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SI Joint Dysfunction

Painful Low Back Issue Responds To Advanced Treatment

One of the many causes of low back pain is related to injuries of the sacroiliac (SI) joint and ligaments. Most common in young and middle aged women, this condition can make sitting and standing quite painful. SI joint dysfunction is difficult to detect, but with precision diagnostics and effective, non-surgical therapy, a board certified specialist can help you obtain significant long-term, potentially permanent relief.

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A complex condition
The SI joints connect the pelvic bones to the lowest part of the spine. Small and very strong, SI joints provide structural support and stability, functioning as shock absorbers for the pelvis and the lower back.

Not a lot is known about why SI joints become painful, but current medical consensus is that a change in the normal motion of the joint may be the source. Too much or too little movement may cause pain in the ligaments and joints, as well as spasms in the supporting back and pelvic muscles. It may be the result of direct trauma such as a car accident or as simple as a missed step when descending stairs. The stress of childbirth can also weaken the SI joint and other supporting pelvic structures causing pain and instability. Sitting, standing and bending at the waist aggravates the pain. When SI joint dysfunction is severe, there can be referred pain into the hip, groin and leg.

SI joint dysfunction is difficult to diagnose because currently there are no radiologic tests available that consistently detect abnormal motion of the joint. Experienced pain specialists, familiar with the mechanics of the SI joint, can conduct a precise musculoskeletal examination of the spine and pelvis. This type of exam can often detect SI joint dysfunction. Tests such as x-rays, MRI, CT scan and bone scan may be used to rule out other causes of back pain, but they generally are not helpful with diagnosing SI joint injuries.

Long-lasting relief without surgery
Simple, non-surgical techniques have proven to be very effective in resolving SI joint pain. Injections of anti-inflammatory medication and local anesthetic in the SI joint and ligaments can greatly reduce pain and discomfort for extended periods of time. Radiofrequency neurotomy creates a longer lasting result through denervation – obstructing the nerve supply to the SI joint. Advanced regenerative treatments, such as prolotherapy and platelet rich plasma therapy, may also show excellent clinical benefit. These treatments specifically promote natural healing of the joint and ligaments. By improving strength and stability, regenerative therapies may offer longterm and potentially permanent pain relief.

Safely performed in a sterile, office- based setting, these therapies offer the potential for significant pain relief without surgery, general anesthesia, hospitalization or prolonged recovery periods.

 

Pelvic Instability

Healing Back, Hip and Groin Pain from Pelvic Instability

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Many women live with the chronic, often crippling pain of pelvic instability, a condition believed to be widespread but not easily diagnosed. This prevalent source of pain in the lower back, hips and groin is difficult to detect because traditional examination and imaging tests do not reveal impairment. As a result, these women are frequently misdiagnosed and untreated. But now, advanced regenerative injection therapies have proven to be effective. They can promote lasting pain relief by healing the injured tissues that lead to instability and pain. The key is to find a pain specialist experienced in both diagnosing and treating this condition.

Common causes
Women are more susceptible to this condition than men, because their pelvic structures are built wider and more flexible for childbirth. The pelvic bones bear the weight of the upper body and distribute it to the hips and legs. This basin-shaped structure consists of the hip, sacrum and pubic bones all held together by ligaments. When the ligaments are injured or overstretched, the pelvis loses its stability and begins to move excessively with physical activities, causing hip, back and groin pain. Even simple movements can become painful, making it difficult to sit, walk, stand, pick up a toddler, drive a car, or merely roll over in bed.

Trauma, a fall on the buttocks or lifting a heavy object, can weaken pelvic ligaments. However, the most common cause is childbirth. Many women first experience pelvic pain after delivering a baby. Symptoms may become apparent soon after birth, or gradually appear years later as ligaments are further impaired by normal physical activities.

Difficult to distinguish
Left untreated, pelvic instability can gradually worsen, leading to severe pain and limitations in activity tolerance. Unfortunately, this condition often goes undiagnosed for several reasons. The symptoms mimic other conditions. The true source of pain is not easily recognized. Today’s imaging technology is unable to detect the abnormal motion of the pelvis or ligament laxity. MRI and CAT scan studies only show torn ligaments, not weak ligaments. Attaining an accurate diagnosis requires a specialized musculoskeletal exam that is performed by a physician experienced in treating the condition.

Often untreated, yet highly treatable
Although difficult to diagnose, this condition can be effectively treated and potentially cured with innovative, non-surgical techniques such as prolotherapy and the revolutionary new platelet rich plasma therapy. These regenerative injection therapies provide pain relief by restoring pelvic stability. Working in tandem with the body’s natural healing process, they strengthen pelvic ligaments by stimulating new growth. Performed without general anesthesia, hospitalization or long recovery, this safe, no pharmaceutical approach can help women regain their active lifestyles – jogging, skiing, even horseback riding – and get back to living again.

Musculoskeletal Applications of Platelet-Rich Plasma: Fad or Future?

Abstract
OBJECTIVE: The purpose of this article is to detail the biology of platelet-rich plasma (PRP), critically review the existing literature, and discuss future research applications needed to adopt PRP as a mainstay treatment method for common musculoskeletal injuries.

CONCLUSION: Any promising minimally invasive therapy such as PRP deserves further investigation to avoid surgery. Diagnostic imaging outcome assessments, including ultrasound-guided needle precision, should be included in future investigations.

KEYWORDS: musculoskeletal imaging • platelet-rich plasma • tendinopathy • ultrasound

Introduction
Chronic musculoskeletal injuries involving tendon, muscle, ligament, and bone have long eluded the use of standardized therapeutic protocols, regardless of cause. Ultrasound-guided fenestration or tenotomy has been used with success as a potential treatment of chronic tendinopathies. In addition, researchers have tested the efficacy of a wide array of injectable agents, from relatively simple solutions such as hyperosmolar dextrose (prolotherapy) to complex orthobiologic agents such as bone morphogenic protein, but none have met with uniform success. Plateletrich plasma (PRP) injection has emerged as a treatment alternative for many musculoskeletal conditions. Although concentrated platelet therapy, which includes PRP, has been used for 20 years, it has recently been popularized by the media after its positive effects were reported to be responsible for an American professional football player’s accelerated return to play and subsequent victory in the 2009 Super Bowl.

PRP is defined as a platelet concentration higher than the physiologic platelet concentration found in healthy whole blood. Some authors have adopted a more objective definition of five times the platelet concentration of whole blood. The ability to concentrate platelets allows a higher concentration of the bioactive growth factors reported to promote healing. There are currently many clinical applications of PRP, including bone healing in oral maxillofacial surgery, postoperative wound healing, and postoperative rotator cuff repair integrity in orthopedic surgery. The positive effects in these intraoperative applications have stimulated the use of PRP in the sports medicine outpatient clinic setting, mostly for chronic tendinopathies and often in a collaborative setting involving a musculoskeletal radiologist who assists in diagnosis, imaging-guided injection of PRP, and follow-up. The recent explosion of the clinical use of PRP has outpaced evidence-based research. Few randomized controlled studies and smaller anecdotal case reports document clinical success of PRP. This article will detail the biology of PRP, critically review the existing efficacy studies, and discuss future research applications that need to be performed if PRP is to be adopted as a mainstay treatment method for common musculoskeletal injuries.

Biology of PRP
The average platelet concentration of whole blood is 200,000 per µL (normal range 150,000–350,000 per µL). Platelets are small anucleated cytoplasmic fragments of megakaryocytes that are commonly thought of as the responsible agents for hemostasis. Although the platelet is central to the coagulation cascade, it is also essential to tissue healing. The first step of the healing process is clot formation and platelet activation. After platelet activation, many growth and differentiation factors are released from the -granules, which are storage units found in platelets. Ninety-five percent of the existing factors are released within 10 minutes of clot formation, whereas the rest of the growth factors are released as they are formed over several days. In vivo and in vitro research also suggest that PRP induces overexpression of additional endogenous growth factors beyond what is contained within the platelet concentrate.

Wound healing involves an intricate process that is often categorized into three overlapping phases: inflammation, proliferation, and remodeling. Once tissue injury occurs, a hematoma forms at the site of tissue damage, platelets adhere to exposed collagen creating a clot, and the inflammatory phase begins with activation of platelets resulting in release of growth, bioactive, and hemostatic factors. Each factor plays a unique but codependent role in the early stages of the intrinsic and extrinsic pathways of the clotting cascade. Access to the wound site by neutrophils and macrophages occurs within hours of injury and likely serves to provide phagocytosis of tissue debris. Within a few days of injury, the proliferative phase begins that is characterized by angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction. Finally, spanning from several weeks to months after an injury, the remodeling phase involves collagen maturation and apoptosis of excess cells.

The potential benefits of PRP are thought to rely on the intrinsic properties and interplay between the concentrated growth factors [6–8, 18]. Some of these important growth factors include platelet-derived endothelial growth factor, transforming growth factor–β, vascular endothelial growth factor, fibroblast growth factor, epidermal growth factor, and insulin-like growth factor -1. The complex interactions of these growth and differentiation factors, along with adhesive protein factors such as fibronectin and vitronectin, are what is responsible for the healing response; promoting the long regenerative process of chemotaxis, cell proliferation, removal of tissue debris, angiogenesis, extracellular matrix formation, osteoid production, and collagen synthesis.

Preparation of PRP
Before the PRP injection, the patient is informed of the procedure and potential risks and benefits similar to other interventional procedures. Risks related to the interventional procedure include infection, hemorrhage, and soft-tissue injury. The use of sterile technique and a probe cover if using ultrasound guidance is warranted. In general, PRP is avoided when there are signs of local inflammation or infection or if there is a history of malignancy. The patient is also educated with regard to short-term and long-term expectations. Because the injection of PRP induces local inflammation, pain should be expected after the procedure. Nonsteroidal antiinflammatory drugs are also avoided 2 weeks prior and at least 2 weeks after the procedure so as to not inhibit the effects of growth factors and the healing response. Although the follow-up protocol may vary, physical therapy at least 2 weeks after the procedure is often considered.

The working definition of PRP is 1,000,000 per µL platelet count, which is five times the normal concentration found in whole blood. PRP is commonly prepared in the laboratory, operating suite, outpatient sports medicine clinic, or radiology setting using a centrifuge. There are different types of centrifuge methods: the gravitational platelet sequestration technique, which requires only a tabletop centrifuge system takes less than 30 minutes; the cell separator, which generally requires a full unit of whole blood; and smaller compact office systems. Centrifuge systems may differ in the ability to separate RBCs from platelets affecting concentration, separating leukocytes from platelets, or shearing platelets during the centrifugation process leading to premature platelet activation and degranulation. Standardizing the concentration and composition of PRP is difficult with such variability in the centrifugation market. No study, to our knowledge, has compared the effectiveness of different PRP preparation systems or platelet concentrations against one another for any indication.

Preparation of PRP begins with venipuncture and subsequent collection of a product-specific volume of autologous whole blood from the patient into a syringe containing an anticoagulant, typically at the point of care. Centrifugation separates the whole blood into three layers: RBCs (bottom layer, specific gravity = 1.09), platelet-poor plasma (top layer, specific gravity = 1.03), and platelet concentrate that contains WBCs (middle layer, specific gravity = 1.06). Typically the RBC layer is discarded after the first spin and a second spin yields a more concentrated platelet layer. The PRP amount is approximately 10% of the volume of whole blood originally collected; about 3 mL of PRP can be collected from 30 mL of whole blood after a 15-minute spin at 3,200 revolutions per minute. Once prepared, the PRP is maintained in a sterile environment and immediately used during an outpatient procedure or surgery. PRP is typically administered with a syringe through a 20- or 22-gauge needle either under ultrasound guidance or using anatomic landmark guidance in the clinic. The needle-induced bleeding during injection provides the clotting factor thrombin needed to activate platelets. Needle fenestration of the tendon may also be considered before the PRP injection. Exposure to collagen within the tissue further activates platelets. Bovine thrombin, calcium, or soluble type-I collagen have also been used to activate platelets but usually in the intraoperative setting. Typically, the use of local anesthetic in the region of the PRP injection is avoided because the effect on PRP success is not clear.

Four categories of platelet concentrate preparation are recognized: leukocyte-poor or pure platelet-rich plasma, leukocyte platelet-rich plasma, pure platelet-rich fibrin clot, and leukocyte platelet-rich fibrin clot. Factors such as centrifugation force and duration of centrifugation can yield different platelet concentration levels and composition. However, each has different biologic effects and potential uses. To our knowledge, no evidence-based classification scheme or guidelines specifying optimal use has been reported.

In Vitro and Animal Studies Using PRP
The first published in vitro study showed that PRP stimulated the proliferation of cell types such as osteoblasts, fibroblasts, tenocytes, chondrocytes, and mesenchymal stem cells. Lucarelli and colleagues showed that PRP had a positive effect on human stem cell proliferation and markedly increased cell numbers with increasing PRP concentration from 1% to 10%. Another in vitro study of cultured human tenocytes showed that PRP promoted tendon regeneration by inducing proliferation and total collagen production. However, other in vitro studies have reported contrasting results. The ability of PRP to differentiate cell lines is also controversial. One study showed that PRP can stimulate stem cell differentiation into osteoblasts, but others had mixed results.

Several animal studies using PRP have produced promising results. Bone healing was enhanced with respect to stronger callus formation in rabbit calvaria defects and in mandibular reconstruction in goats. The mechanism, according to Tomoyasu and colleagues, may be from a positive effect of PRP on osteoblastic differentiation.

Animal studies have also shown a positive effect on tendon healing. PRP injected into rat patellar tendons was found to be safe and had the potential of increasing early tendon healing activity by stimulating type I and III collagen required for repair and remodeling of tendons. However, other animal studies have shown contrasting results. Aghaloo and colleagues found no significant difference in bone graft strength between autogenous rabbit bone, PRP alone, or autogenous rabbit bone and PRP combined. Chaput and colleagues showed that PRP did not play a significant role in increasing bone ingrowth of PRP-treated implants in the distal femur of rabbits. Further investigation is needed using standardized PRP concentration and composition to help clarify biologic effects using animal models.

Clinical Studies Using PRP
Common musculoskeletal injuries account for nearly 100 million office visits annually in primary care and orthopedic clinic settings in the United States. PRP is seen by many orthopedic, primary care, and sports medicine physicians as a new treatment option for tendon, muscle, and bone injuries. Radiology clinics, especially those offering musculoskeletal ultrasound services in a collaborative sports medicine environment, are seeing significant increases in the volume of ultrasound-guided treatments for chronic tendinopathies, plantar fasciitis, and acute ligamentous and muscle injuries.

Clinical studies have reported that PRP use can shorten recovery time, enhance bone strength, produce bone healing in a shorter time, decrease the wound infection rate, and reduce surgery-related swelling and pain. However, most of these have been small nonrandomized studies or anecdotal case reports. The popularity and increased use of PRP is outpacing available scientific evidence; its use has especially increased after receiving media attention for its use in a professional athlete whose accelerated return to play in the Super Bowl was credited to PRP treatment.

An early clinical application of PRP was adding autologous fibrin made from concentrated platelets to cancellous bone during maxillofacial reconstructive surgery. Serial radiographic examinations showed consolidation of the bone at 4 weeks opposed to 8 weeks in control subjects, which was attributed to platelet enhancement of osteoconduction. Further studies detailing the clinical applications of PRP besides maxillofacial surgery have also included plastic surgery, heart bypass surgery, dermatology, and orthopedics. The clinical applications are also starting to permeate radiology practices associated with sports medicine clinics. PRP injections are now commonly used to treat chronic tendinopathies, including lateral epicondylosis (tennis elbow), plantar fasciitis, and Achilles and patellar tendinopathies. Onsite sports medicine clinics are also offering PRP treatments for acute injuries such as acute muscle tears, medial collateral ligament tears, and ankle sprains. A growing number of prospective randomized controlled trials have assessed the effects of PRP.

Tennis Elbow
Lateral epicondylosis is commonly referred to as “tennis elbow.” It is the most common cause of elbow pain in skeletally mature athletes, occurring in more than 50% of tennis players and resulting in weakness, pain, and suboptimal performance in athletes. It is characterized as repetitive microtrauma with mucoid degeneration of the common extensor tendon where it attaches to the lateral epicondyle of the humerus. Ultrasound is useful in evaluating lateral elbow pain, especially in helping to evaluate the extent of tissue damage in patients refractory to conservative management. A pathologic tendon may show hypoechogenicity, an increase in caliber, fibrillar disruption, or hyperemia on Doppler evaluation. Using clinical outcome measures, Mishra et al. reported in a small (n = 15) randomized clinical trial of PRP treatment for chronic elbow tendinosis that subjects receiving PRP in a single injection session had an 81% improvement in pain scores at 6 months and up to 93% at 25 months compared with their baseline status. A recent larger double-blind randomized controlled trial (n = 100) comparing PRP with corticosteroid injections found a statistically and clinically significant difference in disease specific quality of life in pain scores favoring the PRP group. Interestingly, the PRP group progressively improved at 1 year compared with the steroid group, which declined after an initial short-term improvement, suggesting that progressive healing may be responsible for clinical improvement in the PRP subjects. However, ultrasound evaluation was not used in either study, so tissue-specific healing is not known. Research involving imaging studies will help to confirm disease-specific tissue healing. Diagnostic imaging before PRP treatment will also help confirm the clinical diagnosis and establish baseline findings. In addition, ultrasound guidance for PRP treatments will ensure precise targeting of diseased tissue.

Achilles Tendinopathy
Chronic Achilles tendinopathy is a common overuse injury characterized by degeneration and abnormal tissue repair that affects athletes and middle-aged individuals. Achilles tendinopathy can progress to debilitating pain with significant health and economic cost to society. There is generally no effective definitive nonsurgical treatment; and 25–45% eventually require surgery, significantly adding to the cost and morbidity. PRP injections may offer a treatment option although current trials are limited. In a study comparing PRP to blinded sham saline injections, de Vos and colleagues reported significant improvement in both saline and PRP groups that slightly favored the PRP subjects but not by a statistically significant margin. However, the study was limited by a short follow-up period (24 weeks) and small sample size (n = 27) and was confounded by eccentric exercise performed in both groups, which has been reported to be an effective treatment of Achilles tendinopathy. Saline injection may not be the best placebo because it is likely active for tendinopathy; injecting saline into the tendon alters the pressure–volume relationship in a given space, thereby disrupting pathologic vascular and neural ingrowth, and injection-related needle trauma produces local bleeding, which is a known irritant and recruiter of platelets in both groups. One study suggested that dry needling, or percutaneous tenotomy, may be an effective alternative for treating chronic tendinopathy, including Achilles tendinopathy.

Plantar Fasciitis
Plantar fasciitis is a musculoskeletal disorder affecting the fascial enthesis and is the most common cause of inferior heel pain. Plantar fasciitis is an important cause of pain and disability among athletes but also is prevalent in the general population, especially sedentary individuals, affecting an estimated two million Americans annually. The cause of chronic plantar fasciitis may relate to a chronic degenerative condition from repetitive stress injury. These degenerative features are comparable to the tendinosis seen in tennis elbow, Achilles tendinopathy, and patellar tendon (Jumper’s knee). Currently, there is no uniformly effective treatment of plantar fasciitis, and no conventional therapy directly addresses the underlying pathophysiology of the degenerative tissue. Again, patients who have failed conservative management may be ideal candidates for PRP therapy, possibly circumventing the need for surgery.

Barrett and Erredge reported complete resolution of symptoms at 1 year in approximately 78% of subjects with plantar fasciitis treated with PRP. However, the study was limited by a small sample size and lack of a control group. Larger-scale randomized controlled studies are needed to help elucidate PRP as a viable treatment of this common musculoskeletal injury.

Postprocedure care data are limited and without standardization. Typically, after PRP treatment patients are kept nonweightbearing for 48 hours and in a weightbearing boot for 2 weeks with a gradual return to activity over the course of 6–8 weeks. However, some studies have shown a benefit to early rehabilitation with early stretching exercise to mechanically induce healing. Mechanical stimulation in one study of repaired animal tendons resulted in an increase force to failure. This increased strength was attributed to PRP effects allowing mechanical stimulation earlier in the healing process, thereby increasing the growth rate of tendon regeneration. Standardized postprocedure protocols for the various musculoskeletal conditions treated with PRP need to be established.

Acute Ligament Injuries
Despite limited evidence, PRP use for acute musculoskeletal injuries has also continued to gain popularity. In a recent review, Foster and colleagues discussed an unpublished retrospective study involving professional soccer players with grade 2 acute medial collateral ligament injuries showing an accelerated return to play by 27% in the PRP treated group compared with a control group treated with standard rest and rehabilitation. Here too, the sample size was small (n = 22). Similarly, a pilot study by Frei and colleagues described the use of calcium-activated PRP for type 3 ankle syndesmotic injuries in 11 patients. Investigators found an average time of healing of 5.18 weeks, with five patients achieving a full recovery without residual instability at 4 weeks, which differed from previously published reports showing an average return to play of 8 weeks after conservative standard of care treatment. Despite the small sample size, lack of imaging guidance, and absence of a control group, these early results suggest PRP may have an effect on augmenting ligament healing and reducing dynamic instability. Ultrasound guidance can offer precise needle placement for ligament injuries and monitor healing, which adds value to both the patient and clinical colleagues.

Acute Muscle Injuries
Acute muscle injuries (strains) are common athletic injuries, especially among elite athletes. The mechanism of injury is usually a direct blow to the muscle or from uncompensated eccentric loading during muscle contraction. Muscle strains of the thigh were the most common diagnosis (16%) in a survey study of the 2007 International Association of Athletics Federation World Championships. Other common muscle group injuries include gastrocnemius and quadriceps. Characterizing the severity of muscle injury by size and location is important, and imaging can play a vital role in prescribing treatment, monitoring rehabilitation, and stratifying risk for reinjury. The risk of reinjury is high. For example, there is a 30% reinjury rate within 1 year of initial hamstring injuries.

Preliminary clinical data supporting the use of PRP for acute muscle injuries includes work by Cugat et al. (presented at the 2005 meeting of the International Society of Arthroscopy, Knee Surgery, and Orthopedic Sports Medicine) who found a quicker return to play by up to 50% in those treated with PRP under direct ultrasound guidance after aspiration of the hematoma. Follow-up clinical and sonographic outcome measures documented progressive healing of the injured muscle. However, the study had a small sample size, was retrospective, and compared with previously published data on return to play instead of a control group. Validation of the potential role of PRP as an adjunct to standard rest, ice, compression, and elevation therapy will require further well-designed studies.

Discussion
Musculoskeletal injuries are prevalent among both athletes and sedentary individuals. Although most heal with conservative care, a substantial percentage of injuries are refractory to conservative care. Given the vast array of musculoskeletal injuries seen in daily practices, lack of consensus regarding standard treatment, and high cost to patients and society in loss of quality of life and absenteeism from work and sport, any promising advancements in minimally invasive therapies, such as PRP, deserve consideration and thorough investigation. Although PRP therapy has been in existence for the past 20 years, it has only recently been popularized in the United States, in part from extensive media attention. Many PRP studies have shown promising results for augmenting the natural healing response capable of producing stronger bone, regenerating tendon and muscle, and increasing the vascularity of tissue, all in a shorter time period. However, a definitive statement regarding appropriate indications cannot be made because studies are few and have often been limited by methodologic shortcomings. The most recent randomized controlled trials suggest that PRP is a promising therapy for chronic tendinopathy, a broad category of injuries with shared underlying pathophysiology.

Tendinopathy likely occurs from chronic repetitive stress in an area of relative hypovascularity. Unlike the acute inflammatory phase, the vast majority of overuse chronic musculoskeletal conditions, such as tennis elbow, Achilles tendinopathy, and plantar fasciitis, show no histopathologic evidence of inflammatory cells. No consensus about best treatment exists and no conventional therapy directly addresses the underlying pathophysiology of degenerative tissue. The proposed mechanism of action of PRP, assisting the natural healing response at the tissue level through augmented platelets and subsequent growth factors, may disrupt the vicious cycle of tendinopathy and allow normal healing to progress. PRP may be even more effective for acute injuries, such as muscle tears, medial collateral ligament and ankle sprains, and acute hamstring injuries. Such injuries are extremely common in sports and account for significant time lost and cost to society. These injuries are often slow to heal and are prone to reinjury. These acute injuries are often treated at the sports medicine complex or even in the athletic facility. PRP is well positioned as a potential acute-phase therapy because the centrifugation system is portable and easy to use and preparation of PRP is quick with very minimal risk. Current studies have not reported any complications with PRP use.

Investigators also advocate the use of ultrasound-guidance to ensure precise needle placement as well as real-time visualization of the needle during fenestration in preparing the injection site. In addition, areas of neovascularization of inflammation can be specifically targeted during Doppler interrogation of the diseased tissue. MRI or ultrasound can also be used to monitor the healing effects of PRP-treated diseased tissue and should be used in future research studies to document changes in tissue morphology and structure after PRP therapy. Studies involving ultrasound have reported a decrease in thickness and cross-sectional area and normalization of the hypoechogenic portions of the tendon after treatment. In hamstring injuries, MRI plays an important role in characterizing severity of muscle injury by size and location to help stratify treatment options, monitor healing during rehabilitation, and prescribe risk for reinjury.

Other PRP studies have had contradictory results. Some animal and clinical studies have shown no benefit with PRP use. However, critics state that these studies were conducted without a standard PRP dose and possibly inadequate concentration levels. Some investigators have argued that the composition of PRP, such as leukocyte-rich or leukocyte-poor PRP, may lead to different healing responses. Nevertheless, larger-scale randomized controlled trials are needed before PRP can be adopted as a mainstream treatment. Both basic science and clinical research designed to help develop a standard PRP concentration, dose, and composition would help clarify the current mixed results found in the literature. In addition, developing a standard postprocedure protocol that involves short-term immobilization followed by appropriate rehabilitation may also be important in promoting rather than inhibiting the healing effects of PRP.

Research Direction
Despite our current understanding of the healing process, complete knowledge of the complex codependent biologic properties of PRP is largely unknown, and there is yet much to be understood of the clinical effects of its various applications. Future basic science research should address the biologic activity of PRP in various wound environments. For example, what is the optimum concentration of PRP to maximize healing? Is there an inhibitory concentration level? Does the PRP remain within the tendon or muscle injected? Is PRP as effective in the acute setting as it seems to be in the chronic tendinopathy setting? Is the mechanism of action similar in each setting? When is the best time to treat an acute injury of muscle, tendon, or ligament? What is the optimal PRP composition and injection protocol? How important is tendon fenestration or tenotomy in conjunction with PRP? And lastly, a preliminary study showed that efficacy of PRP may be pH-dependent, which may be seen in different wound environments and needs further investigation.

Basic science research for elucidating optimal PRP concentration and composition are needed. Most studies involving PRP have not used a standard protocol of centrifugation, platelet activation, or PRP composition. For example, the leukocyte component of PRP has not been fully studied. Some authors recommend removing leukocytes to make a more pure PRP concentrate, without clear supporting evidence. Leukocytes have been shown to release oxygen-free radicals and may result in secondary tissue damage in the setting of muscle injuries. However, several recent studies have suggested the importance of keeping leukocytes in the PRP concentrate. Leukocytes may provide an antiinfectious environment, promote vascular endothelial growth factor, and regulate immunity. Leukocyte use in PRP has also decreased wound infection rates and did not adversely affect outcomes of PRP use in joint surgery. Recent studies have shown that leukocyte use in PRP is able to promote the regenerating and remodeling process in tendons. Further studies are needed to help differentiate the individual and synergistic effects of platelets and leukocytes to optimize the PRP composition and utility of various platelet-rich preparations.

No evidence-based classification scheme or guidelines specifying optimal use of PRP have been reported. Establishing a classification scheme for the different platelet preparations will help guide further investigations in optimizing an effective platelet concentration and composition.

Billing and Reimbursement Issues
An additional issue with regard to the use of PRP is related to billing and the potential lack of reimbursement for the procedure. The Current Procedural Terminology code for PRP injection, which was implemented July 1, 2010, is 0232 T (Injection[s], platelet-rich plasma, any tissue, including image guidance, harvesting, and preparation when performed). This category 3 code is a temporary code used for emerging technologies, services, and procedures that allows data collection to be used to document widespread usage for Food and Drug Administration approval. Patients must be made aware that a PRP injection may not be fully reimbursed and ultimately they may be held responsible for payment of the procedure. It should be noted that the 0232 T billing code also includes imaging guidance, harvesting, and preparation; therefore, these aspects of the procedure cannot be billed separately. Establishment of this temporary billing code creates problems when attempting to provide patient care; however, this also emphasizes the importance of further research to provide additional information with regard to the potential effectiveness of PRP so that a permanent code can be established.

Conclusion
The application of a promising treatment method for musculoskeletal injuries is always met with considerable enthusiasm, often outpacing basic science and clinical studies. A growing number of orthopedic surgeons and sports medicine physicians are using PRP and are eager to establish its mainstream presence, which has spilled over to radiology practices that can offer MRI or ultrasound assessment of soft-tissue injuries and guide treatment. However, enthusiasm does not replace scientific evidence. The potential role of PRP in healing musculoskeletal injuries, especially in the high-level athlete, is an exciting frontier that may even lead to newer improved therapies, but a healthy amount of caution should be maintained until clinical evidence is established. Further studies are needed to establish effectiveness, indications, and protocols for PRP application in the treatment of musculoskeletal injuries.

Contributing Physicians; Kenneth S. Lee, John J. Wilson, David P. Rabago, Geoffrey S. Baer, Jon A. Jacobson and Camilo G. Borrero

Large Randomized Trial Confirms Value of Platelet Rich Plasma for Tennis Elbow Patients

Commentary on Platelet Rich Plasma, Stem Cells and Regenerative Medicine

84% of patients with chronic tennis elbow who had failed other non-operative treatments were successfully treated using platelet-rich plasma (PRP) in a large randomized trial.  The results were presented at the American Academy of Orthopedic Surgery Meeting in Chicago.

The study was a randomized, double-blind, multi-center controlled trial of 230 patients.  Patients received needling of their elbow tendons with and without PRP.  At 24 weeks the PRP patients reports a 71.5% improvement in their pain compared to 56.1 in the control group. (P = 0.027)  Patients treated with PRP also had less elbow tenderness at each follow up point. (See Graph Below)  Overall, 84% of the PRP patients were successfully treated compared to 68.3% of the control group. (P = 0.012)

This is the largest study done to date using PRP.  There are now over 340 patients who have been treated with the same system (Biomet GPS PRP) and techniques confirming the value of PRP as a treatment for chronic tennis elbow.  Importantly, there is also a decade long experience using PRP with an excellent safety profile.  PRP with this newly released data can now be confidently used for chronic tennis elbow patients prior to considering surgical intervention.

 

Source: http://bit.ly/17f91ZA

The Diet That Prevents Heart Attacks

The Diet That Prevents Heart Attacks

People at high risk for heart attacks, strokes, and death from heart disease can significantly cut their risk if they eat a Mediterranean diet that’s high in fish, nuts, fruits, vegetables, olive oil, and even red wine, according to a major new study published in New England Journal of Medicine.

This groundbreaking research is the first large, randomized clinical trial to evaluate the diet’s effects on cardiovascular risk, and the results were so dramatic that they amazed experts. In fact, the study was halted early (after 4.8 years) because the benefits of this eating plan were so obvious that it would be unethical to continue.

The study included 7,447 participants who were randomly assigned to eat one of three diets: a Mediterranean diet including extra virgin olive oil, a Mediterranean diet including extra nuts, or a low-fat diet.
The researchers found that eating a Mediterranean diet reduced overall risk for major cardiovascular events (heart attack, stroke or death from cardiovascular causes) by 28 to 30 percent, compared to a low-fat diet.
The researchers reported the following results:

  • Eating a Mediterranean diet reduced overall risk for major cardiovascular events (heart attack, stroke or death
  • A Mediterranean diet including extra servings of nuts cut stroke risk by 46 percent.
  • A Mediterranean diet including extra servings of extra virgin olive oil trimmed stroke risk by 33 percent.

What was particularly impressive was the diet powerfully lowered cardiovascular disease (CVD) risk even though most of those who followed it were already taking statins, ACE inhibitors, diabetes medications, or other drugs to cut their heart disease danger.
In addition, the study participants were all at very high risk for CVD, due to being diabetic or having at least three major risk factors, such as smoking, high blood pressure, obesity, high cholesterol, or a family history of developing CVD at an early age. None of the participants had CVD at the start of the study.

Surprising Finding About Cholesterol

One of the biggest surprises was that the low-fat diet lowered cholesterol the most, yet proved least effective at preventing heart attacks, strokes, and death from CV causes. “These results will shock many cardiologists, because high cholesterol has traditionally been considered the leading risk factor for arterial disease,” says Bradley Bale, MD, medical director of the Heart Health Program for Grace Clinic in Lubbock, Texas.

However, new research shows that chronic inflammation—not just high cholesterol—is what drives CVD, adds Dr. Bale. “This explains the puzzle of why many people who have heart attacks or strokes have normal or even optimal cholesterol, while other people with very high cholesterol never suffer these events.”

Foods in the Mediterranean diet, particularly nuts and olive oil, have been shown in earlier studies to reduce inflammation, offering one explanation of why this diet proved so astonishingly effective even though it didn’t lower cholesterol and the people in the study didn’t lose weight—nor did they receive any instructions about exercise.

The Best Food to Stave Off Stroke

Another startling finding was that eating a Mediterranean diet including extra servings of nuts trims stroke risk by a whopping 46 percent, compared to eating a low-fat diet. “That’s a huge risk reduction,”says Dr. Bale. “It’s truly astonishing to see such a powerful effect from one food.”

The group who ate extra nuts also had a 30 percent lower rate of heart attacks, compared to the low-fat group, but the drop wasn’t large enough to be statistically significant. Overall, both groups who ate a Mediterranean diet had about a 30 percent reduction in major cardiovascular events.

In earlier studies, nuts have been shown to have several protective powers, adds Dr. Bale. “We known that nuts are particularly effective at reducing high blood pressure, which is the number one risk factor for stroke, and can also improve the health of the endothelium (blood vessel lining),” making arteries more resistant to plaque buildup.

In addition, nuts have powerful antioxidant properties, adds Dr. Bale.“This study gives a very strong signal that people can significantly reduce stroke risk by eating nuts. The study design is impressive because the researchers controlled for all sorts of cardiovascular risks and also used lab tests to make sure people were eating the assigned diet.”

Benefits of Extra Virgin Olive Oil

The group who ate a Mediterranean diet supplemented with extra servings of extra virgin olive oil had a 34 percent drop in stroke risk, compared to the low-fat group. Heart attack risk fell by about 30 percent in the two groups who ate a Mediterranean diet, but the reduction wasn’t large enough to be statistically significant.

“Extra virgin olive oil contains a compound called oleocanthal that is both a powerful antioxidant and also has an anti-inflammatory effect similar to NSAIDs (nonsteroidal anti-inflammatory drugs) like aspirin or ibuprofen,” says Dr. Bale. Based on scientific research, the European Food Safety Authority has approved the claim that olive oil protects LDL (bad) cholesterol molecules from oxidative damage.

The Healthiest Diet for Your Heart

In the study, the two groups who ate a Mediterranean diet were given these guidelines, all of which are believed to have contributed to the astonishing reduction in cardiovascular danger observed in this very high risk group:

  • Eat white meat instead of red.
  • Eat fish and legumes (such as beans, lentils and peas) at least 3 times a week.
  • Avoid sweets (such as sugary beverages and baked goods) and limit consumption of dairy products and processed meats.
  • Those who drank alcohol were advised to have at least 7 glasses of red wine with meals per week. Dr. Bale recommends discussing the risks and benefits of wine consumption with your healthcare provider.
  • Eat at least 3 servings of fruit and 2 servings of vegetables daily.
  • The group whose diet was supplemented with extra virgin olive oil was told to use at least 4 tablespoons per day.
  • The group whose diet was supplemented with nuts ate one ounce of mixed nuts (walnuts, almonds and hazelnuts) daily.

By Lisa Collier Cool
Feb 25, 2013

The Extraordinary Science of Addictive Junk Food

On the evening of April 8, 1999, a long line of Town Cars and taxis pulled up to the Minneapolis headquarters of Pillsbury and discharged 11 men who controlled America’s largest food companies. Nestlé was in attendance, as were Kraft and Nabisco, General Mills and Procter & Gamble, Coca-Cola and Mars. Rivals any other day, the C.E.O.’s and company presidents had come together for a rare, private meeting. On the agenda was one item: the emerging obesity epidemic and how to deal with it. While the atmosphere was cordial, the men assembled were hardly friends. Their stature was defined by their skill in fighting one another for what they called “stomach share” — the amount of digestive space that any one company’s brand can grab from the competition.

James Behnke, a 55-year-old executive at Pillsbury, greeted the men as they arrived. He was anxious but also hopeful about the plan that he and a few other food-company executives had devised to engage the C.E.O.’s on America’s growing weight problem. “We were very concerned, and rightfully so, that obesity was becoming a major issue,” Behnke recalled. “People were starting to talk about sugar taxes, and there was a lot of pressure on food companies.” Getting the company chiefs in the same room to talk about anything, much less a sensitive issue like this, was a tricky business, so Behnke and his fellow organizers had scripted the meeting carefully, honing the message to its barest essentials. “C.E.O.’s in the food industry are typically not technical guys, and they’re uncomfortable going to meetings where technical people talk in technical terms about technical things,” Behnke said. “They don’t want to be embarrassed. They don’t want to make commitments. They want to maintain their aloofness and autonomy.”

A chemist by training with a doctoral degree in food science, Behnke became Pillsbury’s chief technical officer in 1979 and was instrumental in creating a long line of hit products, including microwaveable popcorn. He deeply admired Pillsbury but in recent years had grown troubled by pictures of obese children suffering from diabetes and the earliest signs of hypertension and heart disease. In the months leading up to the C.E.O. meeting, he was engaged in conversation with a group of food-science experts who were painting an increasingly grim picture of the public’s ability to cope with the industry’s formulations — from the body’s fragile controls on overeating to the hidden power of some processed foods to make people feel hungrier still. It was time, he and a handful of others felt, to warn the C.E.O.’s that their companies may have gone too far in creating and marketing products that posed the greatest health concerns.

In This Article:

‘In This Field, I’m a Game Changer.’

‘Lunchtime Is All Yours’

‘It’s Called Vanishing Caloric Density.’

‘These People Need a Lot of Things, but They Don’t Need a Coke.’

The discussion took place in Pillsbury’s auditorium. The first speaker was a vice president of Kraft named Michael Mudd. “I very much appreciate this opportunity to talk to you about childhood obesity and the growing challenge it presents for us all,” Mudd began. “Let me say right at the start, this is not an easy subject. There are no easy answers — for what the public health community must do to bring this problem under control or for what the industry should do as others seek to hold it accountable for what has happened. But this much is clear: For those of us who’ve looked hard at this issue, whether they’re public health professionals or staff specialists in your own companies, we feel sure that the one thing we shouldn’t do is nothing.”

As he spoke, Mudd clicked through a deck of slides — 114 in all — projected on a large screen behind him. The figures were staggering. More than half of American adults were now considered overweight, with nearly one-quarter of the adult population — 40 million people — clinically defined as obese. Among children, the rates had more than doubled since 1980, and the number of kids considered obese had shot past 12 million. (This was still only 1999; the nation’s obesity rates would climb much higher.) Food manufacturers were now being blamed for the problem from all sides — academia, the Centers for Disease Control and Prevention, the American Heart Association and the American Cancer Society. The secretary of agriculture, over whom the industry had long held sway, had recently called obesity a “national epidemic.”

Mudd then did the unthinkable. He drew a connection to the last thing in the world the C.E.O.’s wanted linked to their products: cigarettes. First came a quote from a Yale University professor of psychology and public health, Kelly Brownell, who was an especially vocal proponent of the view that the processed-food industry should be seen as a public health menace: “As a culture, we’ve become upset by the tobacco companies advertising to children, but we sit idly by while the food companies do the very same thing. And we could make a claim that the toll taken on the public health by a poor diet rivals that taken by tobacco.”

“If anyone in the food industry ever doubted there was a slippery slope out there,” Mudd said, “I imagine they are beginning to experience a distinct sliding sensation right about now.”

Mudd then presented the plan he and others had devised to address the obesity problem. Merely getting the executives to acknowledge some culpability was an important first step, he knew, so his plan would start off with a small but crucial move: the industry should use the expertise of scientists — its own and others — to gain a deeper understanding of what was driving Americans to overeat. Once this was achieved, the effort could unfold on several fronts. To be sure, there would be no getting around the role that packaged foods and drinks play in overconsumption. They would have to pull back on their use of salt, sugar and fat, perhaps by imposing industrywide limits. But it wasn’t just a matter of these three ingredients; the schemes they used to advertise and market their products were critical, too. Mudd proposed creating a “code to guide the nutritional aspects of food marketing, especially to children.”

“We are saying that the industry should make a sincere effort to be part of the solution,” Mudd concluded. “And that by doing so, we can help to defuse the criticism that’s building against us.”

What happened next was not written down. But according to three participants, when Mudd stopped talking, the one C.E.O. whose recent exploits in the grocery store had awed the rest of the industry stood up to speak. His name was Stephen Sanger, and he was also the person — as head of General Mills — who had the most to lose when it came to dealing with obesity. Under his leadership, General Mills had overtaken not just the cereal aisle but other sections of the grocery store. The company’s Yoplait brand had transformed traditional unsweetened breakfast yogurt into a veritable dessert. It now had twice as much sugar per serving as General Mills’ marshmallow cereal Lucky Charms. And yet, because of yogurt’s well-tended image as a wholesome snack, sales of Yoplait were soaring, with annual revenue topping $500 million. Emboldened by the success, the company’s development wing pushed even harder, inventing a Yoplait variation that came in a squeezable tube — perfect for kids. They called it Go-Gurt and rolled it out nationally in the weeks before the C.E.O. meeting. (By year’s end, it would hit $100 million in sales.)

According to the sources I spoke with, Sanger began by reminding the group that consumers were “fickle.” (Sanger declined to be interviewed.) Sometimes they worried about sugar, other times fat. General Mills, he said, acted responsibly to both the public and shareholders by offering products to satisfy dieters and other concerned shoppers, from low sugar to added whole grains. But most often, he said, people bought what they liked, and they liked what tasted good. “Don’t talk to me about nutrition,” he reportedly said, taking on the voice of the typical consumer. “Talk to me about taste, and if this stuff tastes better, don’t run around trying to sell stuff that doesn’t taste good.”

To react to the critics, Sanger said, would jeopardize the sanctity of the recipes that had made his products so successful. General Mills would not pull back. He would push his people onward, and he urged his peers to do the same. Sanger’s response effectively ended the meeting.

“What can I say?” James Behnke told me years later. “It didn’t work. These guys weren’t as receptive as we thought they would be.” Behnke chose his words deliberately. He wanted to be fair. “Sanger was trying to say, ‘Look, we’re not going to screw around with the company jewels here and change the formulations because a bunch of guys in white coats are worried about obesity.’ ”

The meeting was remarkable, first, for the insider admissions of guilt. But I was also struck by how prescient the organizers of the sit-down had been. Today, one in three adults is considered clinically obese, along with one in five kids, and 24 million Americans are afflicted by type 2 diabetes, often caused by poor diet, with another 79 million people having pre-diabetes. Even gout, a painful form of arthritis once known as “the rich man’s disease” for its associations with gluttony, now afflicts eight million Americans.

The public and the food companies have known for decades now — or at the very least since this meeting — that sugary, salty, fatty foods are not good for us in the quantities that we consume them. So why are the diabetes and obesity and hypertension numbers still spiraling out of control? It’s not just a matter of poor willpower on the part of the consumer and a give-the-people-what-they-want attitude on the part of the food manufacturers. What I found, over four years of research and reporting, was a conscious effort — taking place in labs and marketing meetings and grocery-store aisles — to get people hooked on foods that are convenient and inexpensive. I talked to more than 300 people in or formerly employed by the processed-food industry, from scientists to marketers to C.E.O.’s. Some were willing whistle-blowers, while others spoke reluctantly when presented with some of the thousands of pages of secret memos that I obtained from inside the food industry’s operations. What follows is a series of small case studies of a handful of characters whose work then, and perspective now, sheds light on how the foods are created and sold to people who, while not powerless, are extremely vulnerable to the intensity of these companies’ industrial formulations and selling campaigns.

I. ‘In This Field, I’m a Game Changer.’

John Lennon couldn’t find it in England, so he had cases of it shipped from New York to fuel the “Imagine” sessions. The Beach Boys, ZZ Top and Cher all stipulated in their contract riders that it be put in their dressing rooms when they toured. Hillary Clinton asked for it when she traveled as first lady, and ever after her hotel suites were dutifully stocked.

What they all wanted was Dr Pepper, which until 2001 occupied a comfortable third-place spot in the soda aisle behind Coca-Cola and Pepsi. But then a flood of spinoffs from the two soda giants showed up on the shelves — lemons and limes, vanillas and coffees, raspberries and oranges, whites and blues and clears — what in food-industry lingo are known as “line extensions,” and Dr Pepper started to lose its market share.

Responding to this pressure, Cadbury Schweppes created its first spinoff, other than a diet version, in the soda’s 115-year history, a bright red soda with a very un-Dr Pepper name: Red Fusion. “If we are to re-establish Dr Pepper back to its historic growth rates, we have to add more excitement,” the company’s president, Jack Kilduff, said. One particularly promising market, Kilduff pointed out, was the “rapidly growing Hispanic and African-American communities.”

But consumers hated Red Fusion. “Dr Pepper is my all-time favorite drink, so I was curious about the Red Fusion,” a California mother of three wrote on a blog to warn other Peppers away. “It’s disgusting. Gagging. Never again.”

Stung by the rejection, Cadbury Schweppes in 2004 turned to a food-industry legend named Howard Moskowitz. Moskowitz, who studied mathematics and holds a Ph.D. in experimental psychology from Harvard, runs a consulting firm in White Plains, where for more than three decades he has “optimized” a variety of products for Campbell Soup, General Foods, Kraft and PepsiCo. “I’ve optimized soups,” Moskowitz told me. “I’ve optimized pizzas. I’ve optimized salad dressings and pickles. In this field, I’m a game changer.”

In the process of product optimization, food engineers alter a litany of variables with the sole intent of finding the most perfect version (or versions) of a product. Ordinary consumers are paid to spend hours sitting in rooms where they touch, feel, sip, smell, swirl and taste whatever product is in question. Their opinions are dumped into a computer, and the data are sifted and sorted through a statistical method called conjoint analysis, which determines what features will be most attractive to consumers. Moskowitz likes to imagine that his computer is divided into silos, in which each of the attributes is stacked. But it’s not simply a matter of comparing Color 23 with Color 24. In the most complicated projects, Color 23 must be combined with Syrup 11 and Packaging 6, and on and on, in seemingly infinite combinations. Even for jobs in which the only concern is taste and the variables are limited to the ingredients, endless charts and graphs will come spewing out of Moskowitz’s computer. “The mathematical model maps out the ingredients to the sensory perceptions these ingredients create,” he told me, “so I can just dial a new product. This is the engineering approach.”

Moskowitz’s work on Prego spaghetti sauce was memorialized in a 2004 presentation by the author Malcolm Gladwell at the TED conference in Monterey, Calif.: “After . . . months and months, he had a mountain of data about how the American people feel about spaghetti sauce. . . . And sure enough, if you sit down and you analyze all this data on spaghetti sauce, you realize that all Americans fall into one of three groups. There are people who like their spaghetti sauce plain. There are people who like their spaghetti sauce spicy. And there are people who like it extra-chunky. And of those three facts, the third one was the most significant, because at the time, in the early 1980s, if you went to a supermarket, you would not find extra-chunky spaghetti sauce. And Prego turned to Howard, and they said, ‘Are you telling me that one-third of Americans crave extra-chunky spaghetti sauce, and yet no one is servicing their needs?’ And he said, ‘Yes.’ And Prego then went back and completely reformulated their spaghetti sauce and came out with a line of extra-chunky that immediately and completely took over the spaghetti-sauce business in this country. . . . That is Howard’s gift to the American people. . . . He fundamentally changed the way the food industry thinks about making you happy.”

Well, yes and no. One thing Gladwell didn’t mention is that the food industry already knew some things about making people happy — and it started with sugar. Many of the Prego sauces — whether cheesy, chunky or light — have one feature in common: The largest ingredient, after tomatoes, is sugar. A mere half-cup of Prego Traditional, for instance, has the equivalent of more than two teaspoons of sugar, as much as two-plus Oreo cookies. It also delivers one-third of the sodium recommended for a majority of American adults for an entire day. In making these sauces, Campbell supplied the ingredients, including the salt, sugar and, for some versions, fat, while Moskowitz supplied the optimization. “More is not necessarily better,” Moskowitz wrote in his own account of the Prego project. “As the sensory intensity (say, of sweetness) increases, consumers first say that they like the product more, but eventually, with a middle level of sweetness, consumers like the product the most (this is their optimum, or ‘bliss,’ point).”

I first met Moskowitz on a crisp day in the spring of 2010 at the Harvard Club in Midtown Manhattan. As we talked, he made clear that while he has worked on numerous projects aimed at creating more healthful foods and insists the industry could be doing far more to curb obesity, he had no qualms about his own pioneering work on discovering what industry insiders now regularly refer to as “the bliss point” or any of the other systems that helped food companies create the greatest amount of crave. “There’s no moral issue for me,” he said. “I did the best science I could. I was struggling to survive and didn’t have the luxury of being a moral creature. As a researcher, I was ahead of my time.”

Moskowitz’s path to mastering the bliss point began in earnest not at Harvard but a few months after graduation, 16 miles from Cambridge, in the town of Natick, where the U.S. Army hired him to work in its research labs. The military has long been in a peculiar bind when it comes to food: how to get soldiers to eat more rations when they are in the field. They know that over time, soldiers would gradually find their meals-ready-to-eat so boring that they would toss them away, half-eaten, and not get all the calories they needed. But what was causing this M.R.E.-fatigue was a mystery. “So I started asking soldiers how frequently they would like to eat this or that, trying to figure out which products they would find boring,” Moskowitz said. The answers he got were inconsistent. “They liked flavorful foods like turkey tetrazzini, but only at first; they quickly grew tired of them. On the other hand, mundane foods like white bread would never get them too excited, but they could eat lots and lots of it without feeling they’d had enough.”

This contradiction is known as “sensory-specific satiety.” In lay terms, it is the tendency for big, distinct flavors to overwhelm the brain, which responds by depressing your desire to have more. Sensory-specific satiety also became a guiding principle for the processed-food industry. The biggest hits — be they Coca-Cola or Doritos — owe their success to complex formulas that pique the taste buds enough to be alluring but don’t have a distinct, overriding single flavor that tells the brain to stop eating.

Thirty-two years after he began experimenting with the bliss point, Moskowitz got the call from Cadbury Schweppes asking him to create a good line extension for Dr Pepper. I spent an afternoon in his White Plains offices as he and his vice president for research, Michele Reisner, walked me through the Dr Pepper campaign. Cadbury wanted its new flavor to have cherry and vanilla on top of the basic Dr Pepper taste. Thus, there were three main components to play with. A sweet cherry flavoring, a sweet vanilla flavoring and a sweet syrup known as “Dr Pepper flavoring.”

Finding the bliss point required the preparation of 61 subtly distinct formulas — 31 for the regular version and 30 for diet. The formulas were then subjected to 3,904 tastings organized in Los Angeles, Dallas, Chicago and Philadelphia. The Dr Pepper tasters began working through their samples, resting five minutes between each sip to restore their taste buds. After each sample, they gave numerically ranked answers to a set of questions: How much did they like it overall? How strong is the taste? How do they feel about the taste? How would they describe the quality of this product? How likely would they be to purchase this product?

Moskowitz’s data — compiled in a 135-page report for the soda maker — is tremendously fine-grained, showing how different people and groups of people feel about a strong vanilla taste versus weak, various aspects of aroma and the powerful sensory force that food scientists call “mouth feel.” This is the way a product interacts with the mouth, as defined more specifically by a host of related sensations, from dryness to gumminess to moisture release. These are terms more familiar to sommeliers, but the mouth feel of soda and many other food items, especially those high in fat, is second only to the bliss point in its ability to predict how much craving a product will induce.

In addition to taste, the consumers were also tested on their response to color, which proved to be highly sensitive. “When we increased the level of the Dr Pepper flavoring, it gets darker and liking goes off,” Reisner said. These preferences can also be cross-referenced by age, sex and race.

On Page 83 of the report, a thin blue line represents the amount of Dr Pepper flavoring needed to generate maximum appeal. The line is shaped like an upside-down U, just like the bliss-point curve that Moskowitz studied 30 years earlier in his Army lab. And at the top of the arc, there is not a single sweet spot but instead a sweet range, within which “bliss” was achievable. This meant that Cadbury could edge back on its key ingredient, the sugary Dr Pepper syrup, without falling out of the range and losing the bliss. Instead of using 2 milliliters of the flavoring, for instance, they could use 1.69 milliliters and achieve the same effect. The potential savings is merely a few percentage points, and it won’t mean much to individual consumers who are counting calories or grams of sugar. But for Dr Pepper, it adds up to colossal savings. “That looks like nothing,” Reisner said. “But it’s a lot of money. A lot of money. Millions.”

The soda that emerged from all of Moskowitz’s variations became known as Cherry Vanilla Dr Pepper, and it proved successful beyond anything Cadbury imagined. In 2008, Cadbury split off its soft-drinks business, which included Snapple and 7-Up. The Dr Pepper Snapple Group has since been valued in excess of $11 billion.

II. ‘Lunchtime Is All Yours’

Sometimes innovations within the food industry happen in the lab, with scientists dialing in specific ingredients to achieve the greatest allure. And sometimes, as in the case of Oscar Mayer’s bologna crisis, the innovation involves putting old products in new packages.

The 1980s were tough times for Oscar Mayer. Red-meat consumption fell more than 10 percent as fat became synonymous with cholesterol, clogged arteries, heart attacks and strokes. Anxiety set in at the company’s headquarters in Madison, Wis., where executives worried about their future and the pressure they faced from their new bosses at Philip Morris.

Bob Drane was the company’s vice president for new business strategy and development when Oscar Mayer tapped him to try to find some way to reposition bologna and other troubled meats that were declining in popularity and sales. I met Drane at his home in Madison and went through the records he had kept on the birth of what would become much more than his solution to the company’s meat problem. In 1985, when Drane began working on the project, his orders were to “figure out how to contemporize what we’ve got.”

Drane’s first move was to try to zero in not on what Americans felt about processed meat but on what Americans felt about lunch. He organized focus-group sessions with the people most responsible for buying bologna — mothers — and as they talked, he realized the most pressing issue for them was time. Working moms strove to provide healthful food, of course, but they spoke with real passion and at length about the morning crush, that nightmarish dash to get breakfast on the table and lunch packed and kids out the door. He summed up their remarks for me like this: “It’s awful. I am scrambling around. My kids are asking me for stuff. I’m trying to get myself ready to go to the office. I go to pack these lunches, and I don’t know what I’ve got.” What the moms revealed to him, Drane said, was “a gold mine of disappointments and problems.”

He assembled a team of about 15 people with varied skills, from design to food science to advertising, to create something completely new — a convenient prepackaged lunch that would have as its main building block the company’s sliced bologna and ham. They wanted to add bread, naturally, because who ate bologna without it? But this presented a problem: There was no way bread could stay fresh for the two months their product needed to sit in warehouses or in grocery coolers. Crackers, however, could — so they added a handful of cracker rounds to the package. Using cheese was the next obvious move, given its increased presence in processed foods. But what kind of cheese would work? Natural Cheddar, which they started off with, crumbled and didn’t slice very well, so they moved on to processed varieties, which could bend and be sliced and would last forever, or they could knock another two cents off per unit by using an even lesser product called “cheese food,” which had lower scores than processed cheese in taste tests. The cost dilemma was solved when Oscar Mayer merged with Kraft in 1989 and the company didn’t have to shop for cheese anymore; it got all the processed cheese it wanted from its new sister company, and at cost.

Drane’s team moved into a nearby hotel, where they set out to find the right mix of components and container. They gathered around tables where bagfuls of meat, cheese, crackers and all sorts of wrapping material had been dumped, and they let their imaginations run. After snipping and taping their way through a host of failures, the model they fell back on was the American TV dinner — and after some brainstorming about names (Lunch Kits? Go-Packs? Fun Mealz?), Lunchables were born.

The trays flew off the grocery-store shelves. Sales hit a phenomenal $218 million in the first 12 months, more than anyone was prepared for. This only brought Drane his next crisis. The production costs were so high that they were losing money with each tray they produced. So Drane flew to New York, where he met with Philip Morris officials who promised to give him the money he needed to keep it going. “The hard thing is to figure out something that will sell,” he was told. “You’ll figure out how to get the cost right.” Projected to lose $6 million in 1991, the trays instead broke even; the next year, they earned $8 million.

With production costs trimmed and profits coming in, the next question was how to expand the franchise, which they did by turning to one of the cardinal rules in processed food: When in doubt, add sugar. “Lunchables With Dessert is a logical extension,” an Oscar Mayer official reported to Philip Morris executives in early 1991. The “target” remained the same as it was for regular Lunchables — “busy mothers” and “working women,” ages 25 to 49 — and the “enhanced taste” would attract shoppers who had grown bored with the current trays. A year later, the dessert Lunchable morphed into the Fun Pack, which would come with a Snickers bar, a package of M&M’s or a Reese’s Peanut Butter Cup, as well as a sugary drink. The Lunchables team started by using Kool-Aid and cola and then Capri Sun after Philip Morris added that drink to its stable of brands.

Eventually, a line of the trays, appropriately called Maxed Out, was released that had as many as nine grams of saturated fat, or nearly an entire day’s recommended maximum for kids, with up to two-thirds of the max for sodium and 13 teaspoons of sugar.

When I asked Geoffrey Bible, former C.E.O. of Philip Morris, about this shift toward more salt, sugar and fat in meals for kids, he smiled and noted that even in its earliest incarnation, Lunchables was held up for criticism. “One article said something like, ‘If you take Lunchables apart, the most healthy item in it is the napkin.’ ”

Well, they did have a good bit of fat, I offered. “You bet,” he said. “Plus cookies.”

The prevailing attitude among the company’s food managers — through the 1990s, at least, before obesity became a more pressing concern — was one of supply and demand. “People could point to these things and say, ‘They’ve got too much sugar, they’ve got too much salt,’ ” Bible said. “Well, that’s what the consumer wants, and we’re not putting a gun to their head to eat it. That’s what they want. If we give them less, they’ll buy less, and the competitor will get our market. So you’re sort of trapped.” (Bible would later press Kraft to reconsider its reliance on salt, sugar and fat.)

When it came to Lunchables, they did try to add more healthful ingredients. Back at the start, Drane experimented with fresh carrots but quickly gave up on that, since fresh components didn’t work within the constraints of the processed-food system, which typically required weeks or months of transport and storage before the food arrived at the grocery store. Later, a low-fat version of the trays was developed, using meats and cheese and crackers that were formulated with less fat, but it tasted inferior, sold poorly and was quickly scrapped.

When I met with Kraft officials in 2011 to discuss their products and policies on nutrition, they had dropped the Maxed Out line and were trying to improve the nutritional profile of Lunchables through smaller, incremental changes that were less noticeable to consumers. Across the Lunchables line, they said they had reduced the salt, sugar and fat by about 10 percent, and new versions, featuring mandarin-orange and pineapple slices, were in development. These would be promoted as more healthful versions, with “fresh fruit,” but their list of ingredients — containing upward of 70 items, with sucrose, corn syrup, high-fructose corn syrup and fruit concentrate all in the same tray — have been met with intense criticism from outside the industry.

One of the company’s responses to criticism is that kids don’t eat the Lunchables every day — on top of which, when it came to trying to feed them more healthful foods, kids themselves were unreliable. When their parents packed fresh carrots, apples and water, they couldn’t be trusted to eat them. Once in school, they often trashed the healthful stuff in their brown bags to get right to the sweets.

This idea — that kids are in control — would become a key concept in the evolving marketing campaigns for the trays. In what would prove to be their greatest achievement of all, the Lunchables team would delve into adolescent psychology to discover that it wasn’t the food in the trays that excited the kids; it was the feeling of power it brought to their lives. As Bob Eckert, then the C.E.O. of Kraft, put it in 1999: “Lunchables aren’t about lunch. It’s about kids being able to put together what they want to eat, anytime, anywhere.”

Kraft’s early Lunchables campaign targeted mothers. They might be too distracted by work to make a lunch, but they loved their kids enough to offer them this prepackaged gift. But as the focus swung toward kids, Saturday-morning cartoons started carrying an ad that offered a different message: “All day, you gotta do what they say,” the ads said. “But lunchtime is all yours.”

With this marketing strategy in place and pizza Lunchables — the crust in one compartment, the cheese, pepperoni and sauce in others — proving to be a runaway success, the entire world of fast food suddenly opened up for Kraft to pursue. They came out with a Mexican-themed Lunchables called Beef Taco Wraps; a Mini Burgers Lunchables; a Mini Hot Dog Lunchable, which also happened to provide a way for Oscar Mayer to sell its wieners. By 1999, pancakes — which included syrup, icing, Lifesavers candy and Tang, for a whopping 76 grams of sugar — and waffles were, for a time, part of the Lunchables franchise as well.

Annual sales kept climbing, past $500 million, past $800 million; at last count, including sales in Britain, they were approaching the $1 billion mark. Lunchables was more than a hit; it was now its own category. Eventually, more than 60 varieties of Lunchables and other brands of trays would show up in the grocery stores. In 2007, Kraft even tried a Lunchables Jr. for 3- to 5-year-olds.

In the trove of records that document the rise of the Lunchables and the sweeping change it brought to lunchtime habits, I came across a photograph of Bob Drane’s daughter, which he had slipped into the Lunchables presentation he showed to food developers. The picture was taken on Monica Drane’s wedding day in 1989, and she was standing outside the family’s home in Madison, a beautiful bride in a white wedding dress, holding one of the brand-new yellow trays.

During the course of reporting, I finally had a chance to ask her about it. Was she really that much of a fan? “There must have been some in the fridge,” she told me. “I probably just took one out before we went to the church. My mom had joked that it was really like their fourth child, my dad invested so much time and energy on it.”

Monica Drane had three of her own children by the time we spoke, ages 10, 14 and 17. “I don’t think my kids have ever eaten a Lunchable,” she told me. “They know they exist and that Grandpa Bob invented them. But we eat very healthfully.”

Drane himself paused only briefly when I asked him if, looking back, he was proud of creating the trays. “Lots of things are trade-offs,” he said. “And I do believe it’s easy to rationalize anything. In the end, I wish that the nutritional profile of the thing could have been better, but I don’t view the entire project as anything but a positive contribution to people’s lives.”

Today Bob Drane is still talking to kids about what they like to eat, but his approach has changed. He volunteers with a nonprofit organization that seeks to build better communications between school kids and their parents, and right in the mix of their problems, alongside the academic struggles, is childhood obesity. Drane has also prepared a précis on the food industry that he used with medical students at the University of Wisconsin. And while he does not name his Lunchables in this document, and cites numerous causes for the obesity epidemic, he holds the entire industry accountable. “What do University of Wisconsin M.B.A.’s learn about how to succeed in marketing?” his presentation to the med students asks. “Discover what consumers want to buy and give it to them with both barrels. Sell more, keep your job! How do marketers often translate these ‘rules’ into action on food? Our limbic brains love sugar, fat, salt. . . . So formulate products to deliver these. Perhaps add low-cost ingredients to boost profit margins. Then ‘supersize’ to sell more. . . . And advertise/promote to lock in ‘heavy users.’ Plenty of guilt to go around here!”

III. ‘It’s Called Vanishing Caloric Density.’

At a symposium for nutrition scientists in Los Angeles on Feb. 15, 1985, a professor of pharmacology from Helsinki named Heikki Karppanen told the remarkable story of Finland’s effort to address its salt habit. In the late 1970s, the Finns were consuming huge amounts of sodium, eating on average more than two teaspoons of salt a day. As a result, the country had developed significant issues with high blood pressure, and men in the eastern part of Finland had the highest rate of fatal cardiovascular disease in the world. Research showed that this plague was not just a quirk of genetics or a result of a sedentary lifestyle — it was also owing to processed foods. So when Finnish authorities moved to address the problem, they went right after the manufacturers. (The Finnish response worked. Every grocery item that was heavy in salt would come to be marked prominently with the warning “High Salt Content.” By 2007, Finland’s per capita consumption of salt had dropped by a third, and this shift — along with improved medical care — was accompanied by a 75 percent to 80 percent decline in the number of deaths from strokes and heart disease.)

Karppanen’s presentation was met with applause, but one man in the crowd seemed particularly intrigued by the presentation, and as Karppanen left the stage, the man intercepted him and asked if they could talk more over dinner. Their conversation later that night was not at all what Karppanen was expecting. His host did indeed have an interest in salt, but from quite a different vantage point: the man’s name was Robert I-San Lin, and from 1974 to 1982, he worked as the chief scientist for Frito-Lay, the nearly $3-billion-a-year manufacturer of Lay’s, Doritos, Cheetos and Fritos.

Lin’s time at Frito-Lay coincided with the first attacks by nutrition advocates on salty foods and the first calls for federal regulators to reclassify salt as a “risky” food additive, which could have subjected it to severe controls. No company took this threat more seriously — or more personally — than Frito-Lay, Lin explained to Karppanen over their dinner. Three years after he left Frito-Lay, he was still anguished over his inability to effectively change the company’s recipes and practices.

By chance, I ran across a letter that Lin sent to Karppanen three weeks after that dinner, buried in some files to which I had gained access. Attached to the letter was a memo written when Lin was at Frito-Lay, which detailed some of the company’s efforts in defending salt. I tracked Lin down in Irvine, Calif., where we spent several days going through the internal company memos, strategy papers and handwritten notes he had kept. The documents were evidence of the concern that Lin had for consumers and of the company’s intent on using science not to address the health concerns but to thwart them. While at Frito-Lay, Lin and other company scientists spoke openly about the country’s excessive consumption of sodium and the fact that, as Lin said to me on more than one occasion, “people get addicted to salt.”

Not much had changed by 1986, except Frito-Lay found itself on a rare cold streak. The company had introduced a series of high-profile products that failed miserably. Toppels, a cracker with cheese topping; Stuffers, a shell with a variety of fillings; Rumbles, a bite-size granola snack — they all came and went in a blink, and the company took a $52 million hit. Around that time, the marketing team was joined by Dwight Riskey, an expert on cravings who had been a fellow at the Monell Chemical Senses Center in Philadelphia, where he was part of a team of scientists that found that people could beat their salt habits simply by refraining from salty foods long enough for their taste buds to return to a normal level of sensitivity. He had also done work on the bliss point, showing how a product’s allure is contextual, shaped partly by the other foods a person is eating, and that it changes as people age. This seemed to help explain why Frito-Lay was having so much trouble selling new snacks. The largest single block of customers, the baby boomers, had begun hitting middle age. According to the research, this suggested that their liking for salty snacks — both in the concentration of salt and how much they ate — would be tapering off. Along with the rest of the snack-food industry, Frito-Lay anticipated lower sales because of an aging population, and marketing plans were adjusted to focus even more intently on younger consumers.

Except that snack sales didn’t decline as everyone had projected, Frito-Lay’s doomed product launches notwithstanding. Poring over data one day in his home office, trying to understand just who was consuming all the snack food, Riskey realized that he and his colleagues had been misreading things all along. They had been measuring the snacking habits of different age groups and were seeing what they expected to see, that older consumers ate less than those in their 20s. But what they weren’t measuring, Riskey realized, is how those snacking habits of the boomers compared to themselves when they were in their 20s. When he called up a new set of sales data and performed what’s called a cohort study, following a single group over time, a far more encouraging picture — for Frito-Lay, anyway — emerged. The baby boomers were not eating fewer salty snacks as they aged. “In fact, as those people aged, their consumption of all those segments — the cookies, the crackers, the candy, the chips — was going up,” Riskey said. “They were not only eating what they ate when they were younger, they were eating more of it.” In fact, everyone in the country, on average, was eating more salty snacks than they used to. The rate of consumption was edging up about one-third of a pound every year, with the average intake of snacks like chips and cheese crackers pushing past 12 pounds a year.

Riskey had a theory about what caused this surge: Eating real meals had become a thing of the past. Baby boomers, especially, seemed to have greatly cut down on regular meals. They were skipping breakfast when they had early-morning meetings. They skipped lunch when they then needed to catch up on work because of those meetings. They skipped dinner when their kids stayed out late or grew up and moved out of the house. And when they skipped these meals, they replaced them with snacks. “We looked at this behavior, and said, ‘Oh, my gosh, people were skipping meals right and left,’ ” Riskey told me. “It was amazing.” This led to the next realization, that baby boomers did not represent “a category that is mature, with no growth. This is a category that has huge growth potential.”

The food technicians stopped worrying about inventing new products and instead embraced the industry’s most reliable method for getting consumers to buy more: the line extension. The classic Lay’s potato chips were joined by Salt & Vinegar, Salt & Pepper and Cheddar & Sour Cream. They put out Chili-Cheese-flavored Fritos, and Cheetos were transformed into 21 varieties. Frito-Lay had a formidable research complex near Dallas, where nearly 500 chemists, psychologists and technicians conducted research that cost up to $30 million a year, and the science corps focused intense amounts of resources on questions of crunch, mouth feel and aroma for each of these items. Their tools included a $40,000 device that simulated a chewing mouth to test and perfect the chips, discovering things like the perfect break point: people like a chip that snaps with about four pounds of pressure per square inch.

To get a better feel for their work, I called on Steven Witherly, a food scientist who wrote a fascinating guide for industry insiders titled, “Why Humans Like Junk Food.” I brought him two shopping bags filled with a variety of chips to taste. He zeroed right in on the Cheetos. “This,” Witherly said, “is one of the most marvelously constructed foods on the planet, in terms of pure pleasure.” He ticked off a dozen attributes of the Cheetos that make the brain say more. But the one he focused on most was the puff’s uncanny ability to melt in the mouth. “It’s called vanishing caloric density,” Witherly said. “If something melts down quickly, your brain thinks that there’s no calories in it . . . you can just keep eating it forever.”

As for their marketing troubles, in a March 2010 meeting, Frito-Lay executives hastened to tell their Wall Street investors that the 1.4 billion boomers worldwide weren’t being neglected; they were redoubling their efforts to understand exactly what it was that boomers most wanted in a snack chip. Which was basically everything: great taste, maximum bliss but minimal guilt about health and more maturity than puffs. “They snack a lot,” Frito-Lay’s chief marketing officer, Ann Mukherjee, told the investors. “But what they’re looking for is very different. They’re looking for new experiences, real food experiences.” Frito-Lay acquired Stacy’s Pita Chip Company, which was started by a Massachusetts couple who made food-cart sandwiches and started serving pita chips to their customers in the mid-1990s. In Frito-Lay’s hands, the pita chips averaged 270 milligrams of sodium — nearly one-fifth a whole day’s recommended maximum for most American adults — and were a huge hit among boomers.

The Frito-Lay executives also spoke of the company’s ongoing pursuit of a “designer sodium,” which they hoped, in the near future, would take their sodium loads down by 40 percent. No need to worry about lost sales there, the company’s C.E.O., Al Carey, assured their investors. The boomers would see less salt as the green light to snack like never before.

There’s a paradox at work here. On the one hand, reduction of sodium in snack foods is commendable. On the other, these changes may well result in consumers eating more. “The big thing that will happen here is removing the barriers for boomers and giving them permission to snack,” Carey said. The prospects for lower-salt snacks were so amazing, he added, that the company had set its sights on using the designer salt to conquer the toughest market of all for snacks: schools. He cited, for example, the school-food initiative championed by Bill Clinton and the American Heart Association, which is seeking to improve the nutrition of school food by limiting its load of salt, sugar and fat. “Imagine this,” Carey said. “A potato chip that tastes great and qualifies for the Clinton-A.H.A. alliance for schools . . . . We think we have ways to do all of this on a potato chip, and imagine getting that product into schools, where children can have this product and grow up with it and feel good about eating it.”

Carey’s quote reminded me of something I read in the early stages of my reporting, a 24-page report prepared for Frito-Lay in 1957 by a psychologist named Ernest Dichter. The company’s chips, he wrote, were not selling as well as they could for one simple reason: “While people like and enjoy potato chips, they feel guilty about liking them. . . . Unconsciously, people expect to be punished for ‘letting themselves go’ and enjoying them.” Dichter listed seven “fears and resistances” to the chips: “You can’t stop eating them; they’re fattening; they’re not good for you; they’re greasy and messy to eat; they’re too expensive; it’s hard to store the leftovers; and they’re bad for children.” He spent the rest of his memo laying out his prescriptions, which in time would become widely used not just by Frito-Lay but also by the entire industry. Dichter suggested that Frito-Lay avoid using the word “fried” in referring to its chips and adopt instead the more healthful-sounding term “toasted.” To counteract the “fear of letting oneself go,” he suggested repacking the chips into smaller bags. “The more-anxious consumers, the ones who have the deepest fears about their capacity to control their appetite, will tend to sense the function of the new pack and select it,” he said.

Dichter advised Frito-Lay to move its chips out of the realm of between-meals snacking and turn them into an ever-present item in the American diet. “The increased use of potato chips and other Lay’s products as a part of the regular fare served by restaurants and sandwich bars should be encouraged in a concentrated way,” Dichter said, citing a string of examples: “potato chips with soup, with fruit or vegetable juice appetizers; potato chips served as a vegetable on the main dish; potato chips with salad; potato chips with egg dishes for breakfast; potato chips with sandwich orders.”

In 2011, The New England Journal of Medicine published a study that shed new light on America’s weight gain. The subjects — 120,877 women and men — were all professionals in the health field, and were likely to be more conscious about nutrition, so the findings might well understate the overall trend. Using data back to 1986, the researchers monitored everything the participants ate, as well as their physical activity and smoking. They found that every four years, the participants exercised less, watched TV more and gained an average of 3.35 pounds. The researchers parsed the data by the caloric content of the foods being eaten, and found the top contributors to weight gain included red meat and processed meats, sugar-sweetened beverages and potatoes, including mashed and French fries. But the largest weight-inducing food was the potato chip. The coating of salt, the fat content that rewards the brain with instant feelings of pleasure, the sugar that exists not as an additive but in the starch of the potato itself — all of this combines to make it the perfect addictive food. “The starch is readily absorbed,” Eric Rimm, an associate professor of epidemiology and nutrition at the Harvard School of Public Health and one of the study’s authors, told me. “More quickly even than a similar amount of sugar. The starch, in turn, causes the glucose levels in the blood to spike” — which can result in a craving for more.

If Americans snacked only occasionally, and in small amounts, this would not present the enormous problem that it does. But because so much money and effort has been invested over decades in engineering and then relentlessly selling these products, the effects are seemingly impossible to unwind. More than 30 years have passed since Robert Lin first tangled with Frito-Lay on the imperative of the company to deal with the formulation of its snacks, but as we sat at his dining-room table, sifting through his records, the feelings of regret still played on his face. In his view, three decades had been lost, time that he and a lot of other smart scientists could have spent searching for ways to ease the addiction to salt, sugar and fat. “I couldn’t do much about it,” he told me. “I feel so sorry for the public.”

IV. ‘These People Need a Lot of Things, but They Don’t Need a Coke.’

The growing attention Americans are paying to what they put into their mouths has touched off a new scramble by the processed-food companies to address health concerns. Pressed by the Obama administration and consumers, Kraft, Nestlé, Pepsi, Campbell and General Mills, among others, have begun to trim the loads of salt, sugar and fat in many products. And with consumer advocates pushing for more government intervention, Coca-Cola made headlines in January by releasing ads that promoted its bottled water and low-calorie drinks as a way to counter obesity. Predictably, the ads drew a new volley of scorn from critics who pointed to the company’s continuing drive to sell sugary Coke.

One of the other executives I spoke with at length was Jeffrey Dunn, who, in 2001, at age 44, was directing more than half of Coca-Cola’s $20 billion in annual sales as president and chief operating officer in both North and South America. In an effort to control as much market share as possible, Coke extended its aggressive marketing to especially poor or vulnerable areas of the U.S., like New Orleans — where people were drinking twice as much Coke as the national average — or Rome, Ga., where the per capita intake was nearly three Cokes a day. In Coke’s headquarters in Atlanta, the biggest consumers were referred to as “heavy users.” “The other model we use was called ‘drinks and drinkers,’ ” Dunn said. “How many drinkers do I have? And how many drinks do they drink? If you lost one of those heavy users, if somebody just decided to stop drinking Coke, how many drinkers would you have to get, at low velocity, to make up for that heavy user? The answer is a lot. It’s more efficient to get my existing users to drink more.”

One of Dunn’s lieutenants, Todd Putman, who worked at Coca-Cola from 1997 to 2001, said the goal became much larger than merely beating the rival brands; Coca-Cola strove to outsell every other thing people drank, including milk and water. The marketing division’s efforts boiled down to one question, Putman said: “How can we drive more ounces into more bodies more often?” (In response to Putman’s remarks, Coke said its goals have changed and that it now focuses on providing consumers with more low- or no-calorie products.)

In his capacity, Dunn was making frequent trips to Brazil, where the company had recently begun a push to increase consumption of Coke among the many Brazilians living in favelas. The company’s strategy was to repackage Coke into smaller, more affordable 6.7-ounce bottles, just 20 cents each. Coke was not alone in seeing Brazil as a potential boon; Nestlé began deploying battalions of women to travel poor neighborhoods, hawking American-style processed foods door to door. But Coke was Dunn’s concern, and on one trip, as he walked through one of the impoverished areas, he had an epiphany. “A voice in my head says, ‘These people need a lot of things, but they don’t need a Coke.’ I almost threw up.”

Dunn returned to Atlanta, determined to make some changes. He didn’t want to abandon the soda business, but he did want to try to steer the company into a more healthful mode, and one of the things he pushed for was to stop marketing Coke in public schools. The independent companies that bottled Coke viewed his plans as reactionary. A director of one bottler wrote a letter to Coke’s chief executive and board asking for Dunn’s head. “He said what I had done was the worst thing he had seen in 50 years in the business,” Dunn said. “Just to placate these crazy leftist school districts who were trying to keep people from having their Coke. He said I was an embarrassment to the company, and I should be fired.” In February 2004, he was.

Dunn told me that talking about Coke’s business today was by no means easy and, because he continues to work in the food business, not without risk. “You really don’t want them mad at you,” he said. “And I don’t mean that, like, I’m going to end up at the bottom of the bay. But they don’t have a sense of humor when it comes to this stuff. They’re a very, very aggressive company.”

When I met with Dunn, he told me not just about his years at Coke but also about his new marketing venture. In April 2010, he met with three executives from Madison Dearborn Partners, a private-equity firm based in Chicago with a wide-ranging portfolio of investments. They recently hired Dunn to run one of their newest acquisitions — a food producer in the San Joaquin Valley. As they sat in the hotel’s meeting room, the men listened to Dunn’s marketing pitch. He talked about giving the product a personality that was bold and irreverent, conveying the idea that this was the ultimate snack food. He went into detail on how he would target a special segment of the 146 million Americans who are regular snackers — mothers, children, young professionals — people, he said, who “keep their snacking ritual fresh by trying a new food product when it catches their attention.”

He explained how he would deploy strategic storytelling in the ad campaign for this snack, using a key phrase that had been developed with much calculation: “Eat ’Em Like Junk Food.”

After 45 minutes, Dunn clicked off the last slide and thanked the men for coming. Madison’s portfolio contained the largest Burger King franchise in the world, the Ruth’s Chris Steak House chain and a processed-food maker called AdvancePierre whose lineup includes the Jamwich, a peanut-butter-and-jelly contrivance that comes frozen, crustless and embedded with four kinds of sugars.

The snack that Dunn was proposing to sell: carrots. Plain, fresh carrots. No added sugar. No creamy sauce or dips. No salt. Just baby carrots, washed, bagged, then sold into the deadly dull produce aisle.

“We act like a snack, not a vegetable,” he told the investors. “We exploit the rules of junk food to fuel the baby-carrot conversation. We are pro-junk-food behavior but anti-junk-food establishment.”

The investors were thinking only about sales. They had already bought one of the two biggest farm producers of baby carrots in the country, and they’d hired Dunn to run the whole operation. Now, after his pitch, they were relieved. Dunn had figured out that using the industry’s own marketing ploys would work better than anything else. He drew from the bag of tricks that he mastered in his 20 years at Coca-Cola, where he learned one of the most critical rules in processed food: The selling of food matters as much as the food itself.

Later, describing his new line of work, Dunn told me he was doing penance for his Coca-Cola years. “I’m paying my karmic debt,” he said.

This article is adapted from “Salt Sugar Fat: How the Food Giants Hooked Us,” which will be published by Random House this month.

Michael Moss is an investigative reporter for The Times. He won a Pulitzer Prize in 2010 for his reporting on the meat industry.

Editor: Joel Lovell
February 20, 2013

By MICHAEL MOSS