Every 43 seconds...

...someone dies from gun violence.

What an eye-catching public health campaign.

To bad it's not in the United States.

Things Can Change, Perhaps

Tobacco drying. Image courtesy of CDC.

Recently, our family took a step into the modern age by opening a subscription to an online movie outlet so that we can stream movies over the Internet to our television. All this means is that we have spent way too much time over winter break watching movies that we missed when they were released or that we've seen before and of which we are especially fond. Such is the case of the The Insider, Michael Mann's recounting of the beginning of the sea change in opinion against the big tobacco companies.

For those of you who haven't seen it, The Insider takes place in the mid-to-late 1990s. The story revolves around a high-level Brown and Williamson research scientist, Jeffrey Wigand, who told the truth about his employer and the tobacco industry first in a deposition in Mississippi (where the Attorney General was suing tobacco companies to get them to pony up for Medicaid expenses for illnesses related to tobacco use) and then during a Mike Wallace interview on 60 Minutes. The plot becomes more complicated when 60 Minutes aired a heavily edited version of the original interview because its parent organization, CBS/Westinghouse, was concerned about potential lawsuits from the tobacco company. The original interview, which strongly indicted big tobacco as being fully aware of (and working to enhance) the addictive properties of its products and gave evidence that the CEOs of the big seven tobacco companies perjured themselves in a congressional hearing, was aired a few months later. However, it was only aired after other news outlets discredited the smear campaign against Dr. Wigand that was orchestrated by his former employer and outed 60 Minutes as caving to corporate interests.

It was a public health story, corporate whistle-blower story, and a journalism ethics story all rolled into one big messy ball of a movie. And, for the most part, it was true.

What is iconic of that time is the image of the seven tobacco CEOs (referred to as the Seven Dwarfs) standing in the Hon. Henry Waxman's hearing and perjuring themselves by declaring, under oath, that nicotine is not addictive. Below is a Youtube video of this historic moment that exposed these corporations for what they are - makers of nicotine delivery devices.

I was working at the American Cancer Society when these events began unfolding, but honestly, I didn't appreciate the magnitude of them at the time. Sure, everyone knew that tobacco use was the number one cause of cancer and that nicotine was addictive and that tobacco companies wanted to addict people - especially young people - in order to replace customers that would inevitably die. But the power and influence of the tobacco companies were formidable and those of us in public health held slim hope that a right-leaning Congress would support public health over big tobacco.  Fortunately, there were some visionaries who could see the far-reaching effects of the rulings, visionaries who never gave up the fight despite personal and professional hardships.

Because what emerged from all this was a deal of historic proportions: in 1998, the attorney generals of 46 states and the big tobacco companies signed the Tobacco Master Settlement Agreement, (MSA) in which the tobacco companies agreed to pay $246 billion over 25 years to the states, desist from marketing to youth, end all outdoor advertising (remember cigarette billboards?) and other sanctions. Four other states had individual agreements that predated the 1998 MSA. The money has been used to  bolster Medicaid, fund campaigns against smoking and smoking cessation programs, and other health-related items.

So that's the good news.

There is some bad news, too. In fact, there is a lot of bad news. In recent years, criticism has grown against financially strapped states because they are diverting the MSA money away from its intended uses. In fact, they are diverting MOST of it from its intended use. This from the Campaign for Tobacco-Free Kids, which publishes an annual report on how the money from the MSA has been used:

"Our latest report, issued November 17, 2010, finds that the states have cut funding for tobacco prevention and cessation programs to the lowest level since 1999, when they first received tobacco settlement funds.

"The states this year (Fiscal Year 2011) will collect $25.3 billion in revenue from the tobacco settlement and tobacco taxes, but are spending only two percent of it — $517.9 million — on programs to prevent kids from smoking and help smokers quit."

Of course, the tobacco companies love this. Fewer education and smoking cessation programs mean more cigarette consumers. And that is exactly what has happened. Any progress made in reducing smoking has slowed or even stalled. From Campaign for Tobacco-Free Kids' most recent report:

"The CDC recently reported that the adult smoking rate in 2009 was 20.6 percent – essentially unchanged since 2004 when 20.9 percent smoked.   This is a troubling development after decades of progress in reducing adult smoking rates.  While smoking among high school students has declined by 46 percent from a high of 36.4 percent in 1997, 19.5 percent of high school students still smoke and declines have slowed in recent years, according to the CDC. "

So looking at the movie again, during a different phase of my life, is an interesting experience. On one hand, it is an affirming experience because the daily minutiae of working in public health for governments or non-profits can be slow and frustrating. There can be a lot of waste, bureaucracies to wade through, and we all lose sight of our goals from time to time. Therefore, The Insider reminded me that things can change, albeit with great difficulty and usually not very quickly, but every now and then we can hit it out of the park and score big for public health.

On the other hand, watching the movie was incredibly frustrating because by all accounts, politics as usual have minimized the effects of this landmark settlement.

Ultimately, though, if you're looking for an influx of optimism that sometimes good does prevail, or just an interesting way to spend a few hours with a real-life dramatic story, I recommend revisiting The Insider. It is dated a bit - the cell phones look like shoeboxes, the fax machines spit out curly paper, and everyone's eye glasses are so outdated that they're coming back in style again. But the outcome of this David and Goliath story has changed how the world views Big Tobacco and saved many, many lives in the process. Not as many as could have been saved, but it's been at least a baby step in the right direction.

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Tangent: During the research process for this post, I was reminded what a staunch advocate for health we have in California Representative Henry Waxman. He has been in the trenches for years, holding hearings and crafting legislation in order to protect our health and welfare.  He has been a good public servant and we could use more like him.

Orange Things

I just have to say this: I love Nicholas D. Kristoff. I really do. His efforts to raise awareness of crimes against women and girls worldwide have been heroic. And his overall work to shine a light on areas of inequity and poverty are enough to qualify him for, if not a full saint, then at least someone working his way up the rungs of the sainthood ladder. But his Thanksgiving day column that encouraged the development and use of biofortification of certain crops in developing nations gave me pause.

At first glance, one might wonder what's wrong with breeding crops to incorporate iron, zinc, Vitamin A or other important vitamins and minerals into their edible parts. After all, these substances can save vision and lives. As he noted,

"It may turn out that one of the best ways to save children's lives, or to save women in childbirth, doesn't involved doctors, but rather, high-tech seeds." 

Sounds simple, cheap, and easy, right? At the risk of being all wet-blanket-y about it, I think it sounds neither simple nor cheap and also as if it has great potential for unintended consequences.

There are two avenues of research here - conventionally bred crops produced in the public domain, and genetically modified ones developed and owned by corporations. Developing nutrient-dense crops available to anyone is a noble idea and enabling families in Africa to grow vitamin-packed orange sweet potatoes instead of the typical white sweet potatoes that they always have grown is a great idea. However, once it gets more complicated than that scenario, I have concerns.

For one thing, I have long been uncomfortable in rushing science in the name of helping impoverished countries. After all, the United States and Europe are still grappling with the role genetically-modified crops - of which many biofortified crops would be - can play in feeding their citizens, especially in light of the facts that pests are growing resistant to some of those expensive, herbicide-intensive crops and the long-term implications of ingesting those crops are not fully understood even by those who embrace them.  It also seems like bringing back the buggy whip when you consider that some of the crops that are proposed will require pesticides and herbicides, chemicals whose use citizens in the developed world are trying to minimize, due to the mounting evidence of their health and environmental hazards. So why do we think making ever-more complicated plants and encouraging their use in impoverished areas are good ideas - especially when individuals in developed countries are clamoring for simpler, organic, back-to-basics clean food? Is cast-off technology from the developed world the best we can offer to developing countries?

Some may argue that that imperfect solutions are better than nothing when the stakes are as black and white as survival versus death . There is a grain of truth to that argument, which basically falls under the heading of "don't just sit there, do something." However, we already have a perfect solution - vitamins exist in pill and powder forms and some designer waters are already enhanced with some of those vitamins. The problem is that vitamins are too expensive for many developing countries, and the logistics of getting them to every person on a regular basis can be daunting. However.

For-profit companies do just that.

Let's repeat that sentence.

For-profit companies do just that.

They just don't do it with vitamins.

But they do it with cigarettes. And they do it with soft drinks. It no longer surprises me when I see the cheery red and white of Coca-Cola products in the Amazon basin in Brazil or a kid puffing on a Marlboro in Thailand. It seems when the bottom line is at stake, human ingenuity finds ways to source components of products, assemble those products, and then figure out how to market, deliver, and sell them regardless of the challenges presented by the location. For example, by harnessing local ingenuity and providing a profit incentive, Coca Cola has mastered the logistics of getting its, shall I say,  product-of-questionable-nutritive-value into the most remote reaches of Africa. And I believe one of Coke's products is vitamin-enhanced water.

Therefore, for this particular problem, it may be better to practice what Buddhists know: "Don't just do something, sit there." Just sit there and think. Look around. Take a page from Melinda Gates' play book and learn what we can from what Coca-Cola already does.

One of the reasons I would encourage the public health world to look for a simpler solution is firsthand knowledge of how long it can take to create these complicated plants and then figuring out how much of them individuals would have to ingest in order to attain certain levels of the vitamin. Years ago, I used to manage a series of seminars for the American Cancer Society. These seminars were very high-level. The audiences were top-line national medical and scientific reporters. The presenters were the researchers who push the envelope, like the ones who brought you Gleevac, virtual colonoscopies, and basic knowledge about cancer including oncogenes and suppressor genes. The panel chairpersons were directors of national cancer centers, Nobel laureates, and Mary Lasker Award winners. The seminars were three days of intense science and emerging research.

One presentation in 1996 showcased a scientist from Roswell Park Cancer Institute who presented her research on "Transgenic Plants as a New Vaccine Source." The specific project she was working on was inserting hepatitis B antigens into bananas. Once eaten, the theory was that the antigens would effectively vaccinate the banana eaters against hepatitis B,  a leading cause of liver cancer around the world. This edible vaccine would be especially useful, the scientist postulated, in developing countries, where cost and logistics create obstacles to vaccinating the local population.

Sound familiar?

Fourteen years after that presentation, there is still no banana/hepatitis B vaccine. A quick Google search of "hepatitis vaccine banana" returned 27,000 hits, showing that research is still going strong on this concept. But still no edible vaccine.

I'm sure you can see where I'm going with this. We already have vitamins and vaccines against many diseases. What is being proposed - biofortification of existing plants to enable them to carry vitamins - is expensive research. Then, intensive education programs must be carried out so that individuals in countries that need these plants can learn how to grow, harvest, and cook them. And no one has done the research - asked the individuals who will be expected to grow these plants - if they are interested in changing their social norms to eat orange sweet potatoes instead of the white ones, or golden rice instead of white rice. And, last I checked, these plants are still in development.

So, with all due respect to the researchers and to Mr. Kristoff, I'd rather put my money on creating partnerships between the public health world and Coca-Cola or other global brands to oversee the distribution of vitamins that we already have, instead of investing a lot of money into a more complicated situation. The price seems to be a red herring at some level - after all, individuals seem to have the money to purchase Coke products, as evidenced by Mexico's astonishing 665 per capita ingestion of Coke products in 2009. Or, if you want to go further with this concept, Coca-Cola already makes VitaminWater. Couldn't the public health world work with Coke to develop a VitaminWater to deliver the key vitamins lacking in certain parts of the world?

We already have vitamins. Multi-national corporations have distribution systems and perhaps even products that can be tweaked to provide specific nutrients to children, or pregnant women, or the elderly. What seems simple to me is not the creation of complicated seeds that require costly chemicals and unpredictable weather to grow, but a linkage that would combine the best of the knowledge from the public health world and the infrastructures of big corporations in order to get those vitamins where they can do a lot of good.

PS to Mr. Kristoff. I still think you rock.

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An Unexpected Oasis

Today, instead of pointing out yet another dreary problem that confronts our country, I'd like to offer up some good news. For years, we have been hearing about "food deserts," those urban areas that lack sources of healthy foods, but have unhealthy convenience food in abundance. You can see these food deserts everywhere - in inner cities, in small towns along interstate highways, and even in some suburbs where fast food chains and convenience stores line the streets and grocery stores are few and far between. All the nutrition guidelines in the world will not help individuals and families living in food deserts eat as well as they could.

That's why it is exciting to learn that Walgreens is doing something about this lack of healthy food options.  I remember Walgreens as being a Midwestern old-timey five-and-dime chain, best known for its luncheon counters. In recent years, I have noticed more Walgreens stores opening on corners in my Southern city as the chain successfully expanded to become the largest drug store chain in the United States. And now, Walgreens has taken that revitalization to a new level - that of offering groceries and fresh foods in some of its urban Chicago stores.

Food deserts are a big problem in Chicago. The US Centers for Disease Control and Prevention estimates that about 600,000 Chicago residents live in neighborhoods that are either lacking or too far away from conventional grocery stores. And Walgreens has a large presence in inner-city Chicago, making it an ideal partner to get groceries, such as milk, meat, eggs, fruits, and vegetables, into those areas. Of course, this move isn't entirely altruistic - after all, Walgreens is a publicly traded company (NYSE, NASDAQ: WAG) that has shareholders to consider - but it does carry more than a whiff of civic responsibility. You see, Walgreens was founded in Chicago more than 100 years ago and, according to its press release, was asked by Mayor Richard M. Daley's office to start offering groceries in some neighborhoods where grocery stores were scarce. Taking this concept even further, Walgreens has created a partnership with local medical entities to pilot a program designed to educate residents about the link between healthy food choices and preparation and better management of chronic illnesses like diabetes.

This all sounds like a win-win situation to me, one that combines a basic tenet of capitalism of being the first to enter a niche market, and the do-good-ness of a hometown hero. The short-term outcomes may be that individuals and families living near these Walgreens will have expanded food choices and Walgreens may increase its market share over competitors.  It will take awhile to see the longer-term result of better health due to access to healthy foods, but it's not a leap to envision that those results will occur. Research has already shown that people who live in food deserts are more likely to become ill with conditions like diabetes, high blood pressure, and obesity - all conditions that can be helped or prevented with proper nutrition. So it stands to reason that the availability of appropriate foods could counteract or even prevent those conditions.

If you want to read more about food deserts, especially in Chicago, here is a report by Mari Gallagher and Associates, the firm that coined the term. It has some interesting facts, such as many who live in food deserts have incomes over $100,000, as well as important implications for our built environments.

Northwestern University's Medill School of Journalism pulled together a nice video in which residents of food deserts in Chicago are interviewed. The video highlights the lack of access to real food that many people face and allows us to see the type of establishments that residents must frequent if they are limited to shopping in their neighborhoods.

So kudos to Walgreens, the City of Chicago, Northwestern Medicine, and Near North Health Service Corporation for this innovative partnership. Walgreens is keeping a close eye on the initial 10 stores that are offering groceries. If they work well, meaning if they make money from the groceries, the concept could be expanded to other stores, and other cities. Keep your fingers crossed.

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Can This Be True?

Earlier this week, Yale University's Rudd Center for Food Policy and Obesity released a report Evaluating Fast Food Nutrition and Marketing to Youth. Faster than you can say "drive-through window," some startling statistics were racing around the Internet and hitting the mainstream media. The most compelling of those statistics was that 84% of parents taking part in this survey reported feeding their kids fast food in the week prior to their interview.

When I read the 84% statistic, my first thought was, "That can't be true." I thought perhaps it was a sampling error - maybe the researchers asked only parents who lived across the street from a McDonald's, or who didn't know how to cook, or who were employed by Burger King. Or maybe there was some other reason the findings were skewed.

So I dug up the report, certain I would spot some methodological weakness. And, I'm sad to say, I was wrong. It's a whopper (sorry) of a report, but a good, thorough one. The methods section (on page 33 for those who care) convinced me that the sample of parents was, in fact, nationally representative. The researchers took pains to include appropriate racial/ethnic diversity and had a reasonable sample size.

The next thing I wanted to know was why. Why would all those parents take their kids to fast food restaurants so frequently? I thought the answers might be cost and convenience, two factors that could influence any parent's decision on where to eat. This time I was partially correct. A useful bar chart (page 118) shows the main reason parents take their kids to the following restaurants:

• McDonald's and Burger King: the kids like it
• Wendy's: convenience
• Subway: nutrition (as an aside, of the 3,039 food combinations evaluated, Subway had the most choices that met the nutritional criteria for kids. Burger King didn't do so badly, either. But scoring well means choosing milk or juice with the meal, substituting fruit for french fries, and eschewing cheese, among other choices.)

This brought up another question: How did the kids know about the restaurants?

And this time, I got the answer correct. Kids know about these restaurants because of amazingly effective advertising and marketing.

Check this out: In 2009, preschoolers saw an average of 2.8 fast-food television commercials each day, kids aged 6-11 saw an average of 3.5, and teens saw 4.7. And that's just TV, not exposure to radio, billboards, online banner ads or pop-ups, bus ads, airport kiosks, and all the other places that fast food is advertised.

So what's a parent to do?

Even though I'm not a big proponent of TV, especially for small kids, I don't think isolating your kids from popular culture is the answer. Sure, sitting around watching the tube is obviously not exercise, and the exposure to the noxious advertising makes the kids want what they don't have  - clothes, food, and toys included. I also don't think we can sit around and wait for government regulations that would limit marketing to kids. After all, it took almost a decade before Congressional pressure and private lawsuits brought about the retirement of Joe Camel despite his obvious intention of selling cigarettes to kids - intentions that were pointed out by a 1991 article in the Journal of the American Medical Association that showed that 5 and 6-year-old kids could identify him more readily than Mickey Mouse or Fred Flintstone. This wasn't a benign situation. A companion article noted that during Joe Camel's reign, one-third of all cigarettes sold illegally to underage buyers were Camels - up from less than one percent before Joe Camel.  So even though it was clear (and later proven by internal RJR Nabisco documents) that tobacco was being marketing to kids, lawsuits and government action still took years to be effective.

Therefore, I think the most important thing parents can do to counteract the marketing messages targeting our kids is to teach them, from a very young age, that they are being manipulated. Put your kids in the driver's seat and teach them how to make choices. PBS has a "Question the Commercial" guide that is a good start to opening conversations with young kids about commercials.

And don't forget moderation. There is room in a healthy diet for treats: a donut here, couple of cookies there, an outing to a fast food restaurant every once in a while. But when 8 out of 10 parents willingly tell researchers that they took their kids to fast food restaurants in the past week, we know that kids aren't the only ones who need to learn moderation.

The reality is that we live in a world where marketing is everywhere. We can't keep our kids away from it. So we have to teach our kids - and ourselves - how to live with it.

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Not Really a Surprise, But Still...

A super shout-out to Michael Moss's excellent investigative reporting on how conflicted the government is when one of its agencies is charged with both promoting business and promoting health. Moss's article, published on the front page of yesterday's New York Times, focused on the United States Department of Agriculture's schizophrenic mission of encouraging consumption of US agricultural products while also being in charge of nutrition guidelines.

 In his article, Moss explains how the USDA created an organization called Dairy Management, which is a marketing entity charged with increasing the consumption of dairy products in the United States. Dairy Management has achieved its goals magnificently - it is the group responsible for the brilliant marketing campaigns that have boosted Domino's pizza sales, convinced Americans that drinking milk is part of a good weight-loss strategy, and  ingrained "Got Milk?" into our national consciousness. All while one of the main contributors to obesity is saturated fat - yes, the fat found in dairy products.

Therein lies the conflict. You can't encourage Americans to eat more fat and address the obesity epidemic at the same time.

The story is not new. The USDA has long been conflicted about its role in business versus health. Remember the four basic food groups that the USDA touted until 1992? Meat, dairy, grains, fruits and vegetables - the foods most grown by American farmers (disclosure: I grew up on an American grain farm).  The food pyramid came next. This fascinating article, written by a nutritionist who worked on the original food pyramid, shows just how overt the USDA has been in promoting certain foods regardless of their effect on health.

It's unfortunate that we can't look to our government to provide unbiased nutrition information. That's why others, such as the good docs at Harvard's School of Public Health, have created their own food pyramid. Harvard's pyramid and the USDA's pyramid are similar in that both have their foundations in science. But Harvard stops there, without adding the heaping helping of influence from special interest groups that can sour even the best intentions.

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Don't eat the oil

Sorting through my kids' candy bounty after the recent national holiday of Halloween got me to thinking about how slowly change comes to the food industry. It's been fairly well accepted for years now that some food dyes cause adverse reactions, especially in children. After all, children may weigh a fraction of what an adult weighs, but still consume the same level of artificial chemicals in a bag of Skittles. Way before  the EU mandated that foodstuffs carry warning labels if they contain certain artificial colors, the Feingold Association has been publicizing the sensitivities some kids have to artificial colors, flavorings, and preservatives - sensitivities that have been misdiagnosed as conditions as severe as ADHD, bipolar disorder, and obsessive-compulsive disorder. More recently, the Center for Science in the Public Interest has adopted artificial colors as a project, and is lobbying the US Congress to remove some of them from our food supply.

But still, here I sit at my kitchen table, sifting through the Nerds, Skittles, and Starbust Chews for some good old chocolate that hasn't been too adulterated with artificial flavorings (synthetic vanillin is cheaper than vanilla) or colorings. The rub is that having travelled overseas many times in the past few years, I've eaten Starbusts and M&Ms made with natural colors so I know that we don't have to settle for foods that are colored with dyes made from petroleum products.

It bewilders me why the United Kingdom is way ahead of us on this issue. Mars, the company that makes M&Ms, was so sensitive to the public's concerns over red dye #2's possible link to cancer that it removed red M&Ms in 1976, despite the fact that its candies did not contain that specific dye.  However, the company seems resolute in in its use of red #40, the synthetic chemical that has colored its red candies since the late 1980s, even though red #40, is not recommended for consumption by children in Europe and is outright banned in Denmark, Belgium, France, Germany, Switzerland, Sweden, Austria, and Norway.

And it's not just candies that are affected by the regulations in Europe. The syrup in a strawberry sundae from McDonald's in London is colored with real strawberries, whereas a strawberry sundae in Atlanta carries a hefty dose of red #40. Nutri-Grain bars, a snack food many parents consider healthy, are vastly different here and abroad, as the illustration below shows.

                                                    Illustration: Center for Science in the Public Interest                                                       

The issue isn't just one for little kids. Research is showing that you don't outgrow these sensitivities. Teens may act aggressively. Adults may get headaches. The list goes on and on. One of the most compelling real-life examples of the link between poor food and negative behaviors comes from Appleton, Wisconsin. By replacing typical cafeteria fare, sodas, and processed foods in its high school lunchroom and vending machines, this school - which serves troubled youths - has experienced drops in truancy and aggression, as well as increases in attention and learning. Foodie Alice Waters wrote about this school in The Nation, and it has received coverage on Good Morning America as well as numerous other places.


There really is a lot of research out there showing that some people are sensitive to artificial flavorings, colors, and preservatives, and that those sensitivities can be so extreme that they interfere with normal functioning. That's why it is upsetting that the pace of change in this industry is so glacial.   My point is that we don't have to accept impurities in our foods - our European counterparts don't. I encourage everyone to read the labels on their foods and evaluate what is in them. The Center for Science in the Public Interest maintains an excellent food coloring database that lists the synthetic colorings found in common foods. Bagels, cake mixes, cereals, you name it. Most foods that are prepackaged have been tarted up with a rainbow of colors intended to fool us into thinking the foods are purer, freshers, and healthier than they are. Then let your Congressional representatives know that you would rather have the more natural alternative that our friends across the pond enjoy.