Discussion
DR. KOPLAN: We are at our time’s end. Does anyone have comments or questions for our panelists?
DR. FINEBERG: I have a question about economies of scale. I want to get back to that point, Mr. Leach that you made. Economies of scale require resources, coordination, and a broad scope. Just out of curiosity, Dr. Dietz, what is the entire investment that has gone into the VERB program? And Mr. Leach, I would be interested if you could share with us what your company—admittedly a big one—invested in the first year of your program.
DR. DIETZ: In the first year, the VERB campaign received $125 million. To give you a sense of scale against other products aimed at children, $100 million annually is spent on Barbie. In the second year, I think we received $70 million, and in this year’s budget we have $45 million.
DR. KOPLAN: A quick comment on this: Congressman John Porter, a visionary, saw the need to fund the VERB campaign, though it was not called that at the time. His belief, and I think it is one that is shared by public health people, was to compete against state-of-the-art advertising and marketing agencies with pro bono work or efforts that were not state of the art was a losing cause. That funding permitted Dr. Dietz and his colleagues to hold a competition. They had the best advertising firms in the world working on this effort, and were able to pay for the advertising to be placed crucial times of the day. The VERB campaign had
adequate support with Chairman Porter. It had somewhat adequate support the next year, but you can see what is happening to a successful campaign in the amount of funding that it is retaining.
DR. DIETZ: Let me just add that two of the partners, the Disney Channel and Nickelodeon Channel, provided additional advertising at their cost, pro bono.
MR. LEACH: I would just say that $125 million is a really strong advertising effort. There are not too many brands that are spending at that rate. There are a few, but that is a high figure. This year we are going to spend about $26 million on our Smart Spot program. We are budgeting for this campaign as we would for any new product launch. Obviously, in addition to that, we are doing a whole lot of brand advertising as well.
We have big brands. Tropicana has a $50 million advertising budget. Gatorade is well over that. AquaFina is significant. I don’t know what Quaker oatmeal is, but it is far more than that. If you look at it collectively, we are spending a slightly disproportionate amount on our better for you and good for you brands. That effort, in particular, is like a $25 million budget.
PARTICIPANT: I just want to compliment you. Dr. Fineberg, this is the best Rosenthal Lecture I have been to, and I have been to a number of them. I just think it is terrific.
My question is this: It is my understanding that this epidemic is hardly limited to the United States. It seems to be a global problem, or at least in well-developed countries. Is that true? If so, how are other countries waging battle against this problem?
DR. KUMANYIKA: I will answer that. One of my other roles is chair of the prevention group of the international obesity task force. There is a lot of interest in countries, not just the affluent countries, but in lower-income countries, because the health budgets in some of the countries where obesity is beginning to emerge cannot support the care for the comorbidities associated with obesity. Diabetes shows up very soon after you begin to get high rates of obesity, and it is a very costly disease to treat.
So, yes, indeed, it is global, and there is a lot of interest. WHO has taken this on. They had a report in 2000 on the global epidemic, getting together 20 or so countries, including some of
the ones you wouldn’t expect. It is very interesting. Because this is a socially embedded problem, the culture and the economy of each country determines the types of solutions they choose and what types of things they will do.
All the marketing and multinational issues do link the problem across the globe, but within each country there is a filter of culture that determines what can be done with advertising or whether, for example, people actually ride bicycles, and so forth. It is very interesting to look at and compare efforts across societies.
DR. DIETZ: In China the rates of obesity in the major cities along their eastern seaboard has more than tripled in the last decade and is increasingly seen as a health problem there.
PARTICIPANT: You don’t have to go too far. In Mexico, in the 1990s, the rate of obesity in women tripled. So, you have a big problem there. Do you think it is nature or is it nurture? Or perhaps more important, does it really matter? Is that an academic question from the point of view of public health interventions?
DR. KUMANYIKA: I think that there are genetic predispositions. I mean, the ethnic groups are not considered to be genetically defined categories. It is combination of certain gene frequencies and a common history and a common environment. There are genetic predispositions to obesity generally. I don’t think that we have identified any factor that predisposes these groups to obesity so strongly that it is stronger than the environmental factors. So, the baseline risk is there, but there are counterparts of all these populations that are not obese and that have the same genetic make up. In black girls, for instance, obesity was not a problem in the 1960s, but it has increased yet the genetics have not changed. I think we agree that there is a predisposition, but it is really a combination of these environmental factors that is causing the excess risk, and it is much easier to explain it systematically on the basis of your environment than it is on any kind of genetic factor, even though people have been looking.
PARTICIPANT: I would just like to know what you think of these diets that emphasize high protein intake. An example is a granddaughter of ours who runs on the fat side, unlike her parents, who are slim. She went on this diet, the original Atkins diet. It was
effective before she started college. Then she started college and she blew up worse than she ever did.
DR. DIETZ: Actually, the comparison of carbohydrate-free and carbohydrate-containing diets was the topic of my thesis, and I only wish that I had renamed my findings the “Dietz Diet.” There are a couple of relevant points. The first is that the putative mechanism that explains why carbohydrate free diets cause more weight loss is not correct. That is, the mechanism that is proposed is that, in the absence of carbohydrates, insulin levels fall. That means you rely more on fat for your metabolism and you lose more weight. That is not true.
That is not to say these diets aren’t effective. I think they are, and they are effective for two reasons. First, they are boring. You can only have eggs and bacon, or eggs and ham, or steak and eggs for breakfast so many times before it really gets tiring. People get tired of eating the same food over and over again. In addition, protein, which is at the heart of these diets, is very satiating. It makes you full. There is no other food that makes you as full as protein. So, people lose weight on those diets.
I think that one of the remaining questions is that although lipid levels—cholesterol levels—improve on these diets, it is not clear that the improvement is more than you would expect for the weight loss that is achieved.
Now, that said, the way these diets are used in practice is that nobody really stays on them for a long period of time. People go on and off them. To me, the much more important concern is how one achieves weight maintenance after loss, because people lose weight all sorts of different ways. However, they tend to use a narrower base of strategies to maintain their weight over time. People who have lost weight and sustain those weight losses tend to eat breakfast, they consume a low-fat diet, they are physically active for about 60 minutes a day, and they monitor their weight on a regular basis. Those, I think, are the more important long-term strategies than whatever it takes for people to lose weight.
Now, with respect to children and adolescents, I think that there are potential hazards of these diets, because children and adolescents are growing. Our data shows that there can be sustained
protein losses on these diets. I worried a lot when I used these diets clinically.
PARTICIPANT: [Question off microphone.]
DR. DIETZ: Yes, paradoxically enough. Protein utilization is a function of energy intake as well as protein intake. If you lower the energy, you have to raise the protein, but even under those circumstances, some of the adolescents we studied had very sustained protein losses. I always worry about adolescents who follow this diet for a week or two and then suddenly have a carbohydrate binge, because of the potential electrolyte shifts that could occur. The salts in the blood might shift in and out of the heart muscle and cause an arrhythmia. That is a theoretical problem and one which I never saw, but I always worried about it. I think in the case of adolescents, it is not an appropriate diet, unless they are under the care of a physician who knows what he or she is doing with respect to management of these low-calorie diets.
PARTICIPANT: I also would like to commend the panel and Dr. Koplan for what I thought was an excellent report and an excellent presentation. I had two points: One, I was surprised there was no mention about the effects of stress and sleep on obesity. I’m an uninitiated person in the world of obesity, other than having personal experience. I would think that stress and sleep seem to be related to obesity. I wondered if you could comment on that.
The second part is, Dr. Dietz, when you mentioned the need for redundancy in the messages to think more about obesity, it makes me think about anorexia and eating disorders, which are very, very prevalent. I would think it is hard to find a college population where less than half the people are not bothered by that. I wonder what you think about balancing the need for redundancy of the message and, on the other hand, the bad effects of too much message, or what might be the bad effects of too much message.
DR. DIETZ: The first articles related to sleep just appeared, and I haven’t actually read them, but they show that reduced sleep may be associated with increased obesity and that leptin levels are decreased and ghrelin levels are increased, which tend to drive food intake.
The role of stress may have a greater impact on where fat is deposited than on the deposition of fat, because it really depends what you are consuming and how much. In fact, the epidemiologic data that suggests that stress is related to obesity is pretty sparse. There are biochemical or metabolic explanations for how that could happen, but not a lot of good data.
In reply to your second point, the focus on the redundancy of those messages doesn’t say what those messages should be. It only says they should be heard in a variety of places. Mr. Leach, I think, from his marketing perspective knows better than I how one can craft a message like Pepsico has done and McDonalds is doing, which talk about what is good for you or wholesome and that focuses on the benefits of healthy behaviors and not weight control as the reason for adopting these behaviors.
MR. LEACH: We are learning that encouraging people to get started in simple ways is really important. The majority of people are overwhelmed at the prospect of radically changing their diet and radically changing their physical activity. So, if you can get to them with a message that says, “You can do this. It is simple. Just get started, and you will feel better,” you can have a real impact. At least, that has been the findings of our market research. The right kind of message can reach a large number of people who are contemplating behavior changes. That is what we have learned so far.
DR. KOPLAN: I know we have other good questions here. I am sure the panelists will be glad to stay and chat, but to preserve your own caloric intake tomorrow; we want you to get enough sleep tonight. Dr. Fineberg, do you want to make a closing comment?
DR. FINEBERG: I would just like to add my thanks to each of the panelists, and to you, Dr. Koplan, for your work here tonight, and for the things that you have done over the years in your respective capacities to bring better nutrition and better lifestyles to children and to everyone in our country. I want to thank all of you.
I also want to acknowledge particularly our staff, Cathy Liverman, Vivica Kraak, Linda Meyers, and Rose Martinez.
