If CV Prevention Gets a Boost, Does It Matter Who Pays?

Betty Crocker, Coke, and CardioSmart at ACC 2011

Shelley Wood

April 02, 2011

April 2, 2011 (New Orleans, Louisiana) — By 9 am, a small cluster of men, women, and one fidgeting child have gathered in the leafy inner courtyard of the Kingsley House in New Orleans, waiting for the American College of Cardiology's (ACC's) second annual CardioSmart Health Fair to start its free cardiovascular risk screening for the general public.

I myself am among them: a journalist who writes too much about skulking CV risk factors to be blasé about her own. I'm also curious: this year's health fair is part of the ACC's revamped Cardiosmart National Healthcare Initiative , flush with an injection of cash from some deep-pocketed corporations you wouldn't ordinarily associate with heart health.

There's no subterfuge here--the ACC issued a public statement back in November 2010 announcing its partners. Among the smattering of health, drug, and device companies are Coca-Cola, General Mills, and Subway, which together donated hundreds of thousands of dollars. Their logos are prominently acknowledged on the CardioSmart New Orleans Health Fair website, after a cluster of local charities.

The ACC has a "patient-centered care committee" and board of trustees that vet potential sponsors based on "how well the organization and its brand fit with the ACC's goals and values." The ACC says it won't endorse any product or service, that it maintains complete editorial independence over program materials, and that organizations have to be committed to "offering healthy choices."

According to ACC spokesperson Amy Murphy, General Mills gave $100 000 in 2010 as a one-year sponsorship to the ACC's CardioSmart program, Coca Cola gave $500 000, and Subway gave $900 000 for three years of funding. Another atypical backer for CardioSmart is Colgate/Palmolive, also spending $100 000. She notes that these numbers will be publicly reported when the ACC updates its 2010 funding sources online.

Here in the Kingsley House courtyard, logos for all of the sponsors, including national-initiative sponsors Coca-Cola, Subway, and General Mills, are listed on the sign at the entrance. Coke is the only sponsor with a tent on the lawn. A cheerful man named Steve, wearing a red Coca-Cola T-shirt that claims to have once been a plastic bottle, offers me a new flavor of Vitaminwater in Creamsicle orange, juvia sweetened. I can also have a Dasani water.

Communities in need

Over 1800 people died in 2005 when Hurricane Katrina stomped through New Orleans and tore down the levies; by comparison, 14 512 people died of cardiovascular disease in Louisiana that same year.

Without question, New Orleans is a city where citizens could benefit from some free cardiovascular clairvoyance. Dr Richard Milani (Ochsner Health Center, Metairie, LA) speaks glumly about the swath of cardiometabolic disease shrouding Mississippi, Louisiana, and Alabama--with rates "typically in the highest decile for stroke and heart disease in the nation"--and New Orleans "right in the thick of it." New Orleans itself, he adds, consistently ranks as one of the most obese cities in the US.

According to recent stats released by the Louisiana department of health and hospitals, 67.6% of adults in Louisiana are overweight or obese, 36% have high blood pressure, and 37% have high cholesterol.

Before coming to New Orleans, I spoke with Dr Patrick Breaux (Ochsner Hospital, New Orleans), one of the local cardiologists who helped plan the 2011 CardioSmart Health Fair. He points to another demographic detail. Louisiana has risk factors, he agrees, but it's also poor. "Twenty-five percent of our population is on Medicaid and another 25% of our population is uninsured, and those numbers are probably even worse in New Orleans," he says. "To be able to bring cardiovascular screening to the community hopefully will help us identify those [at-risk] groups early in the disease process."

Benefits and harms

When you say 'Coca-Cola,' that doesn't conjure up anything that would be considered healthy.

But the questions nag: what place do sugary drinks and fast-food sandwiches have at a health fair? Milani is taken aback when I tell him about the corporate sponsors. Their products, he points out, are one of the main reasons patients are coming in to his office in the first place.

"When you say 'Coca-Cola,' that doesn't conjure up anything that would be considered healthy," he says. "Yes, these companies make the rare healthy option, but that's not what you get bombarded with, when our kids or anybody else are flipping channels and seeing the commercials."

But do the benefits outweigh the harms? Dr Kelly Brownell of Yale's Rudd Center for Food Policy and Obesity says he's heard this question before and knows the answer.

"It's common for professional organizations and individual scientists to take money from industry believing that the activity that they're going to engage in is so important that it overrides the branding and marketing opportunity that the companies get from these activities," he says. "Food companies don't invest unwisely, so if they're putting, say, $10 000 into this event, they expect to get more than $10 000 back from it in visibility, in good will, in reputation. And so the ACC should be fully aware that they are helping those companies make money and ultimately sell more product.

"I'm sure good things will be done with the money," says Brownell, "but the question is whether damage is also done."

The defense of choice

A few weeks ago, Coca-Cola spokesperson Kristen Witt assured me this was just a "corporate sponsorship," permitting logo visibility (not a "branded sponsorship" as in, presumably, the "Coca-Cola Health Fair"). She's also emphasized that Coca-Cola represents over 400 different brands (500 according to the Coca-Cola website), not all of them sugary drinks.

"Coca-Cola is a company name; it also happen to be one of our beverages, but that's just who we are. And we always have offered a variety of choices," Witt tells me.

Indeed, ask any of these organizations about just why they are involved in community health and you'll hear again and again about "options" and "choices."

The "Eating Healthy" section of the General Mills website asserts in bold type: General Mills tries to help with weight management by offering great-tasting, lower-calorie options.

Likewise, public-relations coordinator for Subway Rob Wilson tells me candidly, "We're pleased to have on our menu options for everybody, whether they are concerned about their health, whether they feel like being indulgent, whether they want a footlong sandwich or a salad with some turkey in it. It's really their choice."

I understand the Great American Defense of Choice--the forefathers didn't die on battlefields so their descendants would be stuck with the Ornish diet--but looking around at the mix of mostly heavy bodies lining up here today, I can't help but think that the marketing folks who first fashioned the concept are laughing all the way to the bank.

The ACC should be fully aware that they are helping those companies make money and ultimately sell more product.

You see the Coca-Cola logo and you think Coke (170 calories)--you don't think Vitaminwater or Odwalla juice. Choose as much you like at the Subway sandwich counter, but the company websites boast that its most popular offerings are the "Italian BMT" (450 calories, 20-g fat in the six-inch sub; its website suggests, "Try it with a Coca-Cola and Doritos nacho cheese") or the "Meatball Marinara" (1160 calories, 46-g fat in a footlong sandwich). And while the General Mills name might conjure up a box of heart-smart Cheerios, this is a company that also brings you Betty Crocker Decadent Supreme cake mixes, Häagen-Dazs ice cream, and Pillsbury Big Deluxe cookies.

I call up Dr Gerald S Berenson (Tulane University, New Orleans) a few weeks before the fair, founder of the original Bogalusa Heart Study and the grandfather of CV prevention in Louisiana. The phone connection isn't great or he's hard of hearing or both, but he's confused about who I am and why I'm asking him about Coke, Subway, and the ACC. At first he seems to be congratulating me for nailing down some big-name sponsors, calling them "great."

"Money is so tight to get to continue our work," he laments. Coca-Cola has been around for a century, he says, and people are going to drink it. "And if they give grants to do prevention, I think it's a benefit. Subway is a newer company, but the same thing applies--you could also go to McDonald's."

When I can make it clear that I'm a journalist, seeking his opinion on this kind of partnership, it turns out he's all about choices as well. "I think the contribution toward health and awareness to the public is a benefit, and the public has to decide whether they will drink Diet Cokes or regular Cokes: they have the privilege of choice, and these companies are providing healthy options."

Reaching the masses

Meredith Hurt has been organizing of this year's health fair from the ACC's Heart House in Washington, DC. She speaks of the vastly expanded effort the ACC has gone to this year to advertise the event: through ads in local papers and websites, fliers to nearby housing complexes, promotions via charity groups, community-health partners, and neighborhood organizations.

"This is open to everybody, of course, but our main goal is to reach the un- and underinsured, so we were definitely targeting those neighborhoods."

Inside the Kingsley House gates, the lawn is dotted with tents offering advice on smoking cessation, nutrition, blood-pressure management, weight loss/management, fitness, and medication management. There's a kids fitness area with skipping ropes and an agility ladder, plus another tent where kids can decorate a paper heart with stickers and baubles.

The health screenings are taking place inside the gymnasium, a pre–Civil War brick structure that was once a cotton mill, at the back of the sprawling lawn. After weighing yourself and entering your personal information into a computer, you progress through stations offering on-the-spot testing for blood pressure, total cholesterol, blood glucose, and waist circumference. Then you're directed to a little table where a nurse or doctor walks you through your results.

The sponsors were not something the local organizers were involved with.

When I call up Breaux in the weeks before the fair, it's clear he's proud to talk about the work he and others have put in; what he does not want to discuss is Coke and Subway. "The sponsors were not something the local organizers were involved with," he says, sounding uncomfortable. "I don't think it raises a big flag in my mind, but I'll defer to the ACC group that is planning this event."

By coincidence, it's Breaux's wife, Donna, a nurse, who reads over my numbers after I've had my arm cuffed, my waist measured, and my fingertip pricked.

She's able to point out her husband, so I can go and introduce myself in person. He had already told me that, in the wake of Katrina, health clinics serving "the indigent and uninsured" opened across the city. "New Orleans probably has in the range of 30 [National Committee for Quality Assurance] NCQA-recognized medical homes," he says, "and the vast majority of those have agreed to having the fair refer patients to them who need follow-up."

Meeting him today, he reminds me again just how many people this fair could help, and he pulls me back into the gym so he can show me the glossy fliers on the tables where people get their test results. One lists the names, addresses, and phone numbers of 65 affordable community health clinics that have agreed to take new patients. Another is a map showing all of the clinics in the area.

Waiting now, under the New Orleans sun, to see who will show up, Breaux says he feels "like a bride at her wedding."

The business of image

These days, physicians, institutions, professional societies, meetings, journals, and their potential ties to drug and device companies are under ever-increasing scrutiny, but that microscope has rarely been focused on ties with other types of corporations. One exception is the National Heart, Lung, and Blood Institute's (NHLBI's) contentious partnership with Coca-Cola for its Heart Truth campaign, a collaboration that led the US Center for Science in the Public Interest's efforts to call for the institute to drop Coke as a sponsor--a request the NHLBI has ignored.

In fact, the ACC's Murphy says the college consulted with the NHLBI when developing CardioSmart.

I don't think we're in the business of improving Coke's image.

"We're not endorsing any of their products, we partner with them because of their outreach to consumer audiences, and they've all been vetted by our membership. We modeled our program in many ways around what the Heart Truth has done, making sure that our policies were in place. We're pretty confident in our own management of our relationships with industry."

What's more, she says, having these particular companies involved will likely lead more people to find out about the health fair, since the target group is "those product consumers."

Local Subway stores, for example, are advertising the fair. Last year, Murphy says, the CardioSmart event saw about 250 people; this year, they are hoping the number to reach into the thousands.

"I don't think we're in the business of improving Coke's image," Murphy insists. "We're not endorsing their products. . . . And there are people at those companies who can talk to you about everything they've done with their healthy-living dollars."

Sparkling repartee

Witt, with her soothing, Southern inflection, is only too happy to tell me about Coca-Cola's commitment to health and nutrition. In 2008, for example, Coke spent $9 million to support active, healthy-lifestyle programs. But try to pin her down as to why, exactly, Coke is sponsoring a health initiative, and you can be forgiven for feeling like you're ice being swirled in a glass.

Is it, per chance, Coke's way of giving back?

"Oh, I wouldn't put it like that," Witt intones, sounding almost disappointed in me for asking. "We have a long tradition of partnering with national community-based organizations to fund ways to help people make a positive impact in their communities and live healthy lives, and the ACC is one of the many health organizations that we work with."

Okay, but why?

"It's part of a tradition we have in supporting organizations that have meaningful programs that we think can benefit people."

Right, but why, what is the goal?

"Well, it's exactly what I've just described to you! This is just part of what we've being doing for more than 50 years."

Altruism and advertising

I turn the why question over to Brownell, a long-time adversary of Coca-Cola; he sounds almost jaded, habituated as he's become to reporters presenting him with these kinds of patently obvious questions and asking him to opine.

"If there were altruism behind the company's motivation, they wouldn't feel the need to do branding and advertising," he points out. "There's very clear research that sugar-sweetened beverages, for example, are related to the risk of obesity, diabetes, and heart disease, and why [the ACC] is taking money from a company that could be contributing to the very diseases that they're trying to remedy is pretty baffling."

Milani is torn. "I'm a big fan of the concept [of free health-screenings] and a big fan of the fact that the ACC is doing this, but I'm also a little hesitant about who they may be partnering with, if they're going to be choosing corporate sponsors that don't walk the walk. Obviously we're going to screen more people if we get this money and maybe we're going to make a difference in somebody's life, but now we're going to be tainted, so what do you do? I don't have the right answer."

Breaux, in the Kingsley House gym, remembers that I had asked him about the sponsors when we spoke by phone--he's quick to point out that logo visibility has been kept to a minimum; there is no mention of sponsors inside the gym, where all the volunteers in white coats, with their vials and cuffs, are measuring the public's health.

"What we're doing here is a good thing for New Orleans," he tells me, watching my face for a reaction. "This is something we need."


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