Health for life

Postmenopausal women who consumed sugar-sweetened beverages were more likely to develop the most common type of endometrial cancer compared with women who did not drink sugar-sweetened beverages, according to a study published in Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research.

Postmenopausal women who reported the highest intake of sugar-sweetened beverages had a 78 percent increased risk for estrogen-dependent type I endometrial cancer (the most common type of this disease). This association was found in a dose-dependent manner: the more sugar-sweetened beverages a woman drank, the higher her risk.

"Although ours is the first study to show this relationship, it is not surprising to see that women who drank more sugar-sweetened beverages had a higher risk of estrogen-dependent type I endometrial cancer but not estrogen-independent type II endometrial cancer," said Maki Inoue-Choi, Ph.D., M.S., R.D., who led this study as a research associate in the Division of Epidemiology and Community Health of the University of Minnesota School of Public Health in Minneapolis. "Other studies have shown increasing consumption of sugar-sweetened beverages has paralleled the increase in obesity. Obese women tend to have higher levels of estrogens and insulin than women of normal weight. Increased levels of estrogens and insulin are established risk factors for endometrial cancer."

Because this study is the first to show the association between high sugar-sweetened beverage consumption and endometrial cancer, such findings need replication in other studies, according to Inoue-Choi.

Inoue-Choi and colleagues used data from 23,039 postmenopausal women who reported dietary intake, demographic information, and medical history in 1986, prior to the cancer diagnosis, as part of the Iowa Womens Health Study.

Dietary intake was assessed using the Harvard Food Frequency Questionnaire (FFQ), which asked study participants to report intake frequency of 127 food items in the previous 12 months. A typical portion size for each food item was provided to give study participants a sense of scale.

As reported in the study, the FFQ included four questions asking usual intake frequency of sugar-sweetened beverages, including 1) Coke®, Pepsi®, or other colas with sugar; 2) caffeine-free Coke®, Pepsi®, or other colas with sugar; 3) other carbonated beverages with sugar (e.g., 7-Up®); and 4) Hawaiian Punch®, lemonade, or other noncarbonated fruit drinks.

"Sugar-free soft drinks" included low-calorie caffeinated and caffeine-free cola (e.g., Pepsi-Free®), and other low-calorie carbonated beverages (e.g., Fresca®, Diet 7-Up®, and Diet Ginger Ale®).

The "sweets and baked goods" category comprised 13 items in the FFQ, including chocolate, candy bars, candy without chocolate, cookies (home-baked and ready-made), brownies, doughnuts, cakes (home-baked and ready-made), sweet rolls, coffeecakes or other pastries (home-baked and ready-made), and pies (home-baked and ready-made).

The researchers categorized the sugar-sweetened beverage consumption patterns of these women into quintiles, ranging from no intake (the lowest quintile) to between 1.7 and 60.5 servings a week (the highest quintile).

Between 1986 and 2010, 506 type I and 89 type II endometrial cancers were recorded among the women Inoue-Choi and colleagues studied. They did not find any association between type I or type II endometrial cancers and consumption of sugar-free soft drinks, sweets/baked goods, and starch.

"Research has documented the contribution of sugar-sweetened beverages to the obesity epidemic," said Inoue-Choi. "Too much added sugar can boost a persons overall calorie intake and may increase the risk of health conditions such as obesity, diabetes, heart disease, and cancer."

Check out Troeltschs perspicacious response to the Disease Management Care Blog assertion in yesterdays posting that a New York City ban on the sale of 16 oz. calorie dense beverages would "work":

What evidence do you have for the comment "it works?" particularly in light of the fact that soda is simply banned in restaurants, and not any where else in the city?

Troeltsch has both right. 

The proposal, as it now stands, would limit the ban to restaurants, street vendors and concession stands and spares grocery stores. So while New Yorkers couldnt buy that "Big Gulp" to-go, theyd still be able to buy that liter of fructose corn syrup-loaded soda and continue their gluttonous ways in the privacy of their own homes.

And whats more, the DMCB did a literature search and can find no published evidence that a calorie-dense beverage ban reduces the prevalence of obesity. Yesterdays claim that "it works" was simply overzealous. DMCB readers can not only spot non-scientific puffery at meetings, in news reports and in marketing materials, but also in the DMCBs weaker-moment writings.

Well done.

That being said, the DMCB still gives the Big Apple some credit. If you go to the original proposal, youll see that the ban is only one of 26 initiatives that seek to improve nutrition and increase exercise in the citys public schools, alter sidewalk and building codes to promote physical activity, require hospitals to offer healthy menus, increase the availability and appeal of tap water and promote wellness, especially among public employees. This is commercial population health management writ large.

And the DMCB still stands by its original assertions. Mayor Bloombergs attack on obesity in the name of public health should remind health care providers that a similar fate awaits their costly ways if shared savings, accountability, bundling, electronic records, the demos and ACOs fail to bend the curve. Instead of trimming excess calories, our politicians will trim excess costs by proclamation.

The DMCB offers three additional observations:

1) Peter Orzag, one of Mr. Obamas health orm architects, famously asserted that the Affordable Care Acts health mandate provision would increase a collective expectation that we should all buy health insurance, much like seat belt laws prompted most of us to buckle up. There may be something to that in the anti-obesity fight, says the DMCB, and Mayor Bloombergs very public attack on sugary drinks may prompt his city to shift to a new cultural norm

2) The DMCB hopes NYCs Department of Health and Mental Hygiene devotes the resources it takes to adequately measure the impact of the ban. The rest of the country needs to know if this works.

3) Last but not least, if nothing comes of this, this is one more warning to a largely uncooperative and unrepentant food industry.

If New York Citys Mayor Michael Bloomberg has his anti-obesity way, the Big Apple will begin banning the restaurant and concession sale of sugary beverages that exceed a volume 16 fluid ounces as early as March of 2013.  The Disease Management Care Blog suspects there is one big reason why Hizonner is deploying brute force in this battle of the bulge, this confrontation of the calories, this attack on adiposity:

It works.

Contrast the approach of simply outlawing obesogenic drinks with kinder and gentler approaches, like those based on education (food labeling and warnings), economic incentives (fat taxes), appeals to self-interest ("youll look and feel better!") or enculturation (starting with food choices in our schools cafeterias).  They all have their role, but lets face it: we dont heed labels, hate taxes, find life-style changes difficult, are suckers for the food industrys marketing and ultimately like the taste rush of corn syrup.  Take a stroll through Manhattan and its pretty obvious we have a problem.

The Big Apple is doing this for our own public health good.

This lesson prompts the Disease Management Care Blog to ponder the largest threat to the success of the "accountability" movement in health care.  By "aligning" economic interests, offering savings-based "gain-sharing," leveraging decision support and enculturating physicians into "systems" of care imbued with best practices championed by physician leadership, we believe our collective taste for high cost testing, technology and pharmaceuticals will fade faster than the flab on The Biggest Loser.

Is that so?  Maybe not, and so the DMCB offers up two observations:

1. Assuming physicians are people and patients have their self-interest at heart, the likelihood that our appetitite for over-testing, the latest tech and brand name drugs will be blunted by electronic health record decision-support warnings, the promise of some savings-based future bonus, appeals at staff meetings to do the right thing or an expectation that physician culture will change is about as realistic as a successful John Edwards White House run in 2016.

2. And assuming that none of that works, the likelihood that future local and national politicians will use the same public health logic and announce a Bloomberg-esque "ban" of some high cost low value tests, technology and drugs is almost certain.

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