why even the most astute clinicians are still working with incomplete information, and why you can disregard almost everything about health you read on the internet and in the newspaper, or see on TV.

I’ve got plenty of material to work with, and will if need be, but I’d prefer the readers to lead the discussion.

So send your questions to nickonchuks@gmail.com and check back in the next issue for more.

Friday, August 23, 2013

Marathon training by the numbers

This Sunday I attempt (operative word: attempt) my first full marathon.  More or less without interruption I've been training for the last 20 weeks.  Reflecting on this makes me realize the enormity of the task at hand.  Tomorrow I will post a short blog on all the gear I have to make sure to bring with me to the run and the race strategy I hammered out to show you just how much preparation goes into the marathon distance.  But I wanted to quickly jot down some numbers, for those of you who enjoy them, to give you a sense of what kind of commitment you have to make to train for a marathon.

For any of you thinking of adding this to your bucket list, don't let these numbers discourage you.  In fact, they should encourage you.  I am just an average man of average fitness (or was before I started training).  I do not eat perfectly healthy, I don't do any strength training or cross training, and according to medical criteria, I am at LEAST 30 pounds overweight (please see below for discouraging news on this front).  Bottom line is, anyone can do this.  But not without commitment, preparation, and a bit of pain and misery along the way.  And copious amounts of stubbornness.  I have that to spare if you need some.

You can't just jump into a marathon.  But you can wade in slowly and hope you make it through.

Weeks of training: 20

Days containing a run: 61

Total miles (km) run: 258 (412.8)

Average miles (km) per week: 12.9 (20.64)
(Which, by the way, is VERY low by marathon training standards. At my peak I was running 20-25 per week.  Most experienced runners do 40+.  However, you have to listen to your body and if you are developing an overuse injury or just plain tiring out, you are better off taking a few days or even a week off to recover than forcing through it.  That is what I did so it brought down the average.)

Total time running: 43hrs 10min 21sec

Average hours per week: 2hrs 9min

Weight, end of July 2012: 199 lbs on a 5'8" frame.

Weight, end of July 2013, after 16 weeks of training: 199 lbs

That's right.  I didn't lose a SINGLE pound during the course of my training.  Many people assume exercise is the cat's meow for weight loss.  It's not.  It is a terrible way to lose weight.  Particularly long distance running.  You know why?  Do you know what running for 18 miles makes you?  Unbelievably hungry.  So hungry you could eat all day and still not be satisfied.

There is an abundance of medical literature showing that exercise is not a very effective way to lose weight.  It is incredibly healthy for you, reduces mortality and disease-free survival, cardiovascular fitness etc etc etc.  But when it comes to body weight, it just sucks.  The only thing it's good at is maintaining body weight.  If you modify your intake and lose weight, ramping up the exercise is almost the only surefire way to keep the weight off.  But it won't help you get there.

In the last two weeks I have been tapering.  This means gradually reducing mileage to help conserve energy for the race.  Without tapering, most people burn out before finishing the marathon.  But tapering had a welcomed side effect.  I wasn't as hungry.  So I focussed on my intake religiously over the last two weeks and have shaved off five pounds.  This is probably the single most important thing I've done for the success of my run on Sunday.  Why?

Let me show you how exquisitely torturous running is on your body.  My goal time on Sunday is 4hrs 30 min (although secretly I hope to come in slightly ahead of the Oprah line).  My starting body weight, for ease of calculation, was 200 lbs.  After shedding 5, I'm at 195.  I average roughly 180 foot strikes per minute while running.  This means each foot hits the ground 90 times in a minute.  Exercise scientists estimate the force at the foot when striking is 2-3 times body weight.  I will be conservative and say 2.  At 200 lbs, each foot over the course of a 4 1/2 hour marathon would endure a pounding equivalent to 4409 metric tonnes.  At 195 this equates to 4299 tonnes.

Therefore, simply by losing 5 pounds, I've spared my feet each 110 tonnes of force.  I've just taken a small blue whale off their backs.  This won't necessarily make me faster, as I have a pretty concrete pacing strategy I'm sticking to so I don't bonk.  But it would if I let it.

According to some, by losing that 5 lbs I should be able to shave 1:20 off my per mile pace.  Not gonna happen.  I'll pass out before the finish line.  But, if I run at my planned pace, I will conserve a lot more energy, should not be quite as exhausted at the end, and hopefully recover faster.

Plus it also allows for a much larger post-race binge.  Five pounds is a lot of food.

Saturday, July 20, 2013

Shakeology: Shaking up its foundations

My wife is really into Beachbody workouts, particularly now Focus T25.  The science behind high-intensity interval training is fairly sound, and I encourage physical activity of any type.  Thus, I have no problem with this.  It helps that it also makes her super fit and even more hot, which I didn’t think was possible when I met her.  I am so impressed with her results from the workout, that when I am done my marathon at the end of August, I plan to take a break from running and do it myself.

However, Beachbody is not just about selling workouts.  They also have an elaborate system of “coaching” whereby individuals sign up to be Beachbody coaches and then promote the workouts and nutrition products to others.  Again, I have no problem with this, aside from it being a multi-level marketing system.  Then she bought Shakeology, dubbed “The Healthiest Meal of the Day” by Beachbody.  

If you have not come across Shakeology, it is a powdered protein supplement, replete with myriad “superfoods” (aside: there is no such thing as a superfood.  Get over it.)  You make a smoothie from it, either straight up or mixed with other foods, and use it as a meal replacement.  Aside from the fact that processed desiccated “food” is not even close to the same thing as the real deal, taste is always of utmost concern to me.  And I find it repulsive.  But others, including her, find it delicious.  

She says it gives her energy and satiates her for long periods of time so she would like to continue buying it.  This surprised me on two fronts.  First, not only is she incredibly fit and at a remarkably healthy body weight, she also eats with an eye to both taste and nutrition.  She eats probably one of the most balanced, whole foods diet of anyone I know.  To replace some of that with processed powder in a bag is out of character.  Second, the price.  My goodness.  Two pounds costs you $120. $120!!!!!!!  TWO POUNDS!!!!  They recommend one scoop per day.  Doing this, one bag would last you 30 days.  Is $4/day all that bad for one meal?  I guess not.  But the greater question is why?  Why use this instead of whole foods?  

I’ll admit I don’t have a massive moral pedestal on which to make this argument, given that I cannot for the life of me forego my daily breakfast cereal.  And not the healthiest kind.  Raisin Bran, Honey Nut Cheerios, etc.  However, she always had incredibly healthy breakfasts, so I asked her why she wants to switch to this.  This led to a challenge to me to research the “science” behind Shakeology and the health claims made on the package.  She should know me better by now.  Such a challenge always results in a lengthy diatribe about the inherent lack of real science in such claims.  And I am not one to walk away from such a gauntlet throw down.  

What follows is not short.  It is anything but.  Mostly because the claims and ingredient list on the package are so detailed and expansive.  Besides, I don’t do brevity.  If you want the Cole’s Notes, here they are.

Bottom Line: The health claims made on the package have no scientific evidence base to support them.  There are insignificant amounts of multiple plant products mixed in with the protein, none of which come anywhere close to duplicating the health benefits of whole plants.  The manufacturing process to make plant powders is a laboratory procedure.  Beachbody does not go out into the field with a mortar and pestle, grind up some plants, hang them in the sun to dry and call it a day.  

Thus, this is protein powder with filler.  If you are happy paying $120 for protein powder, which you can get elsewhere for a quarter of the price, go for it.

The claims from the package

Claim #1: Proprietary Super-Protein Blend: Whey, Sacha Inchi, Chia, Flax, Quinoa, Amaranth, Pea: Helps build lean muscles, improve skin and hair, support mental clarity, and reduce cravings. 

The only part of this that is true is the protein part.  There is nothing “super” about any of them.  Protein is protein.  And in North America, we get enough protein already.  More than enough.  In fact, from meat alone, Americans consume twice the daily amount of recommended protein.  Thus, if protein were truly going to help build lean muscles, we’d all be a bunch of lean, mean, muscle machines by now.  We most certainly are not.  How about better hair and skin, sharper wits, and less desire to eat junk?  For these sorts of claims, I search the ultimate authority on evidence-based natural therapies, the Natural Medicines Comprehensive Database (NMCD).  You need a subscription to access it, so you will have to take my word that what I report is straight from that source.  You can access the National Centre for Complementary and Alternative Medicine, but it is not as complete.  

If you doubt anything I write, I’d be more than happy to take a screen shot and send it your way.  I will also do a quick search of Pubmed to see if any new research exists in case NMCD missed anything.  I will look at all the above ingredients, and then determine whether there is any scientific evidence to support that they lead to any of the stated outcomes.  

Of note, you will notice on the bag and the website, a little asterisk next to each claim.  When you find it far below, you read this: “These statements have not been evaluated by the Food and Drug Administration”.  Meaning that they could just be pulled out of thin air for all it’s worth. But nonetheless, I will give them their day in court.

For every single ingredient listed above in claim #1, there is not a single drop of scientific evidence to support any of the statements made.  I could just as easily say “These whiz-bang superfoods will give you giant muscles, make you more sexually attractive to potential mates, increase your chances of winning the lottery, and exponentially increase your financial net worth!!!!!” and it would have exactly the same amount of scientific credibility.  
I’m not too excited about what I’ll find with the remaining claims, but on I march.

Claim #2: Proprietary Super-Fruit/Antioxidant Blend: (Superfruit.  Sigh.): Camu-camu, acai, acerola cherry, bilberry, goji berry, grape seed, green tea, luo han guo, pomegranate, rose hips: Provides antioxidant support and helps promote a healthy heart and optimal blood pressure.

First off, the antioxidant=health notion is a complete myth.  In fact, it may even be dangerous.  Now, to the others.  

Very preliminary research suggests cardiovascular effects from consumption of grape, grape juice, and red wine (the research did not look at grape seed extract; the differences are substantial; same reason research on omega-3 supplements has not shown the same benefits as those found in populations eating diets high in fish).

However, these studies only showed improvements in vasodilation and suppression of thrombosis.  Extrapolating this to say that it promotes a healthy heart is disingenuous.  We call these “surrogate markers”.  The best example I have to show the risk of using surrogate markers as evidence of hard outcomes is a drug called torcetrapib.  This drug MASSIVELY increased levels of good cholesterol and substantially reduced levels of bad cholesterol, leading many early commentators to suggest that it would be a game changer in preventing heart attacks and death due to cardiovascular disease.  Too bad the studies had to be terminated early because the drug caused a 60% INCREASE in DEATH.  Not just an increase in disease.  An increase in death.  So, that WHOLE grape products “might improve endothelium-dependent vasodilation” is clinically meaningless.  And one study found that it has no clinically significant impact on blood pressure.  

There is, of course, some epidemiological evidence suggesting a benefit of green tea consumption for cardiovascular disease prevention.  However, this just states that people who drink lots of green tea seem to have lower rates of heart disease than others.  It doesn’t account for all the confounders (ie. people who drink green tea may be more health conscious overall, the rest of their diet might be healthier, they may exercise more, etc. etc.)  No sound evidence exists showing the same effect from consuming green tea extract.  

For pomegranate, there are just as many studies supporting a benefit in cardiovascular disease as there are ones that refute it.  The evidence base to date is insufficient to draw any reliable conclusions.  And again, none whatsoever on pomegranate extract. 

For all the other products, there is no evidence whatsoever to support the claims made.  

Claim #3: Proprietary Super-Green/Phytonutrient Blend: Moringa, chlorella, spirulina, spinach, barley grass, kamut grss, wheat grass, oat grass: Helps alkalize the body and promotes detoxification of the liver, kidneys, and blood to restore health and vitality.  

Ugh.  Where do I even start with this one?  It is hard to find evidence for a statement when it refers to physiologic processes that don’t exist and when it uses subjective measurements like “health and vitality”.  

Toxins first.  Suffice it to say, your body does an outstanding job of keeping you free of toxins.  We are not, despite popular belief, awash in harmful toxins.  Other science-based writers have covered this better than I can here and here.  

Alkalization next.  The biochemical pathways charged with maintaining your internal pH are incredibly complex and they do a remarkable job of keeping it there.  So much so, that clinically significant pH excursions typically only occur in the acutely ill, particularly those with kidney disease.  This is called metabolic acidosis or alkalosis and is a serious medical condition.  You wouldn’t be walking around asking for pH strips for your urine if you had it.  Long story short, no one drinking Shakeology has any clinical need to “alkalize” their body.  In case you don’t believe me, read this.  An excellent quote from Quackwatch sums up nicely this cockamamie notion:

“If you hear someone say that your body is too acidic and you should use their product to make it more alkaline, you would be wise not to believe anything else the person tells you.”

But what about the magical superfoods in this “proprietary” SUPER-green phytonutrient blend?  Don’t they do anything?  Let’s see.

Moringa: Nada.  Unless you’re a goat.  
Chlorella: Nothing.
Spirulina: Zilch.
Spinach: Negatory.
Barley grass: Ohhh....ohhhh.....wait for it.....oral consumption of barley just might lower bad cholesterol significantly.  Sadly though, as NMCD says, this does not hold out for all studies: “This lack of effect seems to be the result of processing the barley into a highly enriched beta glucan product.”  And we thought we were so smart we could identify the responsible component of a whole food, isolate it, feed it to people, and get the same outcomes.  Curse you nature.  Wouldn’t matter much anyways as 1 serving of Shakeology contains only 4.75mg of beta-glucan, roughly 0.6% the required amount the Food & Drug Administration requires to allow companies to make claims about its health benefits.  
Kamut grass: That’s a big tall glass of nope.
Wheat grass: Zippo.
Oat grass: Same situation as barley grass.  Possibly effective for cholesterol, but only with whole consumption.

Claim #4: Proprietary Adaptogen Blend: Ashwagandha, astragalus, cordyceps, ginkgo, maca, maitake, reishi, schisandra, tulsi: Helps protect the body from stress, support the immune system, and balance the endocrine system.

Typically, anything claiming to reduce stress, boost the immune system, or balance your hormones, is a complete crock.  But just for fun, let’s evaluate the ingredients one by one to see if they can achieve any of those three remarkable goals.  

The evidence base is so lacking for these, I don’t even know from where they fabricated these claims.  So I ran a Pubmed search for all the ingredients against the search terms “stress”, “anxiety”, “endocrine”, or “immune”.  I got nothing useful.  

Claim #5: Proprietary Pre- and Probiotic/Digestive Enzyme Blend: Yacon root, Lactobacillus sporogenes, Amylase, Cellulase, Lactase, Lipase, Protease, Bromelain, Papain: Helps increase nutrient absorption, promotes regularity, and improves digestion.

NMCD doesn’t have much on these as most are simply digestive enzymes (most of which our bodies make naturally, by the way) and the body is notoriously unfriendly to large proteins.  But I will search nonetheless.  I ran a search in Pubmed with all the ingredients against the claims of nutrient absorption, regularity, and improved digestion.  I’ve limited the search to randomized controlled HUMAN trials, as all other research is potentially interesting, but clinically meaningless.  Nothing.  

There you have it.  With very few insignificant exceptions, all the claims on the Shakeology packaging are completely unsupported by scientific evidence.  That does not mean they are not true.  It merely means that based on currently available scientific research, we cannot confidently conclude that the claims are true.  

After all this I found myself wondering how much of each of the ingredients is within this product.  Thankfully, Beachbody has licensed some of its Shakeology products with Health Canada’s Natural Products Directorate.  Thus, I have a full ingredient listing at my disposal.

The chocolate product, per serving, weighs 42 g.  Here’s a breakdown.

Total protein: 16.8 g
Whey protein isolate: 7.9 g
Pea protein: 5.3 g
Rice protein: 3.6 g

ALL the other medicinal ingredients:
8.27 g

I’m confused, given that the label says the “Proprietary Superfoods” weigh 33g.  What this means is that 7.93 g of these “superfoods” are unaccounted for.  Too bad.  Likely it is the weight of the “superfoods” listed as non-medicinal ingredients (barley grass, spinach, lycium fruit, and wheatgrass) and the other stuff not included in the health claims that you only see when you look in the small print (oat grass, Himalayan salt, some enzymes, luo han guo, cocoa, and lactobacillus)

This still leaves 9 g unaccounted for, which can only be the weight of the non-”superfood” non-medicinal ingredients listed.  They are blueberry flavor, chocolate flavor, cinnamon flavor, D-fructose, guar gum, pectin, stevia rebaudiana leaf, and xanthan gum.  

Might I point out how sad it is that they had to add blueberry flavor even though one of the listed “superfoods” contained in it is blueberry?  Just proves how insignificant are the quantities of the products in this stuff and how far removed these extracts are from the real deal.

So, you are paying for 17 g of protein, which you could get anywhere for SUBSTANTIALLY cheaper, and an insignificant quantity of dried plant powders.  Just to give an example of the insignificance of these quantities, I have some quinoa kicking around the house.  The ingredient listing states there is 617 mg of quinoa in Shakeology.  I couldn’t even weigh this at home as my kitchen scale is not sensitive enough to detect anything under 2 g.  So I had to use my chemistry scale at work.  The resulting mass of quinoa seeds, in a single layer, was about the size of a loonie.  


127 seeds, if anyone’s counting.

The shark wrangler

Good for you. You wrangled a shark onto land just to let it go and then bask in the ensuing web-fame. Of course he's a hero because, you know, sharks kill people, right? About six per year worldwide. The annual killing scoreboard looks like this. Humans 100 000 000: Sharks 6.

But they are the most deadly animal on earth right? Wrong. Mosquitoes, hippos, deer, bees, dogs, ants, jellyfish, cows, horses, spiders, and rattlesnakes kill more people every year.

Well it's not like he was clubbing a baby seal. But while harp seals may be cute, they are not classified as vulnerable as sandbar sharks are (the species Mr. Manly McFamous wrangled). In fact, harp seals are classified as "Least Concern", the same conservation category as humans

We should shun this behaviour, not glorify it. 

Thursday, April 4, 2013

How to make the perfect feast

After availing my friends and colleagues with the tales of my wonderful turkey and stuffing this past Sunday for Easter, I received numerous requests for the recipes I used.  I will outline below the recipes I based my process on and any important modifications I used.  You follow this exactly and I promise you you'll receive accolades and gratitude at your next holiday feast.

1.  Stuffing Bread
This stuffing is a long process.  Mostly because for it to be over the top brilliant, you need homemade bread and, specifically, you need Wild Rice and Onion Bread by Peter Reinhart.  Just make it in loaf pans.  Don't worry about trying freestanding.  Once the recipe is complete and the bread has cooled to a comfortable temperature, cut it into small cubes.  Spread the cubes sparsely over a counter top.  Leave them out overnight so they really dry out and become a bit crusty.  The texture in the final stuffing is better.  Without drying them they almost become a bit soggy.

Wild Rice and Onion Bread from Peter Reinhart's Artisan Breads Every Day

6 cups (27 oz / 765 g) unbleached bread flour
2 1/4 teaspoons (0.6 oz / 17 g) salt, or 3 1/2 teaspoons coarse kosher salt
2 tablespoons (0.66 oz / 19 g) instant yeast
1 cup (6 oz / 170 g) cooked wild rice or another cooked grain
1/4 cup (2 oz / 56.5 g) brown sugar
11/2 cups (12 oz / 340 g) lukewarm water (about 95°F or 35°C)
1/2 cup (4 oz / 113 g) lukewarm buttermilk or any other milk (about 95°F or 35°C)
1/4 cup (1 oz / 28.5 g) minced or chopped dried onions, or 2 cups (8 oz / 227 g) diced fresh onion (about 1 large onion)
1 egg white, for egg wash (optional)
1 tablespoon water, for egg wash (optional)


Do Ahead
Combine all of the ingredients, except the egg wash, in a mixing bowl. If using a mixer, use the paddle attachment and mix on the lowest speed for 1 minute. If mixing by hand, use a large spoon and stir for 1 minute. The dough should be sticky, coarse, and shaggy. Let the dough rest for 5 minutes. 
Switch to the dough hook and mix on medium-low speed, or continue mixing by hand, for 4 minutes, adjusting with flour or water as needed to keep the dough ball together. The dough should be soft, supple, and slightly sticky. 
Transfer the dough to a lightly floured work surface. Knead the dough for 2 to 3 minutes, adding more flour as needed to prevent sticking. The dough will still be soft and slightly sticky but will hold together to form a soft, supple ball. Place the dough in a clean, lightly oiled bowl, cover the bowl tightly with plastic wrap, and immediately refrigerate overnight or for up to 4 days. (If you plan to bake the dough in batches over different days, you can portion the dough and place it into two or more oiled bowls at this stage.)
On Baking Day
Remove the dough from the refrigerator about 2 hours before you plan to bake. Shape the dough into one or more sandwich loaves (see page 23), using 28 ounces (794 g) of dough for 4 1/2 by 8-inch loaf pans and 36 ounces (1.02 kg) of dough for 5 by 9-inch pans; into freestanding loaves of any size, which you can shape as b√Ętards (see page 21), baguettes (see page 22), or boules (see page 20); or into rolls (see page 25), using 2 ounces (56.5 g) of dough per roll. When shaping, use only as much flour as necessary to keep the dough from sticking. For sandwich loaves, proof the dough in greased loaf pans. For freestanding loaves and rolls, line a sheet pan with parchment paper or a silicone mat and proof the dough on the pan. 
Mist the top of the dough with spray oil and cover loosely with plastic wrap. Let the dough rise at room temperature for 1 1/2 to 2 hours, until increased to about 1 1/2 times its original size. In loaf pans, the dough should dome at least 1 inch above the rim. If you’d like to make the rolls more shiny, whisk the egg white and water together, brush the tops of the rolls with the egg wash (see page 135) just before they’re ready to bake.  
About 15 minutes before baking, preheat the oven to 350°F (177°C), or 300°F (149°C) for a convection oven. 
Bake the loaves for 10 to 15 minutes, then rotate the pan; rotate rolls after 8 minutes. The total baking time is 45 to 55 minutes for loaves, and only 20 to 25 minutes for rolls. The bread is done when it has a rich golden color, the loaf sounds hollow when thumped on the bottom, and the internal temperature is above 185°F (85°C) in the center. 
Cool on a wire rack for at least 20 minutes for rolls or 1 hour for loaves before slicing.
2.  Stuffing
My Favorite Bread Stuffing
By Mark Bittman from the How to Cook Everything iPad app
230 g butter
1 cup chopped onion
1/2 cup chopped pecans (my modification; original calls for pine nuts or walnuts; pecans are delightful)
1 loaf of wild rice and onion bread cut into cubes and dried
1 tablespoon minced sage leaves
salt and freshly ground pepper
1/2 cup chopped green onions
1/2 cup chopped fresh parsley

(don’t skimp on the parsley and sage; find and buy fresh; DON’T use dried)
One recipe here is good for stuffing a fairly large turkey, around 17 lbs.  For anything over 10 people, cook one recipe inside the bird and one recipe in a Pyrex dish in the oven.

  1. Put the butter in a large, deep skillet over medium heat.  When melted, add the onion and cook, stirring, until it softens, about 5 minutes.  Add the nuts and cook, stirring almost constantly, until they begin to brown, about 3 minutes.
  2. Add the bread cubes and the herb and toss to mix.  Turn the heat down to low.  Add the salt, pepper, and green onion.  Toss again, taste, and adjust the seasoning.  Add the parsley and stir.  Turn off the heat.
  3. Pack into the bird and roast with it according to roasting recipe for particular bird.  Can also bake in an ovenproof glass or enamel baking dish for about 45 minutes at 350-400F.
3.  The Bird

From her outstanding book Feast.

Ingredients
For the turkey:
10 pints 11 fluid ounces (6 liters) water
4 1/4-ounces (125 grams) table salt
3 tablespoons black peppercorns
1 cinnamon stick
1 tablespoon caraway seeds
4 cloves
2 tablespoons allspice berries
4 star anise
2 tablespoons white mustard seeds
7 ounces (200 grams) caster sugar
2 onions, quartered
1 (3-inch) piece ginger, cut into 6 slices
4 tablespoons maple syrup
4 tablespoons clear honey
Handful fresh parsley leaves, optional (only if you've got some parsley hanging around)
1 orange, quartered
1 (9 to 11 1/4-pound) (4 to 5-kg) turkey
For the basting glaze:
2 3/4 ounces (75 grams) butter
3 tablespoons maple syrup
(DO NOT skimp on any of the seasonings.  FIND THEM in your grocery store.  Don't substitute.  All I ever substitute is I just use regular granulated sugar and instead of star anise I use about 2 teaspoons of anise seed.
Use only the highest quality maple syrup.  Aunt Jemima is NOT maple syrup.)

Place the water into your largest cooking pot or bucket/plastic bin and add all the turkey ingredients, stirring to dissolve the salt, sugar, syrup and honey. (Squeeze the juice of the orange quarters into the brine before you chuck in the pieces.)

Untie and remove any string or trussing attached to the turkey, shake it free and add it to the liquid. Add more water if the turkey is not completely submerged. Keep the mixture in a cold place, even outside overnight or for up 1 or 2 days (DO 2 DAYS) before you cook it, remembering to take it out of its liquid (and wiping it dry with kitchen-towel) a good 40 or 50 minutes before it has to go into the oven. Turkeys - indeed this is the case for all meat - should be at room temperature before being put in the preheated oven. If you're at all concerned - the cold water in the brine will really chill this bird - then just cook the turkey for longer than its actual weight requires. (IF YOUR BIRD IS BIG, I RECOMMEND TAKING IT OUT IMMEDIATELY UPON WAKING IN THE MORNING)

For the basting glaze:
Place the butter and syrup into a saucepan and cook over a low heat, while stirring, until the ingredients have melted and combined.

Brush the turkey with the glaze before roasting, and baste periodically throughout the roasting time.

(This is where I stepped in and added my own personal flare that put this turkey over the top.  Obviously, stuff the bird with the delicious stuffing above.  Then put your hands under the skin above the breast and break the tissue connecting the skin to the meat so that you open up a space under the skin.  Put 1 stick of garlic butter under the skin over each breast.  Yes, 1 stick per breast.  Make sure it is at room temperature.  Should be easily squishable.  Squish it under the skin and massage it in well so it is spread out and completely covering the space under the skin.  Then take a package of bacon.  Good stuff.  Not crap like turkey bacon.  The fattier the better.  Lay 1 strip over the top of the turkey and continue laying strips side by side until the top portion of the turkey is covered.  I put one layer going left to right and one layer pointing front to back.  Ended up using all but 6 strips of bacon in the package.  Then toss that puppy in the oven.  I leave mine uncovered until the final high temperature burst at the end.  I uncover it at that point to give it a final browning.)

Preheat the oven to 425 degrees F.

Cook the turkey for 30 minutes at this relatively high temperature, then turn the oven down to 350 degrees F and continue cooking, turning the oven back up to 425 degrees F for the final15 minutes or so if you want to give a browning boost to the skin. For a 9 to 11-pound turkey, allow 2 1/2 to 3-hours in total. But remember that ovens vary enormously, so just check by piercing the flesh between leg and body with a small sharp knife: when the juices run clear, the turkey is cooked.

Just as it's crucial to let the turkey come to room temperature before it goes in to the oven, so it's important to let it stand out of the oven for a good 20 minutes before you actually carve it.

(Some amendments here.  Aside from the initial baste, I don't rebaste the turkey.  You have a cup of butter and 3/4 of a pack of bacon doing that for you.  You will notice that her cooking times seem short for most people accustomed to the rules of their mothers and grandmothers.  But we all know those people made dry turkeys :-)  Although this turkey is almost impossible to dry out, there is no point in overcooking it.  Nigella's cooking time guidance is below and I rely it almost religiously.  It is perfect almost every time.  You start with the high temp 1/2 hour, down to 350, and then last 15-20 minutes back at the 425.  To check doneness, you can pierce the bird near the thigh and hope its juices run clear. However, if you fear bacteria as much as I do, you should measure the temperature.  I rely on the temperature at both breast and thigh.  Meat thermometers lie.  They will make you dry out your turkey. If the temperature at breast AND thigh is 165F, you are good to go, as long as you have a good probe thermometer.  By which I mean you need a good probe thermometer.  Buy one.  I did and I'm as cheap as they come.  

When you hit the 165 mark take the bird out and put it on a cutting board or counter top or something.  Tent it with foil completely.  It should rest for 30-60 minutes in foil.  Although this cools it slightly, the juices get drawn back into the turkey and it adds such a perfect finishing touch you don't want to miss this step.  

Now, onto the gravy!  (Oh, yeah, you have to carve the turkey too.  Figure it out.  You use a large knife and the mitts God gave you.  After cutting nice orderly pieces off the breast which, just a warning, will squirt butter at you testifying to their uber-juiciness, start tearing away at the rest of the beast like a savage with your fingers.  An hour under the foil tent will leave it warm enough to use your fingers and not scald them.  Leave no piece of turkey on the bone.  It's so good if you leave any on the carcass, your guests will sneak into your kitchen later to scavenge for remains.)

Weight of bird     Cooking Time
2/25kg/5lb            1 ½ hours
3.5kg/8lb              1 ¾ hours
4.5kg/10lb            2 hours
5.5kg/12lb            2 ½ hours
6.75kg/15lb          2 ¾ hours
7.5kg/17lb            3 hours
9kg/20lb               3 ½ hours
11.5kg/25lb          4 ½ hours


4.  The Gravy

I've always been horrible at making gravy.  Horrible.  Finally, I decided that my wife might be smart so took some advice from her as her gravy is always perfect.  She taught me the roux method of making gravy.  And now anyone who has mocked my water thin gravy in the past will roux the day they did so.  (Groan....)

Again, I rely on the genius of Nigella Lawson.  

Allspice Gravy
Also in Feast.


Ingredients
Giblets from turkey (not including the liver)
2 pints water
1 tablespoon allspice berries
1/2 teaspoon black peppercorns
3 fresh bay leaves
1 (1/2-inch) cinnamon stick
1 stick celery, halved
2 carrots, peeled and halved
1 onion, halved, but not peeled
3 teaspoons salt
1 orange, zested and juiced (dig the pulp out and throw that in there too)

Place the turkey giblets, water, allspice berries, black peppercorns, bay leaves, cinnamon stick, celery, carrots, onion, salt and clementine zest and juice into a large saucepan and bring the mixture to a boil. Cover the saucepan with a lid and reduce the heat so that the mixture simmers gently. Cook for 2 hours.

Remove the saucepan from the heat and strain the gravy stock through a sieve into a clean large measuring jug. This should give you about 1 liter of stock.

(The first time you do this, you will realize how juicy this turkey is.  When you open that roasting pan at the end, the bird will be damn near drowning in its own juices.  I had a 17 lb turkey and it gave me EIGHT CUPS of drippings.  Now, this is where I differ from Nigella, and to my advantage.  This is my wife's process.  

You've got your stock from above set aside.  Once turkey is out, scrape everything off the bottom of the roasting pan.  Pour it all into a large measuring Pyrex to determine how much you have.  Make sure to strain through a large-holed sieve just to pull out some of the larger chunks.  

Add the flavor stock from above.  This will give you your final volume.  

Now, for every 4 cups of drippings/stock, measure 1/4 cup of flour and 1/4 cup of butter.  Please don't use margarine.  If you use margarine I will find you.  You just roasted a turkey with a cup of butter and a pack of bacon.  You think the butter in the gravy will put you over the daily fat limit?  Newsflash.  You're already there, and it's a great place to be.

In a large saucepan, melt the butter.  Slowly add in the flour, whisking vigorously so it remains a smooth consistency.  As you get to the last addition it will be quite thick and almost pasty.  Now the key part.  Over medium heat, SLOWLY add the dripping/stock mixture.  SLOWLY.  Especially at first.  I was adding like maybe a tablespoon at a time until about the first 1/4 of liquid was added.  The whole time you have to whisk like a madman.  NO LUMPS I TELL YOU.  Keep adding.  As you get near the end, suddenly your gravy will emulsify and you will get this wonderfully thick, creamy looking gravy that tastes positively divine.  Taste and add a bit of salt and pepper if needed.  

Of course, since you are not an industrial food producer, you don't have an emulsion stabilizer to add to your gravy.  And that's okay.  As the gravy sits, the parts will somewhat separate and you'll see oil on top of the other components.  That's normal.  A quick stir fixes that.  Or you can be a jerk and slowly pour off the buttery goodness onto your plate and leave everything else for the rest of the table.  Your choice.)


There you have it.  Is this easy?  Nope.  Is it quick?  Not even a little bit.  You have to start preparing like 3 days in advance of the meal.  Is this turkey healthy?  Hell-to-the-NO.  Is it the most delicious and moist turkey you will ever eat?  You bet.  The gravy is like nothing you've ever tasted and the stuffing is so good blood relations will come to blows over the last scraps.  

Besides, a feast is a feast.  It is meant to be glorious.  It is meant to be memorable.  It should be something your children dream about when they are older.  Something they tell their friends about when they talk about holidays.  Something they long to carry on when they are parents and hosting their own feasts.  Who gives a flying buttress whether it's healthy?  Anything that takes this much work and time to produce has to be enjoyed guilt free.

Sunday, February 17, 2013

By popular demand

I've never had more requests for a recipe than I did for the cinnamon buns I made recently.  So, I shall post it below.  I hope posting the full reference to the author's book and imploring you to purchase it for its many other wonderful recipes is enough to avoid any sort of copyright problem!

Adapted from "Artisan Breads Every Day:Fast and Easy Recipes for World-Class Breads" by Peter Reinhart

Note: If I put the weight in brackets, I would highly recommend weighing that ingredient versus measuring it volumetrically.  It will make the dough much more consistent between batches and closer to the intended consistency in the recipe.

Sticky Buns

Sweet Dough
6 1/4 cups (28 oz) unbleached all-purpose flour
2 teaspoons salt
6 tablespoons (3 oz) sugar
5 teaspoons instant yeast
2 cups plus 2 tablespoons lukewarm whole milk (about 95F)
1/2 cup melted unsalted butter

Combine the flour, salt, and sugar in a mixing bowl.  Whisk the yeast into the milk until dissolved, then pour the mixture into the dry ingredients, along with the oil.  If using a mixer, use the paddle attachment and mix on the lowest speed for 30 seconds to 1 minute.  If mixing by hand, use a large spoon and stir for about 1 minute.  The dough should form a soft, coarse ball.
Switch to the dough hook and mix on medium-low speed, or continue mixing by hand, for 4 minutes, adding flour or milk as needed to create a smooth, soft, slightly sticky ball of dough (Note: you shouldn't need much flour; will be slightly sticky at first; just a little flour should make it smooth enough to work with)
Increase the speed to medium and mix for 2 minutes more or continue stirring for about 2 minutes more, until the dough is very soft, supple, and tacky but not sticky.
Transfer the dough to a lightly floured work surface and knead for 1 minute, then form into a ball.
Place the dough in a clean, lightly oiled bowl large enough to hold it once doubled.  Cover with plastic wrap.  Allow to rise at room temperature until doubled in size OR refrigerate overnight.

(Note: The above is fairly detailed just for your info.  Honestly I just stirred it until it all came together.  Then I kneaded it with my fingers until everything seemed mixed in.  Then I plopped it on the counter and added a bit of flour and kneaded it until it was smooth and everything was incorporated.  In total took me about 5 minutes.)

If you put the dough in the refrigerator, take it out about 3 hours before you plan to bake.  If not just take it straight from the bowl.  Put onto the counter and divide it in half, forming each piece into a ball.  Cover each ball with a bowl or plastic wrap and let rest for 20 minutes.

On a floured work surface, roll each ball of dough into a 12x15-inch rectangle.  If the dough starts to resist or shrink back, let it rest for 1 minute, then continue rolling.
(Note: I really recommend actually measuring out the space.  It makes the dough the best shape and the buns the perfect size.)

Make cinnamon sugar by whisking 3/4 cup (6 oz) of sugar with 3 tablespoons of cinnamon.  Melt roughly 1/4 cup of butter and brush the surface of the dough with it.  Sprinkle the cinnamon sugar over the surface, leaving a 1/4-inch border.  Roll up the dough like a rug, rolling from the bottom to the top to form a tight log.  Now make the slurry.  (I make it ahead of time so it is ready to roll and the buns don't sit on the counter too long while you make it.)

There are 3 slurry options.  I'll put them all here but the Honey Slurry is my favorite.  With all of them you mix all the ingredients until it's a smooth slurry.  You then pour half into one 9x13-inch baking pan and the other half into another.  Spread it evenly along the bottom.

Creamy Caramel Slurry
1/2 cup (4 oz) sugar
1/2 cup (4 oz) light brown sugar
1/2 cup whipping cream
1 tablespoon melted unsalted butter
1 tablespoon light corn syrup

Honey Slurry
1 cup melted or liquid honey
1 cup melted unsalted butter
1/4 teaspoon salt
(You can also make Honey Almond Slurry by adding 1 teaspoon almond extract)

Sticky Bun Slurry
1/2 cup (4 oz) sugar
1/2 cup (4 oz) brown sugar
1/2 cup melted unsalted butter
2 tablespoons light corn syrup
1/4 teaspoon salt
1/2 teaspoon lemon extract (optional)

Once the slurries are poured into the pans, cut the log of dough into 1-inch slices and place them on the slurry with the nicest side down.  (Divide each log into 12 sections.  Each portion of 12 buns will fit into 1 9x13.)
Cover loosely with plastic wrap and let rise at room temperature for about 2 hours.  Just watch the buns and once they are noticeably swollen and are expanding into each other, they're ready to go.

Put your oven rack on a low position, not the normal middle position.  This is required to caramelize the slurry and cook the bottom of the buns enough.  Preheat the oven to 350F.

Bake for 12 minutes.  Rotate the pan 180 degrees for even baking.  Bake for another 13 minutes.  The slurry will melt, bubble, and caramelize, and the visible dough will be a dark golden brown.

Remove the pans from the oven and let them cool for 2-3 minutes in the pans.  Place a platter or pan over the top of the baking pan.  It should be large enough to cover the baking pan.  Wearing oven mitts, flip the entire thing over to release the buns and caramel onto the platter.  Now the glaze is on top.  It is INCREDIBLY hot at this point so, although you will be tempted, do NOT taste test it.  Learn from my experience!

Cool for at least 15 minutes before serving.