Healthy Food & Healthy Living by Dr. Ayala

The latest on sugary drinks, heart health and weight loss

There’s little question that sugary drinks are not just randomly associated with obesity, but actually contribute to it in a big way. Dozens of studies continue to prove this point, and the only so-called “research” that tries to introduce doubt to this sad conclusion is industry-sponsored.

Nevertheless, this accumulated evidence is seeping in quite slowly into consumers’ consciousness. The average American still takes in more than a fifth of their daily calories from beverages. Perhaps constant, very effective and entertaining advertising (yeah, I do love these ads; they’re the major Super Bowl viewing attraction for me—but don’t tell my kids!) weighs heavier on our minds than evidence and medical advice.

I’m therefore glad to see further evidence presented about the effects of sugary drinks on health, and that leading institutions and scientific bodies are devoting their pulpit to the important public health issue of overhauling in the way we drink.

So here’s a glimpse at some of the recent research on sugary drinks and health from the April ‘09 crop, just in time before warmer weather sets in and increases our hydration needs.

(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 lifesyle for many years.)

Sugary drinks and cardiac health

Harvard researchers looked at the relationship between sugary drinks and heart disease in a recent paper published in the American Journal of Clinical Nutrition. Sugary drinks are associated with obesity and type 2 diabetes—both of which are risk factors for coronary heart disease—and the researchers set out to check if sugary drinks would be associated with heart disease. They also wanted to see whether sugary drinks would be a risk factor for heart disease independent of obesity and diabetes.

The data was taken from the Nurses’ Health Study cohort of almost 90,000 women aged 34-59 years. The study group had no heart disease, stroke or diabetes at the beginning of the study. The group was followed for 24 years, and food questionnaires were administered seven times between the years 1980 and 2004.

In a study such as this one, it’s very important to adjust for potential confounders; therefore non-dietary factors such as age, smoking status, alcohol intake, family history of heart disease, fitness, aspirin use, hypertension and blood cholesterol were taken into consideration in the statistical analysis.

The researches went further in their attempt to isolate the effect of sugary drinks on heart disease, and because drinking sugary drinks may be a marker of unhealthy eating patterns, they adjusted for overall dietary influences on heart disease using the Alternate Healthy Eating Index (AHEI). This index gives points to several key aspects of healthful eating, such as fruits and veggies, cereal fiber, polyunsaturated to saturated fat ratio, trans fat, legumes and soy etc.

Here’s what they found:

• During the 24 years of follow up there were 3,105 ascertained incidences of coronary heart disease (heart attacks).

• There was a significant positive association between sugary drink intake and coronary heart disease—the higher the intake, the greater the risk.

• After adjusting for the non-dietary factors (age, smoking, etc.), women who consumed more than two servings of sugary drinks a day had an almost 40 percent higher risk of heart disease than those that had them less than once a month.

• After adjusting for dietary healthfulness using the AHEI score, drinking more than two servings of sugary drinks a day still had an a 35 percent increased risk of heart disease compared to those that had them less than once a month.

• Even after adjusting for Body Mass Index, or BMI, caloric intake and diabetes, the risk of heart disease in sugary drink heavy users was still significantly higher (drinking more than two servings of sugary drinks a day still added about a 20 percent increased risk of heart disease compared to those that had them less than once a month.)

• There was a weak but marginally significant association between intake of artificially sweetened soft drinks and heart disease after adjustment for dietary and non-dietary factors.

And they conclude:

“We found that consumption of SSB (sugar-sweetened beverages) is associated with a higher risk of CHD (coronary heart disease) in women, even after other risk factors for CHD or an unhealthful diet or lifestyle are accounted for. This finding provides further rationale for limiting the consumption of SSBs.”

Sugary drink reduction as a weight loss strategy

Johns Hopkins Bloomberg School of Public Health researchers published an interesting prospective study in the American Journal of Clinical Nutrition that looked at whether liquid calories are more obesogenic (tending to cause obesity) than solid calories, and whether reduced consumption of different beverages does indeed change weight.

The study included 810 adults aged 25-79 years, who had pre-hypertension or mild hypertension, and were receiving several types of information and advice about weight loss, physical activity and salt reduction as a means to address their elevated blood pressure. No specific advice was given regarding beverage consumption, and the diet advice was rather general.

The researchers looked at dietary recall questionnaires and compared them to weight loss outcomes after 6 and 18 months.

Here’s what they found:

• At the beginning of the trial, the average daily caloric intake from beverages was over 350 calories, or almost 20 percent of total caloric intake. Most of these beverage calories were from sugary drinks.

• The study group as a whole decreased its intake of sugary drinks (as well as coffee and tea) over the 18 months of study.

• A reduction of 100 calories/day of liquid calories was associated with weight loss of about half a pound at 6 months, and about half a pound at 18 months across the study group.

• Reduction of 100 calories/day of solid calories was associated with weight loss of about one-tenth of a pound at 6 months, and about two-tenths of a pound at 18 months across the study group.

• Looking at individual beverages, the researchers saw that reducing one serving of a sugary drink a day (12 ounces) was associated with weight loss of more than one pound at 6 months, and about one and a half pounds at 18 months.

The researchers conclude:

“Our study supports policy recommendations and public health efforts to reduce intakes of liquid calories, particularly from SSBs, in the general population”

Recent advice from experts

•April’s Archives of Pediatric and Adolescent Medicine is devoted to childhood obesity papers, and also includes an advice for parents page titled “Sugary drinks and childhood obesity”.
Their recommendations:

“1. Eliminate sugary drinks at home. Just don't buy them. Replace sugary drinks with water, milk or real fruit and vegetable juices. Encourage your child to drink lots of water.

2. Offer healthy eating choices at home, including healthy snacks.
3. Remember: Small changes every day can lead to success. “

• Harvard’s School of Public Health’s website says it’s high time to address America's hidden drinking problem—the astounding amounts of sugary soft drinks, juices and other beverages we guzzle daily. This informative and referenced (really good references by the way!) source calls for a retraining of America's palate away from heavily-sweetened drinks, and is a call to action for all of us: consumers and parents, beverage manufacturers, government, schools and worksites.

I’d like to end with a little bright spot of news: Mintel reports that the soda market lost almost 16 million adult drinkers in the last five years. But while many consumers did move on to lower- calorie drinks and water, the availability of high-calorie energy and sport drinks has expanded dramatically too, a shift that’s not likely to benefit us in the fight against obesity.

Our eating habits may well be moving slowly towards healthier options, but progress is ever so slow. That’s why there’s a call by many experts for policy changes--such as creating standards for beverages sold in schools, and taxing sugary drinks--which may impact public health and improve the diet of the population as a whole. This might be the only way to encourage healthier choices and especially reach less-advantaged and informed groups, whose rates of obesity and diet-related illness continue to rise.

Are you and your family members consuming fewer sugary drinks than you did a few years ago?

Dr. Ayala

Do Sumo Wrestlers Skip Breakfast?

I'm taking a short spring break to spend time with my family and travel. Meantime, I'm reposting some of my favorite posts from last year so that new readers have a chance to catch up. Enjoy this post and happy spring! - Dr. Ayala

I’ve heard this factoid many times: Sumo wrestlers’ diet regimen includes skipping breakfast, in order to gain more weight and achieve morbid obesity.

Is it true? Does skipping breakfast really make you fat?

Apparently up to a third of teenagers skip breakfast regularly. Whether they do it to loose weight or because of circumstances, it’s not a good habit.

As much as I enjoy backing the advice I give my kids with scientific studies, I think that you don’t need to prove that eating breakfast before going to school is important. Going to school on an empty stomach just doesn’t make sense. Hunger interferes with learning, and I try to feed my kids as many of their meals at home as possible, as I assume that whatever they’ll eat out of home will be nutritionally inferior to what I carefully prepare or select. Sensible eating habits are important, and key to preventing nutritionally caused conditions such as obesity.

So even if the studies said otherwise, I’d look for their weaknesses (those always exist, and are admitted by the authors in the discussion section of the paper), and continue to advocate regular breakfasts before leaving home.

But there are plenty of studies supporting the breakfast habit, and showing that breakfast eaters have better overall nutrition profiles, better cognitive functioning, and are less likely to be obese or diabetic.

A recent study, published in the journal Pediatrics found that middle and high school students who ate breakfast had significantly lower body mass index (BMI) scores than those who skipped the meal. Frequency of eating breakfast was associated with a healthier diet, higher socioeconomic status, white race, and more physical activity, and inversely associated with smoking, alcohol consumption and dieting and weight-control behaviors.

Although the study doesn’t prove that eating breakfast causes a lower BMI, the authors submit that, “Breakfast habits may be important markers of an overall healthful lifestyle pattern in youth and that frequent breakfast consumption may impart important weight-gain prevention effects."

These findings come out of the Project EAT (Eating Among Teens), a 5-year longitudinal study developed to examine eating patterns and weight concerns among adolescents in Minnesota.

There are dozens of interesting published findings from the analysis of data from this large cohort, including:

• Adolescents with a bedroom television watch more television, are less physically active, eat less fruits or vegetables, consume larger quantities of sweetened beverages and fast food, have fewer family meals, and have poorer school performance, see here.

• Among adolescent girls, regular family meals (five meals/week) were associated with a lower prevalence of extreme weight-control behaviors, such as self-induced vomiting, use of laxatives, diet pills or diuretics.

• Dieting in adolescents is associated with weight gain.

• Children in families who watched TV while eating meals together had a lower-quality diet than the children of families who ate together, but turned the TV off.

Back to the Sumo Wrestler’s breakfast, or lack of it.

The “no breakfast” recipe for weight gain is all over the Internet, but the closest I could come to a reliable source was from “Introduction to sumo wrestlers, the world's largest athletes,” in Current Anesthesia & Critical Care, Volume 12, Issue 5, October 2001, Pages 267-272 by R. Ochiai and J. Takeda, of the Department of Anesthesiology, School of Medicine in Tokyo, Japan. “The training of a Sumo wrestler starts early every morning before breakfast, and lasts for about 3 hours,” they claim. The athletes apparently eat a large high calorie meal only after the morning session.

I don’t know whether Sumo wrestlers don’t eat breakfast because they cannot train hard enough on a full stomach, or because skipping breakfast builds a huge appetite allowing them to eat up to five to ten times the meal of an average person.

I tend to think that eating breakfast controls appetite and skipping meals isn’t a sustainable way to eat well or loose weight for most people.

Besides, I love eating. One of the things that get me excited every morning when I wake up is the thought of breakfast (and my cappuccino).

Dr. Ayala

Beware of the Cherry Trees

I'm taking a short spring break to spend time with my family and travel. Meantime, I'm reposting some of my favorite posts from last year so that new readers have a chance to catch up. Enjoy this post and happy spring! - Dr. Ayala

This is a photo of my Magnolia tree. It has reached the point of no return -- the blossoms are ready to open into the most spectacular floral display, and I’m constantly checking the weather forecast, worried about the possibility of late spring frost.

It’s an old tree, probably more than 60 years old, and has no doubt delighted several generations, each of them watching the buds with anticipation, from early fall when they first appear, through the short days of winter, and finally into the warmer weather of spring, and the return of pollinators.

We lose the joy of seeing the tree in bloom quite often. Last year we had snow in April that turned the blossoms brown, and I had to fight my sinking mood during those days. I wish I had a blanket for my tree for those frosty nights, but the tree is taller than my house, and there’s precious little I can do besides hope. The blooms are delicately fragrant, but after the petals shower down they carpet the back lawn, sweetly decomposing, and providing the grass much needed fertilization. The smell at that point is dazzling.

I’m in awe during spring. I plan my travel routes year round by the trees and flowers I want to see on the way. During the spring I keep warning my husband to beware when driving by the cherry trees. There are routes around Philadelphia that are just so gorgeous during the spring; too beautiful to give the task of driving your full attention.

In fact, on one of those splendid days a few years ago, we were driving together on the East River Drive along the banks of the Schuylkill River on our way home from Center City Philadelphia with the weeping cherries heavy with blooms. I was reminding myself to beware of the hypnotic cherry trees, and we stopped at a red light. The car behind us rear-ended us, nothing serious. He was a very nice guy, and he readily admitted that he was looking at the cherry trees a little more than he should.

I hope everyone stops their mundane rush to take in the beauty around us. There are so many gifts around us –- free -- if we just take the time to notice.

This brings us to the Joshua Bell subway experiment.

A few days ago this year’s Pulitzer Prize winners were announced. Among the winners was Gene Weingarten, who won for the feature article “Pearls before Breakfast”, that he wrote in the Washington Post Magazine.

I read this piece when it came out a year ago, and shared it with my kids—who are a bit young to really appreciate the excellence of Weingarten’s writing. But when I mentioned the story again this week, they remembered exactly what it was about: In an experiment designed by Weingarten, Joshua Bell, one of the greatest virtuoso violinists of our time, played some of the loveliest and most difficult music ever created, on his 300 year old, 4 million dollar Stradivarius at a metro station in DC during rush hour to see whether "ordinary people would recognize genius" when it happened their way.

Joshua Bell has been captivating audiences worldwide, has performed with many leading orchestras and conductors, and won the highest prizes. Normally, people pay $100 to hear Joshua play. His albums sell millions of copies. Besides, he’s a good looking guy.

But during the 43 minutes he played incognito at the station, only seven people stopped to listen, if only for a moment. Twenty-seven gave him money, for a total of $32.17. Over a thousand people hurried by, oblivious, not even bothering to look.

Gene Weingarten eloquently discussed how such beauty could be overlooked, and what we can learn from it. Although what happened can be explained many ways, the main reason people miss this and other beautiful things is because we rush. We are always in too much of a hurry.

What does this have to do with health?

I think that setting the rush aside for a moment and taking just a little time to appreciate our world -- nature, the people around us, the arts, good food -- leads to a sense of well-being, and less stress. And if it doesn’t improve your health, it’s guaranteed to give you pleasure.

Wish my magnolia luck this year.
Dr. Ayala

Vegans, vegetarians, diets and health-part 2

I’m devoting this weeks’ post to the current knowledge of the health effects of a vegetarian diet after discussing the vegan diet’s health effects in a post a fortnight ago.

The term vegetarian is quite broad, but for simplicity’s sake we’ll define vegetarians as those who avoid meat, fish/seafood and poultry, and do eat milk and eggs. It’s estimated (by a Harris Interactive poll) that 2.8 percent of the American population is vegetarian.

Much has changed in attitudes towards vegetarian lifestyles in the past decades. As a lifelong vegetarian, the first question I used to get was “Where do you get your protein?” The answer to this question is simple: Contrary to popular myth, plants--especially pulses (peas, beans and lentils), nuts, seeds and grains--have plenty of protein. Animal protein is considered a complete protein, meaning it has all essential amino acids in every bite. We now know that incomplete proteins can be stored in the body for many days to be combined with other incomplete proteins. Since different plant foods together contain all essential amino acids, it doesn’t matter if the proteins are complete or incomplete, and it’s also no longer recommended to bother with combining those different proteins in the same meal. Protein isn’t a problem.

The second question was usually “So what do you eat?” That led to an invitation to join us for a home-cooked meal that I’d prepare, or to a recommendation to try one of the many excellent vegetarian restaurants that prove the case that vegetarian food can be varied, extensive, deeply satisfying and extremely pleasurable.

A vegetarian diet is now much more accepted, vegetarian options have become much more popular, and vegetarian menus are less of a mystery. Many non-vegetarians are looking to eat more vegetarian foods, and it’s now proven that a healthy vegetarian diet is nutritionally adequate, doesn’t lead to any deficiencies of macro or micro nutrients and needs no supplementation. What’s also becoming quite clear is that vegetarian diets even confer some health protection.

As promised, I’m going back to The American Journal of Clinical Nutrition upcoming supplement on vegetarian, vegan and plant-based diets and their effects on health. A paper by Gary E. Fraser provides a balanced summery of the current science.

As you can imagine, studying large vegetarian cohorts is no easy task. There are a few such large cohorts. The California Adventists have been studied since 1958 and the study’s ongoing. The Seventh-day Adventist church is a Christian denomination that observes Saturday as the day of worship, but it’s also known for promoting a “healthy message,” including a vegetarian diet and avoidance of alcohol, caffeinated drinks, tobacco (they’ve been denouncing smoking for 150 years, well ahead of the medical community) and illegal drugs. Not all Adventists are vegetarian, so the effect of vegetarianism can be isolated within the Adventists. Other large study cohorts include the Health Food Shoppers’ Study and the Oxford Vegetarian Study both from the UK, and the German Heidelberg Vegetarian Study.

Fraser finds consistency in outcomes of vegetarian lifestyles across studies for the following considerations:

• Coronary heart disease is clearly lower for vegetarians. A combined analysis of these cohorts shows that non-vegetarians have 32% higher heart disease mortality than do vegetarians.

• Total LDL cholesterol is lower in vegetarians.

• Vegetarians are thinner than non-vegetarians.

• The risk of diabetes and hypertension is probably lower for vegetarians across studies.

Where Fraser finds inconsistent results is in the incidence of colon cancer. There’s general agreement from studies of non-vegetarians that red meat consumption increases the risk of colon cancer. The Adventists studies show that vegetarian Adventists indeed have a lower incidence of colon cancer, but the EPIC-Oxford study doesn’t show that vegetarians fare any better than the general British population. This of course demands explanation and further study.

Fraser concludes:

“Much remains to be understood. However, it seems clear that vegetarians experience less CHD (coronary artery disease) than do others. Their risk factor status would lead us to expect this result. The evidence that risk of diabetes is less in vegetarians is highly suggestive, although as yet it comes from cross-sectional work and mainly from California vegetarians. Again, what is known of causal factors in diabetes would lead us to expect this result. Body weight is lower in vegetarians and much lower in California Adventists. LDL cholesterol is lower in vegetarians, and this is probably true for blood pressure and risk of treated hypertension. The reasons for the blood pressure association are not well understood, and more research may refine our understanding of this.

Studies in both California and the United Kingdom are fairly consistent in finding at least moderate reductions in all-cause mortality in vegetarians, in comparison to other subjects living in the same communities. This would be expected on the basis of reduced cardiovascular mortality, unless some other presently unrecognized cause of death is increased in vegetarians. As suggested by the British work, it is also likely that there are other ways to similarly decrease mortality (the health-conscious nonvegetarians) aside from a dietary habit that is fully vegetarian.”

Vegans and vegetarians choose this lifestyle for many reasons, and the personal health advantage isn’t necessarily the main incentive to abstain from animal products. In fact, I don’t know if the health effects of these diets are a good enough reason for those who enjoy the taste of meat to give it up altogether, and I don’t think that there’s good evidence to suggest that eating quality meat in moderation is all that harmful.

On the other hand, there’s plenty of support for the recommendation to lower the (very high) consumption of red and processed meat in the average American diet.

A very recent study in the Archives of Internal Medicine followed half a million participants and found that red- and processed-meat intakes were associated with modest increases in total mortality, cancer mortality and cardiovascular disease mortality, and that the higher the red- and processed-meat intake, the higher the risk. The study of course cannot tell if it’s the meat that’s causing harm, or if those who eat lots of meat substitute it for beneficial foods, such as whole grains, fruits and vegetables.

There also is ample support for the advice to consume more fruits, veggies and whole grains. I’ve devoted several posts to that, and the evidence continues to accumulate: Just a few days ago, a very large prospective study, which followed more than 450,000 Europeans from ten countries for an average of almost nine years, showed that high consumption of fruit and vegetables is associated with a reduced risk of colon cancer.

My conclusion is that, from the health point of view, there’s plenty of evidence to suggest we should lower our consumption of animal products (especially red and processed meat) and increase our intake of plant-based foods, especially fruits and veggies.

No discussion of plant-based diets (as opposed to animal-based diets) is complete without getting into the impact our eating habits have on the environment, but that’s for another post.

Dr. Ayala