Healthy Food & Healthy Living by Dr. Ayala

Are artificial sweeteners a healthier option?

Sweet tasting foods are rare in nature. Fruits and vegetables have some sweetness to them, but they’re also packed with lots of fiber, water, micronutrients and phytochemicals, and are nutritious and quite filling. Honey was hard to find for most of human history and even harder to harvest—it’s protected by an army of stinging warriors.

It’s only in our modern times that concentrated sweetness—in the form of table sugar—grew abundant, and with the invention of high-fructose corn syrup (made from subsidized corn) it became dirt cheap.

Who doesn’t love sweet tasting food? I’ll readily confess—I love chocolate and wish it was on the bottom, roomy part of the food pyramid.

Our preference for sweetness is most likely innate. Food marketers understood its seductive lure, so they started adding sugars to many foods and replaced plain water and milk with sweet drinks. And the consumption of refined sugar skyrocketed. Sweet foods sell!

Alas, too much sugar is a major factor underlying our obesity crisis. It can undermine normal satiety levels, motivating us to eat more than we need while stimulating food cravings. Too much sugar may also raise blood pressure and can elevate blood triglycerides levels (a risk factor for heart disease).

And although sugar is added to many foods—breakfast cereals, condiments and desserts are a few examples—soft drinks and other sugar-sweetened beverages are the primary source of added sugars in Americans’ diets. Soft drinks and fruit drinks combined make up almost half of an average American’s added sugar, and Americans take in about 300 calories from added sugar a day from sugary drinks alone. No other foods or beverages have been associated as clearly with weight gain and obesity as soft drinks.

To our alleged rescue came artificial, non-caloric sweeteners, offering the same intense sweetness without the caloric price tag. There are several such products in the market, all FDA approved: Aspartame (NutraSweet, Equal), Sucralose (Splenda), Saccharin (Sweet'N Low) Acesulfame K (Sweet One) and Neotame.

Are artificial sweeteners a tool in fighting obesity?

This month, David Ludwig of Harvard and Children’s Hospital of Boston and one of America's foremost obesity experts published a commentary in the Journal of the American Medical Association titled: Artificially Sweetened Beverages, Cause for Concern. In this thoughtful commentary, Dr. Ludwig contemplates the potential downsides of replacing sugary drinks with the artificial stuff. Here are some of his main points:

On the up side:

• Short-term clinical trials show that artificial-sweetened beverages may produce short-term weight loss when they replace sugary drinks.

• Artificial sweeteners have been in use for a century, and although there are recurring questions about cancer risk related to their use, no such link has been found.

However:

• There are very few long-term studies looking at what artificially sweetened beverages do to weight, and since body weight regulation is super complex, it very well may be that over time the calories saved by moving to artificial sweeteners are replaced by other foods; in other words, diet drinks may not assist with weight loss. The two long-term studies cited in the paper, which should be interpreted cautiously, surprisingly showed a dose response correlation between consuming diet drinks and the development of obesity, and a correlation between the consumption of diet drinks and the metabolic syndrome and type 2 diabetes.

• Artificially sweetened beverages habituate (or essentially train) our taste receptors to prefer intense sweetness, leading us to reject less-sweet foods (such as veggies and fruit) and “infantilizing” our taste buds to seek sweetness rather than to “grow up” and seek more complex flavors.

• Diet drinks dissociate between the signal and the outcome: Sweetness signifies to our body that energy and nutritious food are on the way, enacting hormonal and neurobehavioral pathways, yet with diet drinks no calories are actually consumed. The outcome of this disconnect isn’t yet clear, but it’s a concern.

• The popularity of artificially sweetened beverages is rising rapidly, and we’re ingesting very large amounts of these synthetic chemicals that are a relatively new addition to the human diet in what Dr. Ludwig calls “a massive, uncontrolled, and inadvertent public health experiment.”

Dr. Ludwig’s conclusion:

"Ultimately, high-quality, long-term clinical trials comparing all three beverage types are needed: sugar sweetened, artificially sweetened and unsweetened. Even if diet drinks produce long-term weight loss when substituted for sugar-sweetened beverages, they might cause weight gain when consumed instead of unsweetened drinks. For now, diet drinks may best be considered an aid in transitioning from high-calorie beverages to traditional, minimally sweetened beverages like water, mineral waters, teas, and coffee with no more than one gram of sugar per ounce (i.e., two teaspoons per eight-ounce cup).”

A perspective by two other eminent nutrition experts, Richard Mattes and Barry Popkin, in the American Journal of Clinical Nutrition came to similar conclusions, saying that: “There are long-standing and recent concerns that inclusion of NNS (nonnutritive sweeteners i.e. non-caloric sweeteners) in the diet promotes energy intake and contributes to obesity.”

Do you drink diet drinks? Have you used them as an aid in transitioning from regular soda to water? Have you turned away from them? Please share some of your personal experiences.

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.

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

Are we exercising less or eating more?

There are many compelling reasons to exercise. Regular physical activity has been shown to reduce the incidence of heart disease, diabetes and hypertension. It improves mental health, fosters strong muscles and strong bones. It also makes most participants happier and improves our looks.

Physical activity also burns calories. In the past few decades exercise has therefore become one arm of the two pronged approach to combat overweight and obesity. Exercise is the calories expended in the equation; food intake is the calories we take in. Any change in the balance of calories in and calories out that leaves us calorie depleted would, assumingly, lead to weight loss. The best approaches to overall health and weight maintenance employ both increased exercise and calorie restriction.

Inactivity has also been blamed for our weight gain. Our life has indeed become much more sedentary, as the car replaced walking, as convenience and mechanization crept into every aspect of our lives and as we started spending hours without end watching TV.

But blaming inactivity has also become a way for the fast food and processed food industry to escape any responsibility for the highly palatable and calorie-dense foods they produce and promote. It’s of course inconvenient for food manufacturers and for us individually to admit that we’re eating too much; it seems we’d all like to believe that we can just burn a lot more calories through physical activity and allow the party to go on.

Blame games are generally useless, but if we are to address the obesity crisis rationally perhaps it's worthwhile to look at the relative contribution of inactivity and overeating to our weight gain.

Surprisingly enough, there are now serious questions emerging about whether inactivity has contributed to the expanding American waistline in any significant way.

A new study in Obesity Reviews looked at adolescents’ activity levels and asked two questions:

Are American adolescents getting enough physical activity?

And

Have adolescents become less active over the past fifteen years or so?

The reviewers examined nationally representative Youth Risk Behavior Surveillance Surveys taken since 1991, which provide information on adolescents’ physical activity (such as swimming, soccer, running, etc.), physical education at school and sedentary behaviors, such as watching TV and playing video games. Sample sizes were large, ranging from about 11,000 to 16,000 participants each year.

Let’s start with the not-so-great news:

• Only a minority—about a third—of our adolescents met the recommended daily levels for physical activity. (Optimal physical activity is any activity that makes a person increase their heart rate and breathe hard for at least 60 minutes, at least five days a week.) More boys met these criteria than girls, as did more Caucasians compared to minority youths.

• Most participants—about two-thirds of the study population—reported what this study defines as “sufficient vigorous physical activity”—activity that makes a person increase their heart rate and breathe hard for at least 20 minutes, at least three days a week.

On the other hand, the data shows that American adolescents have not decreased their level of physical activity; physical activity levels have been quite stable over the past 17 years. During the same period of time studies show that obesity rates in kids had more or less doubled.

There were also a few encouraging trends:

• Physical education class attendance and engagement have improved.

• TV viewing time had decreased significantly in the past few years (although that doesn’t mean TV hasn’t been replaced by other media, such as the Internet and computers).

The authors, led by Youfa Wang, summarize by saying: “Reduced PE (physical activity) is not likely the major explanation of the recent increase in obesity among U.S. adolescents.”

Another recent study in the American Journal of Clinical Nutrition looked at the relative contributions of food and exercise habits to the development of the obesity epidemic, and concluded that the rise in obesity in the United States in the last three decades was virtually all due to increased energy intake.

These studies, and several others, suggest that the main driver of the obesity epidemic is increased food intake. Increasing physical activity has to be part of the solution because exercise is so very good for health and helps us lose weight, but in order to address the obesity crisis head-on, we have to face the fact that the main target of our efforts needs to be reducing our caloric intake.

We probably can’t—as a society—increase our energy expenditure to compensate for our levels of food consumption. We’d better be realistic about this.

The American Journal of Clinical Nutrition study cited above suggests that to get U.S. kids back to the mean weights we saw in the 1970s, kids would need to decrease their average daily intake by 350 calories/day, or walk an extra two and a half hours daily (while eating the same amount, which is no easy task since exercise drives hunger). Both options seem difficult, but the latter appears totally implausible.

Please don’t misunderstand me; I know the importance of physical activity and truly believe in its critical value. Exercise does help in weight loss and improves health, even if no weight is lost.

But I don’t think physical activity without a serious look at what and how we eat will likely get us and our kids out of the obesity crisis.

Dr. Ayala

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

Healthy neighborhoods can reduce the risk of diabetes

Do you live in a healthy neighborhood?

Is there such a thing as an unhealthy neighborhood?

Personal choice has a big impact on many aspects of our health, but do we really have the wherewithal to choose our lifestyle, or do most of us fall into a pattern determined by what’s easy to do and what everyone else is doing? Sure, there are a few motivated individuals who swim against the stream and set their own trend. Most of us don’t. Whether we realize it or not, we follow the lead of our parents and friends and do what’s easy along a path of least resistance.

There’s no doubt that our collective lifestyles have changed dramatically in the past decades. Convenience is everywhere—we do less physical work around the house, we drive a lot, and cheap highly processed calorie dense foods are everywhere.

But as I’m sure anyone driving through urban and suburban neighborhoods observes, there are great differences between regions. Some neighborhoods have green spaces, joggers, bikers, kids playing outside and farmer's markets and supermarkets with colorful inviting fresh produce. Not far away there are neighborhoods where all life is within four walls, fresh food sources are limited and corner and convenience stores are the sole resource for food.

Can a neighborhood influence health?

That’s a question researchers headed by Amy Auchincloss set out to answer in a recent paper in the Archives of Internal Medicine. They wanted to see if neighborhood’s physical attributes and the availability of healthy food affected the incidence of type 2 diabetes.

The researchers followed 2,285 people, aged 45-84 years at baseline, from three different regions in the US for five years for the development of diabetes. Among the data collected was income, assets, educational level, family history, smoking status, body mass index (BMI), exercise level and dietary measurements.

The data on neighborhood resources was obtained from an independent sample of the participants’ locales (not from the study population). The residents were asked if their neighborhood was easy or pleasurable to walk in, has ample opportunity for physical activity, or if they see other people jog or play sports. The food environment was determined by asking whether there’s a large selection of fresh fruits and vegetables available, whether produce is high quality, and whether there’s a large selection of low-fat products available.

During follow-up, 233 of the study participants (about 10 percent) developed type 2 diabetes.

And the result: Better neighborhood resources for food and exercise were associated with lower incidence of type 2 diabetes

• Participants living in great neighborhoods for activity and healthy food had 36% less chance of developing type 2 diabetes than their counterparts living in neighborhoods with poor resources for activity and healthy food.

• After adjusting for individual variables—such as age, family history of diabetes, socioeconomic status, smoking, physical activity and dietary factors—the environmental association persisted.

• The association was slightly reduced after also adjusting also for BMI.

The authors conclude:

“The prevalence of type 2 diabetes has increased substantially in the past 30 years. This makes it all the more urgent to identify environmental features that may mitigate risk of type 2 diabetes. Our results are consistent with the hypotheses that improving environmental features—such as having nearby, pleasant, safe destinations within walking distance and improving the availability of healthy foods—may halt increases in type 2 diabetes incidence. Many urban environments have developed with insufficient consideration for the ways that environments can promote or discourage healthy behaviors.
Current efforts to foster health-promoting environments include designing and modifying physical environments, such as zoning residential neighborhoods to require safe sidewalks, creating parks and attractive public green spaces, and improving public transportation so that residents rely less on their cars; supporting fresh-food farmers' markets in low-income, urban neighborhoods; and assisting stores in those neighborhoods in improving their selection of healthy foods.
There is unlikely to be a panacea for the obesity epidemic and rising epidemic of type 2 diabetes. However, altering our environments so that healthier behaviors and lifestyles can be easily chosen may be one of the key steps in arresting and reversing these epidemics.”

An accompanying editorial by Mitchell Katz discusses how hard it is to tease apart environmental and individual behavior influences on health. This study is by no means the last word on this complicated issue. But Katz sees us all as participants in a huge multinational study of the impact of the structural environment on diabetes.

In the past 50 years we in the developing world have stopped walking, our household chores are now reduced to pushing a button, fast food and super-sized meals replaced our food, and processed foods are easier to find than fresh fruits, vegetables and whole grains. And while a cause and effect is hard to prove, Katz sees this grand experiment going really badly—these environmental changes coincide with skyrocketing rates of obesity and diabetes all around the developed world.

Katz calls for a change in our environment, one that would make exercise and eating right much easier and more routine.

A closer look at an unhealthy neighborhood

From my home town, Philadelphia, comes a new study in Pediatrics led by Kelley Borradaile which investigates one aspect of an unhealthy neighborhood—the corner store and its impact on kids’ snacking habits.

The study looked at kids’ purchase patterns in urban corner stores, the small stores readily found in Philadelphia’s low-income neighborhoods. These stores carry high-profit less perishable items, which tend to be packaged foods low in nutrients and high in calories. These stores are very close to schools, and in some neighborhoods are the only convenient store, as supermarkets are absent.

As it looked at what kids in the fourth to sixth grade bought at the corner store next to their school on the way to or back from school, the study found that:

• Kids stop at the corner store frequently: More than half of the shoppers stop by daily; almost 30 percent reported stopping by twice a day.

• The average purchase supplies kids with about 360 calories.

• The most frequently bought items were (no surprise) chips, sugary drinks and candy.

• These calories are real cheap—360 calories cost a little over a dollar! For 25 cents, you get a bag of chips or a sugary drink at the corner store.

As the authors discuss, having a corner store next to school qualifies as an environmental and behavioral risk factor for obesity.

These inequity issues are deeply troubling to me. While we have to accept that there are inborn inequities we cannot change—such as the genetic risk for disease—can’t we work toward more of an equal opportunity for a healthy lifestyle for all of us?

A community with walkable, safe streets, safe and pleasant playgrounds and green spaces, and fresh produce for a reasonable price should be accessible to everyone. It should be a basic human right. It’s also likely to save a lot of healthcare dollars and make us happier.
Dr. Ayala

Related posts: When Healthy Food is Hard to Find

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

Health experts favor taxing sugary drinks in new report

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

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

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

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

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

Sugary drink consumption is rising, as is obesity

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

Why would sugary drinks lead to poor health?

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

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

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

Economic rationale to taxing sugary drinks

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

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

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

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

The proposed tax and its projected effects:

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

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

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

Objections, industry reactions and growing public support

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

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

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

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

The authors conclude:

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

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

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

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

How can “cutting added sugar” drive better health?

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

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

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

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

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

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

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

Primary source

Now on to the number one source of added sugar.

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

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

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

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

The article reviews evidence showing that added dietary sugar:

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

Agreement from other authorities

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

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

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

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

What do you think of this image?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Poor nutrition driving rise in kidney stones—in adults and kids

A recent study in the Journal of the American Society of Nephrology, found that a high intake of fruits, vegetables, nuts and legumes, low-fat dairy products, and whole grains and low intake of sodium, sweetened beverages, and red and processed meats was associated with reduced risk of kidney stones. This study, which analyzed data from more than a quarter million participants, led me to repost a piece I wrote last year. It's just one more argument to make for healthy nutrition. Enjoy the rest of your summer, Dr. Ayala

Kidney stones are becoming more common at an alarming rate, and this is one trend you should absolutely try to avoid.

If you’ve ever had one, you know they’re no fun. In fact, women who’ve experienced both kidney stones and child labor describe the pain associated with the passage of a stone as comparable in intensity to that of labor (without an epidural), with much less satisfying rewards.

Diet plays an important role in the development of kidney stones, especially in people who are predisposed to the condition. The incidence of stone disease tends to rise during periods of affluence, and many experts have concluded that kidney stone is—at least in part—a nutritional disease.

A recent article by Laurie Tarkan in the New York Times reports on the alarming rise in the incidence of kidney stones not just in adults, but also in children. Tarkan says that kidney stones in kids—once considered rare—are now becoming a fairly common condition and are seen in ever-younger ages. As with other diseases related to poor diet—such as type 2 diabetes and obesity—there’s a disturbing shift underway in the age of presentation of the condition.

The article interviews several leading urologists, and explores reasons for the rising incidence (emphasis is mine):

"Though most of the research on kidney stones comes from adult studies, experts believe it can be applied to children. Those studies have found that dietary factors are the leading cause of kidney stones, which are crystallizations of several substances in the urine. Stones form when these substances become too concentrated.

Forty to 65 percent of kidney stones are formed when oxalate, a byproduct of certain foods, binds to calcium in the urine. (Other common types include calcium phosphate stones and uric acid stones.) And the two biggest risk factors for this binding process are not drinking enough fluids and eating too much salt; both increase the amount of calcium and oxalate in the urine.

Excess salt has to be excreted through the kidneys, but salt binds to calcium on its way out, creating a greater concentration of calcium in the urine and the kidneys.
“What we’ve really seen is an increase in the salt load in children’s diet,” said Dr. Bruce L. Slaughenhoupt, co-director of pediatric urology and of the pediatric kidney stone clinic at the University of Wisconsin. He and other experts mentioned not just salty chips and French fries, but also processed foods like sandwich meats; canned soups; packaged meals; and even sports drinks like Gatorade, which are so popular among schoolchildren they are now sold in child-friendly juice boxes.

Children also tend not to drink enough water. “They don’t want to go to the bathroom at school; they don’t have time, so they drink less,” said Dr. Alicia Neu, medical director of pediatric nephrology and the pediatric stone clinic at Johns Hopkins Children’s Center in Baltimore. Instead, they are likely to drink only once they’re thirsty—but that may be too little, too late, especially for children who play sports or are just active.

“Drinking more water is the most important step in the prevention of kidney stones,” Dr. Neu said."

Other contributing factors examined in this article are obesity, which experts tie to the formation of kidney stones in children as well as adults, and sugary drinks:

“There is also evidence that sucrose, found in sodas, can also increase risk of stones, as can high-protein weight-loss diets, which are growing in popularity among teenagers.”

I’d like to add one more to the list of suspects responsible for the rise in stones: Vitamin C.

High doses of Vitamin C can result in high levels of oxalate (a type of salt) in the urine and therefore increase the risk for kidney stones. Since high doses of Vitamin C are not proven to prevent or treat the common cold, or aid your health in any way, there’s no good reason to take them.

By no means am I suggesting that parents should worry about kidney stones and devise special diets to decrease their kids’ risk of stones. The experts’ dietary advice for avoiding kidney stones consists of guidelines one should already be following for a multitude of health reasons, and is quite simple:

• Drink adequate amounts of water. Sugar and high-fructose corn syrup-laden juices and sodas don’t count as healthy hydration.


• Avoid excess salt and highly processed foods. The diet that promotes kidney stone disease is high in sodium, animal protein and sugar, and low in fiber, vegetable protein and unrefined carbohydrates. Another way to describe this diet is a processed-food diet.

The sport drink industry has tricked us into thinking that we need electrolyte infusions on a regular basis, for recreational sports as well as everyday life. The fact is that as long as people are consuming food, which contains ample amounts of electrolytes (really just salts) there’s no need to worry about electrolytes.

And wherever electrolytes are added, sweetener is added too, to mask the taste of the electrolytes. That’s a good recipe for stones for those who already are susceptible to stone formation. I’ve written more about sports drinks here.

Dr. Ayala

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

Are “functional” foods healthy foods?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New evidence that simple healthy lifestyle choices can thwart chronic illness

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

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

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

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

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

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

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

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

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

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

• Normal weight (BMI of less than 25).

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

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

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

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

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

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

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

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

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

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

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

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

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

Roger writes:

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

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

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

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

Dr. Ayala

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

From garden to healthy table—zucchini, potato and fresh herbs gratin

As I’ve mentioned before, I’m an amateur organic gardener with many good intentions and a very modest yield.

I give my little vegetable patch lots of love, but the veggies are very slow to grow, and although some of my friends have been boasting home-grown produce for weeks, I harvested my first few cucumbers, tomatoes and zucchini just this week.

I love watching the plant in all its stages, and I’m especially fascinated to see how a fruit evolves from the flower. In the case of the zucchini, the beautiful golden flowers—both male and female—are edible and quite tasty, and can be eaten fresh, sprinkled into salads soups and pasta dishes, or cooked—stuffed zucchini flowers are a gorgeous delicacy.

By the way, only the female flower results in a zucchini: A bud appears at the base of the flower and grows into a zucchini. (And yes, a zucchini is botanically a fruit and not a vegetable.)

One of my favorite zucchini recipies is for an easy gratin. I usually make this with only zucchini, but since I had so few—and I didn’t want to mix my precious zucchini with the store-bought ones—I combined my zucchini with super new potatoes from my local farmer’s market. I was very pleased with this combination, since the lightness of the zucchini and herbs is balanced with the earthiness and heartiness of the potatoes.

As you’ll see, this dish relies on fresh herbs for its explosion of flavor. The fresh herbs also pack lots of nutrition—they’re a powerhouse of phytochemicals and antioxidants, and a great addition to your healthy diet.

Ingredients:

• 4-5 zucchini, peeled (if very fresh no need to peel) and cut to ¼-inch slices

• 8-10 small potatoes, peeled and very thinly sliced (can be done with a mandoline or food processor)

• ½ cup freshly grated parmesan cheese

For the sauce:

• 1 cup of mixed fresh herbs—tarragon, parsley, chives, oregano, thyme and basil are good options; be creative, but use more of the mild herbs, and less of the more potent oregano and thyme.

• 5 tablespoons extra virgin olive oil

• 1 clove garlic

• A pinch of hot pepper flakes

• Salt and pepper to taste

Preparation:

• Heat the oven to 350 degrees F.

• Prepare the sauce. If you have a food processor, pulse all ingredients to a course grind. Otherwise, chip all dry ingredients as finely as you can, and mix with the olive oil and spices.

• Mix all ingredients, taste the zucchini and correct the seasoning.

• Brush some olive oil on an oven-safe baking or gratin dish, and transfer the zucchini potato mix.

• Transfer to the oven, and bake for 60-80 minutes, until potatoes are well-softened. If the top darkens too much, and the potatoes aren’t yet soft, cover with tin foil and bake some more.

Serve immediately (will serve 8-10 diners as a side dish).

Enjoy,

Dr. Ayala

Can Pac-Man help kids make healthier choices?

One-third of American kids are overweight or obese. Obesity rates among kids have tripled in the past thirty years. Many experts blame not only the food environment we live in—comprised of endless opportunities to eat foods of minimal nutritional value—but also the massive bombardment of advertising our kids are exposed to, baiting them to consume these foods.

According to the Federal Trade Commission, the largest U.S. food and beverage companies spent about $1.6 billion (!) in 2006 marketing their products to kids—$492 million for soda ads alone—and I’m sure they wouldn’t be spending this kind of money unless they saw real results.

Most parents are aware of how abundant junk food ads are on kids’ TV programming, but ads lurk in every corner. Media consumption habits have changed, and marketers are keeping up as they find new ways to get their message to kids in new outlets, including social media, product placement in TV shows and movies, sports sponsorships, mobile phones and kids’ favorite websites.

A recent article in the Archives of Pediatric and Adolescent Medicine reported on a study done by the Children’s Digital Media Center at Georgetown University that examined how “advergames” (advertising that appears in computer games) affect kids’ choices of snacks.

The Internet is a favorite pastime for many kids, and most major food and beverage websites have links to special pages designed exclusively for kids, many of them with fun digital games to play online. These games are a relatively inexpensive marketing tool, but are they effective in selling the product? Does playing a game affect food choices?

The Georgetown study included thirty low-income African American third- and fourth-graders from the Washington D.C. area. The researchers created two versions of a Pac-Man-type game, in which a digital character moves through a maze and eats or avoids the foods he encounters on his journey.

In the healthy-food version, the player was awarded 10 points for each nutritious snack eaten by Pac-Man, and penalized 10 points for every less-nutritious snack eaten by the digital consumer. In the less-healthy version, the player was awarded 10 points for each non-nutritious snack eaten by Pac-Man, and penalized 10 points for every nutritious snack he gobbled up. The foods featured in the game were a small banana and a small orange juice on the healthy side, and a small bag of chips and a small can of soda as the less-healthy options.

The kids were randomized to play one of the game versions or to act as the control. After completing the game—which took an average of less than 10 minutes—the kids were asked to select one food and one beverage from the foods that were featured in the game.

The results of this small study are very clear:

• Five of the ten kids who played the healthier version chose two healthy snacks, compared to only one kid making healthy choices from the unhealthy-snack game group.

• Four kids in the healthy-game version selected one healthy snack, compared to none in the less healthy game group.

• Only one kid who played the healthier game version chose no healthy snacks (he picked two unhealthy snacks) compared to nine out of the ten kids playing the unhealthy snack game group.

Ten minutes of exposure affected these kids’ selections and they ate whatever snacks were being marketed by the advergame!

The authors, Tiffany Pempek and Sandra Calvert, write:

“Our findings also suggest that public concerns about online advergames that market less healthy foods and beverages to children are justified. Children selected and ate snacks that were of poor nutritional quality after exposure to the advergame that promoted less healthy foods and beverages. However, as demonstrated by this study, advergames may be used just as easily to promote healthier snacks, an approach recommended by the Institute of Medicine report as a way to help curb the obesity epidemic in the United States. In particular, because so many children play online games, health-promoting advergames can be part of a cost-effective social marketing campaign. Indeed, the children in this study reported liking our advergame. Our advergame had only 2 levels and lacked the "bells and whistles" of most commercial video games, indicating that even simple games can be effective in bringing about behavioral change. More sophisticated games with even more levels of challenge that are played over an extended time may yield even stronger effects.”

The journal also includes an advice for patients piece with their study report, in which parents are encouraged to moderate their kids’ media use. Here are their recommendations:

"Reduce Your Child’s Media Use

• One way to reduce the impact of media on your child's nutrition choices is to reduce the time your child spends interacting with media. This can benefit your child by decreasing the unhealthy messages that media, such as television, can send, as well as giving more time for your child to do other healthy activities, such as playing outside or time spent with friends.

• Avoid having a television in your child's room or watching television during meals.

Media Literacy

• Media literacy means teaching young people how to understand and interpret advertisements.

• Parents can talk to their children about what advertisements they see and how that ad may influence their choices. This interaction helps children understand that not everything seen in the media is real and how media advertisements try to influence behaviors.

• There is evidence that media literacy may protect against some behaviors that the media promote, such as smoking.

Countermarketing

• This technique refers to promoting healthy messages through the media.

• Examples include advertisements for healthy foods and games that promote healthy behaviors."

As a parent, I’ve been attempting to find middle ground and a sensible way to minimize my kids’ screen time while not forbidding it (and in that way inadvertently increasing its desirability).

I find that kids are quick to understand and develop some healthy skepticism when advertising techniques are explained to them. I remember the first ad I watched and explained to them: It was an ad for a cleaning product, featuring a joyful gorgeous mom cleaning a kitchen.
I asked them, “Why do you think she’s so happy?” and we went through the possibilities, concluding that this woman looks so happy because she’s an actress, and she’s paid to look happy, and while this cleaning product may help you clean, it certainly doesn’t make you happy or gorgeous. Indeed most moms (and dads) don’t particularly enjoy cleaning—unless they’re paid handsomely to do it on TV.

Taking junk-food ads apart isn’t difficult—so many of them show kids gaining superpowers, having over–the-top fun, and are associated with sporting heroes and favorite cartoons, while the sad truth is these “eat less of” foods will give you less power, aren’t much fun in the long run, and certainly have nothing to do with the admired basketball star or cartoon character.

But does explaining this take away the powerful repetitious visual message? I doubt we can completely undo the effect of advertising on our kids' preferences.

Do you have media guidelines in your home? How do you deal with your kids’ exposure to ads? Please share!

Dr. Ayala

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

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

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

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

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

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

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

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

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

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

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

• Stop drinking sodas and other sweetened beverages.

• Eat at home instead of eating out.

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

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

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

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

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

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

• Tell Congress that food safety is important to you.

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

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

Dr Ayala

Small bites for better health

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Your moment of Zen

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

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

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

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

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

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

Counting calories to make healthy choices in fast-food restaurants

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

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

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

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

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

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

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

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

Here are some of the findings:

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

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

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

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

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

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

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

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

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

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

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

Room for change

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

They write:

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

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

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

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

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

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

Dr. Ayala