Marion Nestle: Liberty from big soda

Why Bloomberg's 'ban' should be only the beginning of a public health revolution

Marion Nestle, New York Daily News, March 8, 2013

Barring any late legal surprises, Mayor Bloomberg's 16-ounce cap on sugary sodas goes into effect on Tuesday, March 12. After that, restaurants, movie theaters, sports venues and food carts will not be permitted to sell extra-large portions of sugar-packed drinks.

Stay calm. This does not signal the end of democracy in America. This is not the nanny state gone out of control.

If we want Americans to be healthy, we are going to have to take actions like this - and many more - and do so soon. It's long past time to tax sugar soda, crack down further on what gets sold in our schools, tackle abusive marketing practices, demand a redesign of labels - and extend the soda cap, no matter how controversial it may seem. This must be the beginning, not the end, of efforts toward a healthier America.

In short, we need a series of serious changes to make the healthy choice the easy choice. The soda size cap is a nudge in that direction. You will still be able to drink all the soda, and down all the sugar, that you want. The cap on soda size makes it just a tiny bit harder for you to do so.

That "tiny bit harder" is its point. If you have to order two sodas instead of one, maybe you won't. If you have to add sugar to your coffee drink yourself, maybe you will only add one or two teaspoons instead of the 10 or more someone else put in there for you.

For a public health nutritionist like me, the soda size cap is a terrific idea. Unlike other foods, sodas are a unique target for intervention. They contain sugars - and sugar calories - but nothing else of nutritional value. They are candy in liquid form. Candy has a place in healthy diets, but a small one. So it should be for sodas.

It's no surprise that people who drink large amounts of liquid candy have worse diets, are heavier, and have more health problems than those who do not. And it looks like the body doesn't compute the calories from liquid sugars as accurately as it does for sugars in foods.

On top of that, big sizes make the problems worse. To state the obvious, larger portions have more calories. If an 8-ounce soft drink provides 100 calories, then a 16-ounce drink provides 200, a 32-ounce drink provides 400 and a 64-ounce drink provides 800.

But big sizes also have other effects. They induce people to eat and drink more than they would if given smaller portions. Big sizes confuse people into underestimating the number of calories consumed.

Most people eat whatever size is in front of them - the "default," in public health-speak - and are content with that amount. So a reasonable goal of public health intervention is to change the default drink to a smaller size. Hence: Bloomberg's 16-ounce size cap.

From my nutritionist's perspective, a 16-ounce soda is still generous. Just one contains the equivalent of 12 packets of sugar. Just one provides 10% of the daily calorie needs of someone who typically eats 2,000 calories a day. Just one contains the upper limit of sugar intake that health officials recommend for an entire day. Once you down a 16-ounce soda, it's best to stop right there.

You may find this hard to believe, but the original Coca-Cola was 6.5 ounces, smaller than any size available today. In the 1950s, Coke advertised its 16-ounce bottle as large enough to serve three.

Times have changed. The sizes of foods and drinks have expanded, and so have waistlines. This is no coincidence. On the basis of calories alone, larger portions are all you need to explain why Americans are putting on pounds.

City officials concerned about the health of their citizens, as those in New York most definitely are, want to do everything they can to prevent obesity and the illnesses that go with it. Their rationale is humanitarian, but also fiscal. Poor health is expensive for both individuals and society. You don't believe that excessive weight is an issue? Just ask the military.

We can thank Big Soda - Coca-Cola, Pepsi and their trade association, the American Beverage Association - for the contribution of big sodas to weight gain. Soda companies have spent fortunes to create demand, to make drinking large amounts seem normal, to market sodas as essential for health and happiness and, these days, to fight Bloomberg's soda cap and take the city to court over it.

Soda companies may make things you like to drink, but they are not social service agencies. Their job is to get you to buy more soda to satisfy the financial demands of investors. They are about business. They are not about fun or happiness or personal choice - and they certainly are not about health.

The soda industry may profess to care more about your well-being these days, but it ultimately will not do anything to promote health if doing so harms sales.

So-called "nanny-state" measures - like bans on driving while drunk, smoking in public places and, now, selling absurdly large sugary drinks - help to level the playing field. Such measures are about giving everyone an equal opportunity to live a safer and healthier life.

At the moment, it is up to you to make healthier choices, but that's not easy in the face of relentless soda marketing. Governments have a responsibility to provide healthier environments for their citizens.
Here are some additional actions New York City should take, if only it were allowed to.

Close the loopholes. The city does not have jurisdiction over sales of sodas in convenience stores and supermarkets. The state does. Gov. Cuomo denied Mayor Bloomberg's request to extend the size cap to those stores, not on principle but because he hadn't thought about it. He should, right now. Let's keep all sugary drinks to 16 ounces or less.

Fix the price differential. A 7.5-ounce can of soda costs twice as much per ounce as a two-liter bottle, and you can't buy just one; it comes in an 8-pack. Price determines sales. If a 16-ounce soda costs a dollar, a 32-ounce soda should cost two dollars.

Tax sodas. Most people wouldn't dream of eating candy all day, but soda companies have made it seem normal to drink sodas from morning to night. Raising the price of sodas would discourage sales, especially among young people most susceptible to marketing efforts and most vulnerable to weight gain. A one-cent tax per ounce should do the trick and raise plenty of needed revenue besides.

Remove vending machines from schools. Yes, the Beverage Association only puts "better-for-you" drinks in school vending machines, but sugar-filled sports drinks are still liquid candy. And kids should not have to pay for water in schools.

Restrict marketing of sodas to children. Soda companies market extensively to children and adolescents, especially those in low-income neighborhoods. Just look at billboards, celebrity photos on soda cans and Pepsi's $50 million dollar deal with Beyoncé. They should not be permitted to market to kids this way. We already have restrictions on cigarette and alcohol marketing to kids. It breaks no new ground to add sodas to the list.

Don't let SNAP (food stamp) benefits be used for sodas. Bloomberg tried this, but the federal Department of Agriculture said no. There is absolutely no reason that taxpayer-subsidized food assistance for low-income people should go toward junk with no nutritional value. He should try again.

Show full calories on the front of containers. The current way calories are tallied, in a measure called "calories-per-serving," is confusing because the servings are unrealistically small and people don't do the math. Soda cans already give the full calories in tiny type on the Nutrition Facts label, but I want to see the full calories in big type on the front.

Actions like these will evoke ferocious opposition from the soda industry, and it will spare no expense to make sure such things never happen. We would surely hear more and more howls of "nanny-state" from those who insist Bloomberg has led us to the brink of a public health police state. Polls say that many New Yorkers oppose the 16-ounce cap and would oppose measures like this, too.

But I can't tell whether the opposition comes from genuine concern about limits on personal choice or because soda companies have spent millions of dollars to protect their interests and gin up histrionic, misinformed opposition.

Come Tuesday, the 16-ounce soda is the new default size in New York City. While waiting for the court decision and for politics to play out, why not give it a chance? Maybe it will help you live a healthier and longer life.

Nestle is a professor of nutrition, food studies and public health at New York University. She is the author of "Why Calories Count."

Parsing of Data Led to Mixed Messages on Organic Food's Value

Kenneth Chang, The New York Times, October 15, 2012

A team of scientists laboriously reviewed decades of research comparing organic fruits and vegetables with those grown the usual way. They found that, as many had suspected, the organic produce, farmed without synthetic fertilizers or pesticides, was more nutritious, with more vitamin C, on average, and many more of the plant-defense molecules that in people help shield against cancer and heart disease.

That is probably not the study you heard about.

The findings, by scientists at Newcastle University in England, appeared in April 2011 and barely made a ripple in the news media or in the public consciousness.

But last month, after a team from Stanford University conducted a similar review of many of the same studies, they came to opposite conclusions — and set off a firestorm. Organic meat and produce, the Stanford researchers said in an article in Annals of Internal Medicine, is no more nutritious than conventionally grown foods.

A debate erupted between those who saw the Stanford study as validation of their belief that organic food is an expensive, pointless exercise and people who said the report ignored the main reasons they buy organic food and pay a premium: to avoid pesticides, for the health of farm workers and for environmental considerations.

So why the chasm? Part of the issue is methodology. Neither the Stanford nor the Newcastle researchers conducted new field or laboratory work; rather, both groups performed a meta-analysis, a statistical compilation of earlier work by others. It was a meta-analysis, for example, that revealed the effectiveness of aspirin in preventing the recurrence of heart attacks.

Such analyses seek out robust nuggets in studies of disparate designs and quality that offer confounding and often conflicting findings, especially in nutrition and medicine. The way the data from various studies is divvied up or combined in a meta-analysis can make a big difference in the conclusions. In the organic food research, some studies reported many measurements, some only a few. Some included several crops grown over multiple years, while others looked at only a few samples.

In setting up such a meta-analysis, “you can’t just take an average of everything,” said Kirsten Brandt, the scientist who led the Newcastle study.

So, for instance, she decided that if a paper reported results for crops grown in separate years, each year should be regarded as a separate data point, because weather conditions vary so much from year to year. The Stanford group instead averaged the multiple years into a single data point.

The overall Stanford approach, Dr. Brandt said, was similar to what is used for analyzing human clinical drug studies, where the effects of a medicine should be consistent and variations indicate that a study may not have been done well. In agricultural studies, she said, the variations are expected because of differences in plant species, weather, soil and other conditions. “This difference is a genuine difference,” she said, and not an indication of shoddy experiments.

Ingram Olkin, an emeritus professor of statistics at Stanford who was part of the research group there, defended its approach, but added that the Newcastle team might have also made reasonable decisions. “There is no unique art to this,” he said. “A meta-analysis is a tough business.”

Craig Osenberg, an ecology professor at the University of Florida who was not involved in either study, said there was no definitive method. “I can see both approaches being justifiable in different contexts,” he said, “and personally I don’t know which decision I would have made if I had been facing that.”

The Stanford and Newcastle studies agree on many points. For most vitamins and minerals, both studies found no large difference between organic and conventional produce. The Newcastle study found that organic produce had a modest 9 percent increase in vitamin C; the Stanford study did not.

 Both studies also found that organic produce contained more of the compounds known as phenols, believed to help prevent cancer and other diseases. But the Stanford study questioned whether the phenol increase was real, because the magnitude of the increase varied widely among studies.

But some plant biologists have long suspected that plants grown organically are healthier and produce fruits and vegetables that are healthier to eat.

“Most of the difference in nutrient levels in organic versus conventional foods is likely caused by conventional farmers driving down nutrient levels via their pursuit of ever-higher yields,” said Charles M. Benbrook, a researcher at Washington State University and former chief scientist at the Organic Center, a nonprofit group that studies organic farming. “The other portion is from greater pest attacks in organic fields, triggering their defense mechanisms,” he said, “which in turn are driving up secondary defense compounds that are also human nutrients.”

The Stanford researchers have since made four corrections to their paper.

Three are trivial: a misspelling, a transposition of two digits, a transposition of two words. None change any calculations or conclusions..

The fourth correction also looks like a trivial mistyping, but may reflect deeper issues. In a table comparing the amounts of nutrients in fruits and vegetables, the data for “total flavanols” was actually for “total flavonoids.” Flavanols are a class of compounds that plants produce for self-defense. Flavanols are found, for example, in cocoa and green tea, and are thought to help prevent against cancer, heart disease and other ills in humans. Flavonoids are a larger class that includes flavanols.

The Stanford meta-analysis found no difference in total flavonoids between organic and conventional produce, basing that conclusion on five papers that mentioned “flavonoids,” “flavonols” or “flavanols,” but by Dr. Brandt’s count it omitted other papers among the 237 the Stanford researchers used that measured specific flavonoids. “My guess is they would find a significant effect if they did it correctly,” she said.

 Dr. Crystal Smith-Spangler, the lead author of the Stanford study, said the flavonoid error resulted from a miscommunication. “It doesn’t effectively change any of our findings,” she said.

Interesting: The Nutrition Science Initiative

Nonprofits begin with the awareness of a problem that needs to be solved, and then a simple question: if we don’t do it, who will?

Nutrition Science Initiative

For us, the problem is inescapable: Over the course of our lives, we’ve witnessed extraordinary progress in science, technology, and medicine, yet these advances have been accompanied by unprecedented increases in the numbers of obese and diabetic Americans. The seemingly simple question of what constitutes a healthy diet – what should we eat to live long and active lives – has remained mired in endless controversy. The official wisdom certainly doesn’t seem to be helping, and a morass of diet books and websites are at odds about which approaches might be better.

In April 2011, after a brief email correspondence, we met in person for the first time. Sitting in a café in Oakland, California, we spoke at length about our personal and professional obsessions with diet and health, and about this national failure to curb the ongoing epidemics of obesity and type 2 diabetes.

More than anything, we discussed what it might take to solve the problem. One fact seemed clear: the medical research establishment had simply failed to provide definitive, unambiguous answers to these unresolved questions of diet and health. Despite billions of dollars spent on medical research, the definitive experiments had never been done, having been perceived as either too expensive, too difficult, or simply not worth the effort.
Our solution was to create the Nutrition Science Initiative (NuSI), an organization that would provide the resources necessary for independent researchers to do the hard science that could indeed answer these controversial but critical questions once and for all.

We don’t know how this undertaking will end.  We are not invested in particular outcomes.  We are invested in finding scientifically sound solutions, and we remain loyal to the mission of communicating the results in a consistent manner that can be both heard and understood by influential scientists, policy makers, the media, and the general public.  We look forward to the day when NuSI is no longer necessary, when – with the full support of rigorous science – we can choose with informed confidence what to eat and what to feed our families.
We thank you for your interest in NuSI.

Gary Taubes and Peter Attia, M.D.
Founders, Nutrition Science Initiative

Interview with Dr. Neal Barnard

Suzan Koven, The Rumpus, September 26, 2012

I love cheeseburgers. How they smell and how they taste. With fried onions and lettuce and tomatoes and lots of ketchup. I love the memory of eating them in the bar in Baltimore where my husband and I went all the time early in our marriage–the place that served them big as saucers in red plastic paper-lined baskets, with cold National Premium on tap and '80s hits by Donna Summer and Joe Jackson on the jukebox.


I don't eat too many cheeseburgers these days. Middle age, caring for my once-vibrant mother after her heart attack and stroke, and decades spent counseling my patients about the dangers of saturated fat have sobered me into moderation.

But lately I've been wondering if moderation is enough.

Reports of the cruel treatment of animals raised for food, such as a recent undercover video leading to shutdown of a California slaughterhouse, force me to face the fact that eating animals always involves, well, killing animals. Information, presented in the popular documentary Forks Over Knives, about the health problems caused by even "healthier" versions of animal products, such as lean meat, fish, and low-fat dairy products, makes me wonder about avoiding all animal products—going vegan.

Change is hard—especially when it involves food, so deeply tied to identity. Who would I be if I never had another pastrami on rye, hunk of cheddar, or Thanksgiving turkey? But who would I be, as a person and as a doctor, if kept eating these things?

I discussed my quandary with author, medical researcher, and activist Dr. Neal Barnard. Dr. Barnard has advocated for animal protection and veganism for the past thirty years. Physicians Committee For Responsible Medicine (PCRM), the nonprofit he founded in 1985, works to educate clinicians and the public about the benefits of veganism, and to end animal experimentation. Dr. Barnard also conducts research on the effects of vegan diets on diabetes, chronic pain, and other conditions, and lobbies the U.S. government for changes in agricultural subsidies and healthier school lunches.

I met with Dr. Barnard in the Washington office of PCRM. He's 58 but looks…I was going to say "younger" but I really mean healthier. He's lean and energetic and makes you realize how flabby and lethargic most Americans of all ages look these days.

He's an excellent advertisement for a vegan diet.

Dr. Barnard had much to say about what motivates people to adopt veganism, about the idea that humans are natural carnivores, about what's really involved in producing animal-derived food, and about Michelle Obama's "Let's Move" campaign.

Though he was open to discussing any aspect of his work, I was most interested in how people decide not to eat animals and then stick with that decision. I told him that—like the average Rumpus reader, I imagine—I'm not blind to animal cruelty, not blind to the health effects of eating animal products, or to the relation of meat eating to global warming. And yet I've found it hard, over the years, not to slip back into denial about these things and start eating meat again.

I began by asking Dr. Barnard about the moment when he, born into a family of cattle ranchers, decided to become a lifelong vegan.

***

The Rumpus: I read that you stopped eating meat one day when you were in medical school. You assisted in an autopsy on someone who'd had a heart attack, saw the fat in the arteries and the severed ribs. And then you went to the hospital cafeteria for lunch and they were serving…ribs. That moment seems to encapsulate the complementary missions in your career: promoting health and preventing cruelty to animals. At the time, which felt more important to you?

Dr. Neal Barnard: You know there's another piece of it, which is the element of disgust. The way you'd feel if someone handed you a glass of blood. In some cultures that would be a totally normal thing to do. But in our culture, that would be absolutely disgusting. I've heard it said that of all of the motivators, that is the strongest one. The health messages and morality messages pale compared with that.

But to answer your question more directly, both were important. I grew up in North Dakota, and I was aware of what animals go through because I had driven animals to slaughter and I'd killed animals. And I was aware that there were certain ethical issues, but they weren't preying on my mind very heavily. And I was aware of the health issues—sort of.

Rumpus: But isn't there an evolutionary basis for meat eating—for us not to be disgusted by it? We have canine teeth, our forebears speared animals and ate them. Aren't we hardwired for meat eating? Is the fact that cooking meat smells good to us really just a cultural thing?

Barnard: Meat smells good, bleu cheese smells good—to some people. But it's acquired. If you ask a guy who's thirty-five if a cold beer on a hot summer day would taste good, he'd say, "Yeah, that would taste wonderful." But if you could go back in time to his first taste behind the garage when he was fifteen, it probably tasted disgusting. We acquire certain tastes for things.

And if you took a baby and put a bunny in front of him, and if you had a cat and a bunny, the cat at any age would want to attack and kill the bunny and the child would say, "Oh, look at the bunny!" So the idea that we have some innate aggression towards animals…we don't.

About the teeth: if you open the mouth of a cat, a carnivore, you see that they have long canines, way beyond the other teeth. If you open the mouth of a dog, you see the same. If you open your mouth, you don't. You have canines that are the same length as your incisors. If you have long canine teeth, it allows you to do two things: one, it allows you to snatch your prey. The other thing it allows you to do is to pull away the hide. If a dog happens to catch a rabbit or another animal, it can very easily remove the hide. If a cat catches a squirrel, they have no trouble with that. But if a person does that, they will work all day and all night to get the skin off of an animal, because they don't have long canine teeth anymore.

We also don't have claws. Plus we're not fast. Plus we don't have very good vision, or good sense of smell. An owl is a predator and can detect a mouse at a tremendous distance. Dogs have a sense of smell much greater than ours and they're much faster than we are. We have fairly dull senses, fairly slow locomotion. In our Olympic trials, we celebrate speeds that would be an embarrassment to a bird or a dog or another animal.

We have nothing to kill prey with and nothing to remove the hide with. So the question is when did that change come? It's something like 3.5 million years ago that we lost our long canine teeth. And most of the great apes did, too—and they're almost entirely vegetarian. Chimpanzees will eat a little bit of meat. But, they never eat dairy products, and no other animal would do that.

Rumpus: What do you think that's all about, humans eating dairy? Is that an evolutionary thing or purely cultural?

Barnard: It isn't evolution. It's creativity. It's the same as eating meat. Meat eating wasn't really practical until the Stone Age. The Stone Age gave us arrow heads and eventually knives, and that allowed us to kill animals in ways you couldn't before, and once you had them you were able to remove the skin and bones.
We're not carnivores. We've never been carnivores, ever. And even today, the most you can say is that people have become honorary omnivores. And that's only because a) we are creative and find ways to do things that are not natural for us; and b) the dangers of eating animal products occur after the age of reproduction. If people developed cardiovascular disease that was fatal by the age of twelve or thirteen, eating animals would have died out long ago. You get it after you've already reproduced.

Dairy is a northern European invention and nothing that nature ever had in mind. It's all because we figured out how to make cows stand still.

Rumpus: So suppose someone wants to pull back on this 3.5 million years of meat and dairy eating. How do you feel about the incremental approach? Giving up just red meat, say. Or becoming a pescatarian, or a lacto-ovo vegetarian rather than a vegan?

Barnard: It doesn't do a lot of good for your health to move from red meat to white meat, but it gets you further down the road towards making more substantial changes later. So any move is a good move. And while it's certainly true that many people think that dairy doesn't have a cost to the animal, it's because they never went to a dairy farm.

Rumpus: How about this trend I've noticed: super-aggressive meat eating—usually locavore or "farm to table." In the TV show Portlandia, they make fun of these restaurants where the waiter tells you what a nice life the chicken led before it arrived on your plate. I went to a place in Boston that serves locally sourced pork with the jaw and teeth on the side as a garnish. Among modern, urban, liberal people, this seems to be a thing—among the same people who you'd think would be exploring vegetarianism. Have you noticed this?
Barnard: Yeah, that's the same person who reads Cigar Afficionado. It's someone who's thumbing their nose at science and hoping they're an exception to the rule.

Rumpus: But it's a whole movement, it seems, in culinary culture. You think "locavore," etc. is a smokescreen?

Barnard: It's a rationalization—and this too shall pass.

Rumpus: It'll pass because we can't sustain it environmentally and we can't sustain it health-wise? Because ultimately you get just as sick from a free-range chicken as from Chick Fil-A?

Barnard: Apologizing to the animals or having them come from a local farm doesn't change the ethics of it nor does it change the health aspects of it.

Rumpus: How about seafood? I know someone who doesn't eat meat or poultry but she does eat shellfish because she feels that while she couldn't kill a cow or a chicken, she could net a shrimp herself. She can't imagine that a shrimp suffers. Is shrimp really part of the same spectrum of suffering that you talk about?

Barnard: She's just feeling what she can picture—and she can't picture the shrimp suffering very much. On the other hand, if she saw her six-year-old son pulling the wings off a butterfly, or pulling the legs off a bug one by one, would she send him to a psychiatrist or not?

Rumpus: So it's a narrative that works for us—that animals don't suffer as we do—and we go with that?

Barnard: I think that's right. Another thing to think about is why people make the decisions that they do. The evidence that someone who eats animal remains is much more likely to have heart attacks, certain cancers, weight problems, hypertension, dementia of the Alzheimer's type—that evidence is quite conclusive. So why do they do it? Well, first, they might not have the information. There's a lot of noise, a lot of conflicting information out there. That's the first thing.

Rumpus: You mean like about milk being the "perfect food"…?

Barnard: Yes: "you need red meat for iron," "you need 'complete' protein," whatever… The second thing is: where is your herd going? I think herd mentality is a good thing overall. Because if every sheep had to figure out the velocity of the wolf and their personal risk, that would take forever. It's much better to say, "If the herd is running, I'm running with those guys." And humans have herd mentality, too.

Rumpus: I read somewhere that you said there are no non-vegetarians, only "pre-vegetarians." Do you see our "herd" running in the right direction?

Barnard: Well, we're kind of running in two different directions. Overall, our population is in the worst shape it's ever been. Children are in terrible shape. We have absolutely unprecedented numbers of obese and overweight children—one in three now. A generation ago it was something like one in ten. However, meat intake is starting to fall. It peaked in 2004. We're down about 5% from 2004. We were at 201.5 lbs per person per year. I'm talking about all meat together—red meat, chicken, poultry, fish. And we're now at 188.9 lbs per person per year in the U.S. That's good. So we've been in bad shape, and the effects of our previous meat eating are still very evident, but at the same time, conflicting with that in a good way is that the number of people who are changing is bigger than it's ever been.

Rumpus: I've noticed that your work recently has emphasized the public health aspects of veganism, perhaps more than animal protection. Is that because the public health issues are so overwhelming?

Barnard: I think both are really intertwined. Take diabetes: it's the worst it's ever been in the U.S. and in almost every other country. And it's getting worse year by year. The federal government's response is to fund research that is headed towards making new drugs. To do that, the government spends approximately half a billion dollars a year on animal research, consuming about 70,000 animals per year. I am going to assert that the use of those animals in developing drugs would have made sense decades ago before it was really clear that diabetes is a lifestyle-related disease for the most part. So instead, if we studied human beings which can include human genes, human blood samples, and human behavior, then you can leave the animals out of the labs and you can leave them off your plate.

Rumpus: In terms of your work, do you feel that the upcoming election matters a lot? In other words, do you see President Obama as being a positive leader in terms of your work?

Barnard: As a nonprofit we are absolutely not allowed to make any comment about a political candidate, however I will say this: we have pushed the current administration to be more vigorous, and whoever is in the next administration, we'll push them, too. I feel that [Michelle Obama's] "Let's Move" campaign is mostly window dressing. I'd hoped it wouldn't be that way and it doesn't have to be that way. Does she really want to stop childhood obesity? I don't know the answer to that. I can't tell.

Rumpus: But of course she's operating in such a hostile environment…

Barnard: But it has become a very feeble effort. And whether it was ever intended to be more than that, I don't know. But my feeling is, if it's literacy [Laura Bush's cause] or billboards [referring to Lady Bird Johnson's attempt to get ugly signs off highways], you can fool around, because nobody is going to die as a result. But if you're talking about something like childhood obesity, which kills those children when they grow up, you can't say "Do more hula hoops," as if that will solve it. And so we have encouraged the first lady to show some leadership and to try to get this government to stop subsidizing unhealthy food, to stop promoting exercise as a substitute for good eating habits.

Rumpus: And has the administration been receptive?

Barnard: Completely unreceptive.

Rumpus: Just because it's too big to…

Barnard: I can't speak for them. All I know is that they have shown no interest in going in the direction that we have suggested.

Rumpus: What about the medical profession? I can tell you that the colleagues in my primary care group are not promoting vegetarianism, or even talking much about nutrition at all. Some of that has to do with time. Some of it has to do with the fact that we're so poorly educated in nutrition. And yet, why are we not making the connection?

Barnard: I think it starts with doctors knowing what nutrition can do. Up until now, it's been pretty disappointing. You bring a person in with diabetes and start them on "medical nutrition therapy" [a standard, non-vegetarian diabetic diet] and nothing happens. You start them on insulin and you can bring their glucose down as much a you want. When we use vegan diets, the results are much better and you have a much more grateful patient.

Rumpus: And haven't you compared them head to head in a study? Was vegan better?

Barnard: In our NIH trial the vegan diet is way, way better.

Rumpus: What about Atkins, low-carb, or "paleo" diets? Some argue that it's carbohydrates, not saturated animal fats that cause obesity, diabetes, and other chronic conditions.

Barnard: The thinnest people on the planet are those who eat the most carbohydrates. I'm thinking of people in rural Japan and China, where McDonald's hasn't yet arrived. These are the thinnest, healthiest, longest-lived people with the least risk of cardiovascular disease and diabetes. As soon as you put a McDonald's in their neighborhood, rice intake and intake of carbohydrates in general fall dramatically, waistlines get wider, diabetes goes up. In Japan, from 1980 to 1990, diabetes went up from less than 5% to about 11-12% of the population. Just like that. So the idea that carbohydrates are responsible for that is complete nonsense. People do lose weight on an Atkins diet. The reason they lose weight is because of calorie reduction. If a person's caloric intake has not fallen, if they are really shoveling in the steak, they don't lose weight. And a third of low carb dieters will have a substantial elevation in their cholesterol. And there was a paper on cognition, that said that objectively, though they may not be aware of it, people on [an] Atkins diet are slower, their reaction time is not as good.

Rumpus: We have made progress, though. We've gone from those dusty health food stores of the 1970s, to veggie burgers everywhere…

Barnard: Including at the Republican National Convention! They had veggie burgers on the menu!

Rumpus: Do you feel like the environment in which you're working is less hostile and less lonely than back in the early days of your career?

Barnard: Dramatically so. Bill Clinton went vegan, and Rosie O'Donnell, Ellen Degeneres, and the Williams sisters… In the past couple of years there have been all these athletes, including super runners and football players… If you look at what's happened to those dusty health food stores, they're gone. They've been replaced by Whole Foods and similar places that are enormous, that have every possible vegan product that you could ever want.

Rumpus: But Whole Foods is expensive. Have you gone to developing countries? Have you gotten the reaction that veganism is somehow a luxury of rich, Western people?

Barnard: No, it's the reverse. In China, because China is gaining wealth, rice consumption is way down. Rice is a poor person's food, and they're eating less of it. To wait in line at a fast food chain is cool. And they haven't historically had weight problems. So they don't have this culture of, "I need to lose weight." Whereas Americans do have that culture.

Rumpus: But it sounds like they're not far behind us…

Barnard: Oh, they're leap-frogging us! But I don't think China or Japan or India, for that matter—where there's a lot of diabetes now—I don't think they're putting two and two together: that it's the Western diet that's causing it. Since I first went to India twenty some years ago, there's been a palpable change. There's now pizza everywhere, meat is much more popular than it's ever been. Vegetarianism is "that quaint thing our parents did."

Rumpus: So, I just want to circle back to the very beginning of our conversation, to disgust. That's a hard sell if that's the most potent motivator. To encourage veganism do we have to disgust people and make them feel guilty and force them to look at what they don't want to look at?

Barnard: I think we have to do everything that's useful. We're doctors. Our job is to tell the truth. And it doesn't have to be embellished in any way. People have to know that if they've wanted to lose weight, if they've wanted to get their diabetes better and get their cholesterol down, here is how it works. Beyond that point, you can't force people into changes, you have to guide them. I think it's also fair game to play all the emotional cards, which can mean talking about celebrities and how they've changed—which helps us to realize that part of our "herd" are moving in a different direction.

I am always struck by how difficult it is for people to see how much cruelty they are bringing not only upon animals but upon themselves and their loved ones and other people, how much we are screwing up the planet, how much we are hurting our own health, how hard it is to change all that, how eager people are to make a buck at everybody else's expense—all those things are discouraging.

But I think it's fair, if something really is disgusting, to make people aware of it. For example, I just sampled about 120 chicken samples in Buffalo, New York. And we sent them to the lab and tested for fecal contaminaton. We'll find it in about half of the samples. If you take a chicken thigh and wring it out, there's fecal soup that comes out of it because there's chicken feces everywhere in these places, and as they go through the chill bath, that spreads it around and the meat soaks it up and that measurably increases the weight of the chicken product they're selling. How many people know that? They see the little preparation label that tells you to make sure you cook it, as if somehow a little peppering of bacteria has come from the atmosphere. They don't realize that it's chicken dung that's not just on the surface but soaked into the meat. So people are serving their kids cooked poop. I think it's fair game for people to know that. They may decide they're going to do it anyway. But if some people think, "Why am I eating a dead bird soaked in poop?" I think if some people get disgusted by that, it's all to the good. Their coronary arteries will be healthier.


Suzanne Koven is a primary care internist in Boston and a columnist at the Boston Globe. E-mail her at inpracticemd@gmail.com and visit her website at suzannekovenmd.com. More from this author →

NYC Board of Health Passes 'Soda Ban'

Michael Howard Saul, The Wall Street Journal, September 13, 2012

The New York City Board of Health on Thursday approved Mayor Michael Bloomberg’s controversial proposal to ban the sale of large sugary drinks in restaurants and other venues, a sweeping initiative that backers hope will reduce obesity and critics decry as government run amok.

Beginning March 12, the city will prohibit restaurants, mobile food carts, delis and concessions at movie theaters, stadiums or arenas from selling sugary drinks in cups or containers larger than 16 ounces. The city will begin fining sellers for violating the ban in mid-June.

The proposal passed by a vote of eight to zero, with one abstention, one absence and one vacancy on the board. Dr. Thomas Farley, the board’s chairman, called the vote “historic.”

Opponents said they are exploring all possible paths to prevent the new ban from taking effect next year, including the possibility of a legal challenge. Recent polls show a majority of city voters oppose the initiative.

Opponents have complained that the deck was stacked against them because every member of the board is appointed by the mayor. Adding to that perception, before the board voted, the administration delivered a 20-minute presentation rebutting the critics’ points.

After more than 38,000 oral and written comments, the administration proposed no changes to the initial proposal that was made public in May.

Joel Forman, a board member, said there is “overwhelming” evidence that obesity is a major health problem in the city and nation.

“I can’t imagine the board not acting,” he said. “I laud the proposal and I support it.”

Dr. Forman said he hopes the initiative will “spread nationally.”

Pamela Brier, a board member, described the initiative as “terrific” and said she wholeheartedly supported it.

“It’s hard to do – there are a lot of unhappy people,” she said, noting the criticism. She said she hopes the ban becomes the “new norm.”

Board member Lynne Richardson said she was skeptical at first but found the arguments for it “convincing” and “compelling.” She said the opponents engaged in “hyperbole that was stunning.”

Board member Susan Klitzman said the obesity problem in New York is patently obvious. “To not act would really be criminal.”

Deepthiman Gowda, a board member, called the initiative a “small” but “bold” and “exciting” step forward.

“The reality is we are in a crisis,” he said. “We need to act on this.”

Several of the board members stressed that they listened carefully to the public’s input, spending many hours reading the flood of comments both for and against.

The proposal is the latest high-profile initiative from Bloomberg, who has made public health a hallmark of his nearly 11-year tenure at the helm of the nation’s most populous city. In 2002, the mayor persuaded the City Council to approve a ban on cigarettes in restaurants and bars, a law that has since become widely popular in the city and adopted around the globe.

“Obesity is going to kill more people in the world his year than starvation,” Bloomberg said during an interview on MSNBC, just hours before the board’s vote.

The mayor has defended the ban, which he described Thursday as “portion control,” as an upfront way to alert consumers about the dangers of large sugary drinks. While the new rule bans the sale of sugary drinks in large cups, consumers may purchase as many drinks as they choose.

“I don’t think it’s government’s job to ban people from doing things with a handful of exceptions,” Bloomberg said. “But, generally, it’s government’s job to tell you the facts of what is bad for you and let you make your own decision.”

Bloomberg announced Thursday afternoon that the new Barclays Center, home of the Brooklyn Nets basketball team, will be the first major venue to voluntarily implement the ban.

Eliot Hoff, a spokesman for New Yorkers for Beverage Choices, a coalition of individuals, companies and groups opposed to the ban, said there was never any hope the Board of Health would reject the proposal because the mayor appointed all the members. More than 250,000 New Yorkers and 2,100 business owners have signed a petition against the ban because it is “arbitrary and restricts our choices,” Hoff said.

“We’re smart enough to make our own decisions about what to eat and drink,” said Hoff, adding that the ban goes “against the wishes of a majority of New Yorkers and we will not let that fact go unnoticed.”

A sugary drink is defined as any beverage sweetened with sugar or another caloric sweetener that contains more than 25 calories per 8 fluid ounces and contains less than 51% milk or milk substitute by volume as an ingredient. A diet soda, a milk shake or sweetened latte that is larger than 16 ounces wouldn’t be banned.

During the first three months after the ban takes effect, the city will inspect and inform sellers when they are not in compliance with the law. The city will allow a three-month grace period before it begins issuing notice of violations that are subject to fines.

More than half of New York City adults, or 58%, are overweight or obese, and nearly 40% of city public-school students in eighth grade or below are obese or overweight, according to the city.

During the mayor’s tenure, the Board of Health had required calorie counts to be posted on menu boards and banned the use of trans-fats in foods. The mayor’s administration also launched a major effort to limit the intake of salt.

Many of the initiatives, at first, were unpopular but public sentiment then changed, the mayor and other administration officials have pointed out. On Wednesday, for example, McDonald’s announced it will begin posting calorie counts on all its menus nationwide next week.

“Two or three years ago, they sued us to stop doing it in New York City,” the mayor said on Thursday. “I’ll rest my case, thank you.

In other business, the board also unanimously approved another controversial proposal that would require written consent from a parent or legal guardian when oral suction is performed during a baby boy’s circumcision. The written consent will require notification that the city advises against oral suction because of health risks, including the possibility of infecting the baby with herpes.

Dr. Forman said he thinks the board should consider even stronger action. “It’s crazy that we allow this to go on” he said.

Opponents, including some religious leaders, have called the requirement an infringement on their religious rights.

Watch a video about New York’s soda ban:

Mark Bittman: Let's Make Him Do It

Mark Bittman, The New York Times, August 16, 2012

For positive change in the issues that affect our daily lives — not only food but also jobs, income, housing — we need active political leadership. But until President Obama is pushed more strongly by the left, the coming presidential election represents a choice between a full-fledged attack on government services and a continuing slide into the gloomy and depressing world of austerity economics. That’s a real choice, but it’s not a happy one.

When Obama has been pressured on issues, like gay rights, immigration and the Keystone XL pipeline, he’s responded positively. But he hasn’t been pushed on food, and as a result has not followed up on campaign promises like his vow to label foods containing genetically modified ingredients, nor has he used his bully pulpit to try to protect SNAP (food stamps) from the ravages of Congress. Since there isn’t a real food movement — yet! — progressives haven’t made Obama do much.

At least he won’t dismantle government, as Mitt Romney and Paul Ryan would. Ryan’s anti-stimulus plan is an unemployment-boosting scheme that would finance the military at a high level, the social safety net at the lowest possible level (Ryan is calling for a 17 percent cut in food stamps, enough to elicit criticisms from a pair of high-ranking Catholic bishops, for example) and just about nothing else. It benefits no one but the superrich and their representatives.

Not that that’s anything new. Most people — call them working class, middle class or the 99 percent — have less money than they did a generation ago; the superrich have scads more. A vast majority of Americans are on the losing side of the class war, as evidenced by lower pay scales, eviscerated unions, fewer benefits, later retirement, shortened or eliminated vacations, starved municipalities and of course the quality of our food and the impact it has on us and the environment.

Obama has seen more power and money arrayed against him than perhaps any Democrat ever. But his lack of a workable plan for economic recovery and his right-leaning stances on fiscal responsibility and debt reduction remind us that the basic problem is not one of “progressive” Democrats versus “conservative” Republicans.

This isn’t new either: in the last 40 years we’ve witnessed a long, steady move to the right, which Democrats occasionally whine about, protest and even fight, but in which they’ve been mostly complicit. Unless you reduce defense budgets — practically unheard of — whenever you cut taxes, you starve social programs and infrastructure, thus undermining the legitimate and beneficial role of government. (Even “progressive” Democrats are onboard with some cuts to food stamps in the as-yet-unpassed farm bill.) With government providing fewer services, it becomes easy to persuade people that it’s an albatross, so why not cut taxes further? Enter Paul Ryan.

Candidate Obama led us to believe that he was a different kind of Democrat, and he stirred new and even skeptical old voters. Yet he’s disappointed many supporters. You can argue that his hands have been tied: money is power — Citizens United has made this even more so — and until there’s meaningful electoral and campaign-finance reform, along with real limits on lobbying, there’s no chance for real progress.

President Obama didn’t create this system; he’s a product of it. A fundamental problem now is that the right has devised both a strategy and a movement, and the left has done neither. “All the bold answers are only from one side,” Van Jones, author of “Rebuild the Dream,” told me. “But we have to stop acting like there’s one person with agency in America, whose name is Obama. It’s not what he should do — it’s what we should do.”

That’s right. Only by building real movements around food and other important issues can we pressure Obama (or even Romney; just look at the inroads the right made with a Democrat in office) to act in the interests of the great majority. A strategy for this is neatly outlined in the just-published paper “Prosperity Economics” by Jacob Hacker and Nate Loewentheil, which counters the nonsense of austerity economics and lays out a credible plan for public investments and economic security, a plan that could help revive jobs and growth and ensure “that gains are broadly shared.” Their agenda improves on most economic plans by adding demands for dramatic political reform. “The best ideas are of little use without political movements, and those movements can only succeed in a political regime in which votes count more than money,” Hacker said to me.

It’s worth voting for progressives, but it’s equally important to recognize that until there is real pressure from the left, the money and influence of the right will continue to pull any president in that direction.

Efforts to Tackle Global Obesity Shaping a New Investment Megatrend, Says New BofA Merrill Lynch Report

Analysis Pinpoints Sectors and Companies Developing Obesity Solutions. 

Bank of America website, August 2012

Increasing efforts to tackle obesity over the coming decades will form an important new investment theme for fund managers, according to a new BofA Merrill Lynch Global Research report called “Globesity - The Global Fight Against Obesity.”

“Global obesity is a mega-investment theme for the next 25 years and beyond. Obesity may be the most pressing health challenge facing the world today and efforts to tackle it will shape thinking by policy makers and in boardrooms around the world,” said Sarbjit Nahal, equity strategist at BofA Merrill Lynch Global Research.

BofA Merrill Lynch has identified a Global Fighting Obesity Exposure Stocklist-50+ centering on four areas: Pharmaceuticals and Healthcare; Food; Commercial Weight Loss, Diet Management and Nutrition; and Sports Apparel and Equipment.

The report by the BofA Merrill Lynch ESG (Environment, Social, and Governance) and Sustainability team identifies that efforts to reduce obesity is a “megatrend” with a shelf-life of 25 to 50 years. It charts the rise of obesity globally and the ballooning costs. BofA Merrill Lynch analysts across several sectors have collaborated to identify the sectors and companies developing long-term solutions. Earlier this year, the firm’s biotech team highlighted in “The Skinny on Obesity” the growing potential for development of new drugs to combat weight gain. “The FDA has historically had little risk tolerance for weight loss drugs, but recently has shown increased support for their development,” said Steve Byrne, biotechnology analyst at BofA Merrill Lynch Global Research.

Globally, 500 million people are obese and 1.4 billion are overweight. Obesity is the fifth greatest cause of death, leading to 2.8 million fatalities each year. Worldwide prevalence of obesity doubled between 1980 and 2008, according to the World Health Organization. By 2030, 65 million more Americans will be obese if current trends continue. While its impact is well-known in the West, obesity is rising quickly around the world. Obesity in Europe has tripled in 30 years. It is growing rapidly in emerging markets as diets westernize. Brazil, where 16 percent of the population is obese, is on track to match U.S. obesity levels by the 2020s. Obesity has reached levels of up to 20 percent in Chinese cities. A quarter of Russian women are obese.

Growing costs and tighter regulations spur fight against obesity

The costs of managing obesity are much greater than previously believed. In May 2012, the U.S. Institute of Medicine estimated the annual cost of obesity-related illness in the U.S. alone is more than $190 billion – equal to 21 percent of annual medical spending. Previous studies estimated 10 percent.

Medical costs for treating obese patients are 40 percent higher than for non-obese patients. Treating obese patients comes at a higher premium than treating smokers. Obesity adds 50 percent to annual medical costs, while smoking adds 20 percent. High levels of global childhood obesity and growing obesity in emerging markets will further increase global costs.

As happened with smoking, it is likely that the growing cost burden of obesity on governments, corporates and wider society will spur collective action and greater regulation. BofA Merrill Lynch expects widespread scrutiny of lifestyle aspects associated with obesity including food and drink, schools, work environments, insurers, tackling sedentary lifestyles, and encouraging increasing physical activity.

Investment ideas for fighting globesity

Investors should take a long term view and a broad perspective in selecting stocks as part of the globesity theme, in our view. BofA Merrill Lynch Global Research has identified more than 50 global stocks across four key entry points:

· Pharmaceuticals and Health Care – We look at companies taking advantage of the FDA’s increased support for obesity drug development. We also highlight companies tackling related medical conditions and needs including diabetes, kidney failure, hip and knee implants. We also consider equipment such as patient lifts, bigger beds and wider ambulance doors.

· Food – We position companies on their efforts to access the $663 billion “health and wellness” market, as well as on how they are reformulating their portfolios to respond to increasing pressure such as “fat taxes” to reduce sugar and fat levels.

· Commercial Weight Loss, Diet Management and Nutrition – Up to 50 percent of some western populations pursue dieting, targeted nutrition and behavioral change making it a $4 billion market in the U.S. and growing globally.

· Sports Apparel and Equipment – This is the longer-term play, but we believe that promoting physical activity will become a key priority for more government health policies.

BofA Merrill Lynch Global Research
The BofA Merrill Lynch Global Research franchise covers more than 3,300 stocks and 880 credits globally and ranks in the top tier in many external surveys. Most recently, the group was named Top Global Research Firm of 2011 by Institutional Investor magazine; No. 1 in the 2012 Institutional Investor All-Asia survey for the second consecutive year; and No. 2 in the 2012 Institutional Investor All-China, All-Europe and All-Japan surveys. The group was also named No. 2 in the inaugural 2012 Institutional Investor Emerging Markets Equity and Fixed Income survey, covering Emerging Europe, Middle East and Africa; No. 2 in the 2011 All-Latin America and All-America Equity team surveys; and No. 3 in the 2011 Institutional Investor All-America Fixed Income and All-Brazil Research team surveys.

Additionally, BofA Merrill Lynch Global Research was named the No. 1 Global Broker by Financial Times/StarMine, as well as ranking No. 1 in the U.S. and Europe and No. 2 in Asia. The group was also named No. 1 in Asia and No. 2 in the U.S. in the Wall Street Journal Best on the Street 2012 Analysts Surveys. The group was also the winner of the Emerging Markets magazine’s EM Research Global Award for 2010 and 2011.

Bank of America
Bank of America is one of the world's largest financial institutions, serving individual consumers, small- and middle-market businesses and large corporations with a full range of banking, investing, asset management and other financial and risk management products and services. The company provides unmatched convenience in the United States, serving approximately 57 million consumer and small business relationships with approximately 5,700 retail banking offices and approximately 17,250 ATMs and award-winning online banking with 30 million active users. Bank of America is among the world's leading wealth management companies and is a global leader in corporate and investment banking and trading across a broad range of asset classes, serving corporations, governments, institutions and individuals around the world. Bank of America offers industry-leading support to approximately 4 million small business owners through a suite of innovative, easy-to-use online products and services. The company serves clients through operations in more than 40 countries. Bank of America Corporation stock (NYSE: BAC) is a component of the Dow Jones Industrial Average and is listed on the New York Stock Exchange.

Bank of America Merrill Lynch is the marketing name for the global banking and global markets businesses of Bank of America Corporation. Lending, derivatives, and other commercial banking activities are performed globally by banking affiliates of Bank of America Corporation, including Bank of America, N.A., member FDIC. Securities, strategic advisory, and other investment banking activities are performed globally by investment banking affiliates of Bank of America Corporation (“Investment Banking Affiliates”), including, in the United States, Merrill Lynch, Pierce, Fenner & Smith Incorporated, which is a registered broker-dealer and a member of FINRA and SIPC, and, in other jurisdictions, locally registered entities. Investment products offered by Investment Banking Affiliates: Are Not FDIC Insured * May Lose Value * Are Not Bank Guaranteed.

For more Bank of America news, visit the Bank of America newsroom.