Food Politics

So many comments came in to my blog post on Paula Deen’s diabetes announcement, “weighing in on Paula Deen,” that I thought it was worth revisiting in my monthly (first Sunday) column in the San Francisco Chronicle.  The question (edited) came from a blog reader:

Q: I have been diagnosed with type 2 diabetes and am very confused about insulin resistance, and what carbohydrates I can and cannot eat. So much of what I read is contradictory.

A: The first line of defense against type 2 diabetes is weight loss, but you would never know it from listening to Paula Deen, the celebrity Southern cook who recently announced that she has this disease, or even to the American Diabetes Association.

Having diabetes is no joke. It is a leading cause of blindness, kidney failure, leg and foot amputations, and premature death.

The disease comes in two forms – type 1 and type 2 – but type 2 accounts for 95 percent of cases. In both, levels of blood sugar are too high as a result of problems with insulin, a hormone that enables the body to use blood sugar for energy. But the reasons differ.

Type 1 is an autoimmune disease. It causes the pancreas to stop making insulin or not make enough. Type 1 is not yet preventable and requires insulin treatment.

In type 2, insulin may be available, but body tissues resist its use.

Being overweight is the key factor in type 2. Most people can prevent it by not gaining weight. And most people with the type 2 disease can eliminate symptoms by losing some weight.

Genetics is certainly a factor – many overweight people never develop the disease – but 85 percent or more of people diagnosed with type 2 diabetes are overweight or obese.

In genetically predisposed people, being overweight causes insulin resistance. Metabolism does not handle excess calories very well, and this means calories from any source, not just carbohydrates.

Fast food, soft drinks

Children and adults who habitually consume fast food as well as soft drinks tend to take in more calories and weigh more and are more likely to develop symptoms than people who eat healthier diets and are more active.

This makes healthy eating and physical activity the most important approaches. The vast majority of overweight people at risk of type 2 diabetes can prevent symptoms by losing a few percent of their body weight and doing a couple of hours a week of moderate – not necessarily vigorous – physical activity. The same works for treatment. Some people will still need medications, but the drugs work better with diet and physical activity.

As the Centers for Disease Control puts it, “all diabetes-care programs should make healthy weight a priority.”

Dietary advice for type 2 diabetes is the same as advice for everyone else: Eat a wide variety of relatively unprocessed foods, especially vegetables, fruits and whole grains, and don’t consume too much junk food or too many sugary beverages.

Scientists may argue endlessly about the relative importance of calories, sugars and refined carbohydrates in the diets of people with type 2 diabetes, but everyone agrees that eating less of all three would help resolve symptoms.

Why isn’t weight loss better recognized as a treatment strategy? Paula Deen’s announcement said nothing about losing weight.

The ADA does talk about weight loss on its website ( www.diabetes.org), but you must search hard through several complicated screens before you find, “Losing just a few pounds through exercise and eating well can help with your diabetes control and can reduce your risk for other health problems.”

Pharmaceuticals

I can’t help wondering if the lack of prominence given to weight loss might have something to do with the influence of pharmaceutical companies.

A few years ago, I gave a talk on the importance of weight loss in control of type 2 diabetes at an ADA annual meeting. Although many conference talks dealt with drug treatment, mine was the only one on diet – except for a session on sugars sponsored by Coca-Cola.

The exhibit hall was packed with drug company representatives dispensing free pens, writing pads, books, lab coats and stethoscopes – all with corporate logos.

The influence of drug companies on diabetes advice is worth attention. Deen represents a drug that costs hundreds of dollars a month. Drug companies give the ADA millions every year.

Eating less and being active make no money for anyone (unless people can be induced to join commercial weight-loss programs).

Losing weight is a losing battle for many people. It’s hard to lose weight in today’s “eat more” food marketing environment.

Teachable moment

But a diagnosis of type 2 diabetes should be a teachable moment. Shouldn’t the ADA more strongly urge people with the disease to eat less, eat better and move more, and help everyone find ways to cope with “eat more” messages?

The health and economic costs of type 2 diabetes, and its preventability, are reason enough to demand changes in the food environment. The ADA should be working hard to make it easier for everyone to eat more healthfully, be more active and avoid the need for a lifetime of diabetes medications.

Marion Nestle is the author of “Food Politics” and “What to Eat,” among other books, and is a professor in the nutrition, food studies and public health department at New York University. She blogs at www.foodpolitics.com. E-mail comments to food@sfchronicle.com.

This article appeared on page G – 4 of the San Francisco Chronicle

Nature, the prestigious science magazine from Great Britain, has just published a commentary with a provocative title–The toxic truth about sugar—and an even more provocative subtitle: Added sweeteners pose dangers to health that justify controlling them like alcohol.

The authors, Robert Lustig, Laura Schmidt and Claire Brindis, are researchers at the University of California medical center in San Francisco (UCSF).

They argue that although tobacco, alcohol and diet are critically important behavioral risk factors in chronic disease, only two of them—tobacco and alcohol—are regulated by governments to protect public health.

Now, they say, it’s time to regulate sugar.  By sugar, they mean sugars plural: sucrose as well as high fructose corn syrup (HFCS).  Both are about half fructose.

Their rationale?

• Consumption of sugars has tripled over the last 50 years.
• Many people consume as much as 500 calories a day from sugars (average per capita availability in the U.S. is about 400 calories a day)
• High intake of fructose-containing sugars induce metabolic syndrome (high blood pressure, insulin resistance), diabetes, and liver damage.
• Sugars have the potential for abuse.
• Sugars have negative effects on society (mediated via obesity).
• Too much of a good thing can be toxic.

Therefore, they argue, societies should intervene and consider the kinds of policies that have proven effective for control of tobacco and alcohol:

• Taxes
• Distribution controls
• Age limits
• Bans from schools
• Licensing requirements
• Zoning ordinances
• Bans on TV commercials
• Labeling added sugars
• Removal of fructose from GRAS status

In a statement that greatly underestimates the situation, they say:

We recognize that societal interven­tion to reduce the supply and demand for sugar faces an uphill political battle against a powerful sugar lobby, and will require active engagement from all stakeholders.

But, they conclude:

These simple measures — which have all been on the battleground of American politics — are now taken for granted as essential tools for our public health and well-being. It’s time to turn our attention to sugar.

What is one to make of this?  Sugar is a delight, nobody is worried about the fructose in fruit or carrots, and diets can be plenty healthy with a little sugar sprinkled here and there.

The issue is quantity.  Sugars are not a problem, or not nearly as much of a problem, for people who balance calorie intake with expenditure.

Scientists can argue endlessly about whether obesity is a cause or an effect of metabolic dysfunction, but most people would be healthier if they ate less sugar.

The bottom line?  As Corinna Hawkes, the author of numerous reports on worldwide food marketing, wrote me this morning, “there are plenty of reasons for people to consume less sugar without having to worry about whether it’s toxic or not!”

The latest obesity statistics from the Centers for Disease Control and Prevention show no change over the last several years in either adults or children.  No change is good news.

For adults in 2009-2010 the prevalence of obesity was 35.5% among men and 35.8% among women.  Obesity, in these surveys is defined as a Body Mass Index (BMI) at or greater than 30.

This represents no significant overall change compared to rates in 2003-2008.  

Going back to 1999, however, obesity rates increased significantly among men in general, and among black (non-Hispanic) and Mexican-American women in particular.  In more recent years, the rates among these groups leveled off.

 For children and adolescents in 2009-2010 the prevalence of obesity was 16.9%.  For this group, obesity is defined as a BMI at or greater than the 95th percentile of weight for height.

This represents no significant change compared to rates in 2007-2008, but with one exception: the rate of obesity among adolescent males aged 12 through 19 increased.

For decades, rates of overweight and obesity in the United States stayed about the same. But in the early 1980s, rates increased sharply and continued to increase through the 1990s.

The increases correlated closely with deregulatory policies that encouraged greater farm production and loosened restrictions on food marketing.  These led to an increase in the number of calories available in the food supply, pressures on food companies to sell those calories, a proliferation of fast food places, and marketing strategies that made it normal to drink sodas all day long, and to eat everywhere, at all times of day, and in larger portions.

Why are obesity rates leveling off now except among boys?  Nobody seems to know.

I can make up several reasons, all speculative (and I have my doubts about most of them).

• People have gained all the weight they can and are in equilibrium
• People are more careful about what they are eating
• The poor economy is encouraging people to eat less
• Junk food marketing is targeted more to boys
• Girls are more careful about their weight
• Boys are particularly susceptible to “eat more” marketing pressures
• Boys are under greater psychological tension and eat to relieve it

Anyone have any better ideas?  It would be good to figure out the reason(s) as a basis for more sensible public policy.

The amazing New York City Health Department, almost unique in its interest in public health and willingness to do what it can to improve the health of New Yorkers, adds another campaign to its collection of hard hitters.  This one is on the need to reduce portion sizes.

The subway campaign posters in Spanish and English.  Here’s an example in Spanish.

I especially like this campaign because much of the work on increasing portion sizes in the food supply was launched by my former doctoral student, now Dr. Lisa Young.  See:

• Young LR, Nestle M, The contribution of expanding portion sizes to the US obesity epidemic. American Journal of Public Health, 2002. 92(2): p. 246-9.
• Young LR, Nestle M, Expanding portion sizes in the US marketplace: implications for nutrition counseling. Journal of the American Dietetic Association, 2003. 103(2): p. 231-4.

Larger portions do three things:

• They have more calories, obviously.
• They induce people to eat more calories
• They induce people to underestimate the number of calories they are eating

All of these induce people to eat more than they need or should.

The expansion of portion sizes alone is sufficient to explain rising rates of obesity.

The Health Department’s campaign makes sense.  Let’s hope it helps.

Update, January 10: The American Beverage Association doesn’t like the ads much, according to Crain’s:

Portion control is indeed an important piece of the solution to obesity,” said said Stefan Friedman, New York spokesman for the American Beverage Association, in a statement. “But instead of utilizing scare tactics, the beverage industry is offering real solutions like smaller portioned containers and calorie labels that show the number of calories in the full container, right up front, to help people chose products and sizes that are right for them and their families.

And if you think the New York City ads are tough and hard-hitting, try these “Strong4Life ads from the state of Georgia.  Shocking people out of complacency?  Or just shocking?

Update, January 25: The New York Times reports that the shocking photograph of an overweight man with a leg amputation was “photoshopped” from a stock photo.

This is unfortunate, as it opens the Health Department up to unnecessary criticism:

The American Beverage Association, which opposes the city’s efforts against sodas and fast food, called the advertisement overwrought. “This is another example of the ‘What can we get away with?’ approach that shapes these taxpayer-funded ad campaigns,” Chris Gindlesperger, the association’s director of communications, said in a statement.

The UK Government has “quietly disbanded” its independent advisory group on obesity.  Apparently, it didn’t like the advice it was getting.

The firing is quite understandable.  The group was appointed by the previous government as a result of recommendations in what is known as the Foresight report: Tackling Obesities: Future Choices.   This report advised mapping out strategies for obesity interventions that went way beyond education about personal food choices.

The expert group followed this advice and recommended public health programs to change the food environment and counter food industry marketing.

The new government, however, prefers a “nudge” strategy.  Derived from behavioral economics, “nudge” involves no compulsion (e.g., taxes on junk foods).  Instead, people are free to follow advice to eat better but don’t have to.

Thus, the government’s Call to Action on Obesity in England focuses on individual responsibility and says nothing about the influence of food and drink marketing on food choices.

Two members of the expert committee, Goeffrey Rayner and Tim Lang, have publicly criticized “nudge” as “a smokescreen for inaction.”

No wonder the group was fired.

But as Professor Lang explains:

The closure of the expert advisory group is bad news all round: bad politics, bad policy, and bad science. It shuts the door on an important attempt by the state to recognise the systemic nature of what drives obesity…It’s plain as a pikestaff that obesity requires systems change, not a tweak here and there, yet that is what is being offered.

Doing something about obesity requires eating less and eating better, both very bad for business.   For this UK government, business interests trump those of public health.

I subscribe to a weekly or so news feed from the International Association for the Study of Obesity (IASO) in the U.K.  (to sign up, contact newsnet@iaso.org).

Here are some of the items from the October 27 feed:

• US: Consumer groups complain over ‘stealth’ PepsiCo ads
• US: Tell McDonalds to stop hyping unhealthy fast food to kids
• Ireland: Why tax on sugar is a sweet idea for health
• US: Global Sports and Energy Drinks market could hit $52bn by 2016
• US: Researchers question link between sugary drinks and health risk
• US: Researchers find link between sugary drinks and aggression

It’s a good way to keep up on the sugary drinks controversy, if nothing else.

Here are some of the latest reports on how food marketing influences eating patterns and obesity.

American University’s Kogod School of Business publishes a business magazine, Kogod Now.  It latest CoverStory takes a tough look at at how targeted marketing of foods and beverages contributes to the obesity crisis, especially among minority children and adolescents.

Cornell University’s Pierre Chandon and Brian Wansink ask the question, “is food marketing making us fat?”  Their review of the research leads them to conclude that a “small steps” approach ought to help reverse obesity.   Recent analyses, however, suggest that reversing overweight is likely to take a lot more than small steps, but it’s worth reading what they have to say about marketing practices.

Two reports from Canada indicate that industry self regulation has little effect on actual food industry marketing practices.  Instead, banning the marketing of junk foods, as has been accomplished in Quebec, works somewhat better.

The American Academy of Pediatrics takes a look at how television watching affects obesity in children.  If kids watch a lot of TV–and they have a TV set in their bedrooms—they are at high risk of becoming obese.  The obvious conclusion?  Get rid of the TV!

It is heartening that so much of the research on obesity these days focuses on changing the food marketing environment.  Now if policymakers would just pay some attention!

My mailbox is overflowing with new reports and commentary about obesity.  Here are some examples:

State medical expenses: The journal, Obesity, has an analysis of the cost of obesity to states.  Obesity costs states an additional 7 to 11% in medical expenses. Between 22% (Virginia) and 55% (Rhode Island) of state costs of obesity are paid by taxpayers through Medicare and Medicaid.

Robert Wood Johnson Foundation series on preventing childhood obesity: 

• Food marketing to children: U.S. Businesses Show Mixed Progress on Marketing a Healthy Diet to Children and Adolescents
• Industry self-regulation: Self-Regulation by Food and Beverage Industry Does Little to Reduce Kids’ Exposure to Unhealthy TV Ads
• New York City’s menu labeling regulation: Customers Who Use Menu-Labeling Information Order Fewer Calories
• The ban on sugar-sweetened drinks in Boston schools: Boston High School Students Drinking Fewer Sugary Beverages

From the Campaign to End Obesity:

Obesity Rates Projected to Soar, ABC News, 8.25.11: Will half the U.S. population be obese by 2030? The current trajectory would see 65 million more obese adults, raising the national total to 164 million. Roughly one-third of the U.S. population is currently obese.

In U.S., Obesity Rates Remain Higher Than 20% in All States, Gallup, 8.25.11: Colorado continues to be the state with the lowest obesity rate in the country, at 20.1% in the first half of 2011. West Virginia has the highest obesity rate in January through June 2011, at 34.3%, which is also the highest Gallup has measured for any state since it began tracking obesity rates in 2008.

Reversing the obesity epidemic will take time, LA Times, 8.26.11: The old rule that cutting out or burning 500 calories a day will result in a steady, 1-pound-per-week weight loss doesn’t reflect real people, researchers say. For the typical overweight adult, every 10-calorie-per-day reduction will result in the loss of about 1 pound over three years.

I’ve commented on some of these in previous posts.  If you find the avalanche of studies overwhelming, you are in good company.  I do too, but will summarize my take on the literature in my forthcoming book with Malden Nesheim, Why Calories Count: From Science to Politics, due out from University of California Press in March 2012.  Stay tuned.

The British journal, The Lancet, has a special series of papers on obesity and obesity policy, just out.

Don’t miss the Body Weight Simulator! It’s great fun to play with while waiting out a hurricane.

You type in your age, weight, and height (you can change the metrics to pounds and inches), and indicate your activity level.  It tells you how many calories you can eat every day to maintain that weight (Yikes!  That’s all? No wonder I have so much trouble).

It also tells you how many calories you need to reduce in order to lose weight over whatever time period you specify.

And here are the papers, reviews, and commentaries (you will need to log in to read more than the summary):

The future challenge of obesity
David King
Full Text | PDF

Reversing the tide of obesity
William H Dietz
Full Text | PDF

Where next for obesity
Harry Rutter
Full Text | PDF

The global obesity pandemic: shaped by global drivers and local environments
Boyd A Swinburn, Gary Sacks, Kevin D Hall, Klim McPherson, Diane T Finegood, Marjory L Moodie, Steven L Gortmaker
Summary | Full Text | PDF

Health and economic burden of the projected obesity trends in the USA and the UK
Y Claire Wang, Klim McPherson, Tim Marsh, Steven L Gortmaker, Martin Brown
Summary | Full Text | PDF

Quantification of the effect of energy imbalance on bodyweight
Kevin D Hall, Gary Sacks, Dhruva Chandramohan, Carson C Chow, Y Claire Wang, Steven L Gortmaker, Boyd A Swinburn
Summary | Full Text | PDF

Changing the future of obesity: science, policy, and action
Steven L Gortmaker, Boyd A Swinburn, David Levy, Rob Carter, Patricia L Mabry, Diane T Finegood, Terry Huang, Tim Marsh, Marjory L Moodie
Summary | Full Text | PDF

It used to be that the “soda wars” referred to Coke vs. Pepsi.  No more.  Today’s soda wars are fought on the health front, as more and more evidence links sugary drinks to obesity and other health problems.

The current issue of the New Yorker has an article by John Seabrook (in which I am briefly quoted) about Pepsi’s attempt to “health up” its snacks and drinks.

Seabrook’s article, “Snacks for a fat planet,” describes the extraordinary amount of money and effort Pepsi is spending to try to tweak its products to make them seem healthier.  His article doesn’t exactly give Pepsi a pass (as some of my readers have complained), but it does not really come to grips with how sugary drinks and snacks affect health or how Pepsi is marketing its products in developing countries.

That, no doubt, is why Pepsi has sent out a press release to reports that enclosed the complete article and suggested that reporters might be “interested in the company’s focus on its innovative approach to:”

• Reduce salt, fat and sugar across the portfolio – the New Yorker feature explains PepsiCo’s effort to re-shape natural salt so that it has more surface area, and, in turn, is perceived as “saltier” on the tongue – meaning they can maintain all the salty flavor in Lay’s but reduce overall sodium content
• Scale more drinks and snacks made with whole grains, fruit, vegetables and dairy to new markets – e.g. bringing vegetable-based gazpacho (perhaps with an edible whole grain spoon) to the U.S.
• Test new ingredients brought back from “treks” around the world – e.g. using a state-of-the-art robot in PepsiCo’s new Hawthorne, NY research lab to test botanicals and other natural ingredients from near and far – e.g. even secluded villages in the far East – to determine their impact on taste and viability for use in PepsiCo snacks and drinks (Do they intensify sweetness? Can they be a substitute for sugar? Do they have a particular healthful function?)

Score this one as a win for Pepsi.

Along with such pledges, Pepsi is aggressively marketing sodas to teenagers.  The San Francisco Chronicle reports on Pepsi’s new “social marketing” vending machines.

At a trade show in Chicago this week, PepsiCo rolled out a prototype interactive soda machine that lets you send a drink as a gift to a friend or a random stranger.

“Our vision is to use innovative technology to empower consumers and create new ways for them to engage with our brands, their social networks and each other at the point of purchase,” Mikel Durham, PepsiCo Foodservice’s chief innovation officer, said in a press release.

“Social Vending extends our consumers’ social networks beyond the confines of their own devices and transforms a static, transaction-oriented experience into something fun and exciting they’ll want to return to, again and again.”

But these kinds of marketing pushes are not confined to Pepsi.   Advertising Age reports that Joe Tripodi, Coke’s chief marketing officer of Coca-Cola explains the company’s growth strategy: focus on teenagers:

The company sees huge opportunities to grow colas, and the business as a whole, around the world in the next decade. Teen recruitment will be particularly important, as the company follows demographic trends.

“There was a time [a decade ago] when we walked away from teen recruitment and probably lost a generation of drinkers,” Mr. Tripodi said. “Parts of the world lost confidence in cola as the engine of growth. We’ve gotten that back in a big way. …When you look at the massive opportunity in so many huge countries in the world, that’s what energizes us and why we believe cola is still at its very early stages.”

And then there are partnership strategies. The latest is Sonic drive-ins’ campaign for Limeades for Learning. The campaign encourages eaters to vote for school projects like those that support physical activity.  Sonic promises to fund the projects with the most votes. The Limeades, by the way, are 620 calories (for a medium) or 950 calories (for a large).

Finally, for now, the Boston Globe reports that most Massachusetts voters support a sales tax on sodas if the money is used for some useful purpose.  But:

The American Beverage Association has been aggressively fighting taxes on soda, as cities and states across the country look for new tools to counter an obesity epidemic and raise revenue amid squeezed budgets. It has spent millions fighting initiatives that impose product-specific excise taxes on sugar-sweetened beverages and has been successful in nearly every attempt.

Expect more such public relations efforts superimposed on fundamental marketing techniques aimed at kids and fighting back on taxes and other attempts to limit soda intake.

How does this comport with the spanking new advertising guidelines to children or any of the previous pledges? Is sending a soda to a friend an activity or marketing? Or both?

http://www.sfgate.com/cgi-bin/blogs/techchron/detail?entry_id=87904