Healthy Food & Healthy Living by Dr. Ayala

Can super-sizing fruits help you shed weight?

I’m very skeptical of promises that sound too good to be true.

No field is as rife with these as the diet industry, where new dream diets are invented daily and claim to have found a magic trick allowing us to eat as much as we want yet lose weight.

But here’s one worth checking out: Can eating more fruit help you shed weight?

This diet is worth a second look because we have many other good reasons to increase our fruit consumption—fruit and vegetables are an important component of a healthy diet and have a protective effect against many chronic diseases, such as heart disease, cancer and diabetes.

There’s also a plausible explanation for why eating fruit may protect against weight gain: Fruits have a relatively low-energy density, they have a lot of water and dietary fiber, and add lots of bulk. Studies show that food intake may be regulated by the weight of the food, and how long it takes to consume, therefore filling your plate with fruits would lead to greater satiety and less consumption of other foods.

A recent paper in Obesity Reviews analyzes the published studies on the association of fruits and weight loss. The authors specifically sought studies which look at fruit only, and not fruit and vegetables as one category (there are many studies showing that fruit and vegetable intake has an inverse relationship with overweight and obesity).

Of the sixteen human studies that met the inclusion criteria, eleven showed that increased fruit intake facilitated a significant reduction in body weight, decreased the risk of overweight or obesity or was associated with less overweight. The remaining five studies found no significant association, and no studies showed increased weight related to increased fruit consumption.

The studies included in this review were of three different types: Intervention studies, in which a study group is randomly assigned to receive an intervention—in this case increased fruit—and compared to a control group which receives a placebo or no intervention, prospective observational studies, in which a cohort with known exposures (in this case fruit intake) is followed for a health outcome over time (in this case weight), and cross-sectional studies, in which a population is observed at a certain point in time, looking for possible connections between, in this case, fruit consumption and weight. Each kind of study has its strengths and weaknesses.

Results from all three types of studies pointed towards an association between high fruit intake and lower weight. The authors call for large behavioral, randomized, controlled intervention studies to further clarify this issue.

Can supersizing the fruit serving increase fruit intake?

I think we’re all sold on the idea of including more fruit in our daily diet for a multitude of reasons, but many parents struggle with just how to do it—less than ten percent of kids consume their daily recommended number of fruit and veggie servings.

This brings me to another recent fruitful study, this one from the scientific journal Obesity.

Many studies show that increasing the size of the serving of food—entrees, snacks or soda—leads to increased intake, and supersizing the portion leads to supersized eating and supersized people. The authors asked the interesting question: Will supersizing the fruit and vegetables portion lead to higher intake of those in kids?

Forty-three Philadelphia-area kids aged five and six years were included in the study. They were twice fed dinner consisting of pasta with tomato sauce, broccoli, carrots, unsweetened applesauce and milk, with the portions of broccoli, carrots and unsweetened applesauce doubled in one of the meals randomly, while the pasta and milk portions stayed the same.
The results are pretty interesting:

Doubling the portion of fruit and vegetables side dishes resulted in a significant increase of 43 percent in the intake of the fruit—applesauce—but not the vegetables.

Doubling the portion of fruit and vegetables side dishes resulted in a significant decrease in the intake of the pasta dish, with the extra fruit displacing the more energy-dense pasta.

Overweight kids showed a bigger response to over-sizing the fruit and vegetables portion than normal weight kids; they ate more of the fruit and vegetables offered.

The study shows doubling the size of fruit and vegetables portions as a valid method for increasing fruit intake, but also maybe of controlling weight gain, as the fruit displaced a higher calorie food (pasta).

What about the vegetables?

A more careful look at how the vegetables were presented might offer an explanation: the broccoli and carrots were thawed from a frozen pack and served plain, with no seasoning or fat. I think even the most ardent vegetable lovers wouldn’t get too excited by those. Perhaps a more appealing preparation (broccoli sautéed with some olive oil, garlic, fresh ground pepper and salt anyone?) would have gotten a different result.

I think that if you’re plating a meal for yourself or for others increasing the size of the vegetable and fruit component is worth trying. It may very well be that the most obvious way to increase fruit and vegetables consumption is by making them show up in plenty! If they’re on the table, prepared in an appealing way, ready to eat and constantly available they’ll be what we eat when we’re hungry. That’s part of the way manufacturers of sugary drinks and junk foods make sure we consume more—they’re just everywhere and in plenty.

Food for thought!

Dr. Ayala

Health experts favor taxing sugary drinks in new report

A recent New York Times article says the debate over a tax on sugary soft drinks is starting to fizz over.

The story quotes President Obama as saying taxing sugary drinks is an idea worth exploring, and that “every study that’s been done about obesity shows that there is as high a correlation between increased soda consumption and obesity.”

A health policy report from the prestigious New England Journal of Medicine (NEJM) came out last week, and its well-respected expert panel of authors—including Kelly Brownell of the Rudd Center for Food Policy and Obesity at Yale University, Walter Willett of the Harvard School of Public Health and Thomas Farley, the New York City health commissioner—conclude that the reasons to proceed with this tax are compelling.

I’d like to take the time to go through the NEJM’s main points:

(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.)

Sugary drink consumption is rising, as is obesity

The intake of sugary drinks has risen worldwide, practically doubling over the last several decades. At the same time, the evidence showing that sugary drinks and increased body weight are positively correlated is convincing and continues to accumulate. Different study designs, and especially more rigorous studies, show this positive association, and the results casting doubt over this link are for the most part beverage-industry sponsored.

Why would sugary drinks lead to poor health?

The most obvious mechanism is weight gain—obesity is a risk factor for heart disease, diabetes, hypertension, some cancers and many other diseases. Sugar in liquid form has poor satiating properties and several studies cited in the report show how sugary drinks’ calories don’t seem to be registered by our body.

High intake of added refined sugars have known adverse physiological and metabolic effects, including elevation of triglyceride levels, elevation of blood pressure and lowering of high-density lipoprotein (HDL) cholesterol levels—all of which are risk factors for heart disease.

The high glycemic load of sugary drinks would be expected to increase the risk of diabetes by causing insulin resistance and also through direct effects on pancreatic islet cells. (Glycemic load is a measure of the effect of carbohydrates in the food on blood sugar levels. Simple carbohydrates—such as table sugar and high fructose corn syrup—break down quickly during digestion, releasing glucose rapidly into the bloodstream.)

Economic rationale to taxing sugary drinks

The report authors write, “Economists agree that government intervention in a market is warranted when there are ‘market failures’ that result in less-than-optimal production and consumption,” and say that there are several “market failures” when it comes to sugary drinks:

• Lack of information and misinformation: The public doesn’t always know the health consequences of sugary drinks, especially given extensive marketing campaigns that advertise the benefits of drinking these calorie-laden drinks.

• “Time-inconsistent” preferences: The short-term reward of the sugary drink (instant gratification) trumps the long-term harm, especially in the eyes of kids.

• “Financial externalities": Consumers do not bear the true cost of sugary drinks. The drink itself is cheap, but its true cost is very expensive in medical costs. For example, medical costs associated with overweight conditions and obesity are estimated at $147 billion a year, half of which are tax-payer dollars.

The proposed tax and its projected effects:

The authors propose an excise tax of one cent per ounce for beverages that have any added caloric sweetener, and suggest levying the tax on producers and wholesalers, who will pass it on to consumers. Such a tax would increase the price of a 20 oz. bottle of sugary drinks by 15-20 percent, and studies suggest the price hike will result in about a 10-percent reduction in consumption of these drinks. Higher taxes would result in even more reductions in intake.

The authors do not propose taxing non-caloric sweeteners (diet) drinks at this point.

The revenue is projected to be considerable— one cent per ounce would raise $14.9 billion in the first year—and could help fund childhood nutrition programs, obesity-prevention programs and health-care for the uninsured.

Objections, industry reactions and growing public support

A tax on sugary drinks would be regressive. To this valid argument the authors reply that “The poor are most affected by illnesses that are related to unhealthful diets, and brand loyalties for beverages tend to be set by the teenage years. In addition, sugar-sweetened beverages are not necessary for survival, and an alternative (i.e., water) is available at little or no cost; hence, a tax that shifted intake from sugar-sweetened beverages to water would benefit the poor both by improving health and by lowering expenditures on beverages. Designating revenues for programs promoting childhood nutrition, obesity prevention, or health care for the uninsured would preferentially help those most in need.”

Another objection often made is that the tax would not solve the obesity crisis. The authors argue that taxing sugary drinks has to be only part of the plan to combat obesity, but that even a 1-2 percent reduction in caloric intake will have an effect on our health.

The industry reaction to the proposed taxes has been—as expected—strong and clever. The article states that: “PepsiCo threatened to move its corporate headquarters out of New York when the state considered implementing an 18 percent sales tax on sugar-sweetened beverages.” It also alerts us to the devious ways in which the beverage industry is fighting the proposed bills: for example, the beverage industry has created front groups, whose name suggests community involvement, such as Americans Against Food Taxes. Be aware!

But according to this paper, public support is not behind the beverage industry, and the trends are in the opposite direction—public support for a tax on high calorie low-nutrition foods and beverages to address obesity is on the rise.

The authors conclude:

The federal government, a number of states and cities, and some countries (e.g., Mexico) are considering levying taxes on sugar-sweetened beverages. The reasons to proceed are compelling. The science base linking the consumption of sugar-sweetened beverages to the risk of chronic diseases is clear. Escalating health care costs and the rising burden of diseases related to poor diet create an urgent need for solutions, thus justifying government's right to recoup costs.

As with any public health intervention, the precise effect of a tax cannot be known until it is implemented and studied, but research to date suggests that a tax on sugar-sweetened beverages would have strong positive effects on reducing consumption. In addition, the tax has the potential to generate substantial revenue to prevent obesity and address other external costs resulting from the consumption of sugar-sweetened beverages, as well as to fund other health-related programs. Much as taxes on tobacco products are routine at both state and federal levels because they generate revenue and they confer a public health benefit with respect to smoking rates, we believe that taxes on beverages that help drive the obesity epidemic should and will become routine.

I wrote about this volatile subject a few months ago, and made my arguments for considering such a tax. I’m glad to see the discussion heating up. Whether the tax is implemented or not, the discussion will, at the very minimum, make more people aware of the body of evidence linking sugary drinks to obesity and adverse health outcomes. The consumption of these drinks will continue to drop because consumers are smart enough to give up the liquid candy habit regardless of price once they know the facts.

Your thoughts, as always, are very welcome.
Dr. Ayala

How can “cutting added sugar” drive better health?

The American Heart Association’s (AHA) new guidelines published in late August were a refreshing point of clarity contrasting with the vagueness typical of nutrition advice designed not to offend any major food lobby.

The new statement, published in Circulation, replaces AHA’s hazier 2006 one to “minimize the intake of beverages and foods with added sugars,” and provides detailed guidance by recommending an upper limit on added-sugars intake.

Let’s start with the AHA guidelines and look at the numbers:

• The upper limit for added sugars should be no more than half our discretionary calories. (Discretionary calories are at the very tip of the food pyramid, an area that’s small but fun; this is what we can allow ourselves to eat once we’ve eaten a nutritious diet; luxuries such as solid (saturated) fats, added sugars, and alcohol fall into this category, all of which should be consumed sparingly.)

• Most American women should consume no more than 100 calories of added sugars per day (6 teaspoons of added sugars); most men, no more than 150 calories (9 teaspoons of added sugars).

For an average adult woman, who needs about 1,800 calories to maintain her weight, there are about 200 calories in the discretionary budget, and the AHA advises her to spend no more than 100 of these on added sugar. Alas, it’s not that easy to know how much added sugar there is in prepared foods, as the food label lists all sugars—both innate carbs and added sugar —in the sugar component of the label. The sugar content on the nutrition label of fresh fruit looks quite similar to that of a cookie, even though only the cookie has added sugar, and fruits have naturally occurring sugars that act quite differently in our body.

Many prepared foods have lots of added sugar in them—sugar increases palatability, appetite and really “sells” the product. To get an idea of how much sugar is added to common foods you can glimpse into the USDA database, where you’ll see that significant amounts of sugar are added not only to drinks and desserts, but also to many breads, salad dressings, condiments and even baby food. Added sugar even comprises about half of the carbohydrates of many breakfast cereals! Your meager six allotted teaspoons of sugar may very well be already spent with sugar added to cereal, ketchup and yogurt well before you’re thinking about a dessert.

Primary source

Now on to the number one source of added sugar.

(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.)

The article states quite clearly that “Soft drinks and other sugar-sweetened beverages are the primary source of added sugars in Americans’ diets,” and provides a chart showing that soft drinks and fruit drinks combined make up over 42 percent of an average American’s added sugar. Just one 12-ounce can of Coke contains 130 calories in added sugars, which will put you over the AHA recommendation. The new guidelines, therefore, really spell out a recommendation that practically takes these sugary drinks out of the equation—unless one eliminates all other sweets and desserts altogether (and what’s life without an occasional dessert?)

I don’t want to leave the Circulation paper without providing some of the reasoning behind its cautious advice. To summarize, it states that:

“Excessive consumption of sugars has been linked with several metabolic abnormalities and adverse health conditions, as well as shortfalls of essential nutrients. Although trial data are limited, evidence from observational studies indicates that a higher intake of soft drinks is associated with greater energy intake, higher body weight, and lower intake of essential nutrients. National survey data also indicate that excessive consumption of added sugars is contributing to overconsumption of discretionary calories by Americans.”

The article reviews evidence showing that added dietary sugar:

• May raise blood pressure,
• Can elevate blood triglycerides levels (a risk factor for heart disease),
• Contributes to obesity and its many consequences, and
• Can undermine normal satiety levels, motivating us to eat more than we need and create food cravings.

Agreement from other authorities

The AHA statement joins that of many other influential medical authorities.

The American Academy of Pediatrics’ dietary recommendations for kids follow the same guidelines as those of the AHA and say that, “For young sedentary children, the amount of total energy intake that can come from foods used purely as a source of energy, 100 to 150 calories, is less than that provided by a usual portion size of most low-nutrient-dense snacks and beverages.” It has been calling to eliminate all sweetened drinks in schools for years.
The World Cancer Research Fund and the American Institute for Cancer Research report calls to “limit the consumption of energy-dense foods and avoid sugary drinks.”

Yet, the average American still takes in about 300 calories from added sugar a day from sugary drinks alone. We clearly have a long way to go to come close to meeting the recommendations.

To build awareness, the New York City Health Department’s new ad campaign confronts New Yorkers with a bold question posted on subway billboards and print media: Are you pouring on the pounds? “Sugary drinks shouldn’t be a part of our everyday diet,” says New York City Health Commissioner Thomas A. Farley. “Drinking beverages loaded with sugars increases the risk of obesity and associated problems, particularly diabetes but also heart disease, stroke, arthritis and cancer.”

What do you think of this image?

It’s encouraging to see that more and more independent bodies recommend moving away from all sugary drinks and minimizing highly processed foods. Whether it’s the sugar or the calories, the message is becoming clearer all the time. I hope more and more people are listening.

My concern is that the upper limit for sugar intake suggested by the AHA is shockingly low to most; I don’t know many people that can easily adhere to it. We all wish we could have more discretionary calories, just as it would be great if we could have more discretionary spending money and discretionary leisure time. (There is, however, a way to get more discretionary calories: by increasing our energy expenditure significantly through a greater level of physical activity.)

But for many of us, moderation in eating has to be spelt out, and moderation in sugar intake is one of the important messages we can act on to combat obesity.
Dr. Ayala

This entry has been posted as part of The Kathleen Show's Prevention not Prescriptions

Back to school -- five easy tips to improve your kids’ health this school year

I can’t believe the summer vacation is over and kids will be going back to school this week. This summer went by way too fast!

I was happy to get a letter from my daughter’s elementary school announcing new snack policies—the school will not be giving out any more snacks, will not give food as incentives, prizes or rewards, and birthday celebrations at school will become "food free." Parents are being encouraged to send healthy snacks from home, including fresh fruit, cut-up vegetables, dry fruit and trail mix (with no candy).

The reasons cited for this change of policy are dual—better nutrition to prevent childhood obesity and a precaution taken because many kids suffer food allergies.

I’m greatly encouraged to see that change in the way we feed our kids is indeed coming!
And to this hopeful note I’d like to add a few suggestions for simple steps that can add up to better health this coming school year. These steps are indeed small, certainly doable, and can have real impact, especially if they lead to the next small step towards wellness:

• Eat breakfast - Many know that breakfast may be the most important meal in the day. Studies show that eating breakfast is not only associated with better nutrition, better concentration and performance in school but also with less obesity. Yet up to a third of teenagers skip breakfast regularly. Make sure your kids leave home after they’ve had a nutritious breakfast! I’ve written more about the importance of eating breakfast in my post here.

• Teach your kids how to cook - Preparing simple healthy meals is a life skill that is a gift that keeps on giving. Give your kids age-appropriate healthy shopping and healthy cooking lessons, and if you feel you’re in need of a few lessons yourself, you can learn together from books, websites and cooking shows.

• Take the junk-food out - While a little junk every once in a while will probably do no harm, having it available at home on a regular basis enables bad habits and teaches the wrong lesson. Make home a safe haven of healthy, nutritious food. Take the soda, sweet drinks, fatty sweet and salty highly processed snacks out, and replace them with readily accessible fruits, vegetables, nuts and other healthy snacks.

• Find out what’s served in the school cafeteria - Unfortunately, the school lunch in many schools is not a healthy one. What’s more, competing with the school lunch are junk foods sold through vending machines and other sources. Find out what is served in your kids’ school, and if it doesn’t meet your standards, do something about it: Send your kids to school with a lunchbox and healthy snacks from home; speak up and try to effect change in the school lunch program in a practical and positive way.

• Get them moving! - A third of our kids are overweight or obese, childhood obesity has tripled in the past thirty years, and although these skyrocketing rates are mostly a result of the food environment we live in, kids’ inactivity also plays a role. If your kids aren’t getting their daily dose of vigorous exercise, encourage them to join a sports team, pick a new hobby that will get them moving, and incorporate more movement in daily life. If school and other activities are close to home, consider walking rather than driving when weather and time permits. Choose family activities that are active, and get the whole family exercising and out in the fresh air! Many neighborhoods are quite safe, yet kids don’t play outdoors often enough; find a way to get the kids on your block back in the playground or on the open field playing unorganized sports the old fashioned way, with supervision if you see the need, or without.

A happy, healthy start to the new school year to all of us!
Dr. Ayala