Are Sugared-Beverage Bans an Effective Employer Wellness Strategy?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Health impact of sugared beverages

Sugared beverages account for the majority of excess calories Americans take in. Accordingly, a person’s intake of sugared drinks tracks very neatly to his or her risk of diabetes and cardiovascular disease. Even artificially sweetened beverages are linked to early death, possibly through their effect on the bacteria, or “microbiome” growing in our intestines. But getting people to drink less of them is a vexing problem. Countries and cities including Mexico, Philadelphia, and Berkeley, California, among many others, have experimented with taxing sugared drinks, with mostly health-positive results. New York City under Mayor Michael Bloomberg attempted to limit the size of sugared drinks that could be sold to sixteen ounces or less, a move that was eventually blocked by the courts. And banning sugar-sweetened beverages in schools has not reduced consumption, at least in survey data.

Is banning the sale of sugared beverages effective?

Recently the we’ve seen the results of a sugared-drink sales ban implemented by the University of California at San Francisco (UCSF) in 2015 (students and employees were still able to bring drinks on-campus). Investigators followed the habits and health indicators of 202 volunteer subjects before and after the prohibition. Ten months after the ban, subjects’ consumption of sugared drinks was down by almost half: 48.5 percent. Even though the participants still drank a large quantity of sugared drinks after the ban—18 ounces a day, on average—they saw dramatic improvements in health. They lost almost an inch from their waists, and the fraction of the study population who decreased their drink intake the most saw improvements in insulin resistance, the phenomenon that leads to diabetes.

Obstacles to overcome

So the science of limiting sugared drinks at the worksite seems sound, at least in terms of reducing the risk of employee illness. But major obstacles threaten such policies: first, the happiness of workers is likely to be affected, at least in the short-term. Employees may rebel against a workplace culture they perceive as too paternalistic. This viewpoint was exploited by tobacco companies during the implementation of smoking bans in the recent past. This is where an honest outreach program to employees would be worthwhile: we know that excess sugar intake is linked to depression, and that improved dietary habits can profoundly improve mood in depressed people. Sharing these stories with employees in an engaging way that shows light at the end of the sugared-drink tunnel may help. After all, a decade after widespread smoking bans, norms have shifted to the point that a re-introduction of smoking in worksites and restaurants would be met with fierce opposition.

Second, your company may have a contractual arrangement with beverage vendors. This is particularly true of institutions of higher learning. However, possibly sensing the movement of the tide away from sugared drinks, beverage companies are frantically working to offer healthier alternatives and the National Automatic Merchandising Association, the trade organization for vending companies themselves, has pledged to make at least a third of its offered products meet the standards of at least two of the healthy food standards set by Partnership for a Healthier America, the Center for Science in the Public Interest, the American Heart Association, Centers for Disease Control and Prevention, or the USDA’s Smart Snacks. So leaving vending on-site but reducing or eliminating sugared drinks is a potential compromise.

Has your worksite attempted to change the availability of certain snack foods or sugared drinks? The Kansas Business Group on Health would love to hear about your experience.

Links for Monday, August 20, 2018: non-sugar carbs are fine, paint your rooftop white

It turns out eating about half your calories as carbohydrates is associated with the longest life

This isn't surprising. But it's just so hard for this kind of data to survive in a world filled with Bulletproof Coffee and other B.S. Good dietary advice is sooooooooo boring: eat a modest amount of carbohydrates. Avoid processed sugars. Don't drink too much alcohol. Avoid animal proteins and fats. If you read that last two lines without nodding off, you're either really invested in dietary information, or you're a registered dietician. It doesn't have the zing of "Wheat Belly." *Sigh*

White rooftops are a sneaky good way to combat climate change

What a weird thing to post to a health blog. But climate change has health consequences. As in, killing hundreds of thousands of people consequences. And I can speak from experience: we installed white shingles on our house in 2014, and we saw an immediate reduction in summertime heating bills of about $80/month (!). 

Rose wine has a seedy underbelly

But it all tastes like Diet Cherry 7-Up to me.

Kiwi bikes to the hospital to have labor induced

The New Zealand Minister for Woman and Associate Minister for Transport and for Health tied together her two roles in government in a nice, tidy little bike ride. When I first read the headline, I thought she'd gone by bike after having her water break or after the onset of contractions. But alas, she was off for induction. Still, this represents a rare combination of toughness and media savvy. I love the part where she says the gas-powered wheelchair wouldn't fit everyone in the family, so they had to ride bikes. She was obviously not talking about an adult Tonka Toy.

Most of us have plenty of vitamin D. And Michael Holick apparently has plenty of money from trying to convince you otherwise

This is such a bummer. The Endocrine Society (I'm a member) has positioned itself as the kinder, gentler, more conservative (that's old-timey conservative, not Rush Limbaugh conservative) alternative to AACE. But they're as vulnerable to the actions of their members as any other group:

"Dr. Holick’s crucial role in shaping that debate occurred in 2011. Late the previous year, the prestigious National Academy of Medicine (then known as the Institute of Medicine), a group of independent scientific experts, issued a comprehensive, 1,132-page report on vitamin D deficiency. It concluded that the vast majority of Americans get plenty of the hormone naturally, and advised doctors to test only patients at high risk of certain disorders, such as osteoporosis.

A few months later, in June 2011, Dr. Holick oversaw the publication of a report that took a starkly different view. The paper, in the peer-reviewed Journal of Clinical Endocrinology & Metabolism, was on behalf of the Endocrine Society, the field’s foremost professional group, whose guidelines are widely used by hospitals, physicians and commercial labs nationwide, including Quest. The society adopted Dr. Holick’s position that “vitamin D deficiency is very common in all age groups” and advocated a huge expansion of vitamin D testing, targeting more than half the United States population, including those who are black, Hispanic or obese — groups that tend to have lower vitamin D levels than others."

Any supplement that gets an enthusiastic recommendation from Dr. Oz should be receivee with immediate, extreme skepticism. 

Thanksgiving extravaganza! Links for Wednesday, November 22, 2017

17th century food was fibrous, bland, and surprisingly good for you (if you could get enough of it)

This is not to say that their food tasted bad, necessarily. But it was clearly very simple, and very starch-heavy. From China to Europe to sub-Saharan Africa, gruels and stews made out of staple grains or legumes were the daily fare. Italian farmers weren't eating eggplant parmesan or spaghetti with meatballs. They were typically eating either boiled beans or grains, day after day after day.

First mind-blowing passage from this post:

One example: I didn't realize until recently that broccoli, Brussels sprouts, cauliflower, kale, cabbage, and collard greens are all technically the same species, Brassica oleracea. The substantial differences between these sub-species are all due to patient intervention by human farmers over millennia. Many of these changes are surprisingly recent. Early versions of cauliflower may have been mentioned by Pliny and medieval Muslim botanists, but as late as 1600, a French author was writing that cauli-fiori "as the Italians call it" was "still rather rare in France." Likewise, Brussels sprouts don't appear to have become widely cultivated until the Renaissance.

Selective breeding and pollination (the original GMOs) have radically altered what our food looks like. See this picture of fruit from the link. Look closely at the watermelons in the right lower corner. They look nothing like the pink, juicy, almost seedless beasts we see in the grocery store circa 2017:

"as time went by, a dish tended to become sweeter, spicer, and more complicated."

We paid for that sweeter, spicier food, and not just in our waistbands. The Columbian Exchange brought diseases to immunologically naive people and turned people in to chattel. The English didn't have bad teeth til sugar came along. 

Eat up.

You'll only gain 0.8 pounds this holiday season. But if you do that every year you get fat

We overestimate our own weight gain a lot over the holidays:

When Jack Yanovski and his colleagues began their study of 200 National Institutes of Health employees, they were responding to a media environment that frequently cited holiday weight gain averages of 5 to 10 pounds. But they found their subjects gained an average of only 0.8 pounds between mid-November and early January, and that those same subjects overestimated their own weight gain by a factor of 4.

But then we don't lose the modest weight that we do gain, and after a couple decades we're in trouble:

 A 2014 review of six different studies found an average holiday weight gain of 1 pound. A 2017 summary of the research found similar results. Just 1 pound — but a significant pound because research also suggests that it could account for most (if not all) of our average annual weight gain. “Yup, it’s small,” said Dale Schoeller, professor emeritus of nutritional sciences at University of Wisconsin-Madison and author of the 2014 review paper. “But because it’s a large percentage, it’s not unimportant.” Schoeller calculates total annual weight gain by comparing the average weight of a 20-year-old in 1960 to the average weight of a 60-year-old in 2000. By his calculation, Americans gain about 0.8 pounds a year. Over the course of 20 years’ worth of Thanksgivings, he pointed out, it can start to add up.

Links for Wednesday, October 25, 2017: Leonardo and the aortic valve, e-bike smackdown in NYC, candy corn is disgusting but interesting, and McDonalds takes phones away

Leonardo da Vinci understood the anatomy and physiology of the heart better than the physicians of his day

He made wax molds of the aortic valve.

Based on zero deaths reported from e-bicycles, NYC mayor Bill DeBlasio is outlawing them. Super. 

He says not to worry, deliveries by car (responsible for 70 deaths in NYC so far in 2017) will still be available. I'm as skeptical of e-bikes as any long-time cyclist (mopeds and golf carts on the local bike paths cause me to mumble horrible things under my breath), but this is bananas. They should stay on the streets. They're smaller, slower, and infinitely safer to their surroundings than cars.

Candy corn, aka clown droppings, explained

Candy corn is disgusting. But this article is delicious. 

McDonald's is experimenting with locking up phoneworms' devices

My grouchy side says "Your pocket is just as good a place as the Fun Zone locker." My realistic side says that most of us lack the self-control to ignore a device that's in our pocket:

According to a survey of 302 parents conducted by McDonald's in Singapore, most (98%) say they use their mobile device whenever they're with family and more than two-thirds of them admitted using smartphones during meals. Most parents also said their kids use their phone during family time.

Links for Wednesday, August 23, 2017: metformin reframed as wonder drug, cane vs beet sugar, and medicine as an inefficient time suck

Does metformin "promise" to extend life?

It may promise a lot of things, but until I see RCT data, I'm not convinced that we should put an old anti-malarial drug in the water. Metformin, I mean. And that RCT would be the TAME Study. Observational studies of metformin and cancer have been promising, but...

In two controlled trials involving patients with advanced pancreatic cancer, a notoriously difficult cancer to treat, metformin failed to provide any benefit.

So I'll hold out ultimate judgement until after the TAME Study. But this smells a little like 20 years ago when pharma invented osteopenia to sell bisphosphonates, and then tried to encourage "prophylactic" treatment of even osteopenia. (metformin link via marginalrevolution.com)

Are our cooking efforts sabotaged by the substitution of beet sugar for cane sugar? 

Brown cane sugar -- a combination of sugar and molasses, both inherent in the sugarcane plant -- is produced naturally as part of the process of refining white cane sugar by the traditional method, crystallization.

Brown sugar from C & H Sugar Co. and other cane refiners uses the process, but beet sugar is different. It's made by refining the sugar all the way to the final white granular stage, stripping off all the molasses because beet molasses is unfit for human consumption (it's recycled as cattle feed). Then cane molasses is added back into the sugar through a process called "painting."

Painting coats the granules but does not necessarily penetrate them -- the molasses can sometimes be rubbed right off.

As with white sugar, these different types of sugars act differently in the kitchen.

The best medical analogy for this seems to be the auto-substitution of in-class medications by insurance formularies. Detemir substituted for glargine, for example. 

Is medicine a "low-impact" profession?

The folks at 80,000 hours think so, noting that the number of people whose lives will be extended by a single doctor is low, or "pretty modest," as they say:

This analysis confirms the contentions above: physician density is negatively correlated with burden of disease16; the social determinants of health explain more of the variance in health outcomes than physician density17; there are steeply diminishing returns between increases in physician density and decreases in burden of disease16. Further, the ‘bottom line’ figures (which are likely optimistic) suggest an additional doctor adds four health years for every year they work. This is a lot less than can be accomplished through even modest donations to effective charities, and so suggests the ‘direct impact’ of medicine is pretty modest.18

(link from slatestarcodex.com)