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Archive for June, 2009

The thing about sodas

Drink Pop? You’re Probably Round.


“Have you noticed how people who drink pop are round?” an associate remarked to me as we sat around a conference table at the beginning of one more standing meeting. I looked around the room and saw that 6 of 7 people with their big gulp soda tankards had that unmistakable American look that foreigners joke about. You know, that “large” look: 30-50% north of ideal body weight and waist measurements that look down on the measly hip numbers. In short, round. I had to nod in agreement.


Her comment sparked a number of questions that seemed much more stimulating than anything on the meeting agenda so I casually pretended to take notes and, thanking the Wi-Fi gods, began Googling for answers. Learning is so much more fun these days, isn’t it?


First, I found out that the safe acceptable daily intake (ADI) of the various artificial sweeteners wasn’t as large as I thought. It amounted to only 5 mg/kg of sucralose (Splenda) and saccharin (Sweet’N Low, SugarTwin) which is about 5 cans of diet pop or 8.5 packets we all use; 15 mg/kg of Acesulfame (Sunett, Sweet One), about 25 cans of soda; and 50 mg/kg of aspartame (NutraSweet, Equal) the equivalent of 15 cans of soda.


Second, they do seem to work as designed in controlled studies when compared to sucrose (sugar) in short periods where the diet drinkers were noted to have lower total caloric intake, body mass and blood pressures than those drinking sugared drinks.


Third, each of these sweeteners is very sweet, some 200-300 times sweeter than sugar. And because of that they may actually increase our taste for sweet things.


Fourth, studies including the Harvard Nurse’s Health Study show that drinking pop, especially sugary pop, is linked to obesity and diabetes. Diet pop was also implicated. An 8 year-long study by Sharon Fowler, MPH, and colleagues at the University of Texas Health Science Center in San Antonio found that “overweight risk soars 41% with each daily can of diet soft drink.”  A table of her findings is startling:



Increased Risk of Obesity

Cans of Pop Per Day

Regular Pop

Diet Pop

0 – ½ can



½ – 1 can



1- 2 cans



> 2 cans



Adapted from: Fowler, S.P. 65th Annual Scientific Sessions, American Diabetes Association, San Diego, June 10-14, 2005.


Fifth, the average American consumes a huge amount of very sweet tasting carbonated drinks (whether sugared or diet) when compared to the rest of the world (from the equivalent of 12 bottles in 1900 to almost 600 12-ounce cans of soft drinks per person each year in 2005 with young males consumer almost 2 quarts a day!


Sixth, the average weight of Americans has mirrored the increase in soft drink consumption to where we weigh almost 25 lbs more now than we did in 1960 (166.3 lbs in 1960 to 191 lbs in 2002 in males and from 140.2 lbs to 164.3 lbs in women over the same period). In the same period we’ve only grown about an inch taller. Uh, you see roundness in those numbers?


It just seems that even though a direct causal relationship can’t be found, drinking pop (no matter what type) is linked very closely with obesity and diabetes. Why?


Sweet drinks (whether sugared or diet) don’t satisfy hunger nor curb a person’s appetite.  Consuming 150 calories from a can of regular pop doesn’t lead to people decreasing their usual dietary intact by 150 calories. Our bodies still need nutrients that they can’t get from sodas whether sugared or not. Sweet drinks don’t just sweeten out tastes but may even be appetite stimulants according to a number of studies. Those who drink more tend to eat more … and get round.


Most people understand how sugared drinks would cause weight gain. Each one contains the equivalent of 9-12 teaspoons of sugar and can conceivably overwhelm the body’s ability to metabolize that amount in the time most of us down a can of pop. But what about diet pops? Functional MRI studies have demonstrated that there’s no evidence that artificial sweeteners (at least for aspartame) increase the level of insulin like sugar. Yet they produce similar results over the long hall even though they don’t appear to have a direct link to disorders of carbohydrate metabolism.


What did I learn during the meeting? First, sugar, in the quantities present in pop is nothing but bad.  Second, just like how we’ve learned how damaging trans-fats are after years of thinking they prevented heart disease, I suspect we will uncover direct causal relationships between these artificial sweeteners and obesity or diabetes in the upcoming years.


In the meantime we all have choices. Don’t like being round? Start by taking an easy step and drop the pop.

It’s not EMRs it’s CONNECTIONS

Too much emphasis is being placed on individual physician office EMRs. When individual practices implement a stand alone EMR that’s not connected to others it’s marginally better than paper systems. The problem we have in medicine today is that most physician offices are mom-and-pop shops that don’t invest in the same systems or connections to the other physicians, hospitals, labs and 3rd party payers.
This isn’t surprising because most offices can barely afford the $15 – $30K per physician to implement a good EMR system and go paperless in their offices. Interfacing to all of the other offices, labs, hospitals and 3rd party paryers that are involved in the care of their patients would require an investment far greater than what was spent to digitalize their offices. Maintaining these interfaces is also very cost prohibitive.
The US government has failed in its responsibility to set interoperability standards and as a result most systems that are implemented at the office level cannot talk to other offices, often if the other office implemented the same system from the same vendor. One of the reasons the government has failed is that we don’t have a single payer system. A single payer system is distinct from a nation wide singer payer. Like Germany and other countries the government should be the single collector and distributor of premiums but we could have private adjudicators. In this scenario everyone would be adhering to the same rules and all computers would share the same underlying database build but would be free to choose from a large number of vendors.
Examples of this are the standards for rail systms where almost all railroads share the same track gauge so that a railroad car can travel coast to cost without having to unload and reload it’s contents. Another example is that all of us follow nearly identical rules of the road when driving so we can take our cars and travel anywhere without having to switch sides of the road or learn different traffic signs. Most cars also share similar controls.
Unfortunately those underlying rules are not present in the electronic medical record arena so there’s no easy way for the information collected in one doctor’s office or hospital to flow with the patient to other facilities. Until that happens we’re going to continue to flounder and not make much progress in the digitalization of health care. We may also continue to see marginal incremental gains instead of the large savings and efficiencies needed in medicine in order to meat future demands.