Category Archives: Food & Beverage

Free trade, the food industry and obesity: How changes in US – Mexico food trade contributed to an epidemic

Like other countries, Mexico has seen a dramatic increase in obesity and diabetes in the last decade. While obesity has many causes that operate at multiple levels, this report examines how new trade agreements can lead to changes in the practices of multinational companies that can then contribute to health problems. It also illustrates how these global changes interact with national and local trends to influence health.

At the global level, the food market integration between Mexico and the United States that began in the 1980s accelerated after the two countries signed the North American Free Trade Agreement (NAFTA) in 1994 (1). NAFTA removed trade barriers between the US, Canada and Mexico, making it easier for Mexico to export flowers and tropical fruits, for example, and for US companies to sell Mexicans low-cost corn, processed food and other goods and to invest US dollars in the Mexican food industry. Between 1988 and 1997, U.S. foreign direct investment in the Mexican food processing industry increased from US $ 210 million to US $ 5.3 billion, a 25-fold increase (1). This increase had a major impact on the types of food available in Mexico.

Most NAFTA-inspired US foreign direct investment in the Mexican food industry supported production of processed food. Between 1995 and 2003, sales of processed food increased by 5 to 10% annually (1). In the same period, the Mexican diet changed considerably. Between 1992 and 2000, for example, calories from carbonated soft drinks increased by almost 40%, from 44 to 61 Kcal per capita per day. By 2002, the average Mexican was drinking more Coca Cola servings per year, 487, than US residents, who drank 436 8- ounce serving (1).

Increased globalization and consolidation of the Mexican retail food sector and the growing consolidation of supermarkets affected others sectors of society, including agriculture, where small farmers had trouble selling to large supermarkets (2). As a result, many left their farms and moved to the city, leading to more urbanization, decreased access to fresh foods and loss in family and community food self-sufficiency.

How did these changes influence food intake? Between 1988 and 1999, the total energy intake from fat in Mexico increased from 23.5% to 30.3 % (1,3). The increase in urban Mexico City was 32%, compared to the poorer more rural South, where it was only 22 % (3). In this same period, the national prevalence of overweight/obesity increased from 33% to 59%, a 78% increase (4). The overall prevalence of diabetes in Mexico increased from 8.8% in 1993 to 11.4% in 1999, a 30% increase.

In Mexico and other developing nations, urbanization can contribute to higher prevalence of obesity by increasing access to energy-dense fatty foods, especially for low socioeconomic populations groups moving from rural areas (5). Between 1970 and 2000, the proportion of the Mexican population living in urban areas increased from 58% to 75%, the highest rate in Central America. By 2000, Mexico City, the capital, was the second largest city in the world. Furthermore, longitudinal studies suggest that the rapid transition from rural to urban and from high rates of early malnutrition to later childhood overnutrition serve as independent risk factors for obesity, diabetes and cardiovascular disease in adulthood (6). Thus, the particular pattern of economic development that Mexico pursued facilitated gains in weight, especially in the growing urban low income population. When food markets then made high calorie low nutrient foods readily available to newly urbanized, mostly sedentary people, the stage was set for rapid weight gain.

Impact on Health

Growing rates of diabetes, fueled by the epidemic of obesity, consumed larger portions of the nation’s health care budget, depriving resources from other health problems. In 2000, the annual cost of diabetes care per person per year in Mexico was US $607 and one study estimated that total diabetes costs in Mexico in 2000 were US $15.1 billion (7).

At the municipal level, changes in the economy and food availability led to price increases. Between 1992 and 2000, in part as a result of economic changes precipitated by NAFTA, the cost in pesos per megacalorie of food tripled in both urban and rural areas but remained twice as high in urban than rural areas – making low-cost low-nutrient foods more attractive (8). Aggressive marketing of soft drinks and other high calorie, low nutrient snack foods by global and national beverage makers, especially to urban children and young adults, the fastest growing segment of the population and industry’s best hope for increased market share, further encouraged consumption (1). Cities, with dense populations, established media markets and numerous retail outlets, made particularly suitable venues for advertising. Often ad campaigns were planned by increasingly globalized advertising companies (1). In Mexico City, the first McDonald’s restaurant opened in the early 1980s; twenty years later there were 200 Golden Arches in the city (9).

At the neighborhood level, rapid urbanization, loss of green space, the decline in physical labor and high crime rates combined to discourage physical activity, further contributing to obesity. This social environment where diets included more high calorie low nutrient foods and less fresh produce as well as reduced opportunities for physical activity led to weight gain.

Genetic characteristics of the Mexican population also contributed to rates of obesity but it was environmental exposure to a rapidly escalating obesogenic environment that precipitated the phenotypic expression of genotypic vulnerability (10). Moreover, those with Indian ancestry, at higher risk of a genetic predisposition to diabetes, were often concentrated in the low-income urban and rural areas as a result of socioeconomic and ethnic segregation, precisely those areas where food availability was changing most rapidly. For example, a study of diabetes prevalence in a low-income barrio in Mexico City found that 59% of the population had some Native American ancestry (9). Thus, global, national and municipal factors intersected to create a new environment for a specific population with a higher genetic risk for obesity and diabetes.

This case also shows how changes in the practices of global food companies – e.g., increased exports to developing nations; aggressive marketing of high calorie, low nutrient foods and beverages; and expansion of retail outlets to reach diverse sectors of the population– created an obesogenic environment that contributed to the explosive growth of the epidemics of obesity and diabetes in a genetically vulnerable population. Rising rates of obesity and diabetes affected both urban and rural Mexico, but as a result of dense urban markets that facilitated aggressive food advertising, a growing urban middle class that could afford more processed food and a working class population whose food choices became more constrained and less healthy and the declines in physical activity, these epidemics left a distinct footprint in Mexico’s cities. Reversing these trends will require intervention at the multiple levels that have triggered the changes.

Popular mobilization is one potential source of change. In Mexico last year, corn tortillas, a crucial source of calories for 50 million poor people, doubled in price, precipitating protests, demonstrations and eventually government price controls. Whether similar global food changes will lead to a Mexican food justice movement that takes on hunger, obesity and the growing corporate control of food remains to be seen.

By Nicholas Freudenberg, Hunter College, City University of New York.


1. Hawkes C. Uneven dietary development: linking the policies and processes of globalization with the nutrition transition, obesity and diet-related chronic diseases. Global Health. 2006; 28;2:4. 
2. Schwentesius R, Angel Gomez M: Supermarkets in Mexico: impacts on horticulture systems. Development Policy Review 2002, 20:487-502.
3. Rivera JA, Barquera S, Gonzalez-Cossyo T, Olaiz G, Sepulveda J: Nutrition Transition in Mexico and in Other Latin American Countries. Nutrition Reviews 2004, 62:S149-S157.
4. Rivera JA, Barquera S, Campirano F, Campos I, Safdie M, Tovar V: Epidemiologial and nutritional transition in Mexico: rapid increase of non-communicable chronic diseases and obesity. Public Health Nutrition 2002, 5:113-122.
5. Jimenez-Cruz A, Bacardi Gascon M, Jones E: Fruit, vegetable, soft drink, and high-fat containing snack consumption among Mexican children. Arch Med Res 2002, 33:74-80.
6. Jimenez-Cruz A, Bacardi Gascon M,: The Fattening Burden of Type 2 Diabetes on Mexicans.Diabetes Care 2004, 27:1213-1215. 
7. Barcelo A, Aedo C, Rajpathak S, Robles S: The cost of diabetes in Latin America and the Caribbean. Bulletin of the WHO 2003, 81:27. 8. Arroyo P, Loria A, Mendez O: Changes in the household calorie supply during the 1994 economic crisis in Mexico and its implications for the obesity epidemic. Nutrition Reviews 2004, 62:S163-S168.
9. Williams K, Stern MP, Gonzalez-Villalpando C. Secular trends in obesity in Mexico City and in San Antonio.Nutr Rev. 2004;62(7 Pt 2):S158-62.
10. Gonzalez-Villalpando C, Stern MP,Gonzalez ME, Rivera MD, Simon J,Andrade IS, Haffner SM. The Mexico City Diabetes Study: a population-based approach study of genetic and environmental interactions in the pathogenesis of obesity and diabetes. Nutr Rev 1999;5:S72 – S77 


Spotlight on the Food Industry: Coke, PepsiCo, and McDonald’s Pledge Healthier Ads for Kids; Critics question impact

In April 2007, 15 food companies, including McDonald’s, Coca-Cola, and PepsiCo, announced that beginning in 2008, they will devote at least half of their ads directed to children under 12 toward promoting “healthy dietary choices” and/or physical activity. Does this new pledge represent a change in direction or is it simply an effort to avoid stronger public oversight?

At least some companies worry about the growing public focus on obesity. In a recent talk at the Venice Festival of Media, Coca-Cola Company Chief Creative Officer, Esther Lee admitted, “Our achilles heel is the discussion about obesity. It’s gone from a small, manageable U.S. issue to a huge global issue. It dilutes our marketing and works against it. It’s a huge, huge issue.”

A recent study of television advertising for children conducted by the Kaiser Family Foundation found that for children under the age of eight , only one ad out of 26 promotes fitness or a healthy diet and for children 8 to 12, it’s even worse, one ad out of 48. Furthermore, the food and beverage ads directed towards children overwhelmingly promote high fat and sugary snacks or fast food. The study looked at 8,854 commercials aimed at children, none of which promoted fruits or vegetables.

Do these ads affect eating behavior? A recent study at the University of Liverpool found that children who had been exposed to food advertisements on television were more likely to overeat than children who had not been so exposed. In the study, 59 nine to eleven year old children of varying weights were exposed to 10 food or 10 toy ads. The children were then allowed to eat a range of snacks at will – from fruit to potato chips and candy. Results showed that total calorie intake was significantly higher after the children were exposed to the food ads. Children of normal weight increased consumption by 84 percent, overweight children by 101 percent, and obese children by 134 percent even though the foods that the children were allowed to eat were not the ones that were advertised.

According to Dr. Jason Halford, Director of the University of Liverpool’s Kissileff Human Ingestive Behavior Laboratory and an investigator in this study, “That’s important because what we’re showing goes beyond branding effects. Advertisers have always argued that food ads do nothing but get kids to change from one brand to another for the same thing – the same argument tobacco companies used. This study shows that that’s completely incorrect. It doesn’t matter if the ad is for a specific product. It produces consumption. Kids consume after they see them.”

These studies suggest that to reduce over consumption and obesity, children may need to see fewer ads, not different ones. According to Marion Nestle, Professor at the Department of Nutrition and Food Studies at New York University, the main nutrition message Americans need to hear is “Eat less” yet the food industry consistently encourages Americans to eat more, the necessary message for healthy profits if not healthy children.

Several recent and current government investigations have scrutinized food advertising to children. For example, this summer, the Federal Trade Commission will be issuing compulsory requests for information from 44 food, beverage, and quick-service restaurant chains. The FTC is especially interested in marketing practices of in-store promotions, events, packaging, internet marketing and product placement in video games, movies, and TV programs. According to the Institute of Medicine, annual sales of food and beverages to American children was more that $27 billion in 2002. Some researchers have calculated that children are exposed to 27 food ads a day and that most promote foods high in fat, sugar, and calories. As a result, children begin to make their first request for a product by two years of age, and 75 percent of those requests are for sugary cereals.

School foods have also become a new battleground. In an effort to lower the rates of childhood obesity, in April, the Institute of Medicine (IOM) recommended strict standards to cut calories, fat, and sugar in all snacks and beverages sold in school vending machines, at fundraisers, and as a la carte items in school cafeterias. In school systems around the country, parents, teachers and food activists are struggling to clear schools of unhealthy food.

Many food industry executives resent government involvement and dread the close attention. One executive told Advertising Age, “It’s clearly a witch hunt.” He said if anyone is to be picked as the scapegoat it’s likely to be the fast food outlets that buy as much media for the 6-to-11-year-old set as other marketers spend on their entire annual budget.

The April announcement is in part a response to this growing government attention. Food industry leaders hope that their voluntary measures will stave off further oversight. Yet, research evidence suggests that voluntary guidelines developed by industry often fail to achieve their objectives. Recently two nutritionists reviewed changes in portion sizes of sodas, hamburgers and French fries at McDonald’s, Burger King and Wendy’s and found few changes despite pledges by these companies to improve their offerings. The authors concluded that “voluntary efforts by fast-food companies to reduce portion sizes are unlikely to be effective, and that policy approaches are needed to reduce energy intake from fast food.”1

Historically the food and beverage industry have shown their capacity to respond quickly to public concerns about health. In 1991 the industry was called to introduce 5,000 new reduced fat food products by the year 2000 to support the Healthy People 2000 initiative – a goal they met by 1995. Yet as these new products came on the shelf, obesity rates continued to grow.

The Coca-Cola Company has been particularly adept in responding to new market forces. The Company’s global beverage portfolio now includes 400 brands that include soft drinks, diet soft drinks, juices, juice drinks, sports beverages, waters, teas, coffees, milk-based drinks and fortified beverages. However, no advertiser has yet promoted reduced consumption of such beverages or encouraged use of tap water, two messages that nutritionists support.

In fact, soft drink companies have been especially eager to promote physical activity, another avenue to weight reduction, rather than reduced consumption. For example, in its Get Active/Stay Active program, Pepsi Cola encourages young people to engage in sports and other physical activities while it still signs pouring rights contracts that require high schools to serve only Pepsi. The effort to divert blame for obesity to physical inactivity is reminiscent of the tobacco industry’s attempt to point the finger at air pollution as the main cause of lung cancer. Both air pollution and physical inactivity warrant attention but the self-serving goal of the focus makes the message suspect.

Some countries have chosen alternatives to voluntary guidelines. In November 2006, the British food regulator agency banned advertising of high fat, salt and sugar foods in television programs made for children or of particular appeal to children under age 16. In announcing the new regulations, outgoing Prime Minister Tony Blair said, “Particularly where children are concerned, I have come to the conclusion we need to be tougher, more active in setting standards and enforcing them.” The British regulatory agency also decided to prohibit the use of licensed characters, celebrities, promotional offers and health claims in food advertising to children. Whether the United States is ready for such a step could make an important issue for the 2008 election.


1 Young LR, Nestle M. Portion sizes and obesity: responses of fast-food companies. J Public Health Policy. 2007;28(2):238-48.

Scientists, the Food Industry, and Heart Health: An Interview with Dr. Jeremiah Stamler

Dr. Jeremiah Stamler is one of the founders of preventive cardiology, a speciality that focuses on preventing heart disease.. He is now professor emeritus and was founding chairman of the department of preventive medicine at Northwestern University’s medical school in Chicago. He has published more than a thousand articles, monographs and reports and now in his mid-80s, he continues to write, publish, and advise younger researchers around the world. During his career, he has had numerous encounters with the food industry and government agencies concerning the policy implications of his research. In Fall 2006, Corporation and Health Watch founder Nicholas Freudenberg interviewed Stamler in New York City and Sag Harbor, New York. Here we present excerpts of Dr. Stamler’s descriptions of some of his interactions with the food industry and government as well as his advice for young scientists.

CHW: Dr. Stamler, tell me how your research on heart disease first brought you into contact with industry groups.

STAMLER: As you know, I am a cardiovascular researcher primarily focused on atherosclerotic disease as it affected the coronary arteries. I began as an animal experimentalist, got interested in that in medical school, and spent my first ten years focused on animal experimental work, although I soon branched out into clinical trials and epidemiological issues. Early on I became convinced that the animal experimental knowledge was applicable not just to individual men and women, but to whole populations. It became clear to me that the growing epidemic of cardiovascular and, particularly, coronary heart disease, including sudden death, was related to lifestyle.

From the start, we found ourselves involved in hassles with industry. I had one limited personal encounter — an interesting experience. I got a grant from the National Dairy Council, a one year grant, for experiments on feeding cholesterol to chickens. A knowledgeable and decent colleague was the Scientific Director of the Dairy Council, and we dealt with her. We got that grant with the usual rules, which I had learned from my chief, Louis Katz, the Director of Cardiovascular Research at Michael Reese Hospital in Chicago. Dr Katz taught me that if you take money from an industry or an agency related to an industry, the ground rules have got to be very clear.

CHW: And what were Dr. Katz’s rules?

STAMLER: Rule Number 1. The protocol is our responsibility. We’re pleased to show it to you (the funder), but we will not modify it at your request unless we agree the modifications are useful.

Rule Number 2. We make the decision as to the duration of the study. There are no restrictions on the duration of the study. If we think at the end of a given period, spelled out in the protocol, we need to do further work, repeating or modifying or extending the given study, we extend it. You can give us money, enough to support six months, or a year, or whatever; but if we find that we are not well off at that point and we think more work should be done, it’s our right to continue to do so.

Rule Number 3. With regard to publication, we elect to publish or not to publish. If we do not publish, we will give the data to you for your confidential information. It can not be used in the public arena. If we do publish, we will show you copies of the manuscript, but we have complete control of the manuscript.

And Rule 4. Any money you give us is an unrestricted gift. There are no strings whatsoever, even if it may be for a very specific piece of research. It comes as a check for all, so to speak, a deposit in the bank, and that’s it. We use it as we wish. No strings attached. Those are very good rules. Many young people don’t even know about such rules, when they get involved with drug companies.

CHW: Tell me more about what happened with the Dairy Council.

STAMLER: Well, The Dairy Council agreed to these terms and we got a grant. It was a modest sum, $10,000 for one year. In the middle of the grant year, I got a call from the Scientific Director at the Council.

”Jerry, I’d like you to help us with something,” she said.

“Anything, I can do to help. Tell me what you want.” I replied.

“We’d like you to testify.”

“Where would you like me to testify?”

“State Legislature.”

I said “Well, what would you like me to testify about?”


“What about margarine?”

“Coloring of margarine.”

I said, “Oh, you’re in favor of it.” (Which I knew, of course, was not the case.) [The Dairy

Council opposed coloring of margarine that made it look more like butter.]

There was a pause on the other end, and she said “No, we’re against it.”

I said to her, “Look, they say every man has his price. Far be it for me to be Jesus, Moses,

Mohammed, Sir Gallahad, Sir Lancelot — maybe I’ve got a price, too. Maybe if you said a one million dollar deposit in a numbered account in Switzerland, I might think twice. But for one miserable $10,000 grant for which I get nothing in my personal pocket, no way.” The next year I didn’t get renewed.

CHW: Tell me about some of your interactions with government agencies on these questions.

STAMLER: Norman Jolliffe was a distinguished national and international nutritionist who was the Director of the Nutrition Bureau at the New York City Department of Health from 1949 to 1961. As a good public health officer, Norman wrote letters to the Food and Drug Administration, which a number of us co-signed, expressing profound concern with the failure of the FDA to do anything about what came to be known as the diet-heart question. He requested that the FDA go officially on record supporting diets lower in saturated fats and cholesterol, as part of healthy nutrition. You have to understand that prior to the USDA/DHHS dietary guidelines there were only nutritional recommendations for health, focusing mainly on undernutrition. Also, one of the problems was that the dairy industry had a — what is the wrestling term? — a grip lock on nutritional recommendations. The dairy industry, through the National Dairy Council, was the dominant source of nutrition information in elementary schools, high schools, colleges, and rural areas.

Well, the FDA never replied to any of Jolliffe’s letters. No replies at all. None. But finally one day Norman was at FDA headquarters, and he saw the Commissioner of the FDA and said, “Look, what’s going on? We write you letters. You don’t reply. You don’t say no, you don’t say yes, you don’t say anything. You file it, get rid of it. What’s the problem?”

The guy says, “Look, Jolliffe, you get meat, egg, and dairy off my back and I’ll reply.” Just that simple. And for years, the National Heart, Lung, and Blood Institute also avoided making a statement on diet and heart disease for similar reasons. In 1960, the American Heart Association issued its first statement on diet. I was a co-author. We went through seven revisions of a very careful statement on the possibility of preventing coronary disease. It was the first American Heart statement. A year or two before, there was a statement on risk factors for heart disease that Mary Lasker helped to publish through the National Health Education Committee, a private group. But the NIH Heart Institute was silent. The Public Health Service, FDA — for years — silent. Bob Levy, then Director of the National Heart, Lung, and Blood Institute, once had a Congressional staff person say to him, “You organize the Heart Institute to go on record on the diet-heart question, and we’ll cut the balls off your budget.” Simple.

CHW: Let’s turn to salt. The American Medical Association estimates that 150,000 lives could be saved annually if sodium levels in packaged and restaurant foods were cut in half. I understand you spent many decades studying the impact of salt on cardiovascular health. Tell me something about your interactions with Campbell’s Soups and with the Salt Institute, the industry trade group, on this issue.

STAMLER: Well, in the late 1980s, Campbell’s presented soups on the shelves called “Heart Healthy” on the basis that they were low in fat. But as you know by looking at any label of usual Campbell soups, they were then and they are today (except for a few “salt-modified” or “lowsalt” products), very high in salt. So people who were concerned with salt and heart health said “How can you make a claim for heart healthiness when you have a soup that’s so loaded with salt?”

So several advocacy groups went to the Federal Trade Commission and said that this was false and misleading advertising and should be stopped. In January 1989, the Federal Trade Commission cited Campbell’s for making misleading health claims and temporarily enjoined Campbell’s from making such claims, pending a hearing.

CHW: How did the Federal Trade Commission get to you?

STAMLER: A young FTC lawyer came to me and said the Commissioners are saying, “What are the data that refute the argument that salt sensitivity is a minority phenomenon prevalent only among some hypertensives, not a population wide phenomena? Will you come and talk to the Commissioners?” she asked. Before the FTC lawyers could go into the courtroom to get an injunction, they needed approval from the Commissioners. And I went and delivered a talk and then the lawyers got permission to go ahead.

In the court proceeding, I was asked to be an expert witness for the Federal Trade Commission on the question, “Is salt really a public health concern?” The argument repeatedly used by food processors whose products have a lot of salt and the salt industry is “No. If salt relates at all to blood pressure, first of all it’s one of many variables; second, it relates only to people who have high blood pressure, and, third, it relates only to a proportion of them who are ‘salt-sensitive’. Therefore, it is a clinical issue, not a public health issue. There is no reason to say that a soup that claims heart healthiness because of its low fat content can’t make that claim because of public health concern with salt.” By the way, these same syllogisms were used in the past by the food industry special interests that defended high fat food, until they finally more or less gave up on the fat question.

CHW: So what happened at the FTC hearing?

STAMLER: FTC proceedings allow a period of discovery so I was deposed by a distinguished, able, straightforward, calm, businesslike Washington attorney. In a day and a half or two of detailed depositions, his main objective was to try to undermine my scientific foundation for the statement that the problem with the so called salt sensitivity response of the blood pressure to dietary salt is not idiosyncratic, not only a clinical problem ; and does not affect only a small percent of population. Rather, we argued it’s fundamentally a population-wide issue.

Our Intersalt Study has shown that it is a problem throughout the population with, at most, only a small percent of people escaping the consequences with no rise in blood pressure with age. In that study, we found a consistent relationship between salt and blood pressure and concluded that high salt intake is a major preventable risk factor for epidemic cardiovascular disease.

CHW: When you were being questioned by this lawyer, did he know the science? Was he up on the science?

STAMLER: Oh, yes, he was very well prepared to represent his client. But I and my colleagues who were expert witnesses for the Government held our own. It wasn’t readily possible to shake the foundation of our conclusions. This, of course, is supported by the fact that such conclusions have been stated, and restated time and again by independent research groups.

CHW: So what happened next?

STAMLER: Soon after the depositions, Campbell’s Soups threw in the towel and dropped their objection to the FTC finding. I’m sure one of the reasons was that the legal action was costing a fortune. You can imagine what a good Washington law firm was costing them. Even for a relatively rich corporation, they are in the food industry where profit margins are not like in the drug industry.

CHW: Did Campbell’s change their products?

STAMLER: Well, they began to put out more soups that were modified salt, but most of these are still too high. There are three levels with Campbell’s Soup and salt. The first is the usual, which is almost like drinking sea water. The second is a modified version, which is somewhat lower but still too high in salt content. And then there are a few low salt, or really low salt soups. Their problem is that many people are attuned to soups that are high in salt, and there is no good salt substitute that gives the equivalent flavor. They’ve been wrestling with trying to get a substitute; they used potassium, they used other things, but it has been very hard. There are ways you can make soup that’s very tasty without salt. We know a wonderful cook who makes lentil soup for us, and we make tomato soups. Tomato’s a good way to go for taste without salt.

CHW: So what’s happening now on salt?

STAMLER: A new committee created through the Department of Agriculture and the Department of Health and Human Services is reviewing the dietary guidelines for Americans, one of the seven being on salt. The Salt Institute launches a big campaign to get rid of that one, and intensified its harassments and its objections and its criticisms of the latest scientific work on salt. But nonetheless, repeatedly that body has reiterated the salt recommendation. Recently, the World Health Organization had a huge conference in Paris reviewing the whole situation, it’s purpose being not to review the facts but, taking the facts as given, what can be done to reduce the population’s intake in salt. In addition, the American Medical Association joined the effort to reduce salt in processed food and the new USDA/DHHS guidelines reiterated the importance of reducing salt.

CHW: Even though you are a prominent scientist with a long track record of scientific publications, you have never hesitated to step into the policy arena or to take on the special interests that defend health damaging policies. What kind of advice can you give young researchers who want to look at the relationship between the food industry and patterns of illness? What advice would you give for how to study those things or for how to frame the questions in the context of the current biomedical framework?

STAMLER: Well, first of all, unfortunately, too few people have an interest of that kind. There is still prevalent in the scientific community a rejection of what I call the classic Baconian creed on what science is all about. You know, Bacon helped to create the foundations of modern scientific approaches, and struggled against scholasticism — medieval, church-based scholasticism of the kind of “How many angels are dancing on the head of the pin?” His idea was that the task of scientists is to collect information for human welfare, to improve the lot of mankind. And that became the creed of science. To this day there are big hassles in our country on the conflict between basic and applied research. Influenced by Bacon, Pasteur formulated the simple concept “There is no such thing as basic and applied science. There is only science and its application.” Very simple. Very clear. But to this day, throughout the scientific community in America, the good science, the real science, the quality science is still considered basic science.

But how do you define basic science? Do you mean you work at a bench? Do you mean you work on the sub cellular level, the cellular level, the tissue level, the organ level? Is it a level? Is it a place of work? Is it a scientific tool? What’s basic research? When Einstein formulated his famous equation, that was pretty basic research, and when it was made into a bomb, that was a pretty definitive application. Similarly with Fleming and penicillin. So what’s the dialectic there?

CHW: So bring this back to your advice to young scientists.

STAMLER: Yes, let me go back to your question — that was a long diversion. My fundamental viewpoint is that everything having to do with medicine, at every level has to do with a practical, applied branch of human life. Therefore, everybody working in medicine must ask himself/herself the question: “What are the possible applications?” And in fact, when you write a research grant you have to put it in. That’s kind of ironic. There’s no such thing as a research grant — at least not for the National Institutes of Health — where the researcher can say, “I’m doing basic research. I don’t have even a remote idea—a hypothesis– about the application.” By the way, the only real definition of basic research is, research whose application is not currently apparent.

So every scientist working in medical research, wherever, has to be conscious of possible applications. Any scientist who has any application that is in the public health arena at all, and nowadays that covers anything related to treatment because all treatment relates to pharmaceutical and other industries. So as soon as you get to treatment, you’re up to your eyeballs in commercial interests. Therefore, you have to be aware that what you are working on not only may have applications, but may relate to special interests that have an axe to grind in relation to those applications. Sometimes a very nasty axe of downright vicious opposition. C. E. Winslow, the great public health leader the of the early twentieth century, said all progress in public health in the United States is going to be very difficult from now on because every step proposed will be in conflict with special interests. So every scientist must be aware of this. And every scientist who is worth his weight in anything should be prepared to struggle for the integrity of the application, of the sound knowledge that he collects. He or she cannot be indifferent.

Now, this business of indifference is a whole ideology: “ I’m a scientist. I collect the data. I make them available to the policy makers to do with it what they see fit. What is done with these data is not my responsibility.” That’s a whole ideology. Some researchers say “Well, I’ve got to remain objective. If I espouse a cause, I become committed and, therefore, biased.” That’s not true. To espouse the truth is not biased. To fail to espouse the truth is to betray the Baconian tradition.

CHW: So what are the implications for training scientists?

STAMLER: Well, I have certain ideas. If you’re going to espouse the proper application of your findings and other findings, then you have to do it skillfully, carefully, not just a gesture. And that means first and foremost, you have to work with organizations. So if you’re in the cardiovascular field you have to be active in the Heart Association, if you’re concerned with public health, the American Public Health Association. You may even be active in electoral politics at one level or another, you have to respond with articles on policy, not just articles on your scientific findings, etc. Do it well. Do it well. Don’t just give it a lick, a promise, a gesture.

And the final thing is, of course, you cannot allow yourself to be intimidated by special interests who deliberately try to intimidate you. I’ve had my experience with the salt industry and others as well. I received a letter from The Salt Institute’s lawyers challenging our data and demanding the whole data file so that further and “proper” analyses could be done. That could be very intimidating, you know.

In fact, many people prefer not to get involved in the public arena because they don’t want all those hassles, including the time it consumes. It consumes a lot of time. So I think good preceptors need to make all young scientists aware of this set of issues. What is the right tradition of science? Does advocacy mean loss of objectivity? Advocacy for valid, true, clearly established, sound data –so defined by the scientific community? What does that signify? Is such advocacy bias that reflects loss of objectivity? Is commitment biased? Is that a valid line of thinking? Unfortunately, many young scientists are never confronted with these issues.

Two Schoolgirls Force GlaxoSmithKline to Apologize for Deceptive Food Advertising and to Pay Fine

Two recent studies have noted that alcohol industry advertising has a strong effect on youth and contributes to underage drinking. In January of 2006, the American Medical Association’s Archives of Pediatrics and Adolescent Medicine published a study by Snyder et al which found that the number of alcohol ads viewed was positively associated with the amount of alcohol consumed by youth. Each advertisement viewed raised the number of drinks consumed by 1%.

In 2004, two 14 year old New Zealand school girls, Anna Devathasan and Jenny Suo, tested the Vitamin C levels of their favorite drinks for a school science project. One product, Ribena, made by GlaxoSmithKline(GSK), the world’s second largest drug manufacturer, tested much lower than advertised. GSK had claimed that blackcurrants, Ribena’s main ingredient, had four times the Vitamin C of oranges but according to the girls’ science experiment the beverage had much lower levels.

The girls wrote a letter to the company reporting their findings but got no response. According to Jenny Suo, a telephone call to GSK was equally frustrating. “They didn’t even really answer our questions,” she told a reporter for Aukland’s Weekend Herald. “They just said it’s the blackcurrants that have it, then hung up.” Undeterred, the students contacted business watchdog groups, a television consumer affairs program, and, finally the New Zealand Commerce Commission.

On March 27, 2007, three years later, the company appeared in court in Aukland to plead guilty to 15 charges of making misleading claims about Ribena and breaching the Fair Trading Act. The Commerce Commission fined GSK US $168,000 The commission said that although blackcurrants did have more Vitamin C than oranges the same was not true of Ribena . The commission found that ready-to-drink Ribena had no detectable level of Vitamin C. Paula Rebstock, the commission chair, said thousands of New Zealanders had been duped by the company and described the company’s behavior as “a massive breach of trust with the New Zealand public.”

Before the New Zealand decision, GlaxoSmithKline, which has a worldwide turnover of more than $40 billion year, reported itself to the Australian Competition and Consumer Commission. GSK agreed to the Australian Commission’s suggestion that it correct its labeling, cease making claims about Vitamin C, and publish an article in an industry magazine on the importance of accuracy in advertising.

At the Aukland court hearing, Anna Devathasan expressed concern and satisfaction about the outcome. “They’re a multi-billion dollar company,” she told the Sydney(Australia) Morning Herald, “so it’s a bit disappointing, but I think their reputation has been damaged enough to have an effect.”

The Big Apple Just Got Leaner – New York City Bans Trans Fats in Restaurants

On December 5, 2006, the New York City Board of Health voted to ban the use of almost all artificial trans fat in the city’s more than 11,000 restaurants and fast food outlets. Harold Goldstein, the executive director of the California Center for Public Health Advocacy, told the New York Times that, “New York City has set a national standard” and already several cities and states have introduced similar legislation.

On December 5, 2006, the New York City Board of Health voted to ban the use of almost all artificial trans fat in the city’s more than 11,000 restaurants and fast food outlets. Harold Goldstein, the executive director of the California Center for Public Health Advocacy, told the New York Times that, “New York City has set a national standard” and already several cities and states have introduced similar legislation.How did New York City decide to act on trans fats and what are the lessons for health advocates engaged in other efforts to control corporate practices that harm health? First, some background: trans fats are used to enhance the crispness, stability, flavor and shelf life of many processed foods. Trans fats provide food companies with flexibility in food storage and preparation, thus contributing to profitability. By the late 1990s, about 40% of US supermarket products contained trans fats, showing how pervasive exposure was to the public at large.

In 1994, the Center for Science in the Public Interest (CSPI), a national advocacy organization, petitioned the Food and Drug Administration (FDA) to require that food manufacturers label the trans fat content of their food products. The petition was based on research showing that replacing trans fat with healthier oils could prevent between 30,000 and 100,000 premature cardiovascular deaths in the United States each year. Some researchers have suggested that replacing trans fats with healthier alternatives could also significantly reduce the incidence of Type 2 diabetes in the US.

In 1999, despite the opposition of the food industry, the FDA proposed to include the trans fat content of food on the standard food label. The agency claimed that strengthening food labeling was likely to yield significant health and economic benefits, including saving up to 5,600 lives and $8 billion a year.1 Three years later, the Institute of Medicine concluded that they could not determine a healthful limit of trans fat and urged action to reduce its presence in the American diet.2 In January 2006, the FDA rule requiring food labels to include information on trans fats went into effect, but the FDA has turned down requests to ban the product altogether.

New York City took on trans fat in 2005. According to the New York City Department of Health and Mental Hygiene (NYC DOHMH) Health Commissioner Thomas R. Frieden, “New Yorkers are consuming a hazardous artificial substance without their knowledge or consent. Trans fat causes heart disease. Like lead in paint, artificial trans fat is invisible and dangerous, and it can be replaced. While it may take some effort, restaurants can replace trans fat without changing the taste or cost of food. No one will miss it when it is gone.”

The department began its efforts with a year long education campaign to help restaurants voluntarily reduce trans fats. However, a survey before and after this voluntary educational campaign showed that overall use of trans fat did not decline at all. As a result, the Commissioner proposed the ban. Speaking on behalf of the ban, Dr. Walter Willett, Chair of the Department of Nutrition at the Harvard School of Public health noted, “If New Yorkers replace all sources of artificial trans fat, by even the most conservative estimates, at least 500 deaths from heart disease would be prevented each year in New York City — more than the number of people killed annually in motor vehicle crashes. Based on long term studies, the number of preventable deaths may be many times higher. Trans fat from partially hydrogenated vegetable oil is a toxic substance that does not belong in food.”

Some in the food industry supported the ban. Carnegie Deli owner Sanford Levine said, “We’ve been using 100% canola oil for 20 years because it has a better taste and is better for customers. It’s easy to replace artificial trans fat, it costs the same, and the food tastes great. Our cakes and other baked goods are already trans fat free. If we can do it, so can other restaurants.”

But others in the food and restaurant industry vigorously opposed the ban. Although no New Yorker ever walked into a restaurant to order a portion of trans fat, some argued that the ban would interfere with New Yorkers’ freedom. In an op-ed in the Daily News, Richard Berman, a food lobbyist and executive director of the Center for Consumer Freedom wrote, “the proposal to eradicate all artificial trans fats from every restaurant in the city is nothing short of hysterical.” It subjects the restaurant industry to a terrible case of regulatory whiplash. “If they can declare New York City a trans fat free nanny state by bureaucratic fiat, what can’t Commissioner Thomas Frieden and his minions ban?.. Maybe the radical solution is to let consumers not bureaucrats dictate what restaurants do.

In the months leading up to the vote, dozens of New Yorkers wrote impassioned letters to the editor on the subject, newspaper editorial boards took opposing sides on the issue, and hundreds of New Yorkers submitted documents or testified at public hearings on the subject.

In the proposal approved in December, the Board of Health made some concessions to the food industry, extending the time restaurants had to comply with the new rules. In the weeks and months following the New York City debate on phasing out artificial trans fat, several national companies announced their intention to eliminate trans fat from some or all of their product lines. These included KFC, Red Lobster, Olive Garden, Crisco, and Starbucks.

Lessons Learned for Changing Corporate Practices that Harm Health

So what lessons does New York City’s ban on trans fat in restaurants offer for public health professionals and advocates concerned about protecting the public against harmful corporate practices?

Local health departments can play a leading role in challenging harmful corporate practices. The campaign to phase out artificial trans fats was initiated and led by the local health department, which defined its mission as protecting the health of the public against significant threats. While advocates, researchers and health professionals played important supporting roles, the success of the effort depended on a Mayor and Health Commissioner who made public health a priority and were willing to engage in some battles to achieve their goals. Similar efforts in other jurisdictions to control smoking, restrict access to handguns, and reduce exposure to lead paint show the important role local officials can play in protecting public health against health damaging corporate practices.

Voluntary educational campaigns may be a useful starting point.

The health department was able to win over public support for the phase out in part because they first tried a voluntary campaign and were able to demonstrate that this effort was not sufficient to achieve desired public health goals. In some cases, voluntary educational campaigns may work, but beginning with this activity may help to mobilize support for stronger action should it fail.

Framing the issue as protecting people against involuntary threats helps to mobilize people. In the health department’s aggressive media campaign to win support for the proposal to phase out artificial trans fat, spokespeople emphasized that New Yorkers did not choose to eat trans fat. Since the product was neither labeled nor disclosed, the argument that consumers were choosing this product was harder to make. Comparing trans fat to lead paint and labeling it a toxic product was also a clever strategy, since New Yorkers had debated regulation of lead paint for more than 20 years and most New Yorkers understood and strongly supported government action to protect children against lead paint poisoning. Thus, framing policy debates in local terms may help to generate support.

Creating controversy can help to advance public health.

Debate about trans fat received extensive coverage in local newspapers, television and other media for several weeks. While food industry defenders and some libertarians opposed the proposal, many New Yorkers supported it. In the course of the debate, the topic changed from whether to ban trans fat to how best to do it and on what timetable. The conflict provoked discussion and engaged diverse constituencies in the issue.

Some public health professionals have a predictable approach to conflict: partnerships with all stakeholders, compromise, and a willingness to be “reasonable”. By staking out a principled position and sticking to it, the NYC Department of Health achieved its goals, educated the public and set an example for other local health departments across the country.

Forceful advocacy sets the stage for subsequent victories.

While the New York City Department of Health took the lead on this issue, its campaign to phase out artificial trans fat stood on the shoulders of previous advocacy. In 1994, the Center for Science in the Public Interest began a 12 year effort to win the FDA requirement for trans fat labeling on store-bought foods. In 2003, Denmark passed a law that made it illegal for any food to contain more than 2% transfat. A May 2003 lawsuit by Ban Trans Fat against multinational food company Kraft led to a settlement in which Kraft agreed to produce trans fat free Oreo cookies for school markets. Ban Trans Fat also sued McDonalds for false advertising regarding its use of reduced trans fat cooking oil. In 2005, McDonalds settled the case by agreeing to act to limit trans fat and to pay the American Heart Association to sponsor public education on trans fats. In 2006, the American Heart Association became the first major medical organization to urge a specific limit on trans fat in the diet. In 2006, the New England Journal of Medicine published a study that concluded that daily consumption of 5 grams or more of trans fats raised the risk of heart attacks by 25% and that many of the “large” size fast food meals served by McDonalds and KFC exceeded this 5 gram limit. (The study also found that a New York City McDonalds meal had the highest trans fat content of any site in the 20 countries tested around the world.)3

These various efforts helped to educate the public about trans fats, to convince policy makers that it was an issue that deserved attention and set the stage for more assertive actions such as the New York City ban.