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Tag Archives: beverages
The month of March ushered in news of a new report entitled “Obesity in Canada”. Submitted by the Senate, this report was a 21 recommendation paper to try and constructively address the growing concern of why Canadians are following its Southern neighbors in growing rates of obesity in both children and adults. In fact there are is a doubling in obesity in adults since 1980 and children’s obesity rates in this country have tripled in that time. This report was a breath of fresh air from a government group that many today look at with question of why they are even there.
As a Pharmacy owner that discontinued sale of such products in September of 2014, this story caught my eye. Anything having something to do with sugary beverages is a hot topic with the media, as I abruptly found out that day a year and a half ago. Even a small pharmacy in the middle of nowhere can make the national and international news by making “such a bold and forward thinking move” (as it was described) as stopping the sale of everything from pop, juice, vitamin water, sports drinks and chocolate milk.
Any talk of manipulating the sale of a staple in the Canadian diet will bring about cries of a “Nanny State move”. So when news hit that one of the recommendations from the Senate’s report was a proposed tax on such drinks, the naysayers came out of the woodwork, and along with them, the defenders of the plan. One of the first to press against the idea was Jim Goetz, the president of the Canadian Beverage Association who attempted to educate us in a biased way with stories of how this has been tried in other parts of the world and didn’t work, had no effect on obesity and resulted in lost jobs and increased grocery expenditures. Mr. Goetz is a name I learned back when I stopped selling these beverages and saw an article in rebuttal to this type of move. When I read of crazy claims that increased calorie intake had nothing to do with obesity, it really opened my eyes to the war that goes on in this category.
Granted there is no shortage of stories where an increase in tax on a target food group seemed to be a dud with respect to changes in obesity, even when the calorie intake did seem to drop. Denmark, Mexico, the United States, Finland, France, Hungary all are examples of stories where a tax was implemented with results that vary depending on who tells the story. In fact during a recent CBC Radio interview on the Senate report I gave recently, I was pressed on the success (or lack of) in such programs. I was quite persistent though on the complete irrelevance of the obesity outcome but rather we should focus on the fact that we need to pay for the adverse health issues that arise from the obesity that we know these beverages cause.
When I cross from Dartmouth to Halifax on either bridge, I expect to pay a toll. It doesn’t really cause me to take the long way around through Bedford, I pay the toll and drive over the bridge. I do it because I realize the upkeep of the bridge has to happen somehow and if I don’t pay it through tolls, I’ll sure as heck going to end up paying it some other way. It just makes sense for users to pay for that. When I buy tires for my car, I pay a fee that is to be used for the recycling of that tire at its end of life. You just do it because something has to happen to that tire when you’re done with it and that costs money to do.
If you agree that extra calorie intake results in obesity, then what is it that drains the healthcare budget of a country so quick when its population becomes more obese? Children with obesity are more likely to suffer from type 2 diabetes, hypertension and asthma. Adults with obesity have a higher incidence of depression, anxiety, heart disease and diabetes and also are more likely to be absent from work, pursue lower income jobs and earn lower overall wages (and in doing so pay less tax). Last year in the U.S., health care costs as a result of obesity reached $300 billion annually. A simple consideration in mathematics will show how this cost could be somewhat offset by a sugary beverage tax. Even though there are many reasons a nation becomes overweight, sugary beverages are one of them and you can consider it a user fee with that tax.
Lots of other great ideas came from the report, like an overhaul of the Canada Food Guide – without involvement from the food industry and one of my favorite recommendations, stricter controls on advertising unhealthy food and drinks for kids. Well done Canadian Senate!
Graham MacKenzie Ph.C.
Baddeck, Nova Scotia
September 11, 2014 was a busy day at Stone’s Drug Store in Baddeck. The week that followed was a similar pace. After months of contemplation the trigger was pulled to remove the sale of all sugary beverages from the pharmacy on the second Thursday in September. Before opening on that day I removed all of the pop, juice, chocolate milk, and sports drinks from the floor and coolers and put it in our counseling room for what I thought would be a normal day. Perhaps there would be a few questions or even complaints about this but that would be all. https://stonespharmasave.com/blog/?p=560
In response to an editorial by a group close to the beverage industry that this type of move is ineffective in changing overall health, I responded with https://stonespharmasave.com/blog/?s=sugary
Turned out there was a lot of attention grabbed by this move, not just by local and national media, but also from a Scientist at the Propel Centre for Population Health Impact named Leia Minaker. The Propel Centre is a research centre located at the University of Waterloo that aims for overall better health and cancer prevention. Leia’s proposal was to undertake a natural experiment whereby the effects of a local retailer restricting the purchasing of (in this experiment) carbonated beverages in a small town might have effects like less purchasing of carbonated beverages or perhaps lead to switching of purchasing behavior of these products among stores in the village by its residents.
This study would not have been possible were it not for the amazing cooperation of the two other main retailers in the Village of Baddeck, the Coop (the local grocery store) and Needs (the local convenience store). Along with our sales data Leia collected the sales data of these other two businesses for their carbonated beverages for a period of 88 weeks prior to the September 11 date and a total of 128 weeks of data was collected to give a before and after snapshot of sales. The data showed that we at Stone’s sold just 6% of the carbonated sales in Baddeck. With this in mind it is even more amazing to see that after controlling for summer peak sales, weekly carbonated beverage sales declined by 11.4% as a whole in Baddeck in the post intervention period. In a separate statistical analysis, it was determined that after controlling for model specified seasonality, the sales decreased by 21.4%. Not bad for a little store that sold only 6% of the carbonated beverages overall in Baddeck! Another unexpected finding beyond this was that buying patterns did not appear to shift to the other retail outlets in the village
So congratulations to Leia, to Stone’s and to the residents of the Baddeck area for getting the message we drove out relentlessly about what sugary beverages do to you.
Leia and her team are now embarking on a longer term look at this data. Part of this involves trying to determine the overall buying patterns of the Village before and after we stopped selling the beverages. Natural studies can be rare opportunities for this type of evaluation and they certainly want to use as much data as possible in finding the effects of the sugary drink withdrawal.
Common questions asked of me during this time:
Was this something meant to inspire other retailers to do the same thing? Not really, but that would be nice. It was done for the sole purpose of showing my customers that if I stressed on a daily basis how bad a product is and how it so quietly sneaks into your diet and causes long-term health problems for you then I couldn’t sell it anymore.
You still sell bars and chips. Isn’t this a nanny state move to grab headlines in the news? “Haters gonna hate” I always say. The point shows how much we think drinking juice is good for you, how sports drinks are important to increase athletic performance, how chocolate milk is as healthy as white milk and how pop is ok to have daily because of the sheer presence of these pop companies in sporting event advertising and sponsorship – when this is the exact opposite of the truth in all cases.
Who do you think you are controlling what I can or cannot buy? Well, first of all it’s my store. Second of all you can go for a 30 second walk and still purchase these sugary beverages if you need them.
What about all of the other unhealthy things you sell in the drug store? This criticism ranged from homeopathic products, to vitamins and supplements, to weight loss programs, whatever was the last headline in the newspaper that was useless or dangerous. As a pharmacist my number one thought process is to prevent harm as well as providing an effective product. Any pharmacist will tell you of countless customers who take a product different from the one they spent the last five minutes recommending. In that situation we realize they are buying that other product so we just want to make sure their choice will not result in harm, even if that product is homeopathic. Some of the customer’s choices are unchangeable and part of their beliefs for whatever reason. Often it is a part of a process of that patient determining on their own what works for them and what doesn’t.
And what of the hydromorphone capsules I sell and see addiction develop, the chemotherapy pills when they work sometimes and other times they lead to more suffering and therapeutic failure (try explaining the concept of a successful randomized controlled trial with this patient’s family), taking statins and have a heart attack, take NSAIDS and end up with a GI bleed, take a benzodiazepine for anxiety and get addicted? Everyone has their story of something that went wrong in medicine. I can’t remove everything from the store that has risk so I chose to remove the biggest offender.
So what about the bars – are you removing them also? I’ll admit this was one I didn’t really have an answer for right away but I thought why not get rid of all of this. As I described in the last question I needed to strike a balance between what I thought was completely crazy and acceptable in slightest moderation. I believe that the sugary drinks put us in the hospital long-term and shorten our lives. If everyone ate the bars like they consumed the sugary beverages then they would be gone also.
Have you noticed a change in your sales since you made this move?
Getting rid of these coolers and freeing floor space from pop led to a rearrangement of some of the merchandise in the pharmacy. The organic food and gluten free section definitely was one of the first to expand. So sales grew in this area that is largely driven by large consumer demand and we basically carry what they ask for. The main areas that expanded beyond this were related to the nutraceuticals and compounding. The unexpected exposure gained when the sugary drinks were dropped drew the attention of those who were interested in controlling their health and prevention on their own and for many this meant non-prescription means through evidence bases supplements and food that was free of pesticides and herbicides and were GMO free. These are definitely consumer demand driven products and nutraceuticals require a fair bit of education beyond the Pharmacy degree education I received. Compounding had led me to this area. It turned out all of these “beyond ordinary” pharmacy services caught the eye of these preventative medicine patients out there, so this is where we saw the expansion.
What has been the overall reception from the public?
Overall the public’s response has been great and even a year later people come into the pharmacy that never set foot in here to congratulate us. On social media where one’s backbone grows and anonymity is popular there were some comments that were less than complimentary but overall it seemed most people got it when it came to understanding the reason for this and the real message behind it.
Is it really that unsafe for someone to consume pop or juice?
I use the analogy of a person holding out their hands together to catch marbles that are falling. At first they find it easy to catch the marbles but after a while their hands begin to fill with more and more marbles and they eventually let one drop. This represents the tipping point where something happens to your health and the marbles are the insults over a lifetime, like heavy metal exposure, pesticides, herbicides, fertilizers, stress, processed food, and sugar. Perhaps a little bit here and there doesn’t seem to matter, especially early on, but they all add up together. With the growing mountain of evidence of what sugary beverages can do in even low consumption – it really is that unsafe!
Also a special thanks to Dr. Yoni Freedhoff, a family doctor and assistant professor at the University of Ottawa and author of The Diet Fix for sharing this with a guest blog on his ever popular Weighty Matters blog http://www.weightymatters.ca/2014/09/guest-post-pharmacist-who-refuses-to.html and for the Village of Baddeck and its surrounding area for making this study so successful.
Graham MacKenzie Ph.C.
In response to my decision to remove sugary drinks from my pharmacy in September of 2014, there seem to be the odd lingering claim that “…targeting the sale of one particular category is not going to have a significant impact [on obesity]”, and that “information – not restriction – is key.”
While we agree with the point that obesity is a complex, multifactorial problem, it is completely baseless, in fact hovering on outright deception, that extra calorie intake does not increase your weight. In 2013, the journal PLOS Medicine published a systematic review of systematic reviews, which are the most comprehensive forms of evidence that we have. This review by Bes-Rastrollo and colleagues found that 83% of reviews not funded by the beverage industry a relationship between sugar-sweetened beverage consumption and weight gain. On the other hand, 83% of the reviews that were funded by the industry found insufficient evidence to support a positive association between sugar-sweetened beverage consumption and weight gain or obesity.
Also keep in mind metabolic disease which has also been shown to increase with consumption of these drinks and is one of the main reasons we pharmacists see our customers (high blood pressure, increased cholesterol, increased abdominal obesity, and insulin resistance). For example, a 2010 meta analysis in the Journal of Diabetes Care of over 300,000 subjects found that those that consumed the most sugary drinks, one or two per day (pop, juice, vitamin water, iced tea and energy drinks) had a 26% greater chance of developing type 2 diabetes than those that drank none or 1 serving per month. They concluded that weight gain and metabolic syndrome correlates positively with consumption of these drinks. The New England Journal of Medicine published a study in 2011 which followed over 120,000 people and concluded that one 12 ounce sugary beverage serving a day increased their weight more than those that did not consume this beverage. Finally, a 2012 study in Circulation followed 40,000 men and found a 20% higher chance of having a heart attack or dying from a heart attack when one can of sugary beverage per day was consumed compared to men that didn’t. This was verified by a second study.
Calorie consumption from all sugary beverages combined has continued to climb each decade, especially among children and teens. By coincidence, today, the World Health Organization is changing its recommendation for daily total consumption of sugar to 6-12 teaspoons daily. This would be exceeded by consuming even one can of soda. Finally, we are seeing revised recommendations on sugar that follows science. The new recommendation now recommends free sugars being as low as 5% of total calories, meaning a serving of orange juice is off limits – imagine, a recommendation that pushes you to eat the fruit instead of drinking the juice. Brilliant! There is now a separation of total sugars and free sugars. The total sugar concept meant you could gobble up your calories with juice and pop, but now it’s considered free sugar.
The withdrawal of sugary beverages from Stone’s Pharmasave in Baddeck was not meant to “ban” pop sales, and I certainly do not expect to see a drastic change in obesity levels in my town as a result of my decision. I made this decision to help educate my customers on the effects of sugary drinks. I therefore agree that education is an important component of healthy eating. However, in keeping with recommendations from world experts in obesity research (see the 2015 Lancet Obesity Series), I am also aiming to move beyond education by starting to create an environment in my store that is supportive of healthy food choices. As a pharmacist, I know I shouldn’t sell tobacco, no matter what the industry claims. I don’t feel I should sell sugary beverages, either.