Currently browsing posts about: Diabetes

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

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

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

The deaths are highest in low-income communities.

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

Why?  Obesity.

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

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

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

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

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

I spent a lot of time last week talking to reporters about the widely publicized study in PloS One that correlates sugar and diabetes.

The study is based on an econometric model of data food availability and diabetes prevalence in many countries.  Such data are not particularly reliable, but the authors did the best they could with what they had.  They are quite forthcoming about the limitations of their model and the data on which it is based [see addition below].

Their principal conclusion: for every 150 kcal/person/day increase in sugar availability (about one can of soda/day), diabetes prevalence increases by about 1%.

Because no other dietary, weight, or behavioral factor shows this kind of effect in their model, it is tempting to interpret the study as demonstrating that sugar is a risk factor for diabetes independent of calorie intake or body weight.

I’m not so sure.  Take a look at the summary figures and decide for yourself.

Figure 1.  Relationship between obesity and worldwide prevalence of diabetes.

Despite outliers, this figure shows an obvious and strong correlation between obesity and diabetes.  Compare this to Figure 2.

Figure 2.  Relationship of sugar availability to worldwide diabetes prevalence.

The correlation here is much less obvious.  Without statistical tests, you could just as easily draw the line straight across the graph.  The statistical significance is much weaker than that in Figure 1.

This means that these data cannot easily distinguish between several possibilities:

(a) Calories –> Obesity –> Diabetes

(b) Sugar –> Diabetes

(c) Sugar –> Calories –> Obesity –> Diabetes

While waiting for science to clarify these distinctions, the bottom line is the same for all of them.

As I explained in yesterday’s post, everyone would be healthier eating less sugar.

Addition: The authors have posted detailed comments about their methods.

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

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

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

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

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

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

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

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

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

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

Fast food, soft drinks

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

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

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

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

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

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

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

Pharmaceuticals

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

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

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

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

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

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

Teachable moment

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

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

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

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

The huge fuss over Paula Deen’s type 2 diabetes is understandable.   She is, after all, the queen of high-calorie Southern cooking.  And diabetes rates are especially high in the South.

Perhaps less understandable is the reaction of the American Diabetes Association.  As reported in the New York Times,

Heredity, according to the American Diabetes Association, always plays some part. “You can’t just eat your way to Type 2 diabetes,” said Geralyn Spollett, the group’s director of education.

Wrong.  You most definitely can eat your way to type 2 diabetes.

Type 2 diabetes is closely linked to overweight and obesity.  No, not everyone who is overweight develops type 2 diabetes.  But most people who have type 2 diabetes are overweight.

The first line of defense?  Lose a few pounds.  Even a relatively small reversal of calorie balance can make symptoms of type 2 diabetes disappear and reduce or eliminate the need for drugs.

Mrs. Deen does not mention weight as a factor in her disease, or losing weight as an effective treatment.

Instead, she is now a spokesperson for the drug Victoza.

According to the Times’ account, Mrs. Dean says that it is elitist to criticize her food:

You know, not everybody can afford to pay $58 for prime rib or $650 for a bottle of wine. My friends and I cook for regular families who worry about feeding their kids and paying the bills.

Really?  Does Mrs. Deen think those families can afford to pay the $500 a month drug companies charge for Victoza?

Victoza costs in other ways too.  It has to be injected and is not exactly benign.

Victoza^® is not recommended as the first medication to treat diabetes. Victoza^® is not insulin and has not been studied in combination with insulin…It is not known if Victoza^® is safe and effective in children. Victoza^® is not recommended for use in children

In animal studies, Victoza^® caused thyroid tumors—including thyroid cancer—in some rats and mice.  It is not known whether Victoza^® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early…Inflammation of the pancreas (pancreatitis) may be severe and lead to death.

The company also advises:

Victoza^® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise.

Diet and exercise?  Why not just do that in the first place?

As for the American Diabetes Association: its disinterest in promoting diet and exercise is easily explained.  It is funded by drug companies.

I gave a talk at an annual meeting of the Association a few years ago and was astounded by the number of drug companies giving things—writing pads, pens, and tape holders, but also lab coats and stethoscopes—at the trade exhibit.  Much of the scientific meeting was devoted to drug studies.  I spoke at the only session that year on dietary issues.  And Coca-Cola sponsored a session on sugars in diabetes.

Mrs. Deen’s food is best eaten in moderation.  She would do more for her own health and that of her fans if she used her television presence to promote healthier lifestyles.

Update, January 30: Brad Jacobson interviews drug reps on AlterNet (I’m quoted).

As I mentioned in a previous post, the United Nations General Assembly met this month to consider resolutions about doing something to address rising rates of “non-communicable” diseases (i.e., chronic as opposed to infectious diseases such as obesity-related coronary heart disease, type 2 diabetes, and cancers).

The Declaration adopted by the Assembly disappointed a consortium of 140 non-profit public health advocacy groups who issued a statement noting the conflicts of interest that occur when international agencies “partner” with companies that make products that contribute to an increase in disease risks.”

The consortium suggested actions that they hoped the U.N. would recommend, such as:

• Realign food policies for food and agricultural subsidies with sound nutrition science
• Mandate easy-to-understand front-of-pack nutrition labeling
• Ban the promotion of breast-milk substitutes and high-fat, -sugar and -salt foods to children and young people
• Prohibit advertising and brand sponsorship for alcohol beverages
• Increase taxes on alcohol beverages
• Expand nutritious school meal programs

The group also said that the U.N. should still work on:

• Developing tools to navigate the trade law barriers to health policy innovation,
•  Establishing disease-reduction targets and policy implementation schedules
• Instituting mechanisms to keep commercially self-interested parties at arms-length and public-interest groups constructively involved

Food companies and trade associations are actively involved in lobbying the U.N. not to do any of these things.  This consortium has much work to do.

In what Bloomberg News terms an “epidemic battle,” food companies are doing everything they can to prevent the United Nations from issuing a statement that says anything about how food marketing promotes obesity and related chronic diseases.

The U.N. General Assembly meets in New York on September 19 and 20 to develop a global response to the obesity-related increase in non-communicable, chronic diseases (cancer, cardiovascular disease, respiratory disease, type 2 diabetes) now experienced by both rich and poor countries throughout the world.

As the Bloomberg account explains,

Company officials join political leaders and health groups to come up with a plan to reverse the rising tide of non- communicable diseases….On the table are proposals to fight obesity, cut tobacco and alcohol use and expand access to lifesaving drugs in an effort to tackle unhealthy diets and lifestyles that drive three of every five deaths worldwide. At stake for the makers of snacks, drinks, cigarettes and drugs is a market with combined sales of more than $2 trillion worldwide last year.

Commenting on the collaboration of food companies in this effort:

“It’s kind of like letting Dracula advise on blood bank security,” said Jorge Alday, associate director of policy with World Lung Foundation, which lobbies for tobacco control.

The lobbying, to understate the matter, is intense.  On one side are food corporations with a heavy financial stake in selling products in developing countries.  Derek Yach, for example, a senior executive of PepsiCo, argues in the British Medical Journal that it’s too simplistic to recommend nutritional changes to reduce chronic disease risk.  [Of course it is, but surely cutting down on fast food, junk food, and sodas ought to be a good first step?]

On the other side are public health advocates concerned about conflicts of interest in the World Health Organization.  So is the United Nations’ special rapporteur for  the right to food, Olivier De Schutter.  Mr. De Schutter writes that the “chance to crack down on bad diets must not be missed.”

On the basis of several investigative visits to developing countries,  De Schutter calls for “the adoption of a host of initiatives, such as taxing unhealthy products and regulating harmful food marketing practices…Voluntary guidelines are not enough. World leaders must not bow to industry pressure.”

If we are serious about tackling the rise of cancer and heart disease, we need to make ambitious, binding commitments to tackle one of the root causes – the food that we eat.

The World Health Organization’s (WHO) 2004 Global Strategy on Diet, Physical Activity and Health must be translated into concrete action: it is unacceptable that when lives are at stake, we go no further than soft, promotional measures that ultimately rely on consumer choice, without addressing the supply side of the food chain.

It is crucial for world leaders to counter food industry efforts to sell unbalanced processed products and ready-to-serve meals too rich in trans fats and saturated fats, salt and sugars. Food advertising is proven to have a strong impact on children, and must be strictly regulated in order to avoid the development of bad eating habits early in life.

A comprehensive strategy on combating bad diets should also address the farm policies which make some types of food more available than others…Currently, agricultural policies encourage the production of grains, rich in carbohydrates but relatively poor in micronutrients, at the expense of the production of fruits and vegetables.

We need to question how subsidies are targeted and improve access to markets for the most nutritious foods.…The public health consequences are dramatic, and they affect disproportionately those with the lowest incomes.

In 2004, the U.N. caved in to pressures from food companies and weakened its guidelines and recommendations.  The health situation is worse now and affects people in developing as well as industrialized countries.  Let’s hope the General Assembly puts health above politics this time.

My post last week about KFC, Pepsi, and cause marketing elicited a lively dicussion along with some further examples.

Ken Leebow of “Feed Your Head” sent this one along with a comment: “Don’t pollute the Earth, but your body: Go for it!”

Cara Wilking of the Public Health Advocacy Institute (PHAI) sent this one: Give blood, eat a Whopper.  Cara, by the way, has done her own piece on why organizations that care about health should avoid partnerships with soft drink companies.

And Lisa Young sent a note about Coca-Cola’s sponsorship of continuing professional education credits for dietitians, for a course about bone health.  On that same site, if you pledge to LivePositively.com, Coke’s Sprite Zero will donate $1 to the American Cancer Society.

For those of you who insist that these kinds of partnerships raise money for Good Causes, please consider whether soft drinks are good for bone health or whether artificial sweeteners are good for cancer prevention.  The answers may not be in, but the questions are worth asking.

Cause marketing, I submit, is much more about the marketing than it is about the cause.

I collect things like this—examples of food company marketing alliances with health and nutrition organizations that by all rights should be advising their members and clients not to eat much of the company’s products.  This one promotes mega-size Pepsi to raise funds for the Juvenile Diabetes Research Foundation.

This particular treasure comes from a blogger, Joe Tower, who runs a business—“Selfish Giving”—that helps companies do cause marketing.  This one crosses a line, even for him:

I’ve said this before: I don’t have a problem with nonprofits and fast-serve chains doing cause marketing. What I do have a problem with is when fast serve chains like KFC encourage consumers to buy products that directly contribute to the health conditions – in this case diabetes – they are supposedly trying to prevent by partnering with the cause in the first place….What was JDRF thinking? I’m not sure, but I’m calling them today to see if I can find out!

Here are excerpts from the response from JDRF:

We appreciate your concerns and your questions about the banner promoting a JDRF fundraising activity at KFC. Please understand that the fundraiser in question is a local initiative in Utah involving a single KFC franchise owner with a personal type 1 diabetes connection.That said, JDRF values its supporters, both individual and corporate, and their efforts to raise funds to support research aimed at improving lives and curing type 1 diabetes. JDRF carefully reviews national partnership opportunities to ensure that they are appropriate prior to joining corporate campaigns to raise funds.

Regarding this particular promotion, we understand that one of the criticisms has been the association with a sugary product, which many have associated with contributing to diabetes. It’s important to note that JDRF supports research for type 1 diabetes, an autoimmune disease that results when the immune system attacks the cells in the pancreas that produce insulin, therefore requiring a child or adult with the disease to depend on insulin treatment for the rest of their lives. It is a common misconception that type 1 diabetes is caused by obesity or eating too much junk food or sweets.

Finally, JDRF does not endorse any particular products, nor any particular diet. People with type 1 diabetes should work with their healthcare team to determine a diet that works best for them. JDRF fully supports people living with type 1 diabetes engaging in healthy eating habits and lifestyles.

–Gary Feit, National Manager, External Communications, Juvenile Diabetes Research Foundation

As I find myself saying again and again, you cannot make this stuff up.   And how does Pepsi, now promoting itself as a wellness company, feel about this?

[Thanks to David Schliefer for sending]

Update June 17: I hear rumors attributed to a Pepsi V.P. that the promotion is “no longer running.”