Nov 27 2012

HFCS v. Diabetes: Correlation does not mean causation.

The latest study on the evils of High Fructose Corn Syrup (HFCS) so annoys the Corn Refiners Association that it broke the study’s embargo.

Reporters were not supposed to write about the study until today, but the Corn Refiners issued a press release yesterday: “Caution: New Study Alleging HFCS-Diabetes Link is Flawed and Misleading.”

The New York Times quickly posted its own pre-embargo account.

Why the fuss?  The study reports that countries with the highest levels of HFCS in their food supplies also have a 20% higher prevalence of diabetes in their populations.  This is a correlation between HFCS and diabetes.  It does not mean that HFCS causes diabetes—an important distinction.

But the authors’ press release (sent to me in an e-mail message) makes it sound like causation.  They say (also see Dr. Goran’s comments added to this post below):

HFCS appears to pose a serious public health problem on a global scale,” said principal study author Michael I. Goran…The study adds to a growing body of scientific literature that indicates HFCS consumption may result in negative health consequences distinct from and more deleterious than natural sugar.

This conclusion is based on their observations that the amounts of other sugars in the food supplies of countries with high and low HFCS are about the same.  But HFCS is a form of sugars that adds to total sugar availability.

The authors obtained information about diabetes and obesity prevalence and HFCS and other dietary factors in the food supply from existing sources of data, all of them questionable.   The data do not distinguish between type 1 and type 2 diabetes, for example, and the two different sources of data on diabetes prevalence give different results.

Inconsistencies abound.  For example, Mexico has more diabetes than does the U.S., but rather low HFCS availability (Mexicans prefer sucrose in their sodas).  Some countries with high diabetes rates report no HFCS availability at all.

As with all correlational studies, something else could be going on that causes HFCS, sugars of all types, and diabetes to increase.

That was the point I was trying to make when I spoke to Stephanie Strom of the New York Times:

 “I think it’s a stretch to say the study shows high-fructose corn syrup has anything special to do with diabetes,” Dr. Nestle said. “Diabetes is a function of development. The more cars, more TVs, more cellphones, more sugar, more meat, more fat, more calories, more obesity, the more diabetes you have.”

She noted that the study “falls right in the middle of the Corn Refiners fight with the Sugar Association,” a reference to the legal war being waged between the two industry groups over the marketing of high-fructose corn syrup.

The Corn Refiners press release quotes its president, Audrae Erickson:

This latest article by Dr. Goran is severely flawed, misleading and risks setting off unfounded alarm about a safe and proven food and beverage ingredient.  There is broad scientific consensus that table sugar and high fructose corn syrup are nutritionally and metabolically equivalent…The bottom line is this is a poorly conducted analysis, based on a well-known statistical fallacy, by a known detractor of HFCS whose previous attack on the ingredient was deeply flawed and roundly criticized.

Whew.

Yes, HFCS is sugar(s)—glucose and fructose.  So is table sugar (sucrose).

But the bottom line goes for both: Everyone would be better off eating less sugar(s).

Addition to post: Dr. Goren wrote two e-mails to me in response.  With his permission, they follow.

Hi Marion,

I saw your comments in the NYT article that was published about our global HFCS paper.

You say that: “Diabetes is a function of development. The more cars, more TVs, more cellphones, more sugar, more meat, more fat, more calories, more obesity, the more diabetes you have.”

I wanted to mention that an often overlooked issue is that obesity is not the only factor contributing to type 2 diabetes and even the causal link between obesity and type 2 diabetes is unknown. Other factors include inflammation, oxidative stress, insulin resistance etc. In the study that was done with my colleague at the University of Oxford, the countries with high and low/zero HFCS were matched for obesity levels as well as total calorie and sugar availability. In essence this allowed us to isolate the effects of HFCS as a contributing factor, independent of obesity and the other factors that you mention that are related to obesity. I agree, as stated in the paper, that the ecological type analysis has its limitations, but in the case of HFCS it provided an opportunity to study its effects at the broader macro level. We did this because it is impossible to evaluate individual levels of HFCS consumption because we don’t know specifically how much is added to food/beverages.

The main critique of our study from the corn refiners association is based on their assertion that fructose and glucose are the same when in fact its textbook knowledge that their metabolic fate/pathways are very different. The CRA now says that sucrose and HFCS are “almost identical”. Almost identical acknowledges that they are different in some way which they are. Its a fact that HFCS-55 has at least 10% more fructose than sucrose and our prior study in which we analyzed popular beverages showed this was on average 20% and in some cases as much as 30% higher fructose. The key question in my mind is whether the additional fructose in HFCS is enough (even if its only 10% higher) to tip the balance towards the negative metabolic effects of fructose on health. This is at the heart of the issue and should be the focus of investigation. Our study, with its accepted limitations, adds to the growing body of evidence that the additional fructose coming from HFCS may indeed be enough to tip this balance.

His second message:

Thanks for responding, and yes, I’d be pleased if you added this to your blog –  - I think this will be a good addition. The question of whether the extra 10% fructose matters is indeed critical.

We also by the way did analyze total sugars versus diabetes in a much larger data set of 200 countries but the reviewers asked for that to be taken out which we did because we also thought the focus on HFCS would be unique. We also did see a clear relationship between total sugar and diabetes – some of that relationship was mediated by obesity but there also was an independent association between total sugars and diabetes. So, I agree – - both obesity and total sugars contribute to diabetes – - but I also believe, as shown in our paper, that HFCS has a separate link, and that this is probably due to the higher fructose content in HFCS.

Also, you mentioned in your blog that the different estimates of diabetes gave different results. That’s not really correct. The estimates of diabetes were different from each other, but regardless of which diabetes estimate we used, we still found a consistent association between HFCS and the 2 prevalence estimates of diabetes as well as fasting glucose. So in essence the results were validated using different prevalence estimates of type 2 diabetes.

Nov 26 2012

The farm bill is still in limbo. Now what?

My NYU Food Policy class meets tonight and we’ll be talking about the farm bill and Dan Imhoff’s most helpful book Food Fight: The Citizens’ Guide to the Next Food and Farm Bill.

To review what’s up with the 2012 farm bill:

Congress updates farm bills every five years or so.  It passed the last one in 2008, with an expiration date at midnight on September 30, 2012.  This was the first time Congress ever set an expiration date to land in the midst of a presidential election.  This was asking for trouble.  Congress is paralyzed in election years.

That date has now come and gone.

But in June 2011, the Senate passed its version of the bill: The Agriculture Reform, Food and Jobs Act of 2012.

The House, however, was unable to come to agreement on its version: The Federal Agriculture Reform and Risk Management Act of 2012.

Why?  Election-year politics and disagreements about whether and by how much the SNAP (food stamps) budget should be cut.  More than 80% of farm bill spending goes to SNAP benefits—a whopping $72 billion last year–making it a prime target for budget cutting.

This situation puts us in farm bill limbo.

The significance of limbo is best explained by the National Sustainable Agriculture Coalition (NSAC).

  • Without a new farm bill, commodity (corn, soybean, etc) support programs revert to permanent law contained in the farm bills passed in 1938 and 1949.  Why?  Because unlike subsequent bills, these did not have expiration dates.
  • The old laws reintroduce much higher support prices (through certain loans instead of payments), require much smaller crop production, and lead to much higher consumer prices.  They do not include  support for soybeans, other oilseeds, peanuts, or sugar, making them woefully out of date.
  • Limbo has no effect on SNAP or crop insurance.  Congress covered SNAP with a resolution for continued funding through March 2013.  The Federal Crop Insurance Act effectively authorizes crop insurance permanently.
  • Dairy programs are in turmoil.  Milk payments to farmers ended in September.  The dairy price support program ends on January 1.   Under the 1949 law, government-supported prices would be about four times higher than current law and about twice as high as current market prices.
  • The Agricultural Appropriations Act extended some—but not all—conservation programs through 2014.
  • The permanent law does not support the hard-won programs that encourage fruit and vegetable production: organic, farmers’ market, beginning farmer, socially disadvantaged farmer, or specialty crop programs.  These now have no funding.

This leaves Congress with three options between now and January:

  • Finish the current process and pass a bill (unlikely since it only has a few weeks to do this)
  • Vote to extend provisions through the 2013 crop year, or
  • Start from scratch all over again in a much tighter budget environment—the infamous “fiscal cliff.”

As NSAC explains:

The farm bill is the nation’s major food and agricultural policy vehicle and is about much more than the big ticket items: food stamps, crop insurance, and commodity support.  The farm bill is also about conservation and environmental protection, rural economic and community development, food system reform and agricultural research.

With no new farm bill or extension, the programs that address rural and urban job creation, natural resource conservation, renewable energy, and improved production and access to healthy food are in big trouble.

This is a big mess, and a serious result of dysfunctional government.  It will be interesting spectator sport to see how Congress handles it.

Will Congress find a way to bring agricultural policy in line with health policy?

Or will Congress simply do whatever is most expedient, given the budgetary mess it has also created.

It’s too bad so much is at stake.

Nov 19 2012

Energy drinks, Cracker Jacks, and caffeine: enough already

People who consume caffeinated energy drinks may be dying right and left (Because of the caffeine?  The drinks?  Hard to say) but that isn’t stopping food manufacturers from adding it to everything: Cracker Jacks, jelly beans, Gummi Bears, brownies, mints, and maple syrup.

The FDA has just released its data on problems reported among users of three caffeinated energy drinks.

According to the New York Times,

The three products involved in the release — Rockstar Energy, 5-Hour Energy and Monster Energy — are all marketed as dietary supplements. Other energy drinks like Red Bull, NOS and AMP are marketed by their producers as beverages. There is not a mandatory reporting requirement for beverages, though makers can do so voluntarily.

In releasing the filings, the F.D.A. said it thought that even with the mandatory reporting requirement for dietary supplements, “only a small fraction of adverse events associated with any product is reported.”

…The records related to Monster Energy and 5-hour Energy came to light because they were released by the F.D.A. under the Freedom of Information Act.

The choice of labeling these products as foods or supplements deserves scrutiny.  By an act of Congress, dietary supplements do not have to meet the same standards for content and health claims as foods, and the FDA cannot do much to regulate them unless the products are demonstrably harmful.

Even though people died after drinking these products does not necessarily mean that the products caused the deaths.  Even this number of deaths could be a coincidence.

But earlier, the Times reported that

Since 2009, 5-Hour Energy has been mentioned in some 90 filings with the F.D.A., including more than 30 that involved serious or life-threatening injuries like heart attacks, convulsions and, in one case, a spontaneous abortion….

Some lawmakers are calling on the F.D.A. to increase its regulation of the products and the New York State attorney general is investigating the practices of several producers.

I looked up the Supplement Facts label for 5-Hour Energy.

According to statements given to Beverage Daily, 5-Hour Energy says there isn’t any evidence that its products cause deaths.  Its shots contain no more caffeine than a cup of coffee, and do not contain herbal ingredients.

But the product label does not list caffeine content.  The FDA does not require companies to disclose caffeine levels.

It allows them to market the products as drinks or as dietary supplements. Monster Energy contains 240 mg caffeine in 24 ounces.  It has been associated with the deaths of five people so far.

The Times points out that healthy adults can consume large amounts of caffeine with no evidence of harm but that caffeine can be risky for people with underlying conditions like heart disorders.  How much is risky?  It’s hard to say.

Most adults know how much caffeine they can handle without getting shaky or sleep-deprived.  But kids don’t, necessarily.

Consumer Reports tested products and found that some energy drinks contained more than 240 mg per serving, but notes that packages sometimes contain more than one serving.

The FDA considers caffeine to be safe.  But in an opinion last updated in 2011, FDA’s Select Committee on GRAS Substances found that “it is inappropriate to include caffeine among the substances generally recognized as safe (GRAS). At current levels of consumption of cola-type beverages, the dose of caffeine can approximate that known to induce such pharmacological effects as central nervous system stimulation.”

The Times notes that sales of energy drinks in the U.S. are booming, growing by about 16% last year and bringing in nearly $9 billion.

What to do?  A lawyer for the parent of one of the teenagers who died after drinking Monster Energy is urging the FDA to ban the drinks to minors.

The FDA should investigate the cases, for sure.

And how about adding amounts of caffeine to labels.  That seems like a no brainer while the investigations are in progress.

Nov 16 2012

Chicago emulates New York’s public health policies? Not quite.

Chicago’s Mayor Rahm Emanuel is not exactly Michael Bloomberg when it comes to public health approaches to obesity and chronic disease prevention.

In October, he announced that he’d gotten Coca-Cola, PepsiCo, and Dr Pepper Snapple to agree to post calorie information on vending machines in Chicago government buildings (something that they will have to do anyway whenever the FDA ever gets around to issuing final rules for menu labeling).

At the same time, he announced a health competition between Chicago city workers and those in San Antonio with rewards paid by the American Beverage Association through a $5 million gift.  This partnership was widely interpreted as a ploy to stave off the kind of soda tax and cap initiatives proposed by the Bloomberg administration in New York City.

And now, in yet another deal with soda companies, Mayor Emanuel has accepted a $3 million grant from Coca-Cola to pay for a park district program “to fight obesity and diabetes by offering nutrition education as well as exercise classes run by armed forces veterans.”

If the idea of soda companies funding anti-obesity campaigns strikes you as ironic—don’t sodas have something to do with obesity in the first place?— you need to understand Mayor Emanuel’s point of view.

His stated philosophy is that it’s better “to give people personal responsibility and the information necessary to make the right choices about their health than it is to legislate their behavior.”

Maybe so, but when faced with today’s “eat more” food environment, personal responsibility doesn’t stand a chance.

But wait: Isn’t Chicago making an important environmental change?  Its public schools are banning energy drinks.

Well, almost.

The new policy sets nutrition standards for all vending machine food and a la carte items sold in cafeterias and excludes energy drinks—with one exception: Gatorade, a PepsiCo product, “can only be used after students have engaged in a school sports activity.”

Are public health partnerships with soda companies a good idea?  The money is nice and undoubtedly badly needed, but worth the price?  Mayor Emanuel thinks so.

I’m dubious.

Nov 14 2012

Where are we on the farm bill and where should we be?

The best explanation of what’s happening with the long-delayed 2012 farm bill comes from the National Sustainable Agriculture Coalition.  In September, it produced a still very much relevant Q and Aon the topic. The 2008 farm bill expired without being renewed.  If Congress does not act soon, farm policy will be in big trouble. Here are some brief excerpts:

What is the relationship between the farm bill and the automatic budget cuts scheduled for January 1? The new farm bill, when and if it becomes law, will cut more spending from farm bill programs overall, on a net basis, than the automatic budget cuts scheduled to begin on January 1 under the requirements of the Budget Control Act of 2011…Whether Congress postpones the start date for automatic cuts or in other ways amends the Budget Control Act when it returns to DC after the elections is one of the biggest issues hanging over the lame duck session.

What are the farm bill choices that Congress has during the lame duck session? There are two theories about what happens next.  In one, the House returns after the elections and finally brings its bill to the floor, passes the bill with amendments, the House and Senate versions then get reconciled in a farm bill “conference” committee, and a melded final bill is…sent to the President for his signature — all within the three to five weeks of the short “lame duck” session. In the other theory, Congress returns after the election and works out the details of a bill to extend, with some modifications, the 2008 Farm Bill until a date in the spring, summer, or fall of 2013.  Under this scenario, the new session of Congress that begins in January (and lasts for the next two years) will start the five-year farm bill process all over again, with both House and Senate Agriculture Committees formulating a new bill that will then go through the entire legislative process all over again….

Could a new Congress next year simply revert to the farm bills passed this year? No, not exactly.  Legislation does not carry forward from one Congress to the next.  The process must start all over again, with bills introduced, markups in Committee, and votes on the floor of both bodies… That said, if the leaders and members of the Agriculture Committees (some of whom will be new next year) decide to bring forth and approve essentially the same bill they produced in 2012, that is an option open to them.  But it still must go through the normal process and be subject to amendments and voting all over again.

What is the best path forward? There can be little doubt that the best path forward is for Congress to finish its work on the 2012 Farm Bill in 2012.  That will mean getting the House bill to the House floor very quickly when the lame duck session begins, but leaving plenty of time for debate and amendments.

Sigh.  The Q and A explains the consequences of congressional inaction.  The elephant in the farm bill, of course, is SNAP (formerly food stamps), which accounts for roughly 80% of farm bill spending at a time when budget cuts head the congressional agenda.  The most recent data show SNAP participation—and, therefore, costs—to be at a record high: more than 47 million.

As to what to do about the farm bill: The Atlantic has just posted a speech by Wendell Berry on “the 50-year farm bill.”

I have described the need for a farm bill that makes sense of and for agriculture — not the fiscal and political sense of agriculture, as in the customary five-year farm bills, but the ecological sense without which agricultural sense cannot be made, and without which agriculture cannot be made sustainable. “A 50-Year Farm Bill,” which has been in circulation now for more than three years, is a proposal by The Land Institute in Salinas, Kansas, with the concurrence of numerous allied groups and individuals. This bill addresses the most urgent problems of our dominant way of agriculture: soil erosion, toxic pollution of soil and water, loss of biodiversity, the destruction of farming communities and cultures. It addresses these problems by invoking nature’s primary law, in default of which her other laws are of no avail: Keep the ground covered, and keep it covered whenever possible with perennial plants.

We need a farm bill that promotes health–of people and the planet.  Buried in the messy politics of the farm bill is an opportunity to do much good.

Will Congress take it?  Only if we insist.

Nov 13 2012

Food books worth blurbing: just published

I get asked to blurb books every now and then and say yes to the ones I especially appreciate.  Here are three recently published books, well worth having and reading: 

Fred Kaufman, Bet the Farm: How Food Stopped Being Food, Wiley, 2012.

In Bet the Farm, Fred Kaufman connects the dots between food commodity markets and world hunger.  Kaufman is a wonderfully entertaining writer, able to make the most arcane details of such matters as wheat futures crystal clear.  Readers will be alternately amused and appalled by his accounts of relief agencies and the interventions of rich nations.  This book is a must-read for anyone who cares about feeding the hungry in today’s globalized food marketplace.  It’s on the reading list for my NYU classes.

Counihan C, Van Esterik P, eds.  Food and Culture,  Routledge, 2012.

Food and Culture is the indispensable resource for anyone delving into food studies for the first time.  The editors have conveniently gathered readings from classic texts to the latest writings on cutting-edge issues in this field.  Although in its third edition, the book has so much new material that it reads as fresh and should appeal and be useful to students and others from a wide range of disciplines. 

Jon Krampner, An Informal History of Peanut Butter, The All-American Food, Columbia University Press, 2012. 

Creamy and Crunchy is a fast-paced, entertaining, and wonderfully gossipy look at the history of everything about peanut butter, from nutrition to allergies and genetic modification—and with recipes, yet. Everyone who loves peanut butter will want to read this book (personally, I prefer crunchy).

Nov 12 2012

Kids don’t need kids’ food

I did an interview for Childhood Obesity with Jamie Devereaux, its features editor.

Here are the first and last questions.  For the entire interview, click here:

The issue of access to healthy food is a major topic in the overall childhood obesity discussion in America. How important do you think it is to focus on solving the problems of food access as an objective in addressing childhood obesity?

I was impressed with Michelle Obama’s choice of targets for reducing childhood obesity—improving access to food in inner cities and improving school food. Both are excellent targets and, in a rational world, should attract widespread bipartisan support. It’s self-evident that it is more difficult to make healthier food choices  when no healthy food choices are available or when healthier foods are relatively expensive.

Some years ago I lived in a low-income Washington, D.C., neighborhood and was appalled at the poor quality of the supposedly fresh foods offered in the single grocery store within walking distance. I wouldn’t buy it and wouldn’t expect anyone else to want it either. Some studies report that inadequate access is a huge problem in inner cities and rural areas; others say the opposite. Without getting into arcane details about how the studies differ, the access problem just seems obvious and obviously needs to be fixed.

Finally, if you could shape the discussion of healthy food access for children in America—how would you frame it and what would you focus on?

Kids don’t need kids’ food. If adults are eating healthfully, kids should be eating the same foods that adults eat. Babies don’t need commercial baby food. Older kids don’t need kids’ products. Families can all eat the same foods, and that should make life easier for all concerned. If you don’t want your kids drinking sodas, don’t bring them home from the supermarket. Teach kids to eat real foods early on, and they will be great eaters throughout life.

Nov 3 2012

Tuesday’s election: Food politics at issue

My monthly (first Sunday) Food Matters column in the San Francisco Chronicle deals with the implication of Tuesday’s election for food politics.

Q: Neither of the presidential candidates is saying much about food issues. Do you think the election will make any difference to Michelle Obama’s campaign to improve children’s health?

A: Of course it will. For anyone concerned about the health consequences of our current food system, the upcoming election raises an overriding issue: Given food industry marketing practices, should government use its regulatory powers to promote public health or leave it up to individuals to take responsibility for dealing with such practices?

Republicans generally oppose federal intervention in public health matters – witness debates over health care reform – whereas Democrats appear more amenable to an active federal role.

The Democratic platform states: “With prevention and treatment initiatives on obesity and public health, Democrats are leading the way on supporting healthier, more physically active families and healthy children.”

Policy or lifestyle?

In contrast, the Republican platform states: “When approximately 80 percent of health care costs are related to lifestyle – smoking, obesity, substance abuse – far greater emphasis has to be put upon personal responsibility for health maintenance.”

At issue is the disproportionate influence of food and beverage corporations over policies designed to address obesity and its consequences. Sugar-sweetened beverages (sodas, for short) are a good example of how the interests of food and beverage corporations dominate American politics.

Because regular consumption of sodas is associated with increased health risks, an obvious public health strategy is to discourage overconsumption. The job of soda companies, however, is to sell more soda, not less. As a federal health official explained last year, policies to reduce consumption of any food are “fraught with political challenges not associated with clinical interventions that focus on individuals.”

Corporate spending

One such challenge is corporate spending on contributions to election campaigns. Although soda political action committees tend to donate to incumbent candidates from both parties, soda company executives overwhelmingly favor the election of Mitt Romney.

As reported in the Oct. 12 issue of the newsletter Beverage Digest, soda executives view the re-election of President Obama as a “headwind” that could lead to greater regulation of advertising and product claims, aggressive safety inspections and characterizations of sodas as contributors to obesity. In contrast, they think a win by Mitt Romney likely to usher in “more beneficial regulatory and tax policies.”

As for lobbying, what concerns soda companies is revealed by disclosure forms filed with the Senate Public Records Office. Coca-Cola reports lobbying on, among other issues, agriculture, climate change, health and wellness, and competitive foods sold in schools. PepsiCo reports lobbying on marketing and advertising to children. Their opinions on such issues can be surmised.

But Coca-Cola also says it lobbies to “oppose programs and legislation that discriminate against specific foods and beverages” and to “promote programs that allow customers to make informed choices about the beverages they buy.”

Lobbyists

Soda companies have lobbied actively against public health interventions recommended by the White House Task Force on Childhood Obesity in 2010 and adopted as goals of Michelle Obama’s Let’s Move campaign to end childhood obesity within a generation.

Implementation of several interventions – more informative food labels, restrictions on misleading health claims, limits on sodas and snacks sold in schools, menu-labeling in fast-food restaurants, and food safety standards – has been delayed, reportedly to prevent nanny-state public health measures from becoming campaign issues.

To counter New York Mayor Michael Bloomberg’s 16-ounce cap on soda sales, the industry invested heavily in advertisements, a new website and more, all focused on “freedom of choice” – in my mind, a euphemism for protecting sales.

Soda tax

Although the obesity task force suggested that taxing sodas was worth studying, the American Beverage Association lobbied to “oppose proposals to tax sugary beverages” at the federal level. The soda industry reports spending more than $2 million to defeat Richmond’s soda tax ballot initiative Measure N, outspending tax advocates by 87 to 1.

In opposing measures to reduce obesity, the soda industry is promoting corporate health over public health and personal responsibility over public health.

Supporters of public health have real choices on Tuesday. I’m keeping my fingers crossed that Let’s Move will get another chance.

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