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Thursday, February 21, 2013

Soft drinks create hard choices

Responding to our justifiably increasing preoccupation with widespread obesity, the Coca-Cola Company has released a masterful television ad on the subject. They characterize their own efforts, and invite us all to "come together" to combat this scourge. The whole "come together" concept receives great emphasis, with evocative images from the (presumably) good old days of: "I'd like to buy the world a Coke ..."

Predictably, the collective response of my friends and colleagues in public health has been less than warm and bubbly. Sensing a blend of propaganda, evasion, hypocrisy, and desperation in Coke's efforts, my clan has largely reacted with their own blend of dismissal, derision, and disgust. In essence, they have invited us all to lose this lunch, and roll our eyes.

I confess, I am sorely tempted to join them. But before we can lose our lunch, we are perhaps obligated to chew on it. And before rolling our eyes, we may need to read the writing on the wall, fine print, and all.

Before that chewing and reading begins, I do want to insert a disclaimer. I am the furthest thing from a food industry apologist. I have devoted years of my life to the development of programs for children and adults alike that reveal the all-too-often lamentable truth about the so-called "food" supply. At every opportunity, I have highlighted the fact that "betcha' can't eat just one" was far more than a clever ad campaign; it was a threat to public health, backed up, at least in the case of Kraft, by nutritional biochemists and neuroscientists using functional MRI scans to determine how to maximize the number of calories it takes for us to feel full. And I have noted repeatedly, as I will continue to do, that as we got fat and our kids got diabetes, somebody was chuckling about it all the way to the bank.

Nor do I have even a little love for the Coca-Cola Company. I consider their flagship offering a chemistry experiment in a cup. I haven't had a soda in some 35 years since I first saw that light. Coca-Cola has systematically opposed public health campaigns to reduce soda consumption, deflected criticism, denied epidemiologic truths, and distorted their own contributions to epidemic obesity. I have, at least in moments of private rage, considered them an evil empire. Regarding my brief encounter with their CEO, I can only say I felt the dark side of the Force was strong with him.

And when it comes to polished and compelling ads that obscure any semblance of truth, Coca-Cola has an impressive track record. They have given us polar bears enjoying Coke as they frolic in their winter wonderland.

This is wrong in so many ways it's hard to know where to start. For one thing, polar bears don't drink soda. For another, that's not likely to help them much, because we are blithely destroying their winter wonderland. And guess what? Concocting chemical potions in factories to drink out of plastic bottles when a glass of water would do nicely is part of the reason, as such industrial activity contributes to global warming and the melting of Arctic ice on which the livelihood of real polar bears depends. So, no, Coke is not offering polar bears a drink. It's part of the reason they may have nothing left to eat. But, of course, only part of a much bigger reason.

Reacting to Coke's misleading depiction of polar bears, the Center for Science in the Public Interest engaged musician Jason Mraz, to give us the "real" bears. I fully support this campaign to show what might happen if polar bears actually did drink Coke. But of course, these aren't "real" bears, because as noted, polar bears don't drink soda. So, the "real" issue is that we may not be smarter than the average bear after all. Bears are still eating and drinking what bears should eat and drink, to the extent we aren't making it impossible for them. We, on the other hand, have been drinking Coca-Cola out of ever-larger containers.

This just isn't about bears and the choices they make. It's about us, and the choices we make. And we apparently have some hard ones. We have water, but choose to drink Coke. We have broccoli, but choose to eat bologna. There are no bears involved. We have met the enemy, and it is us.

Yes, we are also the victim. Yes, the food industry really has manipulated us with foods engineered to specifications born of functional MRI scans. But come on: Does anyone think Coke is good for them? Does anyone not living under a rock think you can drink a gallon of that stuff daily and not suffer any consequences? Is there really anyone left who has not heard the rumors about sugar? And does anyone bemoaning the unbearable (pun intended) burden of a soda tax truly not know where to find a water fountain?

Coke is quite right about one thing: We are all in this together.

Consider that when McDonald's, another good contender for the food industry's evil empire award, gave us McLean Deluxe, we didn't buy it. The product expired not for want of supply, but for want of demand. Folks, that's not McDonalds' problem. It's yours, and mine. It's our kids' problem.

Similarly, remember Alpha-Bits cereal? If you haven't seen it lately, here's why, courtesy of some inside information. Post reduced both the salt and sugar content, actually making the product more nutritious, and people stopped buying it. Sales plummeted from about $80 million a year, to $10 million.

Most product reformulations that allegedly give us better nutrition are actually lateral moves, fixing one thing, breaking another. Salt is reduced, but sugar is increased. Sugar is reduced, but trans fat is increased, and so on. I have an intimate view of all this, courtesy of my work with the NuVal program, which has established a detailed nutrient database for over 100,000 foods it has scored. All too often, banner ads implying better nutrition are entirely misleading. Low-fat peanut butter is substantially less nutritious than regular. Multigrain breads may or may not be whole grain.

But on those rare occasions when the food industry actually gives us better products, we don't buy them.

Which brings us back to Coke: What, exactly, do we want from them?

As I see it, against a backdrop of a growing burden of national and global chronic disease in which they are complicit, Coke has four options. They can (1) ignore the public health problem, and keep on keeping on; (2) acknowledge the public health problem, but say it's not their problem, and keep on keeping on; (3) confess their corporate sins and absolve themselves with ceremonial suicide; or (4) change.

Choices one and two have pretty much run their course. Shareholders are unlikely to bless option three. Which leaves us with option four: change. Change their product formulations. Change their inventory. And change their messaging. Stop talking about frolicking polar bears, and start talking about obesity. And while we have cause to be suspicious about Coca-Cola's motives, that's just what the new ad appears to be doing.

Yes, they sell us chemistry experiments in a cup. Yes, they help us become fat diabetics. But they are also a large company, employing a lot of people. If we simply want to drive a stake through their corporate heart, the result would be a lot of newly-unemployed people, still prone to obesity and diabetes while drinking Pepsi, or Mountain Dew, or Dr. Pepper, while perusing the want ads.

And yes, the new ad about obesity is only in response to mounting pressure from a concerned public, and restive federal authorities. But is it bad or surprising that supply-side changes are responsive to a changing demand? The business of business, after all, is business, and keeping the customer satisfied.

If we want truly meaningful changes in the quality of our food and drink, we will in fact require changes in both supply and demand. It won't help if they build it, and we don't come. There are ways to propagate a shared taste for change, and such a course might allow for substantial improvements in the public health without blowing up the Fortune 500.

Admittedly, the new Coke ads addressing obesity are slick. Stunningly slick. In other words, they are just plain good, working over the chords of emotional response exactly as intended. A testimony to what really deep pockets and top advertising talent can do. This could be just another reason to hate Coke, I suppose.

But on the other hand, the simpler times when Coke was an innocent pleasure are not a Madison Avenue fabrication; they actually happened. We baby-boomers lived through them. There was a time before ultra-uber-gulps and widespread childhood obesity, and soda seemed an innocuous pleasure, whether or not it ever really was. If that has changed over time, then so must we, and so must Coca-Cola.

What would such change look like? Probably something like the new ad.

As a closing aside, I attended the meeting of my local school district wellness committee this week, as they took on the task of complying with Connecticut nutrition standards. The gentleman who runs the high school store noted that by complying with the new regulations, he would lose business to the array of fast-food outlets accessible to the students just across a parking lot. And, I suspect he's exactly right.

I share my colleagues' visceral opposition to everything Coke. But I think we may be letting our abdominal viscera get the better of vital organs situated higher up. Soft drinks do exist; they are big business. Doing something about that involves hard choices.

Change, incremental change, is the most promising and plausible of them. So we have to allow for it if what we want is progress. If we won't accept change without calling it hypocrisy, then we don't really want progress. We want revenge.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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