Dr. Ayala Healthy Living Blog

Small bites for better health

My grandma used to say, “Eat slowly, with small bites, so that you digest your food.” She was partly right.

Unfortunately for us, we humans are quite efficient at digesting our food regardless of how quickly we eat it. Whether we chew well or not, our bodies will still extract nutrients from the food further down our intestinal tract. Had hasty eating been detrimental to digestion, we’d be a very thin nation.

But Grandma was oh so right about the other part: Eat slowly, with small bites.

I devoted a previous post to studies showing how liquid calories don’t lead to satiety, and therefore drinking caloric drinks can enable people to consume more calories than they need.

Now, there’s evidence that the speed with which we eat can also have an impact on the amount of calories we consume and how quickly we feel full.

Researchers are trying to get to the bottom of the satiety phenomenon, understand its underlying mechanism and how it relates to the consistency of food, rate of intake and the oral pleasure food gives us.

A new neat study in the American Journal of Clinical Nutrition looks at the effect of bite size and the time that a food morsel spends in the mouth on food intake. The Dutch group, led by Cees de Graff, tested 22 healthy, normal-weight volunteers seven separate times under different conditions to see how much chocolate custard they could eat until they were full.

Each subject ate first with a “free” bite size—a portion size that they determined—and swallowed that bite at any pace they wanted. The group then went through other variations: a free bite size with three seconds in the mouth before swallowing, a free bite size with nine seconds in the mouth before swallowing, a measured small bite size (five grams or roughly a teaspoon) with three seconds in the mouth before swallowing, a small bite size with nine seconds in the mouth before swallowing, a measured large bite size (15 grams, resembling a soup spoon) with three seconds in the mouth before swallowing and large bite size with nine seconds in the mouth before swallowing.

All sessions were conducted at lunchtime or dinnertime, on a fairly empty stomach with at least three hours of no food before the test, and tests were separated with at least one day of non-testing between them.

The results were very clear: a smaller bite size led to lower intake. Details:

• Mean intake in the small bite experiment was 381 grams for the three-second mouth-transit time and 313 grams for the nine-second mouth-transit time.

• Mean intake in the large bite experiment was 476 grams for the three-second mouth-transit time and 432 grams for the nine-second mouth-transit time.

Large bites prompted the volunteers to eat about 100 gram more (or about extra 100 calories in chocolate custard) before satiety set in.

The results clearly show the time the food spent in the volunteers’ mouth also made a difference; they ate more when the oral exposure was three seconds rather than nine seconds.

These results should of course be taken in context: the volunteers ate under experimental conditions, using only one food item that was semi-solid, but there are other studies to support the advice to eat with small bites, slowly, with as much oral sensory exposure in order to feel more satisfied with less food. You can read more on eating quickly and the risk of obesity here.

Your moment of Zen

Health and weight reasons aside, eating slowly and leisurely can be a reprieve from our rushed lives, and can have a profound effect on our well-being.

Carlo Petrini the founder of the International Slow Food Movement famously said: “The quest for slowness, which begins as a simple rebellion against the impoverishment of taste in our lives, makes it possible to rediscover taste.”

I think there’s nothing like a family meal to get all members of the family to eat slower. Eventually. When my kids were very small, our family meals weren’t leisurely at all for us parents. By the time I got to my own plate, the babies were not interested in sitting for much longer, and I found that I ate so fast that at times I hardly felt the taste of the food.

But as the kids grew up they got accustomed to what a meal should be like, and since they had a notion that mid-week meals will take at least 30 minutes, and weekend ones much longer, they stopped asking to be excused and learned to make the most out of it. They began to enjoy the food and each other’s company.

Any advice on how to eat more leisurely? Please share.
Dr Ayala

Counting calories to make healthy choices in fast-food restaurants

Michelle Obama gave a good nutrition lesson to the kids who helped harvest crops in the White House vegetable garden last week. Talking about obesity she said, “When I was growing up, fast food was a rarity. It wasn't something you did every day. It was a special treat, and we would beg to get it, and it was exciting if we drove into a fast-food place and got a hamburger…Eating out was a luxury because at least in my family we couldn't afford it. If we got pizza on a Friday night, that was a treat.”

Our first lady sees fast food as one of the culprits of the obesity epidemic. Most health experts are with her.

Obesity rates have doubled in the past thirty years in parallel with an increase in caloric intake. At the same time, there’s been a major shift in the average American diet—in 1970 about one-quarter of food dollars were spent on prepared food; in 2001 it went up to nearly one-half.

A major part of these made-out-of-the-home food dollars go to fast-food chains. Not only do people visit these outlets more often than they used to (one in four Americans eat fast food on any given day) they’re also served more food on any given meal.

Many studies have shown that eating fast food is associated with overeating and a poor diet, I’ll cite just a few. A study in the Journal of the American Dietetic Association shows that adults eating at fast-food restaurants consume 205 more calories per day than those who do not eat out; children consume 155 more calories, and all age groups who reported eating fast food had a higher intake of fat, saturated fat, sodium, carbonated soft drink, and a lower intake of vitamins A and C, milk, fruits and vegetables than those who did not report eating fast food.

A large study published in the Lancet followed young adults for 15 years and showed that those who ate at fast-food restaurants more than twice a week had gained an extra ten pounds and had twice the risk of insulin resistance (a risk factor for type 2 diabetes) compared to those that ate fast-food less than once a week.

Recently, new laws mandating calorie posting on menu boards were introduced in two states (California and Massachusetts) and several cities (including New York City and my hometown, Philadelphia). Will calorie posting change the way people order in fast-food outlets?

A new study in Obesity takes a different approach in investigating what people eat at fast-food in New York City just before these laws were set in place. While most studies rely on individuals’ recall of what they ate, this study is based on customers’ detailed receipts for 7,318 lunch meals (consumed between 12-2pm) in 167 fast-food locations. Caloric values for the specific meals were obtained from the companies’ websites.

Here are some of the findings:

• Customers bought an average of 827 calories for lunch. When excluding single-item purchases (people coming in for just a drink, a side order or a sandwich), the average calories per customer rose to 961 calories.

• More than a third of all customers ordered more than 1,000 calories for lunch. When excluding the single-item purchases 44 percent of customers ordered more than 1000 calories.

• At chicken-oriented fast food chains (KFC, Popeye’s) —which averaged the highest calorie purchase (931 calories) —almost half of the customers ordered more than 1,000 calories for lunch.

• At hamburger-oriented fast food chains (McDonald’s, Burger King, Wendy’s) about 40 percent of the customers ordered more than 1,000 calories for lunch.

• At Domino’s and Pizza Hut, the mean purchase was more than 1,000 calories.

• The two sandwich chains in the study had lower average calorie purchases: Subway at 749, and Au Bon Pain at 555.

The study also looked more closely at the three hamburger fast food chains:

• Combo meals (consisting of a sandwich, side order and drink) were bought by about a third of the burger chain patrons in the study, and had an average of 1,100 calories. Burger King wins the prize, with an average of 1,271 calories; McDonald’s comes in second with 1,187, and Wendy’s is third with 1,106. French fries and other sides comprise about a third of combo-meal calories; beverages account for about 20 percent.

• Most meals (58 percent) included a beverage, and three out of four of these drinks were soft drinks, consisting of about 200 calories. Diet drinks comprised only seven percent of drink receipts at McDonald’s and water only two percent.

How many calories should people eat for lunch?
There is no right answer to this question. The way one divides the daily allowance of calories (an average of 2,000/day is about all most people need) is a matter of personal preference and habits. One can argue that Burger King’s combo lunch can be recipe for weight loss—provided it’s the only food you have that day.

I think most people can see that subtracting a combo meal (with no dessert) from the daily allowance of 2,000 calories doesn’t make staying within the limits of a balanced caloric intake easy or realistic. On top of that, I’d argue that our nutritional needs are far from met by fast-food, and to balance this rather empty meal one would have to eat super healthy nutritious food for the rest of the day.

Room for change

The Obesity study authors discuss several modifications fast-food restaurants can easily make to cut some calories, such as reducing the portion sizes or abandoning the practice of discounting combo and value meals when one buys more calories.

They write:

"Customers can modify their fast-food selections to reduce calorie intake. The most popular combination meal at McDonald's was the Big Mac, "medium" order of French fries and "medium" size non-diet soda, totaling 1,130 calories and priced at $5.59... Downsizing only the French fries and soft drink to "small" sizes would save 190 calories but cost only 10 cents less than the standard combination meal. This suggests a built-in economic disincentive to downsizing, a simple modification that could reduce calorie intake.

Substituting water or another non-caloric drink for a sugar-sweetened soft drink, or the selection of smaller sizes of sandwiches, hamburgers or sides can cut hundreds of calories. Selection of grilled rather than fried items also reduces calories, although grilled items typically are more expensive. A request to "hold the mayo" can cut 100–200 calories from a meal. One common misconception is that salads are always lower in calories, when, in fact, they are often filled with high-calorie ingredients. Some salads on fast-food menus are more than 600 calories without dressing, and dressings can range from 40 calories for low fat up to 270 calories.

Calorie-conscious modifications are hardly encouraged in quick-service settings where consumers contend with a wide array of high-calorie options. Portion sizes at fast-food chains have increased over time; with these larger servings, there has been a corresponding increase in the calorie content of purchases.”

The authors will be repeating this study to see what effect—if any—New York City’s calorie posting have on purchase. It will be interesting to see whether calorie posting changes what fast food outlets offer and what people actually buy. There are indications that small changes are already happening—I wrote about some in a previous blog post, and New York Times’ Tara Parker Pope had an interesting post about some positive changes in the offerings and choices at fast-food outlets this week. I’ll keep you updated as new studies come out.

By the way, I think most people know fast-food isn’t healthy. Eric Schlosser’s book "Fast Food Nation" certainly drove that point home. Morgan Spurlock’s movie “Super Size Me” painted a vivid picture of what happens to one’s weight, liver function and stamina when one eats fast-food on a regular basis. The calorie posting right next to the products’ price will certainly reinforce that notion. Still, fast-food meals are very popular mostly because they’re convenient, cheap and have taste appeal. Not only is fast-food here to stay, we’re also very successful at exporting it abroad, so I do hope modifying fast-food offerings and providing nutritional information can save consumers here and around the world a few hundred calories.

I also hope Michelle Obama’s little ambassadors—the kids who enjoyed the fresh, simply prepared food from the White House garden—will follow her guidance and show their friends and family just how easy it is for kids to think differently about food.

Dr. Ayala

Healthy summer frozen treats and the dreaded brain freeze

My dear kids bought me an ice cream maker for Mother's Day—they know my favorite gifts are connected to the kitchen and food. To their delight, I’ve been experimenting with frozen healthy treats for the past few weeks, and they get to sit on the sunny steps outside our kitchen where they taste, comment and compare.

These recipes call for an ice cream maker. Not every kitchen has or needs one—I give instructions for making these fruit treats without one—but if you have the space in your kitchen these small appliances aren’t expensive (under $50), and will probably earn their keep.

When making frozen desserts at home you’ll be using pure fresh ingredients, and none of the stabilizers, gums, colors and preservatives that are often found in the in prepared versions from the frozen food section of your supermarket.

Here are a few of our favorites:

Lemon, Verbena and Geranium Sorbet

Ingredients:

• 2 cups boiling water
• 1/2 cup sugar
• 5-8 leaves of rose geranium* (can be replaced by French tarragon or 1 teaspoon lavender flowers)
• 1 cup lemon juice
• 1 tablespoon minced fresh Lemon Verbena
• ½ teaspoon grated lemon peel (yellow part only)

*Another option is to replace rose geranium with 1 bottle of Ayala’s Herbal Water Lemon Verbena Geranium. If you do this, use just ½ cup of boiling water to melt the sugar.

To prepare:

Stir the sugar and rose geranium leaves in the boiling water until sugar is dissolved. Chill completely. Remove leaves just before making the sorbet.

Add the lemon juice, lemon Verbena and lemon peel.

Freeze in an ice cream maker according to manufacturer's directions 25-30 minutes.

If you do not have an ice cream maker

 Place mixture in freezer-proof container
 Freeze for one hour
 Remove from the freezer and beat the mixture using an electric mixer
 Repeat this entire process two more times (it’s worth it)

In case you’re wondering how I make the lemon zest spirals--it’s really easy, use a lemon zester in a circular motion around a washed lemon (see picture).

Very Berry Sherbet

Ingredients:

• 1 pound mixed berries. I like using a combination of sweet and tart berries: blueberries, strawberries, raspberries and blackberries. Frozen berries also work; let them thaw just a little before preparation
• 2-4 tablespoons sugar or agave (depending on berry sweetness)
• 1 cup milk (I use 2%)

To prepare:
Process all the ingredients coarsely in a food processor or blender.
Freeze in an ice cream maker according to manufacturer's directions, 20-25 minutes.

If you do not have an ice cream maker:

 Place mixture in freezer-proof container
 Freeze for one hour
 Remove from the freezer and beat the mixture using an electric mixer
 Repeat this entire process two more times

Watermelon Mint Slurpee

Ingredients:

• 1 pound sweet ripe watermelon
• 10 mint leaves, finely chopped
• Lime juice from half a lime
• a pinch of salt

To prepare:
Process all the ingredients in a food processor or blender.
Freeze in an ice cream maker according to manufacturer's directions for about 10-15 minutes. The consistency needs to be slurpable through a straw, so this one’s not supposed to completely freeze.

If you do not have an ice cream maker:

 Place mixture in freezer-proof container
 Freeze for one hour
 Remove from the freezer and beat the mixture using an electric mixer
 Repeat this entire process one more time

Serve in tall glass, with a wide straw.

Serving suggestions

These recipes serve 4-6 people

Sorbets may be served as a dessert or between courses to refresh the palate.

The texture of the sorbets varies by ingredients, preparation and temperature. These recipes are designed to be served immediately. If you do store the sorbet in the freezer, make sure you allow a short time to thaw before serving.

The dreaded brain freeze

Ice cream can teach us a very important healthy eating lesson—eat slowly. Although it’s always good advice to pace our meals, allow satiety to sink in and give ourselves time to really enjoy our food, ice cream, sorbets and other very cold foods often provide a very clear reminder to slow down: The dreaded ice-cream headache. This “brain freeze” not only causes us to momentarily stop our own eating, but if anyone else happens to cry out as they suffer this stinging pain, we all almost instinctively slow down in order to avoid it ourselves.

According to an editorial by neurologist Joseph Hulihan in the British Medical Journal, the ice cream headache is the most common cause of head pain, and affects a third of the population. It has no connection to other forms of headache. The pain begins a few seconds after gulping down cold foods or beverages--when really cold food touches the roof of the mouth--and peaks in 30-60 seconds. The good news is that it doesn’t last long.

Scientists aren’t sure about what causes this pain. One leading theory suggests that the cold food or drink may temporarily constrict blood vessels and cause pain in much the same way a migraine does. In any case, no need to worry. Hulihan concludes with:

“No treatment is usually required, and sufferers rarely seek medical attention. Since the posterior aspect of the palate is most likely to produce the referred pain of ice cream headache, avoiding contact of the cold food with this area can effectively eliminate the symptoms. Most people arrive at such preventive measures without the advice of doctors. Ice cream abstinence is not indicated.”

And you can always call on the classic trick to speed up recovery from brain freeze: press your tongue to the roof of your mouth until the pain subsides.

Your comments on summer treats or brain freezes are as always welcome.

Enjoy the warm weather in good health.

Dr. Ayala

Could a tax on junk food drive healthier choices?

I’m about to open a huge can of worms, but I’m pretty passionate about this idea, so here goes.

I think a “junk food” tax could help us deal with a major health epidemic.

The idea of taxing foods and drinks that have low nutritional value has been tossed around before, but the combination of cash-strapped state budgets, the obesity epidemic, and the growing evidence that sugary drinks are one of the key drivers of this epidemic may have provided for what some see as the perfect opportunity for this kind of policy to be considered.

Would it be effective? Is it fair?

(Full disclosure: I’m vice president of product development for Herbal Water, where we make organic herb-infused waters that have zero calories and no sugar or artificial ingredients. I’m also a pediatrician and have been promoting good nutrition and healthy lifestyle for many years.)

Could it work?

Price generally affects purchase decisions, and with the exception of luxury goods, higher price reduces consumption. In this respect, if a tax is high enough, sales of sugary beverages should decrease and there are indications that soda sales are very price sensitive.

Lessons from tobacco:
Junk food and soda are not the same as tobacco, but perhaps we can learn a lesson from the role of taxes on the cigarette sales. Many believe that taxation was one of the most effective tools available to policy makers to reduce smoking, and economic research shows that every 10 percent increase in the real price of cigarettes reduces overall cigarette consumption by approximately three to five percent, reduces the number of young-adult smokers by 3.5 percent, and reduces the number of kids who smoke by six or seven percent. Every single state that has significantly raised its cigarette tax has seen smoking go down sharply.

Lessons from other states:
Most states have general sales taxes which don’t apply to food for home consumption, but there are exceptions: Some states do have a small tax on soft drinks, candy or snack foods (that includes my home state of Pennsylvania, which taxes soft drinks unless they’re purchased with food stamps--can you believe that?).

A study in the American Journal of Preventive Medicine looked at the association between the presence of a soft drink/snack tax in the years 1991-1998 and the increase in obesity rates for those years at the state level. Adjusting for age, income, race on other variables, they found that states without a soft drink tax were more than four times as likely to have a high increase in obesity prevalence, and that states that repealed a soda/snack tax between 1991-1998 were more than 13 times more likely to see a high increase in obesity.

This data doesn’t prove that a tax reduces consumption—there can be other explanations: maybe states in which a tax policy could be passed are those in which social norms act against obesogenic behaviors anyway. But it is encouraging data.

The Yale Rudd Center cites several studies in a public policy brief, and finds that:

“Based on the best estimates to date of the responsiveness of demand for soft drinks to changes in price, a 10% tax could result in about an 8% reduction in consumption. The effects could be higher for heavy users of soft drinks.
Based on November 2008 price increase and volume sales information on Coca Cola and Pepsi sales in the U.S., demand for soda is “elastic” (-1.15) meaning that a 10% tax would reduce consumption by 11.5%.”

A tax on sugary drinks will certainly help balance state budgets—given the incredible popularity of these drinks, even a modest tax will bring in lots of much-needed revenue, which states propose to use for health insurance and other health initiatives.

Is it fair?

The main argument against the tax is its regressive nature: this tax will affect low-income people more than it would impact higher income households. Consumption of soda is highest in lower socioeconomic homes and minority groups.

It’s a valid argument.

On the other hand, low-income people can benefit most from reducing their intake of soda—the health problems caused by obesity fall disproportionately on the poor. Many also argue that the programs that these taxes will fund—be it health insurance coverage, wellness programs, anti-obesity initiatives or subsidies for healthy foods—will benefit low-income people the most.

The other argument often made, and with some passion, is that the state should stay out of our plate, and not try to dictate what we should be eating.

This one’s pretty easy to deflect. Policy decisions dictate food prices and availability all the time. One of the reasons processed foods and sweetened beverages are so cheap is because of subsidies—dictated by current public policies (and not a small amount of lobbying by special interest groups). Corn is subsidized while fresh produce isn’t. There’s always been politics in food industry, and I think it’s high time new policies start to serve the health and well- being of people, and not those of “big food”.

As I mentioned before, most states have a sales tax that excludes groceries and prescription drugs (yet is imposed on prepared foods). That, again, is a policy, and I assume that the reasoning behind it that food and medications are essentials. I find it hard to call sweetened beverages an essential—quite the contrary.

The price of sweetened beverages is artificially but also ridiculously low—it doesn’t include the external costs of consuming them. Obesity and its consequences cost society huge amounts of money in healthcare costs (paid mostly by Medicare and Medicaid), absence from work and reduced productivity. This should somehow be reflected in the price of these junk foods.

If people worry about the regressiveness of such a tax, or that soda drinkers will replace the sweet drink habit with another equally unhealthy one, why not consider coupling a junk food tax with a fresh produce subsidy? a tax will also create an economic incentive for companies to produce healthy foods. It’s just mind-boggling to see that the unhealthiest foods are the cheapest, and that the more you buy of them the less you pay per ounce.

I think the argument for and against a soda tax is an interesting one (and I’m looking forward to responses to this post). It’s clear that debating the possibilities is a great way to make us look more carefully at junk food and healthy food policies.

What do you think about junk-food taxes? Do you have a better name for them? Would love to hear your thoughtful opinions!

Dr. Ayala

How we can end overeating and eat healthier

This week I’d like to reflect on one of my recent food related reads—David Kessler’s excellent “The End of Overeating.”

No, it doesn’t offer five easy ways to achieve a perfect beach body this summer, nor does it have a new magic trick to overcome food craving and obsessions. Rather, it‘s a lucid, well-researched and gentle book that takes a shot at explaining why we overeat. Knowing and understanding this could be a valuable first step toward eating better and with less torment, and maybe to losing weight or avoiding weight gain too. I think that Kessler’s book is a good read for anyone who eats food and for every parent raising kids in our food-crazed culture, and that includes those of us who have never struggled with overweight.

David Kessler M.D., a pediatrician, former dean of the Yale and University of California medical schools and former Food and Drug Administration commissioner has led the battle against the tobacco industry and dramatically reinvented the food label, and in this book goes deep into how the food industry, assisted by very clever marketing, designs and promotes products perfected to hijack our appetite and our brain and get us to consume more of their food.

Kessler admits to being one to obsess over food and struggle with uncontrolled eating and weight. His book combines personal stories with many scientific studies that delve into the science of obsessive, or what he dubs “conditioned overeating,” the kind in which food has power over you, draws you in, leaves you always wanting more and rarely satisfies your hunger.

The formula for irresistible food

According to Kessler, American industrial food has perfected a formula for food that’s highly palatable. The main driver of food desire is sugar, and when you layer that with fat and salt, food becomes irresistible (despite that these formulaic products are terrible for your body). Kessler cites food consultants and designers who describe processed food as “adult baby food” —free of the elements of whole healthy food, it goes down very smoothly and quickly, and delivers lots of calories without much chewing.

Processed foods manufacturers make what they know consumers want-- sugar, fat and salt in perfect balance, with the right texture, mouth feel and flavor. Flavor of course can be completely designed by food chemists and can make the blandest of raw material into a highly palatable food. Chemists can imitate a multitude of traditional, expensive or exotic ingredients, and create processed food in which the only real thing is cheap readily available ingredients with not much taste, yet the end product is optimized to give it great sensory appeal. Technology enables the food industry to make anything they want from a few simple cheap building blocks and plenty of sophisticated chemical inventions. It looks like food, it captures your attention (and your taste buds), but it isn’t nutritious and doesn’t satisfy.

Add to that the ingenious selling machine that pushes these foods and makes them available everywhere and you start to understand why it’s so easy to overeat.

How to regain control

The first step to improving your diet is to look at these foods critically--see them as addictive, not nutritious, and designed only to sell. Kessler calls for a perceptual shift of the kind that occurred with tobacco. The next step is to fight back. Kessler devotes several chapters to a strategy that starts to enable people to free themselves of overeating and obsessing. The treatment plan includes planned eating (rather than eating in an unstructured impulsive way), controlling portion size, choosing the right foods, finding joy in eating and overcoming the old unrestrained eating behaviors.

He also believes several public policies can make food manufacturers change their products for the better. Among these are calorie posting in restaurants, prominent display of added sugar, refined carbohydrates and fats on the food label, monitoring and exposure of food marketing ploys that promote harmful behavior, and education campaigns informing the public of the dangers of eating unhealthy foods loaded with sugar fat and salt.

But Kessler thinks the main power we have as consumers is our ability to change what’s acceptable as food—when we change social norms, and better food in moderate amounts is what’s expected by us the food landscape will change too.

Can we prevent junk-food craving?

I think that very few people are completely free of worries about eating and weight, and most people who care about their health and weight exercise control over eating on a regular basis—I certainly do. But one of the nagging thoughts I had while reading this book was that I personally couldn’t really identify with the attraction to the processed hyper-palatable foods that are rich in sugar, fat and salt that Kessler sees as conditioning us to overeat.

I don’t think I was ever attracted to these sweet, fat and salty processed foods. Did I reason with myself and turn against them because they’re unhealthy and fattening? Maybe, but honestly, I think I rejected them based on taste. When Kessler describes the milkshakes, chocolate chip cookies, fried foods and the offerings at Chilli’s and Cinnabon’s, my mouth didn’t water at all. I know I wouldn’t eat these foods even if I was hungry.

I tried to think about my kids, who are unconcerned with weight issues. While they do have a notion that eating well is important to their health, they don’t worry about it much. I do believe they, too, would reject these foods (even a triple-thick chocolate milkshake) on the basis of taste and appeal.

And in that thought lies a hopeful message to us parents: I believe that if you feed your kids real, unfussy food made from fresh, quality ingredients, they’ll develop a taste for it. They’ll also develop an expectation for how one feels after eating a good balanced meal, and contrast it with how one feels after consuming the super-sized fatty fast food meals. Real food has a sophistication and complexity that is very appealing if you’re sensitive to it. When you’re used to healthy real food, fast food feels like a heavy bombardment of sweet, fat and salt that’s really quite crude and indeed unsatisfying.

I do think that it’s just like art appreciation: once you’ve immersed yourself in the real thing, the reproductions pale.

I was thinking of Kessler’s book again when we were at a party last weekend. I was selecting dinner from the extensive buffet that included foods with “kid appeal”, such as French fries and onion rings. My ten year-old and her friend were right next to me, and her friend called with delight: “Asparagus! I love asparagus!” and filled his plate with the grilled stems topping them with hot sauce. My daughter selected nothing but cucumber sushi rolls. I don’t think the fried food had a chance with these kids—they simply didn’t think of it as food.

Part of the strategy to end our overeating, I think, lies with developing good competition to the sweet, fat and salty in the form of simple, healthy, tasty food.

Did you ever feel like food has power over you? Do you have ways to free yourself? Please share!

Dr Ayala

The gluten-free health fad: the good and the bad-part 2

In the previous post I reflected on the rapid expansion of the gluten-free market share and the rising popularity of the gluten-free diet, and said I'm glad to see the growing awareness of celiac disease, and also happy that keeping a gluten-free diet is becoming easier.

But is there a downside of the gluten-free fad? Are we replacing lack of awareness of celiac disease with confusion?

There are now several categories of gluten-free people: Genuine celiac patients, people who suspect they may have celiac and have gone gluten-free without a doctor’s diagnosis, and gluten-free lifestyle adopters, who joined in for perceived health benefits or as treatment for ailments that are not proven to be aided by a gluten-free diet.

The first group, celiac patients, needs to adhere to a very strict gluten-free diet for life. How strict? Very! Even small amounts are forbidden. Gluten sometimes hides in unexpected places, and can cross contaminate food. Although many celiac patients will not experience discomfort after eating some gluten their bowel will feel it and there are long-term consequences to non-adherence.

The second group needs to be evaluated by a doctor, and the diagnosis of celiac confirmed or excluded. Without a clear diagnosis and treatment plan they may be doing themselves harm, or alternately, putting themselves through unnecessary restrictions.

As to the third group they may adhere to the gluten free regimen loosely or strictly, and may feel better on it--we cannot argue with success. But the different degrees of adherence to gluten avoidance is a source of much confusion as we’ll cease to identify a gluten free diet as the extremely strict--not a bread crumb to touch that food--that a celiac patient needs.

Perhaps it's time to give the diet concentrating on gluten avoidance of those without celiac a unique name, such as "low-gluten" or "reduced-gluten" diet. This way it will be clear both to those on it and those cooking for them that they don't have to be extremely strict, and on the other hand it'll be clear to the public that unlike other diets and food preferences a celiac patient's shouldn't be on just a low-gluten diet, but rather on a truly a gluten-free one.

If we don’t understand gluten-free as a medical entity, we won’t treat is with the seriousness it deserves. Gluten-free will have more than one meaning, and there will be gluten-free for celiac and for hobbyists.

Who’s making gluten-free food?

The FDA has a proposed draft that will allow the “gluten-free” claim for voluntary use on products if:

“food does not contain any of the following: An ingredient that is any species of the grains wheat, rye, barley, or a crossbred hybrid of these grains (all noted grains are collectively referred to as ”prohibited grains”); an ingredient that is derived from a prohibited grain and that has not been processed to remove gluten (e.g., wheat flour); an ingredient that is derived from a prohibited grain and that has been processed to remove gluten (e.g., wheat starch), if the use of that ingredient results in the presence of 20 parts per million (ppm) or more gluten in the food; or 20 ppm or more gluten.”

The amount of gluten accepted in a gluten-free product is minute: 20 parts per million, so you can see that contamination by even tiny amounts of wheat flour, which has about 80,000 ppm, brings a gluten-free food to unacceptable levels.

At this point it’s up to the manufacturers of gluten-free food items to guarantee such a claim.

Now it’s one thing to manufacture gluten-free packaged goods in a controlled production facility, and quite another to offer gluten-free options in a busy restaurant.

The growing gluten-free demand is encouraging many restaurants to offer gluten-free options. I believe they mean well, but could they really guarantee a meal is gluten-free? It takes much more than using special gluten-free pasta to make a meal fit for a celiac patient.

My daughter has a close friend who has celiac disease. When I cook a meal for her and her family I will usually skip any gluten-containing food for the entire meal for everyone because it makes cross contamination less likely. If I’m going to still make bread or use any other flour-based recipe, I will do so hours before making the rest of the meal, then completely clean-up the kitchen, store the flour, put my apron in the wash, and cook gluten-free.

Many parents of kids with celiac opt for a gluten-free kitchen because it’s so difficult to avoid contamination. I find it quite hard to imagine that a restaurant kitchen—with many people working under intense pressure using lots of shared equipment—can really make sure the flour from the pasta maker doesn’t touch the rice and that the spoon stirring the gluten-free soup didn’t also go into the barley soup. I think that, try as a restaurant might, it’s very hard to keep menu items truely gluten-free, and the best advice to patients with celiac is to eat at restaurants as little as possible.

Gluten-free junk

While there are a few really wonderful and innovative new gluten-free foods, there’s also a proliferation of gluten-free junk. One of the advantages celiac patients used to have was that they were somewhat protected from our fast- and junk-food environment, and ate home-made naturally gluten-free foods. Do they really need dozens of new processed foods reformulated without gluten?

The take-home message about the gluten-free label

Gluten-free should not read as “healthy” or “pure.” Gluten-free should be read like allergen information (celiac is not an allergy to gluten, but in terms of how strictly the diet needs to be kept, a serious nut allergy is a good comparison) and just like nut-free is information for those allergic to nuts, not signifying good or bad attributes, so it is with gluten: Gluten-free means it’s food that acceptable to those with celiac; it can be nutritious or pure junk—you’ll have to read the ingredients.

If you don’t have celiac, and are ready to make a change for better health, why not spend your time, energy and money on strategies that make more sense, and reduce (not necessarily eliminate) more serious offenders, such as fast and highly processed foods, or resolve to follow the age old advice of eating more fruits and veggies?

What I hope we’ll all get from the gluten-free boom (before it busts) is greater awareness of celiac disease (along with timely diagnosis) and some great tasting gluten-free breads and pastas, which are no small feats.

What do you think of the popularization of gluten-free foods?

Dr. Ayala

The gluten-free health fad: the good and the bad - part 1

Have you noticed the gluten-free food explosion? I have the privilege of attending many food shows, and I’m stunned by the proliferation of grain based foods—prepared meals, cookies, snacks bread and crackers—developed for the benefit of those on a gluten-free diet and with “gluten-free” as a marketing proposition.

Gluten-free foods are a necessity for people with celiac disease, a disorder resulting from an immune reaction to gluten. But are these foods good for everyone else?

While the precise prevalence of celiac disease isn’t known, it’s estimated to range from about 0.4 percent to about one percent of the general population in the U.S. (up to three million Americans). The number of Americans with physician-diagnosed celiac however, although growing, is still not very large, and estimated anywhere in the range of 40,000-110,000 cases.

Not to sound cynical, but even a one percent consumer base wouldn’t drive manufacturers and retailers to the accelerated expansion of the gluten-free options we’re seeing. The reason food manufacturers have jumped in full force into this market is because gluten-free products are now favored not only by celiac patients, but by many people without the diagnosis—gluten free is indeed the latest food fad—and it’s a huge opportunity to make money. Research firm Mintel estimates that nearly 10 percent of shoppers currently seek gluten-free foods; they forecast 15- 25-percent growth in gluten-free product sales in coming years.

I’m glad to see the growing awareness of celiac, and also happy to see that keeping a gluten-free diet is becoming easier, more acceptable, and requires less sacrifice on taste.

On the other hand, the “fad” aspect of the gluten-free boom worries me quite a bit.

Is gluten bad for you?

Gluten is a protein found in wheat or related grains. It's a remarkably large molecule that’s quite central to the structure and texture of dough.

Gluten is definitely not an evil food component for those not afflicted by celiac. Gluten is part of whole-wheat flours and whole wheat, barley and rye grains—parts of a healthy diet. Although many junk foods contain gluten, gluten isn’t what makes these foods not nutritious—it’s the other ingredients or the processing of the grains that makes them so. If going gluten-free means choosing from the gluten-free menu at Wendy’s or Dairy Queen, or replacing wheat based snacks with corn based ones, you haven’t done yourself much good.

What’s a gluten-free diet good for?

There are only two established medical reasons to avoid gluten: celiac disease and dermatitis herpetiformis, a very itchy chronic skin rash of bumps and blisters, frequently linked to celiac. In celiac disease, complete removal of gluten from the diet is necessary for life, and results in complete resolution of symptoms. Non-adherence to a gluten-free diet can have dire consequences (even if the person is asymptomatic), including poor growth, infertility, osteoporosis, anemia, bowel narrowing and bowel cancer.

A gluten free diet is now touted for many other conditions, from autism to attention-deficit disorder, irritated bowel syndrome, multiple sclerosis and now even weight loss.

Although there are anecdotal stories about gluten-free diets making a difference for these conditions, there's really no good evidence to support such advice.

Autism

The gluten-free casein (milk protein)-free diet is a very common treatment attempt for autism.

A Cochrane review did an extensive literature search to identify randomized controlled studies of gluten-free or casein-free diets as an intervention in autistic features. They found only two small randomized controlled studies, with a total of 35 patients between them. The results of one of these studies indicated that a combined gluten- and casein-free diet reduced autistic behavior, but the second study showed no significant difference in outcome measures between the diet group and the control group.

The researchers concluded (emphasis is mine):

“Research has shown of high rates of use of complementary and alternative therapies (CAM) for children with autism including gluten and/or casein exclusion diets. Current evidence for efficacy of these diets is poor. Large scale, good quality randomised controlled trials are needed.”

Weight loss

There's no logical reason why adopting a gluten-free regimen should result in weight loss. Unless you have a strategy of reducing caloric intake on what just happens to be a gluten-free regimen, I can’t see how gluten-free for weight reduction makes any sense.

In fact, patients with celiac often gain weight once they start a gluten-free regimen. The reason is that while they’re eating gluten, many suffer abdominal pain, malabsorption and other symptoms that lead to reduced consumption or utilization of food. Once they’re on the gluten-free diet they thrive, eat well and gain weight.

Perhaps paying more attention to food—no matter what the regimen—can anecdotally lead to weight loss, but there’s nothing inherently low calorie or healthy about a gluten-free diet.

I learned from nutritionist Janet Helm about Elisabeth Hasselbeck’s book “The G free diet,” which Janet criticizes for inaccuracies, and also for “glorifying gluten-free and making it appear to be the best thing since, um, sliced bread.”

In the introduction to her book, Hasselbeck (who has celiac disease, and therefore greatly benefited from going gluten-free) writes:

“But a gluten-free lifestyle can help countless others as well. People suffering from a wide range of diseases—from autism to osteoporosis, from diabetes to rheumatoid arthritis—can often benefit from this change in diet. Even people with no health issues have a great deal to gain by giving up gluten. The G-free diet can help with weight management. It can elevate your energy levels, improve your attention span, and speed up your digestion.”

To which all I have to say is: Show us the proof! I searched Medline (the online computer database for biomedical journals) and couldn't find it.

But is there a downside to giving gluten-free a try? I'll get to that on the next post, in the meantime, your comments as always are welcome.

Dr. Ayala