Healthy Food & Healthy Living by Dr. Ayala

The health and weight of the (young) nation

It has been many a pediatrician’s nightmare prediction: rising obesity rates are likely to cause an increase in type 2 diabetes in teens, in much the same way these two conditions are linked in adults.

And this fear has come to pass. Type 2 diabetes, unheard of in kids just a few decades ago (it used to be called adult-onset-diabetes for just that reason!), has become unexceptional in pediatric practice.

But what we’ve seen so far seems to be just the tip of the iceberg. A new article in Pediatrics looked at a group of about 3400 nationally representative teens (aged 12-19), and found that diabetes and pre-diabetes nearly tripled in less than 10 years, jumping from 9 percent in 1999-2000 to 23 percent in 2007-2008.

The authors, led by Ashleigh May, warn that these results should be interpreted cautiously: Diabetes and pre-diabetes were diagnosed by a single fasting blood sugar test. The true prevalence of type 2 diabetes in kids is hard to know unless blood tests are done because the disease can have little or no symptoms for a very long time. The numbers do look high, and it’s going to be interesting to see if other large-population studies corroborate them.

Teens at serious cardiovascular risk

High blood sugar wasn’t the only cardiovascular risk factor facing the teens in the study. Overweight and obesity were common – 16 percent of the kids were overweight and another 18 percent were obese.

On top of that, 14 percent of kids had pre-hypertension or hypertension, 22 percent had borderline or high LDL (bad) cholesterol, and 6 percent had low HDL (good) cholesterol.

All these above mentioned risk factors were seen much more frequently among the kids with overweight and obesity, in fact, among obese teens 61 percent had at least one cardiovascular risk factor on top of their weight status, and 8 percent of the obese teens had 3 or more of the tested risk factors. But even among normal weight teens 37 percent had a cardiovascular risk factor (the most common of which was high LDL), showing that even when teens aren’t overweight they can benefit from interventions promoting a better diet and more physical activity.

A bit of good news if I may: it seems like obesity rates have leveled off and they haven’t changed much during the 9 years covered in this study. For overweight and obesity to level off at a third of the pediatric population is of little comfort, though

Diabetes in teens carries extra burden

Kids with diabetes not only have more years to accumulate the disease’s serious complications – the longer one has diabetes the more likely heart, kidney, eye, nerve and other body systems are to suffer its consequences. Type 2 diabetes is also proving to be much harder to treat in young patients according to recent studies.

It doesn’t have to be so!

I assume that the vast majority of the kids in this study had pre-diabetes – a condition that if left unattended can, and often will, develop into diabetes (the article doesn’t differentiate between diabetic and pre-diabetic teens). But pre-diabetics can reverse their metabolic state with just modest weight loss and exercise.

And for all of us, type 2 diabetes is mostly a lifestyle disease. It is really up to us to feed kids better and help them become more active so they’re not doomed to develop totally preventable disease and disability as young adults.

What to do? HBO’s excellent Weight of the Nation looks at this complex issue in depth and with compassion. If you haven’t seen it yet, I highly recommend the Children in Crisis chapter (I actually think it’s a good idea to watch the chapters out of order – I found the first installment, Consequences, to be so depressing that I have a feeling some viewers might have just given up on both the series and on dealing with obesity before that chapter was over).

As Dr. Tom Frieden, CDC director, says: The weight of the nation is not healthy. And to get it healthy, we’re all going to have to do our part.

 

Dr. Ayala

 

Forks Over Knives: Can a Plant Based Diet Reverse Disease?

“Isn't it enough to see that a garden is beautiful without having to believe that there are fairies at the bottom of it too?” Douglas Adams

There’s no doubt in my mind that the western diet – characterized as highly processed, animal product rich, sugary, fatty and salty – is bad for our health. Its spread is closely followed by a huge rise in the incidence of obesity and several “western” chronic diseases such as heart disease, hypertension and type 2 diabetes.

Traditional diets and especially plant based diets are associated with much healthier populations and lower risk of many diseases. Ample amounts of evidence show that.

Since I know that a whole foods, plant based diet is the best nutrition advice we can come up with, and I’m a lifelong vegetarian (for a multitude of reasons, the main one being animal welfare) I expected Lee Fulkerson’s documentary “Forks Over Knives” to be music to my ears.

Forks Over Knives

Forks Over Knives follows the research and personal journeys of nutrition scientist Dr. T. Colin Campbell (The China Study) and surgeon Dr. Caldwell Esselstyn. Campbell and Esselstyn independently came to the conclusion that abandoning the American diet and maintaining cholesterol levels well below those historically recommended by health policy experts on a plant based diet can prevent and even reverse heart disease and other illnesses.

The movie is peppered with engaging personal tales of people whose lives were changed by a plant-based diet: A diabetic mother, a diabetic, hypercholesterolemic meat-loving landscaping company owner, a vegan mixed martial artist, and the film’s writer and director, Fulkerson, himself – his Red Bulls and soda habit led to less than stellar lab results. Vegans, we learned, not only are healthy, some of them are really cool and really strong.

The vibrancy on the 70 something year-old vegan doctors and their plant-eating patients and the beauty of the rainbow-colored veggie fruit and grain dishes are in sharp contrast to the footage of obese, sickly, tired people and greasy super-sized unappetizing meaty food.

Forks Over Knives advocates an idea I generally believe to be true. It is a rather entertaining film, and definitely good food for thought.

However, it falls short on nuance, balance and hard facts and pushes a strict vegan way of life beyond what the science presented can support. Here are a few of my qualms:

• Where are the nuts?

The first question that comes to mind when watching a movie about food-as-cure is what’s the recipe? Forks Over Knives isn’t very clear on what the various people shown in the movie are eating. Prominent in their visual absence are the nuts – a mainstay of many plant based diets. I suppose nuts and seeds aren’t mentioned because Dr. Esselstyn’s diet, which arrested and even reversed severe coronary disease, I found out when I pulled out his study, is a very low fat vegan diet, which eliminates not only all animal products including eggs and dairy (except non-fat milk and yogurt), but also nuts, avocados and all vegetable oils. No extra virgin olive oil in this one. Perhaps sharing these details would have made this food-cure less tenable and less of a no-brainer, and that’s why the details weren’t presented.

Dean Ornish’s study, not mentioned in the movie, is an interesting comparison. Ornish’s regimen, which includes stress reduction through yoga and meditation, a low-fat vegetarian diet, smoking cessation, and regular exercise, also not only stopped the progression of coronary artery disease in the 20 patients in the treatment group, but also reversed some of it. The Ornish diet is very similar to the Esselstyn diet, but allows for some nonfat dairy products -- skim milk, nonfat yogurt, nonfat cheeses, nonfat sour cream, and egg whites. (Nuts and oils are out in the Ornish regimen, too.)

What the Esselstyn and Ornish diets have in common is not only very low intake of animal products and lots of wholesome plants – they’re both very low fat diets.

• Could food be the only medicine we need?

Although it is not explicitly said, the movie gives the notion that a plant based diet is all you need to reach a cure. The patients depicted gladly abandon all their diabetes, hypertension and cholesterol lowering meds upon adopting the lifestyle. (Dr. Esselstyn does note that in acute cases a coronary bypass is necessary).

However, in Dr. Esselstyn long term study, on which much of the movie relies, the patients* with severe coronary artery disease were on cholesterol-reducing medications as well as on a plant-based diet. The combination of diet and drugs is what got Dr. Esselstyn’s patients to a blood cholesterol of 150 mg/dL and to no repeat heart events.

• If high amounts of animal food are bad, does it prove that we should eat none at all?

If a little is good, more isn’t necessarily better (think vitamin toxicity), and I don’t think it’s self-evident that if meat consumption is correlated with disease – which is what the China Study showed – consuming any amount of animal products is harmful.

And although Dr. Esselstyn had remarkable results in his study of 17 heart patients on a low fat vegan diet, since there was no non-vegan control group, we can't really conclude that veganism cured his patient’s arteries.

• Can a plant based diet cure metastatic breast cancer?

Perhaps the most disturbing bit in Forks Over Knives was the story of Ruth Heidrich, a breast cancer survivor now in her 70s, 30 years after the diagnosis of metastatic breast cancer. Ruth, a six-time Ironman Triathlon finisher, tells a story of miraculous healing through a vegan diet and exercise. This, unfortunately, is an anecdote – there are no studies showing that a vegan diet alone can treat breast cancer. Suggesting a vegan diet can cure cancer is dangerous and irresponsible, especially when the movie features several authoritative medical doctors and scientists.

Eat food. Not too much. Mostly plants

I was glad I came to Forks Over Knives already “sold” on a plant-based diet, because the movie oversold plant-based diets to the point in which those of us not already in the choir might not think of joining.

Michael Pollan’s less assured and more moderate recipe for healthy eating, summed succinctly in “Eat food. Not too much. Mostly plants”, has, I think, much more of a chance of changing people’s mind and behavior.

Between the convenience-foods/fast-food diet and the strict vegan diet there are many shades of green. Adopting a more wholesome plant-based diet isn’t an all or nothing choice, and you can definitely eat for pleasure – and not just for health – while eating mostly plants.

Forks Over Knives reminds us of the prevention and healing powers of a healthy diet – a power that can’t be denied. I’ll need lots more proof before I believe in fairies, but the garden sure is beautiful!

Dr. Ayala

*Dr. Esselstyn’s study group initially included 22 participants, 5 dropped out within 2 years, 11 completed 5.5 years of follow-up, and at 10 years 6 were still on the diet.

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

Back to school with a healthy lunch

I'll be taking a few weeks off to spend time with my family and travel, and will write infrequently during August. Meantime, I'll be reposting some of the more popular posts I’ve written over the past years so that new readers have a chance to catch up.

I hope you all had a great summer, and a happy new school year to all!

As kids go back to school it’s a good time to take a good look at another aspect of their school days: What our kids eat at school, and which steps we can take to improve their nutrition, eating habits and food enjoyment this year.

Start with breakfast

It’s quite intuitive and common sense that children should eat breakfast before they leave home in the morning. Research has also shown that children who skip breakfast don't do as well in school as students who do, and tend to actually be heavier than breakfast eaters.

Yet many kids skip breakfast, and up to a third of teenagers skip breakfast regularly.

Whatever the kids eat at the breakfast table is better than no breakfast at all, but I’d recommend whole grain cereal, oatmeal or bread, a protein such as cheese, peanut butter or an egg, and fruit. Whole fruit, by the way, is much better than fruit juice.

I do not see pastries such as donuts and muffins as breakfast food. Those really sweet cereals that taste like a cookie fall into the same category. To me they're desserts, best eaten sparingly, infrequently, and on a full stomach.

What’s for lunch?

We’d like to believe that we can trust the schools to feed our kids’ bodies as well as their minds. Schools are in a unique position to help improve kids’ eating behaviors and prevent and reduce obesity.

Unfortunately, most school’s food environments are a far cry from what’s taught in nutrition classes. All to often cafeterias rely heavily on cheap processed food.

So take a good look at what’s offered at the cafeteria, and ask your kids what they actually pick from the offerings--if there is a salad bar, that doesn’t mean that the kids eat from it when the other option is French fries.

Also look at the competitive foods offered at schools. Those are the foods available for purchase, in a la carte lines, vending machines, school stores and school fund raisers, and consist mostly of beverages and snacks of poor nutritional quality—sugary drinks, chips, cookies and candy.

The only USDA regulations regarding the sale of competitive foods is that foods of minimal nutritional value shouldn’t be sold during meal times in areas of the school where USDA school meals are sold or eaten. However, those foods can be sold anywhere else on campus – including just outside the cafeteria – at any time. Foods of minimal nutritional value include chewing gum, lollipops, jelly beans and carbonated sodas.

On the other hand, chocolate bars and chips are not considered foods of minimal nutritional value and therefore can be sold right in the school cafeteria during meal times. Schools count on the revenues from these sales, and are reluctant to impose additional restrictions to their availability.

Yes, it’s hard to believe, but schools and the snack food industry share a common interest of peddling junk food to kids.

What’s a parent to do?

There are some schools that are great food environments, in which kids don’t only learn about nutrition, but also grow their own food, connect with local farmers, learn how to cook, and have delicious meals made from scratch freshly made in the school kitchen daily. I hope and believe the number of these schools is growing, but unfortunately, there are many schools that introduce kids to unhealthy eating habits and lots of junk food.

After assessing what’s offered in your kids’ school, if you don’t like what you see, voice your concern. Your opposition to the status quo can be a short letter or email to the school. Raise the topic when you meet fellow parents, or get more active and involved if you have the time and will.

But for immediate results you can decide to opt out. And the explanation you give your kids is as important as what they actually eat.

Packing your kids lunch on some or all school days gives them an idea of what you think lunch should be. Introduced right, it will be interpreted as some extra loving care and an opportunity for kids to have their own choices of good food, and not as a denial of treats.

There are vending machines in my kids’ middle school. I gave them some money on the day they visited the school for the first time, to “buy junk” – making sure they know that this will not happen often. As long as it’s framed in the right perspective, I think a little bit of junk will do no harm, and turning junk into forbidden fruit gives it too much importance and allure.

On the other hand, confusing these items with lunch, and eating them on a regular basis is why many people think that the school food environment contributes to the obesity epidemic.

Have some healthy food ready when they come home

My kids come home really hungry. Considering that there are many hours between lunch and the time kids arrive at home that’s not surprising. That’s why a small mid-afternoon or early evening meal makes sense.

Having a bowl of fruit or nuts out works well. In the past year I started serving yesterday’s leftovers as the afternoon small meal. It’s nice to sit together in the afternoon and talk about the day, and makes good use of the leftovers.

Regardless, the last thing you want is kids grazing on snacks the entire afternoon. Better sit them down for some real food and some conversation.

What’s your school’s food landscape like? What suggestions do you have for improving our kids eating habits?

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