Healthy Food & Healthy Living by Dr. Ayala

Silly science, silly inventions and other 2011 follies

It’s that time of year again.  Time to put aside the pursuit of better health through science and look at exceptionally ridiculous science and innovation achievements in food and nutrition — proven to improve health through the remedy of good cheer.

A better way to get drunk

Is your mouth too busy with other input or output? Danish urban folklore suggests an alcoholic footbath is another way to get tipsy.  Maybe that was the drunken excuse winemakers of ancient times — who regularly stomped grapes with their feet as part of their process — gave for their constant intoxication.

Three researchers put this legend to the test by submerging their feet in laundry tub full of vodka for 3 hours while measuring their blood-alcohol levels every 30 minutes.  The study was published in the British Medical Journal.

Unsurprisingly, not much happened to their blood alcohol levels.  On the other hand “self confidence and urge to speak increased slightly at the start of the study, probably due to the setup”.  The sober conclusion: feet are impenetrable to the alcohol component of vodka.

But then again, if you're trying to absorb alcohol through your feet, you've probably had too much already.

Loosing weight through fertility treatment

The Wild West of the diet industry has many advances each year, many of them bizarre, deceitful and uncannily contagious.

Here’s the new ploy for shedding weight: The hCG diet combines a 500-calorie-a-day diet with daily injections of the hCG hormone. hCG (human chorionic gonadotrophin) is naturally produced by the embryo during early pregnancy, and is used as a drug in order to induce ovulation.

It was suggested, many years ago, that hCG not only suppresses appetite, but also mobilizes fat — creating a more attractive body shape — and brings about a sense of well-being.

The hCG diet is becoming the latest rage.  Since the hCG injections require a prescription, many homeopathic forms of hCG including oral drops, pellets and sprays with weight-loss claims have appeared in the market.

So does it work? Well, a 500-calorie-a-day diet will result in — what many experts suggest is unhealthy — weight loss, if you can maintain it.  A meta- analysis concluded that there is no scientific evidence that HCG helps the regimen.

And if you don’t mind daily injections and the $1000-per-month price tag here’s the huge downside to consider: The side effects of hCG injections include increased tendency for blood clots, which could cause pulmonary emboli.  Which could kill you.

Nowadays, whenever I hear about a young, apparently healthy, non-pregnant person suffering from a pulmonary embolism, I wonder.

There are quite a few medications and disease states that affect appetite, and I wonder which one will be the next new wonder drug for weight-loss.  No, I’m not going to suggest which drugs come to mind when a doctor thinks of the differential diagnosis of loss of appetite — I want nothing to do with the next fad.

Wasabi, not just with sushi

Each year, I excitedly await the Ig Nobel awards.  The ceremony, held at Harvard University, spoofs the Nobel prizes and is presided over by real Nobel winners.  

A group of Japanese researchers won the Chemistry Ig Nobel for their lifesaving horseradish-based alarm system.  After trying hundreds of odors, including rotten eggs, they determined that inhalation of air-diluted wasabi is the ideal wake up call.

If you’re aiming for the coveted Ig Nobel and don’t have much lab experience here’s a route you might want to consider.  The math prize this year was awarded to the end-of-the-world predictors for their fine calculations.   Among them: Dorothy Martin (who predicted the world would end in 1954), Pat Robertson (who predicted the world would end in 1982), Elizabeth Clare Prophet (who predicted the world would end in 1990), and Harold Camping (who predicted the world would end on September 6, 1994 and later predicted that the world will end on October 21, 2011).

Preventing kiss-borne illness

Who said brushed teeth should smell fresh and clean?  After completing your ritual brushing consider reintroducing the flavors you washed away with innovative floss.  Already on the market: bacon floss, frosted cupcake floss, as well as pickle flavor.

But what about almighty garlic, the aroma famous for preventing kiss-borne disease?

I hope we’ll see that in 2012.

 

Happy holidays,

Dr. Ayala

 

To read my previous year’s notable silly science choices go here and here.

 

 

Distracted into trouble

I overheard a short exchange between my three kids several years ago. My daughter is my youngest, her brothers just a few years older than her, and she must have been no more than 5 years-old at the time.

My daughter: “You don’t know how to handle dad. I’ll handle him for you.”

Her brothers: “How?”

“You go into his office when he’s really busy and ask for it. He’ll say yes because he wants you to go away. Then you leave. Grown-ups don’t go back on their words”.

“And mom”?

“She hates overruling dad”.

Outwitted by preschoolers! My daughter figured out how to use distracted decision making to her advantage, and we grown-ups are dumb enough to believe we’re great multi-taskers.

My husband is a huge multi-tasker. He’s actually not bad at it. But even he’s not as good as he thinks, and definitely not good enough for my daughter.

And all this could be quite funny if this over confidence in our ability to engage in more than one thing didn’t cost so many lives.

Distracted driving

Here are a few facts, courtesy of Distracted.gov, the “Official US Government Website for Distracted Driving” (I‘m sure they didn’t mean it that way—they must be against distracted driving…):

• In 2008, almost 20 percent of all crashes in the year involved some type of distraction (National Highway Traffic Safety Administration - NHTSA).

• Nearly 6,000 people died in 2008 in crashes involving a distracted driver, and more than half a million were injured (NHTSA).

• The younger, inexperienced drivers under 20 years old have the highest proportion of distraction-related fatal crashes.

• Drivers who use hand-held devices are four times as likely to get into crashes serious enough to injure themselves (Source: Insurance Institute for Highway Safety).

• Using a cell phone while driving, whether it’s hand-held or hands-free, delays a driver's reactions as much as having a blood alcohol concentration at the legal limit of .08 percent (Source: University of Utah).

One would think that common sense and a few statistics would be enough to prevent us from fumbling with an electronic device while driving, but that ain’t so.

So, thirty states have put into law bans on texting while driving. It’s a welcome, rational step, but unfortunately instead of turning the device off it has led overconfident drivers to put the device lower in their lap, where it can’t be seen by police.

Self-confidence is a beautiful thing. Cockiness enables people — even young kids — to occasionally do unbelievable things. But when it comes to driving it’s a huge mistake to believe that you’re an above average driver. First of all because you’re not – statistically speaking it’s unlikely – and besides, handling heavy machinery at high speed is not an innate human skill, and even if you’re better than most you’d better be humble. We’re incredibly attuned to some things in our surrounding – I believe many of us can hear an infant‘s cry even with a lot of background noise – but not to the unexpected dangers of the road. To be a decent driver we need both hands and our head as engaged as much as humanly possible.

A crop of new apps and gadgets surface daily since the no-texting bans were signed into law. Some are no more than clever ways to stay within the letter of the law while providing new – equally distracting – ways to text, email and call while driving.

If you feel you have to have an app for that here’s what you should look for: an app that helps you stop using the phone. Even SAFECELLapp, which rewards drivers with cash for not using their phone when the app is turned on and the car’s moving, is much more distracting than simply turning the device off.

What if someone needs to reach you? They’ll reach you later, or find another solution. The world worked just fine fifteen years ago, when most kids could not reach mom at all times and executives weren’t constantly plugged.

It’s hard to pay attention

I could have added, for visual effect, scary footage of accidents. I won’t. Instead, let’s do a little experiment. Please don’t peek at the end of the post before you complete the video.
 
If you’ve heard about this experiment before, you’d have known what to expect, but when this video is shown in a controlled situation, 50 percent of people don’t see the gorilla, even though the gorilla is there for 9 seconds, and thumps its chest in the middle of the screen. If you still believe you can multitask and pay attention to more than one thing at a time I recommend Christopher Chabris and Daniel Simons’ “The Invisible Gorilla” – a fascinating read.

Please, just think about this: Would you feel comfortable if your kids’ school-bus driver texted while driving?

I welcome your comments,

Dr. Ayala

Can Google be trusted with your health?

It’s the middle of the night. Your baby’s sick. You’re sick with worry.

Ever thought of Googling his symptoms for some free medical advice or a second opinion?

Many people use the Internet for health-related information, and used correctly it’s a great resource. But how reliable or accurate is a search engine without medical guidance?

A group of British researchers found that health information on the Internet ranges from poor to excellent, depending on the topic and the resource. They Googled UK-based websites on five common pediatric issues in which the best practice is pretty clear, and found that only about 200 of 500 sites offered correct information. The results of their study were published in the Archives of Disease in Childhood.

The five search topics chosen for the study were "MMR autism" (current practice: there’s no association between the vaccine and autism), "HIV breastfeeding" (current practice: HIV-positive moms are advised not to breastfeed), "mastitis breastfeeding" (current practice: a mom with mastitis should breastfeed), "baby sleeping position" (current practice: a baby should be put to sleep on his back) and "green vomit"(current practice: if baby vomits green, go see a doctor).

Their analysis showed that governmental sites were accurate every time. Educational sites, companies, interest groups and individual’s sites performed rather well, and were accurate around 80 percent of the time. News sites did poorly (they had a 55 percent “correct” rate), and no sponsored site gave correct advice.

The authors conclude:

“Healthcare professionals should continue to strive to be the main source of information for patients but we should be aware that most will continue to use the internet to gather information. We suggest that in addition to verbal and written information, patients and parents should be signposted to NHS (National Health Service), governmental or other preapproved websites”

Google has no clinical judgment

This study posed to Google questions to which there are only two possible answers. Most health questions are much more complicated, and a search result brings in an enormous amount of information to sift through.

If your child has a fever—perhaps the most common reason to see a pediatrician—a search engine is practically of no help at all. A study looking at advice for kids with a fever found only three out of 22 sites visited gave information which matched current "best practice" guidelines. You may wind up worrying your head off over exotic and life-threatening causes of fever which have no relevance to your child. But how would you know? A study of Internet information on lumbar disc herniation ("slipped disc") found that less than 10 percent of relevant websites were of high-quality. Try searching “headache” and see what comes up.

Doctors don’t have secret information. Even complicated medical knowledge is widely available. The Internet is full of good information—and bad information and misinformation, too. Making sense of the information is what’s become harder and harder to do.

Doctors work many years to master clinical judgment—the application of information gathered from talking to and examining patients, combined with knowledge of the science of medicine, and that impossible-to-define art of medicine—that’s what makes a good doctor.

There’s no recipe for acquiring clinical judgment. The knowledge-base needs to be there (a service Google provides fairly well), but the thoughtful application of information comes from immersion in the care of patients, experience, interaction with peers and mentors, and a constant refinement and learning process. I don’t think a machine will ever be able to learn clinical judgment.

The Internet is one of my favorite inventions of all time, but it will never be able to answer complicated health questions, nor will it ever be able to offer comfort or compassion. Surfing health issues on the Internet is a great example of how a little knowledge can be a very dangerous thing.

Nevertheless it’s a great resource for gathering information—provided you use reliable and authoritative sources—and that knowledge can be a great starting point for a discussion with a health professional who can help make sense of it all, put things in perspective and individualize it to your specific health issue.

Do you use the Internet for health related issues? Who do you trust?

I promise to share some of my favorite online sources of reliable medical information in a future post.

Dr. Ayala

Another apple-a-day may save more lives than the Toyota recall

Many health organizations, including the World Health Organization and the National Cancer Institute, recommend five servings of fruit and vegetables daily to help ward off disease.

Some people (I’m not one of them) go even further and propose that eating enough fruits and vegetables provides strong protection from cancer.

Cancer is a complex group of diseases. We still know very little about what causes some cancers, but it’s probably safe to say that increased risk for most cancer types usually stems from a combination of factors—some genetic and environmental, which are hard to control, and some that we have much more power over. Smoking, exercise, obesity, diet and sun exposure have all been shown to affect cancer risk.

A healthy lifestyle has many components, and I personally don’t believe any one healthy diet habit by itself—even if practiced religiously over a lifetime—has a hugely dramatic effect on cancer incidence in a population.

Having said that, every little bit helps, and while we shouldn’t exaggerate any intervention as the “solution” to cancer, these small measures together do add up and help prevent some disease.

That, by the way, is why I see all health claims on food as at least a little misleading. The diet-health relationship is real, but is always more complicated and variable than what a simplistic statement implies.

A new study in the Journal of the National Cancer Institute got quite a lot of coverage in the past few days; it found what the authors called only a weak association between high fruit and vegetable intake and reduced overall cancer risk. The headlines in many news publications (“Eating Vegetables Doesn’t Stop Cancer " in the New York Times, “Fruit and vegetables have little effect on cancer risk, study finds ” in The Guardian) suggested deep disappointment over fruits and veggies’ “poor performance” against cancer.

Is this a blow to the five-servings-a-day advice? Let’s first take a closer look at the study.

Paolo Boffetta of the Mount Sinai School of Medicine in New York and colleagues analyzed data from the EPIC study (European Prospective Investigation into Cancer and Nutrition), which included almost 500,000 participants from ten Western European countries. In about nine years of follow-up, more than 30,000 participants were diagnosed with cancer.

The authors found a small but statistically significant association between high intake of fruits and vegetables and reduced overall cancer risk--the higher the intake the lower the risk.

The data shows a 3 percent lower risk of cancer for every 200 grams, or seven ounces, of fruits and vegetables a day a person eats. People who ate five or more servings a day had 11 percent fewer cancers than those who ate 0-1.5 servings a day.

These results were consistent across the countries studied.

Higher intakes of fruits and vegetables in this study group were associated with other healthy behaviors, such as smoking avoidance, limited alcohol consumption and exercise, which may also be protective from cancer. But the small protective effect of fruits and veggies persisted even after adjusting for these factors.

How significant is 3 percent protection from cancer?

Numbers are often hard to understand without context—they aren’t as absolute as they sound. Is 3 percent a small number?

There is of course no one right answer to that.

Let’s take a look at the Toyota recall and compare risk/benefit ratios.

The chance of an owner of a recalled Toyota experiencing a deadly acceleration problem is assessed at 2.8 in a million. (There were 17 fatal accidents related to acceleration in 10 years, before six million cars were recalled. New complaints are now pouring in, which is quite typical after a recall and law suits are announced.) But we all expect Toyota to recall and fix all relevant cars, and we’re angry they failed to address this problem sooner.

The yearly cancer incidence in the U.S. is estimated at 4,600 in a million; one and a half million Americans are diagnosed with cancer each year, and 1,500 die of cancer daily. If, as this study suggests, eating an additional seven ounces a day of fruits and veggies can reduce cancer incidence by 3 percent we’d have 40,000 fewer Americans receiving the diagnosis of invasive cancer yearly.

In Toyota's case we demand action when the current risk is as small as 2.8 in a million, yet with cancer, where the disease risk is as high as 4,600 in a million, some suggest that a reduction of 3 percent in risk does not make much of a difference.

I wouldn’t perhaps recommend a drug with many side effects if it reduced a rare disease’s risk by 3 percent, but for an “intervention” as benign as eating an additional apple a day, and a disease as serious and common as cancer a 3 percent risk reduction looks like a decent size reward.

What if fruits and veggies offer no protection from cancer?

When a study shows only a small difference in outcome between the studied groups, there’s also the possibility that this difference can be explained by chance, and by something other than the variable studied. In this case we have to bear in mind that eating more fruits and veggies is generally associated with a healthier lifestyle, and no matter how hard the authors try to control for the other healthy lifestyle factors, some bias may remain.

So even though this study and several others show a probable small reduction in all-cancer risk, let’s bear in mind that it’s also possible that eating your veggies might offer no significant protection from cancer.

Yet, this “worst case” scenario still leaves us with many excellent reasons to continue promoting fruits and veggies. Here’s a partial list of good reasons to eat plenty of fruits and vegetables:

• They help lower the risk of heart disease and stroke (a study showed a 30 percent lower risk in people eating five servings a day, compared to those who eat only 1.5 servings a day)

• They help lower blood pressure

• They help lower diabetes risk

• They help lower risk of eye (cataract and macular degeneration) and digestive (constipation and diverticulitis) problems

• They provide lots of fiber, both soluble fiber, which helps lower cholesterol and regulate sugar, and insoluble fiber, which is important to digestive health

• They provide vitamins, minerals and many other beneficial plant molecules—phytonutrients—many of which we’re only starting to understand. (And I’m sure there are a few we have yet to discover. My mom knew nothing about lycopene, for example, when she fed me tomatoes and watermelon.)

• They have high nutritional value and low caloric density, so eating many fruits and vegetables (rather than practically any other food) helps lower caloric intake and maintain optimal weight

• They taste good, are beautiful to look at, and connect us to nature

My last item on the virtues list is completely non-objective; I’m guilty of total fascination with colorful growing things that we can also eat.

If, in all the years that fruits and vegetables have been consumed and studied, the worst we can say about them is that they’re not as thick a shield against all cancers as some had hoped, this speaks to just how good for us they really are.

So keep those fruits and veggies coming!

Dr. Ayala

Reposted as part of Food Renegate's Fight Back Fridays--go join the food fight!

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

Michelle Obama to food makers: Make healthier food, now

First Lady Michelle Obama gave some tough love to the food industry last week.

In her remarks at the Grocery Manufacturers Association meeting in Washington D.C. last week Mrs. Obama was tactful, diplomatic and generous with praise for the advances already made by food makers.

Yet, she didn’t shy away from criticism, and explicitly described some of food makers’ obesogenic practices.

I’m going to peel away the praise, and serve just her between-the-lines reprimands, since I think that’s where we’ll find the bigger and most important messages.

You put stuff in our food that helps your sales yet undermines our health

• “We all know that human beings—I, for one, know—are hard-wired to crave sugary, fatty, salty foods. And it is tempting to take advantage of that—to create products that are sweeter, richer, and saltier than ever before."

• “But doing so doesn’t just respond to people’s natural inclinations—it also actually helps to shape them. And this can be particularly dangerous when it comes to our kids, because as all of you know, as parents, the more of these products they have in their diets, the more accustomed they become to those tastes, and then the more deeply embedded these foods become in their eating habits.”

You’re bombarding our kids with ads and marketing that shapes bad choices and eating habits

• “Our kids didn’t learn about the latest sweets and snack foods on their own. They hear about these products from advertisements on TV, the Internet, video games, schools, many other places. And any parent knows, this marketing is really effective. We’ve all had to endure those impassioned pleas in the grocery store for one product or another. Some of us have been treated to full-scale reenactments of TV commercials and jingles, word for word, right on key.”

• “More than 70 percent of foods marketed to kids were still among the least healthy, with less than 1 percent being among the most healthy.”

• “What does it mean when so many parents are finding that their best efforts are undermined by an avalanche of advertisements aimed at their kids? And what are these ads teaching kids about food and nutrition? That it’s good to have salty, sugary food and snacks every day—breakfast, lunch, and dinner? That dessert is an everyday food? That it’s okay to eat unhealthy foods because they’re endorsed by the cartoon characters our children love and the celebrities our teenagers look up to?”

You manipulate the food label to confuse us into buying your food

• “We can give parents all the information in the world, but they still won’t have time to untangle labels filled with 10-syllable words or do long division with these portion sizes.”

• “But we know those labels aren’t always as helpful as they could be. And it’s hard enough to figure out whether any one food item is healthy. It’s even harder to compare items. And folks just don’t have the time to line products up side by side and figure out whether these compare or not. And they shouldn’t have to. Parents shouldn’t need a magnifying glass and a calculator to make healthy choices for their kids.”

You’ve convinced us to eat more, when we need to eat less

• “While kids 30 years ago ate just one snack a day, we’re now trending toward three—so our kids are taking in an additional 200 calories a day just from snacks alone. And one in five school-age kids has up to six snacks a day.”

• “In the mid-1970s, the average sweetened drink portions were about 13.6 ounces. And today, our kids think nothing of drinking 20 ounces of soda at a time.”

• “All told, we’re eating 31 percent more calories than we were just 40 years ago—and that’s including 56 percent more fats and oil and 14 percent more sugars and sweeteners. In fact, we now add sweeteners to all kinds of products in amounts unimaginable just a generation ago.”

You’re very creative reformulating products that can be marketed as healthy without making them any healthier

• “But what it doesn’t mean is taking out one problematic ingredient, only to replace it with another. While decreasing fat is certainly a good thing, replacing it with sugar and salt isn’t. And it doesn’t mean compensating for high amounts of problematic ingredients with small amounts of beneficial ones — for example, adding a little bit of Vitamin C to a product with lots of sugar, or a gram of fiber to a product with tons of fat doesn’t suddenly make those products good for our kids.“

Finding common ground

Food makers are important and powerful players in shaping our food environment, and bringing them on board in the “Let’s Move” effort is really critical to its success. While fighting obesity will have to involve some “eat less” commitment—a message that clearly conflicts with food makers’ bottom line—Mrs. Obama’s focus is on finding common ground.

Her encouragement to food makers to join the healthy food movement is something that’s a win-win for all. Mrs. Obama pointed at the growing interest and demand for healthier foods—a trend she believes is here to stay and will only expand—and promises to food makers that if they make it healthy, consumers will come.

Speaking of demand: Food makers’ repeated lame excuse for the junk they make is that they only make what consumers want. And that’s why I especially love Mrs. Obama’s call to enlist the extraordinary marketing talent—which helped get us to our staggering obesity rates—for some good:

“If there is anyone here who can sell food to our kids, it’s you. You know what gets their attention. You know what makes that lasting impression. You know what gets them to drive their parents crazy in the grocery store. And I’m here today to ask you to use that knowledge and that power to our kids’ advantage. I’m asking you to actively promote healthy foods and healthy habits to our kids.”

Brilliant speech! I hope Mrs. Obama inspires some meaningful changes in the food industry that are indeed more than just tweaking and lip service—deep changes that would actually help kids and parents eat better and promote health.

Dr. Ayala

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.

Misleading health claims finally under fire

Is the health claim party coming to an end?

This past week, the Food and Drug Administration released 17 letters of warning to food manufacturers whose product claims don't adhere to federal labeling rules. FDA Commissioner Margaret Hamburg, MD, also sent an open letter to the industry, encouraging food makers to rid their labels of misleading and downright bogus claims, and be part of the effort to make food labels a tool consumers can use to improve their nutrition and make healthier choices. (She of course said it in a much nicer way.)

The letters targeted mainly companies making unauthorized health claims and nutrient-content claims.

Please bear with me while we go through the different types of label claims; I promise it’s going to make you a more informed consumer:

• A health claim describes a relationship between a food or food component and a disease, and it must be pre-approved by the FDA. There are currently slightly more than a dozen of these approved claims.

Health claims must be phrased in the specific language the FDA requires. The claim must also indicate that the disease may be caused by a variety of causes, and must state that the food should be consumed as part of a healthy diet. The appearance of a health claim means a food meets certain nutritional requirements.

The POM Wonderful complaint is an example of misuse of health claims: POM was criticized for claiming its juice will treat, prevent or cure diseases, including hypertension, diabetes and cancer. These types of health claims are drug claims and are not allowed on food products. They are allowed on drugs only after extensive and rigorous testing.

• A nutrient claim is a statement that establishes the quantity of a particular ingredient, such as fat, cholesterol and fiber. Statements such as "low sodium," "high fiber" and "fat-free" are examples of nutrient claims. These statements can be included on the label only if the food product meets specifications established by the FDA.

Nestle’s Juicy Juice was criticized for an inaccurate nutrient claim: its labels implied that the products are 100% juice when they are actually juice blends with added flavors.

The giant loophole

Although Commissioner Hamburg’s actions are good news, I’m afraid the misleading label claim party isn’t over yet. There’s a giant loophole in the FDA’s rules, and many of the most misleading and absurd claims fall into a category that’s practically as regulated as the Wild West.

That loophole is the structure/function claim.

Structure/function claims describe a role of a nutrient or substance in a food or a food supplement in affecting the normal structure or function in the body. Unlike a health claim, it doesn’t relate to a disease or a health-related condition. The verbs “support,” “improve,” “boost” and “maintain” are often a telltale sign of a structure/function claim.

Nestle’s Juicy Juice Brain Development Fruit Juice was reproached for a nutrient claim—"no sugar added" isn’t allowed on products intended for kids under 2 years of age—yet the more glaring claim on the box is “Helps Support Brain Development”. I don’t think the FDA believes this juice develops young brains, but there’s no legal action it can take against such structure/function claims.

A structure/function claim requires no FDA pre-certification. It can be attached to any food, including junk food. There are no overarching nutritional requirements for structure/function claims. They can be phrased in many ways that are at the discretion of the manufacturer. While the claim “must be truthful and not misleading”, there’s no specification about how much evidence is needed to make the claim. It doesn’t require significant scientific agreement, unlike a health claim.

Those food labels luring us with endless promises to protect our joints, boost our brain and support our immunity make structure/function claims.

Unfortunately most consumers can’t tell the difference between a health claim and a structure/function claim. “Calcium builds strong bones” and "fiber maintains bowel regularity”—both structure/function claims—sound quite the same as “calcium reduces the risk of osteoporosis” and “fiber may reduce the risk of some cancers,” which are regulated health claims.

The structure/function claim has been a boon to food manufacturers. Since there are so few limitations on its use and the trusting public can’t easily distinguish between the different types of claims, structure/function claims have proliferated. Market research shows these structure/function claims really help with sales, putting great pressure on companies that don’t have claims to consider them, just to level the playing field. This is an arms race in which the consumer loses.

And until the FDA takes care of structure/function claims, food labeling won’t get any clearer.

In a recent commentary in the Journal of the American Medical Association, two of the most respected and independent nutrition and obesity experts, Marion Nestle, PhD, MPH, and David Ludwig, MD, PhD, explain why claims are inherently misleading: Few if any claims can be verified. Hyping the benefit of a select component of a food doesn’t give the whole picture. “Healthier” is not necessarily healthy. Junk food with a little less fat or sugar is still junk. Allowing claims poses an inherent conflict of interest—food companies want to sell more, while the label’s public health purpose is to educate consumers.

Their suggestion is very simple: do away with all health claims:

“If health claims are allowed on food packages, they should be regulated more strictly according to rigorous, evidence-based national standards. Because such standards are inevitably arbitrary and subject to manipulation, consideration should be given to an outright ban on all front-of package claims. Doing so would aid educational efforts to encourage the public to eat whole or minimally processed foods and to read the ingredient lists on processed foods.”

Kudus to Dr. Hamburg for taking on this difficult and important issue! I hope one of the next steps includes creating regulatory standards for structure/function claims, or following Nestle and Ludwig’s suggestion and get rid of them all.

Dr. Ayala

Further reading: The Center for Science in the Public Interest’s excellent Food Labeling Chaos

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.

Related post: Are “functional” foods healthy foods?

Reposted as part of Food Renegate's Fight Back Fridays--go join the food fight!

Jamie Oliver's wish: Teach every child about food

Celebrity chef Jamie Oliver recently received the prestigious TED Prize, an annual award given to a speaker at the TED (Technology, Entertainment, Design) Conference, which entitles the speaker to one wish that can change the world and $100,000 as down payment for the magic wand.

Jamie's wish: "I wish for your help to create a strong, sustainable movement to educate every child about food, inspire families to cook again and empower people everywhere to fight obesity."

This is a wish that can come true--I truly believe that. We all have the power to help make Jamie's wish a reality--for our own sake.

You can jump right in and sign Jamie's petition.

You can take a look at Jamie's plan and needs and see if you can offer assistance.

Or maybe just have your Jamie Oliver moment with your own family tonight: I'll be teaching my kids another simple, nutritious dish they can cook by themselves when they come home from school.

One of the "TED commandments" is the strict time limit of 18 minutes per talk, which Jamie exceeds by a few minutes, but this video is well worth watching. I think it's awesome!

Dr. Ayala

Reposted as part of Food Renegate's Fight Back Fridays--go join the food fight!

”Let’s Move” to reform school food

School food received some major media attention in the past week.

Michelle Obama launched the Let’s Move anti-obesity campaign last Tuesday, with improving school food as a major program cornerstone. Congress will reauthorize the Childhood Nutrition Act this year—with some planned overhauls and budget proposals underway. And the Obama administration wants Congress to remove sugary snacks and drinks from school vending machines.

Say what? The federal government is trying to limit big food’s footprint in our schools?

If Agriculture Secretary Tom Vilsack gets his way, he intends to do just that: "Food served in vending machines and the a la carte line shouldn't undermine our efforts to enhance the health of the school environment,” he said.

A short introduction to school food

On any school day more than 30 million kids eat a school lunch and 10 million kids eat a school breakfast. Fifty-nine percent of the kids eating a school lunch are from low-income homes, as are 80 percent of school breakfast eaters. The school lunch program operates in all public schools and in many private schools.

The National School Lunch Program was created with a dual purpose—to feed kids and prevent dietary deficiency and to provide an outlet for surplus agricultural commodities. One can already see that the dual purpose of the program throws in some problematic conflicts of interest, but let’s go on.

The government provides $2.68 per day for kids qualifying for a free lunch, $2.28 per day for a reduced-price lunch, and $0.25 per day for all other kids. That sum includes the overhead and facility costs associated with the meal, which leaves just $1—or less—for the food itself. This is clearly not enough money to fund from-scratch cooking or quality, fresh produce. President Obama proposes bumping up the school lunch budget a tad—which will be better than nothing—but the additional funding probably won’t afford a huge amount of change.

What kind of meal can you get for $1?

An adventurous school teacher vowed to eat the school lunch every day this year, and she’s posting musings and photos of her cafeteria meal in a daily blog. Take a look at the pictures (take note of the amount of packaging) and you’ll get the idea.

I’ve devoted several posts to this subject and analyzed the typical school lunch menu, concluding that the best description for this food is “fast-food”. Overall, it’s salty, sweet and fatty; the meat is breaded and crunchy; and it’s been highly processed—even the fruit and vegetables aren’t fresh for the most part. Most of the schools have no kitchens and just heat and un-wrap low-grade foods. Nevertheless, the subsidized school lunch complies with some nutritional guidelines and provides plenty of protein and vitamins, and while I think guidelines based on the nutrient profile of foods alone are an ill-advised way to evaluate food quality, at least some rules exist.

But if the federally sponsored and regulated school lunch program leaves much to be desired wait till you get the full picture, because challenging the school lunch, are what’re called competitive foods.

These competitive foods—comprised of foods and beverages sold in the cafeteria or in a school store, from a vending machine or in fundraising events—are expressly marketed to our kids and make up a big part of what kids actually eat while they’re in school.

Kids love the vending machines and the school stores, but that’s not the only reason these outlets exist. Schools depend on the revenues that vendors bring in to fund much-needed programs. This creates an unusual and worrying conflict, in which schools share an interest with the manufacturers of snacks and junk foods.

School candy-land

Here are some facts about the scope of the competitive food problem. (The source is an article in the Journal of the American Dietetic Association that looked at data collected in 287 nationally representative schools and included 2,314 kids.)

Availability:

• One or more sources of competitive foods are available in 73 percent of elementary schools, 97 percent of middle schools, and 100 percent of high schools.

• À la carte foods sold in the cafeteria are common in all school levels.

• Vending machines are available in more than one quarter of elementary schools, 87 percent of middle schools and virtually all high schools.

Consumption of competitive foods :

• 40 percent of school kids consume these foods on any given day.
Consumption is much higher among high schoolers—55 percent.

Energy contribution of competitive foods:

• Kids consume about 280 calories per day from competitive foods, and almost two- thirds of these calories were from “low-nutrient” and “energy-dense” foods. (The study defines “low-nutrient, energy-dense food” to include cakes/cookies, desserts, donuts, toaster pastries, snack chips, French fries and caloric beverages, excluding milk and 100% juice.)

• A typical high school kid gets about 340 calories per day from competitive foods, 65 percent (or 220 calories) of which are from junk food.

The most commonly consumed competitive foods:

• Desserts, snacks (cakes, cookies, candy and ice cream) and sweetened beverages.

So, we have low-quality foods sold in the schools competing with a low-quality school lunch–a competition that’s a lose-lose for our kids. Wherever our kids turn they have snacking opportunities that contribute mostly empty calories.

The only existing federal restriction on foods sold in school is that foods of “minimal nutritional values,” such as candy and soda, won’t be sold in the cafeteria during meal times. That of course doesn’t mean they can’t be sold right outside the cafeteria doors. And although some school districts have taken initiatives to impose restrictions banning some junk food sales in schools, progress is very slow.

It is high time school food begins to resemble a lesson in how to eat healthfully. Right now, the school lunch—and especially the school foods for sale—resemble all that’s wrong in our popular food culture, and explain quite well why one in three American kids is overweight or obese.

Kids spend half their waking hours in school and consume half of their daily calories while on campus. Changing school food is critical in the effort to combat obesity.

I applaud the White House and especially our First Lady for taking on this important issue. “Let’s Move” is the politically savvy way to name what will have to really become a “Let’s Eat Less Junk” effort—but whatever it takes let’s indeed move it!

Dr. Ayala

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.

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

Why do we care what the Surgeon General weighs?

As soon as President Obama announced Dr. Regina Benjamin as his pick for surgeon general last July she came under fire for—can you believe it?—her weight!

Dr Benjamin’s figure has received more scrutiny and bashing from bloggers and commentators than her exemplary qualifications and achievements.

Last Monday, on Dr. Benjamin’s swearing-in date, she gave an interview to Good Morning America, in which she honestly responded to the comments about her figure. “Most women want to be attractive,” she said. “You don’t want to see negative things, people calling you names. So it was very hurtful.” Such straightforwardness and openness is refreshing.

I have two things to say about this:

First: Where are our manners?

Aren’t we the nation of political correctness? I don’t support euphemisms and practices that empty language of all meaning, but there’s something to be said for good manners: Language is the expression of thought, and suppressing language that might offend people not only spares these people’s feelings, but hinders the social acceptance of what’s ultimately bad manners.

It seems obesity is one of the final frontiers of out-in-the-open social marginalization and stigmatization--obesity bias is still socially acceptable and regularly expressed without any shame.

Strange that in a nation in which the majority of the population is overweight—and one in three adults is obese—where talking about a person’s color, ethnic background or religion can get you into major trouble, criticizing body fat is considered just fine.

And second: What does weight have to do with being a good surgeon general?

Our celebrity-obsessed culture confuses us into thinking that one’s appearance and personal story are major qualifications for any job.

Nothing can be further from the truth, certainly in most professional roles, and especially in science- based disciplines.

The Surgeon General is the leading spokesperson on matters of public health in the federal government. Quoting from the Office of the Surgeon General’s website, “The Surgeon General serves as America's chief health educator by providing Americans the best scientific information available on how to improve their health and reduce the risk of illness and injury.”

The key words here are “best scientific information.” The Surgeon General is a physician. She practices a discipline in which evidence and scientific inquiry are the main tools. A doctor’s personal opinion about most subjects hardly matters. When you consult a doctor what you’re supposed to get is what medicine knows about your condition, and hopefully, a treatment plan that has been proven to work. Doctors aren’t supposed to draw from their anecdotal personal experience or gut feeling when they’re on the job; they should be looking at evidence, referencing clinical studies and applying the gathered experience of many other trained professionals.

That’s why a male physician can be an excellent obstetrician, a pediatrician needn’t be a parent, and psychiatrists don’t need first-hand experience with overcoming mental illness. You follow a doctor’s advice (and the guidance of any other expert) because he knows his stuff and has sound clinical judgment, not because he’s a role model.

The Surgeon General is the country’s head doctor, not a health celebrity. She’s a professional, dispensing advice based on evidence, science and the consensus of peers in order to promote our national health.

Criticism that Dr. Benjamin might have a credibility problem when talking about obesity and can’t lead a national discussion on the subject is as absurd as insisting that a male physician couldn’t guide the delivery of a baby.

A weight-loss guru, touting a miracle diet that’s a quick cure-all for obesity, has a credibility problem if he’s overweight. (Actually, he’d have a credibility problem even if he’s skinny, because we should all know better and question whether such a fix could actually work.)

Prevention and public health are at the top of Dr. Benjamin’s to-do list and obesity is the number one public health issue facing America right now. Regardless of the Surgeon General’s personal experience with weight, her office would be looking at the same studies referenced by physicians and nutrition experts all around the world.

The data shows that obesity is multifactorial, isn’t easy to solve, isn’t a failure of personal will-power, and that telling people to lose weight—whether this comes from a thin or a fat person—is hardly an effective enough solution to this complex problem.

One of the most important roles of the Surgeon General is to influence public policies. In the case of obesity and the very sorry state of our country’s eating habits, a major effort is needed in order to change our obesogenic environment so that one won’t need such enormous self-control in order to be fit and thin.

I have no idea why we’re looking so hard for role models, and why we seem to expect no less than perfection from public figures.

Competency, wisdom and honesty from real people seem like plenty to me; and we’re fortunate that there’s so much more to admire in our new Surgeon General.

Most people can’t name many—or any—previous Surgeons General, have no idea what they did, and certainly don’t know their size. I hope Dr. Benjamin attracts more public attention than her recent predecessors did, and when she speaks it's the message--not the messenger--we should be paying most attention to.

I’m looking forward to a heated discussion on this topic.

Dr. Ayala

Reposted as part of Food Renegate's Fight Back Fridays--go join the food fight!

Immunity boosting foods? Really?

The connection between diet and health was proposed some 24 centuries ago by Hippocrates, and I can imagine he first heard of it from his mom, who heard it from her ancestors.

Today, grandmas, moms and physicians have piles of scientific evidence supporting their observations and advice. It’s true: Diet does play an important role in health. We’re learning more each day and the discovery is fascinating.

Unfortunately, scientific discoveries are being overly-interpreted to promote the sale of foods, and scientific jargon appears all too often as buzzwords on packaged goods.

Our latest Flu season and the spread of the new H1N1 virus have given rise to a new barrage of immunity claims shouting at us from every supermarket shelf and commercial. It’s a perfect time to look at the diet/health connection and these claims.

A short introduction to food label claims

There are several types of claims allowed by the FDA on foods.

A health claim describes a relationship between a food or food component and a disease, and it must:

• Be pre-approved by the FDA. There are currently slightly more than a dozen of these approved claims.

• Be phrased in the specific language the FDA requires. The claim must indicate that the disease may be caused by a variety of causes, and must state that the food should be consumed as part of a healthy diet.

• Appear on food that meets certain nutritional requirements.

A structure/function claim is quite a different animal.

Structure/function claims describe a role of a nutrient, a substance in food or a food supplement in affecting the normal structure or function in the body. Unlike a health claim, it doesn’t relate to a disease or a health-related condition. The verbs “support”, “improve”, “boost” and “maintain” are often a telltale sign of a structure/function claim.

A Structure/function claim:

• Requires no FDA pre-certification.

• Can be attached to any food, including junk food (there are no overarching nutritional requirements).

• Can be phrased in many ways.

• Is the manufacturer’s responsibility. While the claim “must be truthful and not misleading”, there’s no specification about how much evidence is needed to make the claim.

A few quick examples:

“Calcium reduces the risk of osteoporosis” is a health claim; “calcium builds strong bones” is a structure/function claim.

“Fiber may reduce the risk of some cancers” is a health claim; "fiber maintains bowel regularity," is a structure/function claim.

Confused? You’re in good company. Most consumers can’t tell the difference.

Even the pros in the food industry can’t necessarily make sense of structure/function claims. They consult expert lawyers whose entire practices are devoted to advising companies on the language of the label. Creative marketing devises the claim and legal counsel makes sure it’s defensible and at least somewhat based on reality.

What’s clear is that the structure/function claim has been a boon to food manufacturers. Since there are so few limitations on its use and the trusting public can’t distinguish between a health claim and a structure/function one, why not be creative, develop a claim that meets your goals and slap it on the package? Market research shows these structure/function claims really help with sales.

What's the evidence backing these “immunity” claims?

There are, in fact, no approved health claims related to immunity.

What does that mean? It means that no one has presented to the FDA enough evidence of a relationship between a food, a food ingredient or a dietary supplement and reduced risk of contracting or of treating an immune mediated or infectious disease such as the flu to warrant a health claim.

That means the immunity claims you see everywhere are all structure/function claims.

What are the claims based on? The immune system is very complicated, and its integrity depends, among other things, on good nutrition. States of vitamin, mineral or protein deficiency lead to reduced immunity and correcting the deficiency does improve immunity.

But while it’s true that if you had a vitamin C or zinc deficiency you could improve your health and immunity by eating a vitamin-fortified cereal or a vitamin supplement, it’s clear that shouting “Immunity!” from the cereal box is misleading. Vitamin deficiencies are rare, and therefore the cereal might be yummy, but it’s not doing much for your immune system.

Most food contributes to one’s health, so by that token we can add a structure/function claim to pretty much anything:

• Sleep, for example, is very important to immunity; should we advertise mattresses as immunity boosters? All mattresses or only some brands?

• Exercise improves immunity. Maybe “immunity now!” should be painted on sidewalks?

• Stress reduction improves immunity; how about an “immunity massage”?

• Why, even breathing air supports immunity.

These immunity claims are all without much substance I’m afraid, but it’s especially outrageous to see them on junk food. Cocoa Krispies is 40 percent sugar, but hey, don’t you need to maintain normal sugar levels for good immunity? Correcting potential hypoglycemia is critical for good immunity, isn't it?

Thankfully, after receiving a letter from San Francisco’s city attorney last November, Kellogg announced it would phase out the immunity claims on Cocoa Krispies.

Will misleading claims ever end?

Two scenarios I can imagine:

• Consumers will start rejecting these claims, viewing them as a hyped and misleading insult to their intelligence, and move toward products that are marketed in a more sensible and honest way.

The only reason these claims abound is because we’re buying them.

And here comes my question: Do people really believe that they can buy immunity in box? Or are they buying it knowing that an easy fix is a fantasy, but it still feels good to dream?

• The second option is the litigious route: A few really big class action suits, representing misled consumers who saw no health benefits from investing their hard-earned money in products that failed to deliver can change everything. In that respect, the recent FDA warning letters to manufacturers who post misleading or false claims could act as important evidence and actually make a difference.

I prefer the first scenario.

There’s actually a third possibility.

The FDA can overhaul the whole health-claim structure/function scene, crackdown on false and misleading claims and help consumers understand that good health (and building a strong immune system) has nothing to do with buying products that make health claims. People need to just eat well by consuming healthy, real foods over a long period of time.

Sorry, but that’s the truth—eating well is about good habits and good food, not about sprinkling vitamins, anti-oxidants and omega 3 on processed food. The Center for Science and Public Interest (CSPI) is urging the FDA to do just that in a report it recently sent. (It’s 158 pages, but well worth a read, and it includes lots of pictures.)

So, what to make of these medicinalized foods?

I think it’s best to simply leave them on the shelves and opt for good, healthy choices. As Hippocrates said, “To do nothing is sometimes a good remedy.”

To your health!
Dr. Ayala

Related post: Are “functional” foods healthy foods?

Reposted as part of Food Renegate's Fight Back Fridays--go join the food fight!

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