by Marion Nestle

Currently browsing posts about: Obesity

Sep 23 2013

Pepsi, Mexican style

In Mexico, you can get most kinds of sodas in 3 liter bottles.  At 17 pesos ($1.33) for 3 liters, Pepsi is cheaper than water.

IMG-20130921-00081

Note the 3-peso penalty if you buy two 1.5-liter bottles.  

It’s hardly a coincidence that Mexico has high soda consumption and high rates of obesity.  Taxing sodas seems like a particularly good idea in this situation.

Jun 19 2013

MIni book review: specialized but worth reading

Policy wonk types: try this one!

Melvin Delgado.  Social Justice and the Urban Obesity Crisis: Implications for Social Work.  Columbia University Press, 2013.

This is an academic’s analysis of the social causes of obesity, especially among the urban poor, and what to do about it.  Although the book is aimed at social workers, it works for public health as well.  Delgado calls for community-based participatory health promotion principles and interventions.  These are clearly needed.

If only they weren’t so hard to do…

Tags: ,
Jun 11 2013

NYC Health Department: one New Yorker dies of diabetes every 90 minutes

The NYC Health Department goes to court at noon today for a hearing on the 16-ounce soda cap (I’ll be there).

Yesterday, it released alarming data on diabetes deaths, now at an all-time high.

The press release notes that although NYC’s overall deaths are going down,  diabetes-related deaths are going up.

The deaths are highest in low-income communities.

In April, the Health Department reported that nearly 650,000 New York adults have diabetes, an increase of 200,000 in a decade.   Most of these are due to type 2 diabetes, the “adult” kind.

Why?  Obesity.

Although a small percentage of overweight people develop type 2 diabetes, most people with type 2 diabetes are overweight.

Losing weight is the first thing to do to prevent or treat type 2 diabetes.

Reducing intake of sugary sodas is the first thing to do to lose weight.

That is why the health department wants to reduce the portion sizes of sugary drinks at food service establishments.

Today’s court hearing should be interesting. Stay tuned.

Apr 25 2013

Coca-Cola: obesity is your fault, not ours

A reader sent me an e-mail received from Coca-Cola:

As you know, obesity is an issue that affects all of us. At Coca-Cola, we believe we can help solve it by working together. As you heard back in January, we are committed to doing our part – by offering more low- and no-calorie choices, more portion controlled packages, and useful calorie information in more places than ever before.

As part of our ongoing commitment to provide more information about calories, we want to share a new “Calorie Balance”  infographic that we created. This is posted on our Company website here.

Our infographic is a simple, easy tool that informs people about where Americans’ calories are coming from and what we can all do to maintain a healthy, active lifestyle.

It communicates government data and third-party published studies in a compelling way, showing that too many calories consumed as compared to those expended can lead to weight gain.

OK.  I can’t resist.  Here’ just one piece of Coke’s infographic:

Guess what #4 is.   And what food is responsible for more than one-third of calories from sugars in U.S. diets?

The infographic gives no guidance about food choices or amounts best for health, but it is quite specific about physical activity.  Do lots!

Overall, I read the infographic as saying “Hey, it’s not our sugar-water that’s making you put on weight.  It’s up to you to choose what you drink and work it off with physical activity.”

Getting active is always good advice, but doesn’t Coke’s phenomenally comprehensive and astronomically expensive  marketing offensive have anything to do with food choices?  Coke must think all that is irrelevant.

I think it’s quite relevant.  And so does the research.

Jan 18 2013

Should sugar-sweetened beverages be regulated? NEJM readers vote yes.

As part of an interactive case study and point-counterpoint on regulation of sugar-sweetened beverages, the New England Journal of Medicine (NEJM) conducted a poll of its U.S. and international readers.  The poll elicited responses from 1290 readers from 75 countries.

Overall, 68% of respondents favored government regulation.

High as this percentage is, the average is much lower than percentages from most countries as a result of one outlier—the United States.

Only 58% of U.S. voters in the poll favored regulation.  Everywhere else in the world, the percent in favor averaged 84%.

These results reminded me of change-in-sales figures from a few years ago:

Americans have reduced soft drink consumption, causing soda companies to focus their marketing efforts overseas.  Trends like these explain Coca-Cola’s new obesity ad campaign and Pepsi’s $50 million deal with Beyoncé. 

In America these days, 58% is an impressive majority.  NEJM readers are likely to be physicians, scientists, and health and health policy professionals. I suspect we will be hearing more about this idea.  Stay tuned for this one too.

Jan 16 2013

Coca-Cola fights obesity? Oh, please.

In case you missed all the publicity about Coca-Cola’s new ad campaign positioning the company as a force for public health, take a look at its new two-minute TV ad.

The video—how much do these things cost?—argues that the company is producing lower-calorie products in smaller sizes and promoting community activity, that all calories count, and that it’s up to you to fit Coke into your healthy active lifestyle.

The ad is an astonishing act of chutzpah, explainable only as an act of desperation to do something about the company’s declining sales in the U.S. and elsewhere.

If Coke really wanted to help prevent obesity, it would STOP:

  • Targeting its “drink more Coke” marketing to kids.
  • Targeting marketing to low-income minorities.
  • Lobbying and spending a fortune to defeat soda taxes and caps on soda sizes.
  • Fighting attempts to remove vending machines from schools.
  • Pricing drinks so the largest sizes are the best value.
  • “Bribing” health professions organizations to shut up about research linking sugar-sweetened beverages to poor diets and weight gain.
  • Pushing Coke sales in developing countries where rates of obesity and related conditions are skyrocketing.

Instead, it’s doing all these things, but not talking about them in videos.

The company is supposed to be releasing a second video tonight, explaining how to work off the “140 happy calories” in a soda by dog-walking, dancing, or laughing. If only.

I can’t wait.

Addition, January 18:  Someone who calls himself John Pemberton has gone to the trouble of presenting the 2-minute commercial with a somewhat different narrative—the real story about Coca-Cola and obesity.  If that link doesn’t work, try this one.

Jan 9 2013

Let’s Ask Marion: Can It Really Be Healthier To Be Overweight?

Every now and then, Kerry Trueman challenges me with a difficult question about some current topic.  Our most recent exchange, published yesterday in the Huffington Post, is about the so-called “obesity paradox” (defined below).

Trueman: There’s a brouhaha in the blogosphere over Paul Campos’ NY Times op-ed in which he claims that our current definition of what constitutes a ‘healthy weight’ is dead wrong. Campos cites a new analysis from The Journal of the American Medical Association claiming that overweight or obese individuals have a lower mortality rate than people whose weight is ‘normal.’

He speculates that our obsession with obesity is a misguided and manufactured controversy foisted on us by the multibillion dollar weight loss industry and Big Pharma. Marion, you’ve been called a lot of things over the years, but have you ever been accused of being in cahoots with Jenny Craig and Eli Lilly?

Nestle. I love it when people invoke conspiracy theories to deny that obesity raises disease risks.

Paul Campos is a lawyer. He views matters of diet and health from a legal perspective. From that viewpoint, if a statistical analysis shows little effect of obesity on mortality except among very obese people, then nobody need be concerned about weight gain except at the extreme.

If only the science of diet and health were that simple. Scientists, alas, must struggle with a number of vexing questions about such studies:

  • Does a finding of statistical significance necessarily imply clinical or biological significance?
  • Do statistical findings based on populations necessarily count for individuals?
  • Do statistical associations provide guidelines for behavior?
  • Are the methods used in statistical studies adequate to draw conclusions about behavior?

We are talking here about a huge meta-analysis of 97 studies of obesity and mortality carried out by Katherine Flegal and her colleagues at the National Center for Health Statistics.

When I read papers by excellent statisticians published in prestigious, peer-reviewed journals, I start by taking the results at face value. Then I ask critical questions about what the results might mean.

I found the figures in the paper difficult to follow so I’ve summarized the results below:

RELATIONSHIP OF WEIGHT CATEGORY TO THE RISK OF MORTALITY.

WEIGHT CATEGORY BMI RANGE MORTALITY RISK (RELIABILITY)
Normal 18.5 – 25 1.00
Overweight 25 – 30 0.94 (95% CI, 0.91-0.96)
Obesity, Grade 1 30 – 35 0.95 (95% CI, 0.88-1.01)
Obesity, Grades 2 and 3 >35 1.29 (95% CI, 1.18-1.41)

My interpretation: Compared to people with BMI’s in the normal range, those with BMI’s considered overweight or somewhat obese display no increased risk of mortality. Indeed, those in the obesity grade 1 category may have a slightly reduced risk. The study only finds an increased risk of mortality—by 29%—when the BMI exceeds 35.

My first reaction? This is not news.

Since this is a study of previous studies, we’ve seen results like this before. Flegal herself published a similar analysis in JAMA in 2005. In that paper, she presented the results in a way that is easier to visualize:

RELATIONSHIP OF BMI TO MORTALITY AT VARIOUS AGES

2013-01-08-BMI1.png

2013-01-08-BMI2.png

These earlier results show what is called a “J-shaped” curve, meaning that the risk of mortality increases at BMI’s below as well as above the normal range.

The new study is consistent with these earlier—and equally controversial—results.

But the earlier results point to some of the difficulties in interpretation.

  • What’s going on at the lower end of these curves?
  • Are mortality results skewed by people who are ill and weigh less?
  • Is BMI an adequate indicator of health status?

At the moment, there is no way to answer these questions at a level of precision that might satisfy legal thinkers.

What we do know is that obesity above the normal range sometimes—never always—raises the risk for chronic diseases like type 2 diabetes, heart disease, and others. Risk is about probability. Risk never implies legal certainty.

It seems clear that for some people—perhaps many—having a chronic disease does not cause a decrease in lifespan. Since 1970, people throughout the world have gained slightly more than ten years of life expectancy overall, but are now spending many more years living with injury, illnesses, and disabilities—conditions caused by cigarette smoking, excessive alcohol consumption, and poor diet.

With respect to overweight, this is sometimes called the “obesity paradox,” understood as the survival benefits of modest overweight and obesity for people who already have a specific medical condition.  For them, many studies—not all—show that survival is modestly better at higher weights.

The Flegal study deals only with the statistical significance of the mortality survival component of the paradox. It does not deal with issues related to the effects of obesity on quality of life.

As a result, some of my colleagues have made harsh comments about the study, calling it “a pile of rubbish.”

I wouldn’t go that far. The study is what it is—a statistical meta-analysis. It’s up to scientists and clinicians to figure out whether statistics like these have meaning in the real world.

In the real world, it doesn’t take much overweight to induce type-2 diabetes in susceptible individuals, and many people—not all—with type-2 diabetes can completely eliminate symptoms by losing a few pounds.

Campos may be willing to let his weight go to where it will and take his chances that statistics are on his side. That’s his choice.

As for me, I’d prefer to avoid weight-related illnesses for as long as I can. I’m hedging my bets and continuing to watch my weight.

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.