Healthy Food & Healthy Living by Dr. Ayala

Silly science, silly inventions and other 2009 follies

Who says science can’t serve up some holiday cheer? As 2009 draws to a close, I’d like to share some of the studies I failed to mention during this passing year, and pay tribute to some outstandingly ridiculous achievements in food, health and safety.

The food and health related Ig Nobel prizes for 2009

The Ig Nobel awards are a parody of the Nobel Prizes, and have been awarded each fall for the past 19 years for funny, absurd or unexpected (but all too real and methodically correct) scientific research in a ceremony attended by real Nobel laureates at Harvard University.

Of course, traditions are part of the ceremony, including the famous prompt that cuts grateful winners’ lengthy acceptance speeches in a high-pitched girls’ voice with "Please stop. I'm bored!" and the closing words, "If you didn't win a prize — and especially if you did — better luck next year!"

Not to be missed, there were some really funny Ig Nobel Prizes awarded this year for food and health research:

• The Veterinary Medicine Prize was awarded to Catherine Douglas and Peter Rowlinson of Newcastle University, England, for their research showing that cows that have names give more milk than cows that are nameless. This is a study that will probably interest many people in the sustainable agriculture movement, not to mention those who care about animal welfare. Apparently, this study joins others showing that fear of humans affects cattle’s productivity. Not so surprisingly, among the 516 dairy farmers surveyed, 90 percent thought cows had feelings, 78 percent thought cows were intelligent, and on farms where cows were called by name, milk yield was 258 liters higher than on farms where cows had no individual identity.

• The Ig Nobel Peace Prize went to a Swiss group that set out to test whether it’s better to be smashed over the head with a full bottle of beer or with an empty one. The sensible answer would be that it’s better to avoid both (either one can fracture a human skull), but to answer this most important question the researchers tested the fracture properties of full and empty bottles from a drop-tower, and determined that the empty bottle has a higher impact, leading to the satisfying conclusion that you can enjoy your beer, and have a deadly instrument too.

• The Biology Prize was given to a Japanese group for showing that kitchen trash can be reduced more than 90 percent in mass by using bacteria extracted from the feces of giant pandas.

• The Public Health Prize was given for a patent, registered by Elena N. Bodnar, Raphael C. Lee and Sandra Marijan of Chicago, for a bra that in case of emergency converts into not one but two protective face masks. You’ll always want a well-endowed woman by your side—with a cup size matched to the size of your nose—in case disaster strikes!

• The Medicine Prize was given to Donald Unger for investigating whether cracking knuckles causes arthritis—as his mom, aunts and mother-in-law warned. Donald diligently cracked the knuckles of his left hand but never cracked the knuckles of his right hand every day for more than sixty years. He found no evidence that it caused arthritis. Nothing happened. Unger prides himself for conducting the study entirely at his own expense, without grants from any governmental or pharmaceutical company. (I wonder if anyone will try to confirm these results with a slightly larger group and some randomization. And no, this doesn’t mean you can pop your knuckles—moms, aunts and mothers-in-law still find it annoying.)

The Ig Nobel’s tag line is “Research that makes people LAUGH and then THINK.” I think it does just that; can’t wait to see 2010’s winners.

The 2009 Darwin Awards

I’m not really sure if the macabre and sublimely idiotic deaths by stupidity that are “celebrated” through the Darwin Awards are humorous or just sad.

This prize is named after Charles Darwin and given to people who "do a service to humanity by removing themselves from the gene pool" (i.e. they lose the ability to reproduce, either by death or by sterilization, in a especially foolish fashion). You can judge for yourself. The Darwin Awards website is run by Wendy Northcutt, who tries to verify every story (while many of the circulating email Darwin Award stories apparently aren’t true).

In many ways I prefer the Honorable Mentions, given to stupid acts that almost rendered the participant worthy of the award, but somehow, luckily, spared their life. I believe in second chances and that everyone has, at some point, done something incredibly stupid.

As you might imagine, some of these mishaps happen in the kitchen, and many involve fire, electricity and heat.

Here’s one Honorable Mention Darwin Award for 2009 to warm your heart:

"(February 2009, Sweden) Welcome to Sweden. Home of Swedish massage, Swedish cuckoos, and one Swedish meatball who decided to warm himself in an industrial- strength oven. The incident took place in freezing February at a facility operated by a maker of kitchen cabinets and fixtures (Ballingsl'v). The heating system in the loading area had ceased to function, leaving a shivering truck driver defenseless against the frigid winter. Looking to escape the cold, this driver wandered toward the shrink-wrap oven and asked the operator if he could take a spin on the conveyor belt to get warm.

Although the driver was freezing his umlaut off, the operator hard-heartedly denied the man's request. Undaunted, the driver waited until no one was looking and managed to hoist himself onto the conveyor belt for a blissful toasty ride. But all those Swedish meatballs took their toll. The massive (cough) trucker was too heavy for the belt and the motor shut down, leaving him stuck in the 360-degree oven.

Luckily, the oven operator noticed the stoppage and was able to drag the man out of the searing heat before he sustained serious injuries—except, perhaps, an industrial-strength tan. Following the incident, Sweden's Work Environment Authority offered the oven operator counseling to work through the shock he suffered, and intends to carry out a risk assessment of surveillance around the shrink ovens. Apparently they are too tempting to leave unguarded.”

Silliest diet for 2009

This one’s never easy. Competition among fad diets is tough; I’m truly astounded by the food regimens people impose on themselves and by the outrageous claims diet marketers make. But the Primal Diet is—to me—a clear winner for sheer craziness.

The premise: Return to the diet of our cave-dwelling ancestors, before they mastered the practice of taming the power of fire.

Founder: Aajonus Vonderplanitz

The recipe: An all-raw eating plan consisting of raw meat, eggs and dairy. Advanced adopters go for “high meat” or animal flesh that has “aged” and decomposed. The diet is 95 percent raw meat, and the rest is made up with vegetable juices and low-carb fruits, such as avocados and coconut. There’s not much need for recipes as all food is raw, though maybe a light touch of a marinade adds a little extra something.

The promise: A cure for everything, including advanced cancer, while inspiring a natural high, mental clarity and a sense of well-being.

If this diet doesn’t actually prolong life, it’s sure to make life seem much longer.

Warning: Don’t try this at home! You’re pretty much guaranteed to be eating many harmful bacteria.

Silliest kitchen gadgets for 2009

The British Landfill Prize compiled a top-ten list of the most ridiculously unnecessary and wasteful products of the year. Not surprisingly, kitchen gadgets are disproportionately represented.
Among the top prizes were:

A motorized ice-cream cone, for those too lazy to roll the cone around for an even lick. Dishwasher safe.

A motorized fork, which effortlessly twirls pasta towards the mouth.

I’d like to add to these the French-Fry Holder. This is one of those how-did-we-live-without-it car devices that fits into the standard cup holder (of which most cars have a dozen of, enough to accommodate a five-course meal with drink pairings) and holds a French fries container and even has a small holder for ketchup. It’s the perfect way to encourage even more un-healthy eating!

I have a feeling we may have peaked in terms of wasteful consumerism for a while. The competition will hopefully grow easier next year; we may even miss some of these excesses of the past.

Please feel free to share your silly findings for 2009. I plan to make this a yearly tradition, and I’ll be looking ahead for what 2010 brings.

Dr. Ayala

Our health report card for 2009: Are we making progress?

As 2009 winds down and the season for gratitude is upon us, this is a great time to reflect on our progress and contemplate the road ahead. This year especially, with the ongoing debate over public-policy directions for the U.S. health-care system, the collective state of our health deserves our attention.

America`s Health Rankings’ 2009 report came out just recently, and as a two-decade continuous assessment of our nation’s health, it’s a great tool for checking how we’re doing and—I hope—springing us into some action.

The longest-running annual assessment of the nation`s health on a state-by-state basis, the rankings urges all populations and communities to take action to improve health.

There are some bright spots in the report: Over the past 20 years, our nation has seen improvements in the reduction of infant mortality (a 33 percent drop), infectious disease (down 53 percent), prevalence of smoking (down 33 percent), cardiovascular deaths (29 percent fewer incidents), violent crime (a drop of 23 percent), air pollution and children in poverty (8 percent reduction), and there has been an increase in immunization rates of 42 percent.

We deserve a very light tap on the back for these advances since our progress has been slow. Even smoking cessation efforts, which have been the focus of a very large public health effort, has left nearly one in five Americans still smoking. Childhood poverty—which had been going down consistently—has gone up in the past year by a percentage point.

The past 20 years have also been very challenging in two important measures of public health: Obesity prevalence has increased by 129 percent since 1990, and the rate of uninsured Americans has increased by 14 percent, and now stands at about 15 percent. And yes, obesity rates are still climbing and have gone up since 2008.

Let’s take a closer look at obesity.

Obesity rates are climbing fast. The average American man has added about 17 pounds in the past 20 years and the average American woman has gained about 15 pounds. About a third of Americans are obese, and if obesity continues to grow at the same rate, the report predicts 43 percent of Americans will be obese by 2018, and since excess weight drives health-care costs, our collective weight gain will add $344 billion to our health bill bottom line.

There’s also great disparity among different ethnicities, with minority groups showing overall higher rates of both obesity and smoking compared to non-Hispanic whites.

National and international comparisons

The report ranks states’ healthfulness taking into account a multitude of measures from high school graduation, violent crime rates, health funding and prenatal care to obesity, smoking, binge drinking, and cancer and cardiovascular deaths.

The state-by-state assessments add a nice sense of competition, and I’m sure you’d like to see how your state ranks in health compared to others (after you finish reading my post!). Ranks go from 1 (healthiest) to 50 (least healthy). The winner is Vermont, up from 4th last year, with its low rates of kids in poverty, low obesity rates ('only' 23% of the Vermont’s population), a high rate of high school graduation, and low smoking rates (8th in the nation). Vermont’s downside: a high rate of binge drinking and low immunization rates.

At the very bottom of the list is Mississippi, which has won the dubious rank of least healthy state in the nation eight times in a row. Mississippi remains uninsured, poor, uneducated, the most obese of the states and one of the highest consumers of cigarettes (44th in the nation).

The thinnest state is Colorado.

My home state of Pennsylvania is ranked 28th—making us totally in the middle and unremarkable—with a 2 point improvement from last year. Pennsylvania’s main strengths are a high rate of high school graduation (7th in the nation) and a relatively low rate of uninsured (7th in the nation). The challenges are air pollution and a high rate of infectious diseases, and of course obesity (36th in the nation)—that goes without saying, as all American states suffer from high rates of obesity. Even Colorado.

Besides encouraging a healthy sense of rivalry, these comparisons are a great resource to draw upon, and see how we can learn from other states and implement best practices for good health.

But the comparison to other developed countries is what deserves our greatest attention.

When we measure ourselves against other countries, the conclusion is obvious—and there’s no softer way to put it—we simply aren’t the best.

Healthy life expectancy is the number of years a newborn can expect to live a healthy and productive life. The Japanese are at the top, and enjoy 76 healthy years on average. We in the US rank 30th, are on par with the Czech Republic and Chile, and our average healthy lifespan is 70 years. We rank #37 in infant mortality among 193 countries rated.

We spend more on health care than any other country in the world yet have a lower life expectancy, less access to care, less patient safety and definitely less equity than many other countries.

A short quote from the report:

“Based on two decades of consistent tracking, the 2009 Rankings calls for the nation to change unhealthy behaviors that are contributing to preventable, chronic diseases as the key to improving our nation`s health. Trends cite smoking as the greatest health challenge of the past 20 years and warn obesity is likely to be the next national health battle. When it comes to our national pursuit of health, Americans have benefited from disease treatment while preventable illnesses continue to decrease quality of life for many. With focused attention, change is possible.”

The way ahead

As the U.S. health care-reform debate continues, we’re becoming increasingly aware of the staggering cost of treating disease.

But prevention and improving public health are still very much missing in the general conversation.

I’m not referring to screenings (and I definitely don’t want to get into the mammograms schedule issue); screening is usually aimed at early detection and timely treatment of disease, which is a very important, but quite different from prevention.

What I’m talking about is modification of risk factors and prevention of disease through simple and proven changes in lifestyle. Smoking, poor eating habits and inactivity contribute to chronic diseases in a big way, and we’ll have to put some serious effort toward modifying these risk factors in order to slow the rise in chronic illness and truly reform our health-care system.

The incidence of diabetes has doubled in a decade, and we know that improved diet, obesity prevention and physical activity are the key to reversing this trend in type 2 diabetes, which is costing us both unnecessary suffering and lots of money.

The late Ted Kennedy said this in 1994 about health-care reform: "What we have in the United States is not so much a health-care system as a disease-care system."

Not much has changed in the past 15 years. Although disease treatment has progressively improved, preventable illnesses prevalence is still rising, causing a lot of suffering and impairing the quality of life for many.

Please check out the useful Take Action resource section in the report, which can help individuals, employers, community leaders and health care professionals take concrete steps toward the goal of changing unhealthy behaviors and preventing disease.

There’s much we can do, both individually and as a nation, to improve our health and prevent disease.

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

Are “functional” foods healthy foods?

I was disturbed by a short exchange I had with my ten-year-old daughter today. I told her we would be cooking a cholesterol-free dinner tonight, because one of our guests is trying to lower her cholesterol without medication, to which my dear daughter replied, “She should eat Cheerios.”

Apparently General Mills’ health claims—prominently displayed on every box—have reached my daughter, and she accepts them as fact.

Skimming through the New York Times later in the day, I read an Associated Press article, reporting on a Pricewaterhouse Coopers research paper just released, showing that even in a struggling economy America’s appetite for “functional foods” has not diminished. In fact, this category—accounting for more than $27 billion in sales a year of vitamin-, fiber-, calcium- and omega 3 fatty acids-fortified foods—is growing, and the report estimates a future growth range of from 8.5 to 20 percent per year—far more than the 1 to 4 percent forecast for the food industry as a whole.

The AP article cites nutrition experts who openly criticizing this trend, such as New York University nutrition professor Marion Nestle who says: "Functional foods are about marketing, not health. They delude people into thinking that these things are healthy,” while David Schardt, nutritionist for the consumer group Center for Science in the Public Interest, says: ''It's really a junk food dressed up to look prettier than it is. People are going to be deceived into thinking a lot of these products are especially healthy for them when there's little evidence they are. There's more hype to these products than there is reality.''

The article also warns against simplistic thinking, such as if a nutrient is good for you, then more is better, and that eating the nutrient in isolation, and not contained in the whole food it typically is part of, is just as beneficial. All too often the opposite is true. Indeed, studies have shown that several vitamins—such as vitamin A and E in excess—are actually harmful, and the benefits of eating fruits, vegetables and whole grains are not observed if vitamins and fiber come only from supplements.

Back to Cheerios—is it indeed a wonder drug? The package, website and ads claim that Cheerios can reduce "bad" cholesterol levels by four percent in just six weeks and ward off heart disease and cancers of the colon and stomach. The FDA authorized health claim, which General Mills (producer of Cheerios) is allowed to post (because the cereal is a food that contains whole grain), is: “Eating diets low in saturated fat and cholesterol, and high in fiber-containing fruit, vegetable, and grain products may reduce the risk of heart disease.” Big difference!

The FDA in fact issued a letter of warning to General Mills in May this year, informing the company the claims on the box make Cheerios 'an Unapproved Drug.'
I think that if a study performed on the stairs of a building proved that climbing up and down for thirty minutes a day lowered cholesterol and improved heart health, the take home message—provided the study was well preformed and backed by other evidence—would be that exercise is beneficial to heart health and lowering cholesterol, and perhaps that we should take the stairs at work. I can hardly see crowds forming at the research building queuing–up to climb the stairs used in the specific study—as if there’s anything unique about them.

But many people are humbled and confused by nutrition science, and it’s easy to leap to erroneous conclusions. The reality is that if a study on a certain berry shows benefits, that doesn’t mean that only this berry has the alleged benefit—perhaps all fruit do—and it certainly doesn’t mean that the micronutrients in that berry in isolation will be beneficial as well. Also, if a certain nutrient shows promise in rodents or a cell culture, it’s certainly exciting for the scientific community, which will further study the issue, but it’s hardly actionable news for consumers.

Many studies show that whole grain is indeed an important component of a healthy diet. Replacing refined grains with whole grains is a very good idea. There are many ways to add whole grains to your diet, and the best way is to add them through whole foods—using whole wheat or whole wheat flour, brown rice, whole oats and quinoa for instance.

If you’re shopping for breakfast cereal, look for the ones that are made with whole grain (and less sugar)—morning cereals are a practical way for many kids to eat a good breakfast. But don’t for a second be confused about which food is better for you: the fruit is better than the fruit drink with a health claim on it, and the corn on the cob you cooked is better that the corn flakes, despite the health claims.

So while moving from sausage, egg and cheese biscuits and triple chocolate muffins to Cheerios is a move in the right direction (and I’ll admit I have Cheerios at home), the health claims and “functionality” of these cereals is very misleading. Indeed, it’s all about marketing, and not about health.

So what’s on my no-cholesterol menu for tonight? Very simple—I’ll be cooking a vegan meal. No animal products—no cholesterol. I’ll be making some baked tofu, with wild mushroom and garlic whole-wheat pasta (with grated parmesan cheese on the side), an herbed fennel and zucchini gratin, a big green salad and a fruit sorbet for dessert. No cholesterol, lots of fruits veggies, whole grains and fiber.

But I won’t put a health claim on it; that could be confusing.

In case you’re interested in my recipes for whole grain foods here a few links (1, 2)

What do you think about health claims and functional foods?
Dr. Ayala

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

New evidence that simple healthy lifestyle choices can thwart chronic illness

With healthcare reform on many people’s minds, and awareness of the rising and overwhelming costs of chronic disease, I want to bring to your attention two recent articles in the Journal of the American Medical Association (JAMA), both of which study the effects of lifestyle factors on two all-too-common chronic illnesses in two different populations.

The first study by Forman et al looks at the relationship between six modifiable lifestyle factors and the lifetime risk of heart failure. Heart failure is a very serious situation in which the heart structure or function is impaired, and cannot keep up with the body’s blood supply needs. The most common causes of heart failure in the U.S. are coronary artery disease and hypertension.

The study included 20,900 physicians, all apparently healthy, and with an average age of 53.6 years at the baseline. The six healthy lifestyle factors were: Normal weight (body mass index, or BMI of 25 as the cutting point), not smoking, exercise (fitness in this study defined as exercising five or more times a week), moderate alcohol consumption (5-12 drinks a week), fruit and vegetable consumption (more than four servings a day) and breakfast cereal consumption (more than one serving a week).

The group was followed for an average of 22.4 years. During that time 1,200 men developed heart failure. The lifetime risk of developing heart failure in the general population is 20 percent; overall, it was 13.8 percent for this group of physicians.
Here’s what the study found:

• Each healthy lifestyle behavior was individually and jointly associated with lower lifetime risk of heart failure; in other words, there was a clear inverse relation between the number of healthy lifestyle factors and the risk of heart failure.

• Men who adhered to none of the healthy lifestyle factors had a lifetime risk of about 21 percent.

• Men who adhered to four or more of the healthy lifestyle factors had a lifetime risk of about 10 percent.

• When looking at only three of the healthy lifestyle factors—normal weight, not smoking and exercise—the lifestyle factors’ protection persisted.

These numbers show quite nicely that having a higher education is not enough to lower the risk of heart failure; the physicians who didn’t adhere to any healthy habits had as high a risk as that of the general population. It’s probably the physicians’ healthier habits and modifiable lifestyle factors that lower their overall risk of this chronic disease.

Not to neglect us women, the second study by Djoussé et al was conducted in more than 80,000 female nurses, aged 27-44 years, who were free of hypertension at the baseline, and were followed over 14 years, looking at the association between diet and lifestyle.
The healthy lifestyle factors in this study were:

• Normal weight (BMI of less than 25).

• A healthy diet: This was assessed by a looking at the foods prescribed in the Dietary Approaches to Stop Hypertension (DASH) trial. The DASH score is based on a high intake of fruit, veggies, nuts, legumes, low-fat dairy, whole grains, and low intake of red and processed meats, sweetened beverages and sodium.

• Daily vigorous exercise, lasting an average of 30 minutes a day.

• Modest alcohol intake: This amounts to intake of more than zero, but less than one alcoholic beverage a day—which seem to be protective for hypertension. Larger amounts of alcohol are associated with a higher risk of hypertension.

• Infrequent use of non-narcotic analgesics: Non-narcotic analgesic drugs (Tylenol, aspirin, non-steroidal anti-inflammatory drugs) have been associated with hypertension.

• Folic acid supplementation: Studies show women with low dietary folic acid intake are at higher risk of hypertension and benefit from supplementation.

The results involve some pretty complicated statistics, but here are the main findings:

• During follow-up, 12,319, or 15 percent, of the women developed hypertension.

• The strongest risk factor was overweight or obesity: Obese women had a risk five times higher than that of women with a BMI of under 23, and 40 percent of new hypertension cases can be hypothetically attributed to overweight or obesity.

• The other five healthy lifestyle variables were also associated with lower risk of hypertension, but are less influential than overweight and obesity.

• Women who had several healthy lifestyle factors had progressively lower risk: A combination of normal weight (BMI less than 25), exercise and a good diet reduced risk by about 50 percent!

For those of us that fear that family history puts us at a high risk no matter how well we take care of ourselves, this study repeated the analysis after taking into account a family history of hypertension, and showed that women with a family history had almost as low a risk as those without it, when they adhered to a combination of low-risk behaviors. In other words, family history is much less of a risk than is being overweight.

The results of these studies join a large body of evidence—some of which I’ve mentioned in previous posts—supporting the conviction that there’s a lot we can do to keep healthy.

In a fascinating editorial accompanying these studies Mayo Clinic researcher Véronique L. Roger discussed, among other things, the role of public health policy on lifestyle. The argument she makes is that a healthy lifestyle can’t be just an individual choice—there needs to be a social climate that enables people to make healthy choices more easily, and lifestyle is an interplay between individuals and the society they live in. Examples given in the editorial are the effects of smoke-free workplaces and interventions eliminating trans-fats from restaurants have on the public’s cardiovascular health, regardless of individual initiatives to choose a healthier lifestyle.

Roger writes:

“At this point, the national cost of treating cardiovascular diseases cannot be sustained, and prevention is urgent. Because prevention can benefit from policies aimed at creating a healthier environment, this approach must be expanded, with obvious targets being school-based meals provided to children, which still do not meet national dietary recommendations for good health, and the conceptualization and restructuring of the environment to promote physical activity. These and other public health measures should be envisioned as complementary and synergistic with clinical care, because unhealthy societal choices that lead to illness result in unsustainable strain on health care systems.”

I, for one, really would like to see steps taken to ensure healthy choices are easier to make, and aren’t prohibitively expensive in a way that makes them accessible only to those with both will and means.

Sure enough, when unhealthy food is cheap (and subsidized), and healthy foods—such as fruits and vegetables—are expensive, and one needs a gym membership to keep fit, it’s going to take a lot of individual determination to acquire the healthy habits and healthy weight we need to avoid cardiovascular disease.

I wonder what you think about government’s role in ensuring that a healthy lifestyle is an easier choice for everyone.

Dr. Ayala

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

Go see Food, Inc. and improve your food and health

The New York Times called it “one of the scariest movies of the year.”

I wouldn’t know, since I generally avoid horror films, but while Robert Kenner’s Food, Inc. is indeed deeply disturbing and isn’t the light entertainment typically screened in the heat of summer, it’s an important movie to watch, and it does offer a hopeful note and an action plan. I bet you’ll be moved by this movie, and understand more than ever that there’s plenty we can do to affect our own diet and the food landscape in which we all live.

We buy our food in clean pastoral looking supermarkets. It’s beautifully packaged, and marketed as the bounty of our land and the product of smiling healthy looking farmers.

Once Kenner lifts the veil, the industrial food system looks very different and so much uglier.

Our industrial conventional foods are controlled by a handful of very large and powerful conglomerates shown to often put profit ahead of other consideration, including consumer health, the livelihood of the American farmer, and the safety of workers and the environment. Most of our supermarket foods are made from cash crops and subsidized grains, and the huge variety of processed foods (the average supermarket sells 47,000 items) is pretty much corn and soy rearranged to into something new, or what Michael Pollan—who’s featured in this film—dubs “food-like substances.”

The movie features very upsetting visuals of industrial animal farming. From the feedlots, where cows never see grass, to the chicken coops where chicken never see daylight, to the meat processing plants, the cruelty to the animals is horrific. The movie claims at one point that when companies treat animals with such cruelty and disrespect, they’ll soon lose compassion for their human workers, and it’s heartbreaking to see illegal workers, most of them with temporary jobs, endangering themselves while receiving so little back for their effort.

Even more upsetting is the fact that the industrial feedlot is the source of many food-borne health outbreaks. The tragic story of Barbara Kowalcyk, who lost her perfectly healthy two-year old Kevin after he contracted E. coli O157:H7 from a hamburger he ate on vacation, is a personal example of how this food system, which produces large quantities at a low price, has made food less safe and deteriorated our environment and therefore really costs us a fortune. This is the food system that, due to subsidies, created the absurd situation in which a hard-working low-income family (in which the dad already has diabetes) resorts to eating burgers and fries from a fast-food drive-in, because it’s so much cheaper than fresh produce (which isn’t subsidized). The unintended result of our food system is skyrocketing obesity and diabetes rates.

Mind you, this is not a movie that comes at you from the point of view of a vegetarian. Food, Inc. does not consider the raising and slaughter of animals as an ethical dilemma. It’s the life and death of the industrially raised animal that’s criticized and contrasted with the way organic farmer Joel Salatin raises his animals, which is seen as farm animals living quite a happy life. They work for the farmer but are also cared for in return (although they too are seen slaughtered for food).

The film ends with an empowering note: We do get a say in what we eat, and therefore we can affect what foods will be sold and how they’re made. We get to vote three times a day. If we demand better food, someone will make it!

Here are the 10 simple actions the movie makers share before they send us home:

• Stop drinking sodas and other sweetened beverages.

• Eat at home instead of eating out.

• Support the passage of laws requiring chain restaurants to post calorie information on menus and menu boards.

• Tell schools to stop selling sodas, junk food and sports drinks.

• Embrace Meatless Mondays—go without meat one day a week.

• Buy organic or sustainable food with little or no pesticides.

• Protect family farms; visit your local farmer's market.

• Make a point to know where your food comes from—READ LABELS.

• Tell Congress that food safety is important to you.

• Demand job protections for farm workers and food processors, ensuring fair wages and other protections.

I highly recommend seeing Food, Inc. Learning how industrial food is making us sicker, fatter and poorer isn’t pretty or funny, but it just might stir a few more people into action. I’d love to hear your thoughts.

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

Let the Obamas eat what they want!

I’m super excited about Barack Obama’s inauguration this week. Just like everyone else, I’m expecting a new era to start this Tuesday, and I’m hopeful for positive change.

Obama is greatly admired, and expectations from a president have never been so high. President Obama is expected not only to rescue the global economy, fix the environment, solve health care and bring peace to the Middle East, but seemingly, to be our role model for everything—model parent, model spouse, a fitness guru, a fashion icon—you name it.

The food world has joined in with their total obsession around Obama’s food habits. They (we) would love to embrace him as a model of healthy, ethical, sophisticated eating, and one of their (our) own. But is Obama a dedicated healthy, organic eater?

The New York Times Kim Severson says:

“… no one is sure just how serious Mr. Obama really is about the politics of food. So like mystery buffs studying the book jacket of “The Da Vinci Code,” interested eaters dissect every aspect of his life as it relates to the plate.”

Severson’s article refers to Obamafoodorama.com—an incredibly entertaining and informative website, that’s dedicated to the Obama foodscape.

To judge by the feverish speculation in blogs about the selection of White House chef, one might think the position is as important as Secretary of State. (In the end, Michelle Obama announced she’s keeping Cristeta Comerford, the current White house chef.)

I enjoy Obamafoodorama.com. I’ll also admit that I did put my name on the petition urging the Obamas to replant a large organic Victory Garden on the First Lawn (the symbolic idea of growing food in the White House is just too good to ignore).
But I really think that by looking too carefully at what the First Family puts in their mouths we’re really missing the point.

What we need and what I’d like to see is President Obama enacting wise food policies.

I’d like to see the new government making the fight against obesity a very high priority. I’d like to see more oversight on food safety. I think that it’s high time we addressed the issue of sustainable agriculture. Food is important, and it should be put high on the agenda; I hope, and believe, that the new administration will do so.

But just as a good psychiatrist doesn’t need firsthand experience of mental illness, and a male doctor can be an excellent ob/gyn, Obama can eat junk food, even have an occasional cigarette and still enact wise food and health policies.

No one likes their picture taken with food in their mouth; eating is quite a private matter. The level of scrutiny given to each food morsel Barack Obama (or his family) eats has reached the point of silliness. Does our new president need to be careful not only about what comes out of his mouth, but also what the world sees going in?

Food has become quite a sport in recent years, with more people watching cooking shows and surfing food websites. The irony is that many of these spectators aren’t actually cooking more and eating more family meals. Perhaps it’s time to stop looking at food as a spectacle, and just eat together a little better.

I wish our new president the best of health and many happy meals with his family in the White House. I, for one, will not to be disappointed by what he eats—it's entirely his call, and completely none of my business.
Ayala

Sugary drink consumption still on the rise

With the holiday season—and all of the celebrations that go with it—in full swing, it seems fitting to take a look at a new study about the consumption of sugar-sweetened beverages. The news is not good.

The study published in the American Journal of Clinical Nutrition shows that the number of adults consuming sugar-sweetened beverages has increased dramatically in the past two decades. Two-thirds of adults now consume sugar-sweetened beverages, with an average daily intake of almost 300 calories, or 15% of the 2,000 calories/day recommended for the typical diet.

Sugar-sweetened beverage consumption was highest among young adults, and particularly among young African Americans followed by young Mexican Americans, and was highest in populations at highest risk of obesity and diabetes.

The study analyzed the 24-hour dietary recall data of more than 15,000 people collected in the National Health and Nutrition Examination Survey (NHANES) for the period 1988 to 1994 and compared it to the survey data of more than 13,000 participants for NHANES for the period 1999 to 2004.

Sugar-sweetened beverages in this study included soda, sports drinks, fruit drinks and punches with added sugar, sweetened teas and other sweetened beverages. It does not include other caloric drinks such as 100% fruit juice, milk and alcohol. (Another study looking at the total calories consumed in beverages showed that the typical American consumed a staggering average of about 480 calories a day in 2002.)

The Clinical Nutrition study is a cross-sectional study (a study that looks at a population at a single point in time), whose purpose was to describe the national consumption trends, demographics, quantities and consumption behaviors of participants. While the study does not attempt to estimate sugary-drinks’ influence on the obesity epidemic, as cross- sectional studies aren’t useful to determine cause, other studies provide strong evidence for a cause-and-effect relationship between sugary drinks and obesity, the authors say.

Here are the main findings comparing the 1999-2004 population to the 1988-1994 group:

• Overall sugary-drinks consumption rose from 58% to 63% (a 5% increase).

• Average daily consumption increased from 22 ounces to 28 ounces.

• Average daily consumption increased from 239 calories/day to 294 calories/day.

• Average serving size rose from 11 ounces to 17 ounces.

There are a few interesting findings looking at consumption patterns that give me some hope:

• The largest share of sugary drinks was consumed at home. This should be useful information for anyone doing the shopping for the household—if you don’t bring these drinks home, they won’t be in your pantry.

• Overweight and obese people trying to lose weight consumed less than people without weight loss intention. It seems like weight watchers are starting to get the message, and are trying to reduce this most obvious source of empty calories.

The researchers, led by Sara N. Bleich, conclude:

“SSB (sugar-sweetened beverage) consumption has increased dramatically in the past decade in the United States, in parallel with the rising prevalence of obesity and type 2 diabetes. Large epidemiologic studies provide strong evidence for the independent effect of SSBs on weight gain and type 2 diabetes. Efforts to encourage replacing SSBs with low-caloric or noncaloric alternatives may be an important strategy to reduce consumption of empty calories. Physicians and public health professionals are well positioned to identify and promote concrete behavioral targets aimed at decreasing adult SSB consumption, making awareness of these changes critical among that group. The workplace and home offer key areas of intervention for reducing the energy imbalance in young adults.”

Although practically all guidelines for healthy eating include a recommendation to limit the amounts of added sugars, we still have a long way to go to decrease the most obvious and, in my opinion, least satisfying source of added sugar in the diet—sugary drinks.

New York governor David Paterson recently boldly proposed an 18% sales tax on soft drinks (fruit drinks with less than 70% fruit juice, non-diet soft drinks, sodas and other full-calorie sweetened beverages). The thought is that a price increase will discourage people, especially young ones, from excessive consumption of these beverages. It will also create much needed revenue. Some argue that the most effective measure in the fight against smoking was high taxation, and a tax on sugary drinks can help in this battle for public health, too.

So, as you celebrate this holiday season, encourage those around you to try an alternative to a sugary drink, and share a toast to a New Year of healthy living.

What do you think?

Ayala