Healthy Food & Healthy Living by Dr. Ayala

What would you change about the Nutrition Facts Panel?

Nutrition Facts labels became law in the US some 15 years ago, and the familiar panel we all know and strain our eyes over—the one that provides some key nutrition information, an ingredient list and allergen declarations—continues to evolve.

Do you read it? All of it? Do you understand it? Are you looking for your reading glasses?

In all fairness, not all labels are as detailed as the one I’ve included here—some are shorter and simpler. This is a cereal label, which I chose because I think it’s a good example. Breakfast cereals are a staple in most homes (that’s what my kids eat most school days), there are dozens of cereals to choose from, and this is a fine example of a purchase situation in which we’d like some good, clearly presented information to help us with the selection process before the day is over.

Well, if you’re baffled by the label, you’re not alone. The FDA feels your pain and is re-examining the Nutrition Facts Panel and will consider modifications to the label in order to help consumers make more informed food choices

Consumer attitudes towards the Nutrition Facts Panel

A recent paper in Nutrition Reviews looked at consumer attitudes and perceptions of nutrition labels around the world. Most of the data on US consumers was from the International Food Information Council (IFIC) research, and shows that, although almost 60 percent of consumers say they use the Nutrition Facts Panel, only a quarter of them find it easy to use.

The calorie information on the Nutritional Facts Panel gets a glance from 75 percent of consumers, yet most consumers cannot put the calorie count in context: A quarter of people asked are unaware how many calories they should consume, and about half overestimate their daily suggested intake.

The percent daily values, typically located above the actual ingredients, are either ignored or poorly understood by most.

The paper gathered key consumer recommendations for improving the Nutrition Facts Panel, and here are some of them:

• Readability: Increase the font size (Duh!); use bold face text for serving size

• Usability: Maintain standard serving size across similar products

Ensure information on serving size is easily interpretable

• Clarity: Clarify the meaning of “percent daily value”

• Visibility: Move key information to a small panel on the front of the package.

I’d say all these recommendations are pretty obvious. Apparent as they may seem, I hope that the FDA takes especially seriously the benefits of standardizing the serving size across similar products. Check out your cereal cabinet and you’ll see that serving sizes range from ¾ to 1 cup and from 30 to 55 grams a serving—the savvy consumer needs not only a magnifying glass but also a calculator and a something to write on to compare any nutritional attribute across products.

CSPI’s proposed makeover

The Center for Science in the Public Interest (CSPI) proposed its ideas for a makeover for packaged foods’ nutrition labelling with some compelling graphics to make its case.

The CSPI addresses two needs: improved clarity of information and workarounds for marketers’ and food manufacturers’ tricky ways of intentionally emphasizing and de-emphasizing parts of the label, which make consumers believe their product is better than the sum of its ingredients actually suggests.

Take a look at the CSPI’s re-imagined (and I think better) label:

To summarize the key changes in the CSPI proposal:

Calories—Loud and clear.

Added sugar—This is a dramatic change. The FDA doesn’t require food labels to disclose the amount of added sugar in products separately, and the naturally occurring sugar in milk or fruit is listed in much the same way as the added high fructose corn syrup in sodas.

The American Heart Association recently published its guidelines, calling for a dramatic cut in added sugar in the American diet and has petitioned the FDA to create a label requiring that added sugar be listed as such.

The CSPI concurs, as do many health experts.

Sugar has as many calories whether it’s naturally occurring or added, but the health impact is very different.

The other major change CSPI proposing is lumping all sugars together, and then detailing which specific sugars are in the product. The trick many manufacturers use is that by including several kinds of sweeteners, each sugar’s relative contribution is rather small, and since ingredients are listed by concentration, sugar isn’t the first ingredient listed. Take another look at your cereal cabinet. If you have some of the sugary cereals at home you’ll see that sometimes because there are a bunch of sweeteners in the product even though sugar is the main ingredient in them it’s not first on the list.

I like this proposed change! The first thing we need to know as consumers is how much sugar is added, and the secondary question is which ones.

Fiber—CSPI: “Only fiber from whole grains, beans, fruits, and vegetables, and not faux fibers such as polydextrose and maltodextrin, would be considered to be fiber on the nutrition label.”

Whole grains—If the food contains grains, the label should convey what percent of the grains are whole grains. “Contains whole grains” just isn’t useful.

Ingredients—CSPI called for a clearer format, plain-spoken ingredients without hyped names, percentages of key ingredients, a hierarchy—with major ingredients listed separately from minor ingredients—and allergy information getting a place of its own.

Get rid of what doesn’t work—The CSPI label edited out the footnote section with the percent daily values for fat, cholesterol, sodium, carbs and fiber. (There is an exemption from this footnote under current law for smaller-size labels anyway). CSPI thinks this isn’t useful for most consumers. Eliminating it made room for bigger fonts and a clearer label. The same goes for calories from fat--information overload.

Couldn’t agree more. The time and place for a nutrition lesson isn’t at the point of purchase.

And while we’re at it

A few other suggestions I’d like to add:

Vitamins: Much like the CSPI's fiber suggestion above, I’d advise that only naturally occurring vitamins—those that are an integral part of the food—be listed in the Nutrition Facts Panel. Why?

Foods that are rich in vitamins—such as fruits and vegetables—are an important part of a healthy diet, but there’s really no evidence that foods with added isolated and lab-produced vitamins add anything to health. While it’s true that fortification of some processed foods with the vitamins they were stripped of during processing may have prevented vitamin deficiencies in our age of high consumption of highly processed foods, it hardly makes sense to fortify every processed junk with a bunch of vitamins and have the Nutrition Facts Panel endorse its “wholeness“ (or as the manufacturers would prefer, its “holiness”).This also feeds into the false notion that we should be counting our vitamins and further encourages our obsession with these micronutrients--eating well isn't about getting enough vitamins.

The ability to put the added vitamins on the nutrition panel has been a boon for the makers of some of the worst junk out there. Take a look again in the cereal aisle or the vitamin drink section and you’ll see what I mean. Having a bunch of vitamins sprinkled in does not a health food make.

Serving size: Let’s make it simple: A small package is one serving. Take a close look at today’s labels and see how they express serving size: Whom are we kidding?

How many people actually consume only half a candy bar, 40 percent of a single-serve bottle or a quarter of an individual pack of chips? “Serving size” has historically been a loophole to enable food marketers to make their products look better—lower in calories fat sugar and sodium—than they are.

What changes would you like to see in the Nutrition Panel Label?

Dr. Ayala

For an FDA tutorial on how to read the Nutrition Facts label go here.

Full disclosure: My familiarity with the food label panel is not only as a consumer and pediatrician, but also as a VP of product development for Herbal Water, an organic herb-infused water that has zero calories and no sugar or artificial ingredients. While bringing Herbal Water to market I studied the many aspects of the label guidelines.

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

Coke did make America fat

Coca-Cola’s CEO Muhtar Kent recently wrote a much viewed op-ed in the Wall Street Journal titled “Coke Didn't Make America Fat,” in which he claims Americans need more exercise, not another tax, and should “enjoy the simple pleasures of a Coca-Cola.”

While it’s perfectly understandable that Mr. Kent would fight the soda tax idea—not because it threatens American’s freedom to choose, but because it will undermine soda companies’ profits and image—the article includes so many untruths and misleading statements that it begs a fact check and a response.

First off, I’ve read many of the proposals for a soda tax, and nowhere have I seen them selling it as “the solution” to our obesity issues. But it is one tool in what needs to be a very large tool box.

(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.)

Now, let's look at a few of Mr. Kent's points:

Kent: “Sugar-sweetened beverages have been singled out in spite of the fact that soft drinks, energy drinks, sports drinks and sweetened bottled water combined contribute 5.5% of the calories in the average American diet, according to the National Cancer Institute."

Not true! Sugary drinks are a major contributor of calories in American’s diet. The caloric contribution of added sugar from soft drinks in the average American's diet is much greater than what Mr. Kent cites. We can only wish the average American consumed 5.5% of their calories from sugary drinks. Studies show that they take in 2-3 times that!

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

Another recent study in Obesity paints an even grimmer picture: The average American gets twice as many calories from beverages as they did in the 1960's. The study quantified trends and patterns in beverage consumption among 46,576 American adults using nationally representative surveys of food intake, and over the past four decades total daily intake of calories from beverages increased by 94 percent.

I’m not sure where Mr. Kent found the 5.5% figure. What’s easier to find and ever present in the National Cancer Institute’s materials is a recommendation to stick to unsweetened beverages—such as water—in order to control weight and prevent obesity, which is an important risk factor for many types of cancer.

Perhaps an even better cancer-prevention resource is the World Cancer Research Fund and the American Institute for Cancer Research report, which looked at huge amounts of research and advises clearly: “Limit the Consumption of Energy-Dense Foods and Avoid Sugary Drinks.” Sugary drinks were targeted specifically in one of their recent reports where they wrote, “Such beverages appear to exert little influence on total daily self-selected energy intakes and their habitual consumption can lead to rapid and sustained weight gain even in the face of restricted solid food intake”.

Sugary drinks are different from other caloric dense foods

Kent: “It's difficult to understand why the beverages we and others provide are being targeted as the primary cause of weight gain when 94.5% of caloric intake comes from other foods and beverages.”

This is not difficult to understand at all! Some eating patterns are more conducive to overeating and overconsumption. Paramount among the foods that lead to an overconsumption pattern are sugary drinks.

There’s mounting evidence showing that when we drink beverages with calories we don’t compensate by eating less food (we might even eat more food), and that calories in liquid form produce less satiety than solid calories.

There are many studies to prove this point: In the cute Jelly bean study, researchers gave men and women 450 calories a day of either soda or jelly beans for a month, then switched them for the next month and kept track of total consumption. Candy eaters ate less food to compensate for the extra calories. Soda drinkers didn’t; they ate more calories than usual. Nutritionist Barbara Rolls from Penn State gave women water, diet soda, regular soda, orange juice, milk or no drink before lunch. Those given caloric beverages consumed about 100 calories more than those given diet soda, water or no beverage at the meal, without significantly affecting satiety ratings.

There’s also little question that sugary drinks are not just randomly associated with obesity, but actually contribute to it in a big way. Dozens of studies prove a connection between sugary drink consumption and obesity, and the only so-called “research” that tries to introduce doubt about this sad conclusion is industry-sponsored.

Taxing soda may very well change behavior

Kent: “Will a soft drink tax change behavior? Two states currently have a tax on sodas—West Virginia and Arkansas—and they are among the states with the highest rates of obesity in the nation.”

Actually, dozens of states impose some type of sales tax on sodas or snack products exceeding the standard state sales tax for food. The additional tax on soda is usually rather small.

Looking at The Kaiser Family foundation’s map of states with additional sales tax on soft drinks paints a clearer picture of which states have higher taxes on soda; neither West Virginia (2 percent tax) nor Arkansas (0 percent tax) are one of them.

The states with the highest soft drink tax are Rhode Island (7 percent), New Jersey (7 percent), Washington (6.5 percent) and Minnesota (6.5 percent). I’m not suggesting correlating soda taxation and obesity makes any sense—there are many other confounding variables—but since Mr. Kent suggested the method, lets humor ourselves and see how the high soda tax states rank in obesity rates (a scope of “1” would be the most obese state; “50” the thinnest) Rhode Island scores 46, New Jersey-42, Washington-32 and Minnesota-30. Eerie, isn’t it? The higher the soda tax the thinner the people!

Here’s a more scientific way to look for a correlation: A study in the American Journal of Preventive Medicine looked at the association between the presence of a soft drink/snack tax in the years 1991-1998 and the increase in obesity rates for those years at the state level. Adjusting for age, income, race on other variables, they found that states without a soft drink tax were more than four times as likely to have a high increase in obesity prevalence, and that states that repealed a soda/snack tax between 1991-1998 were more than 13 times more likely to see a high increase in obesity.

This data doesn’t prove that a tax reduces consumption—there can be other explanations: Maybe states in which a tax policy could be passed are those in which social norms act against obesogenic behaviors anyway. But it is encouraging data.

I’m sure that Mr. Kent predicts the tax will reduce consumption; that’s why the beverage industry opposes this idea so vehemently.

Lack of exercise didn’t make us fat; more exercise without cutting calories won’t make us thin

Kent: “If we're genuinely interested in curbing obesity, we need to take a hard look in the mirror and acknowledge that it's not just about calories in. It's also about calories out.”

Kent is right in his encouragement to be more active and spend less time in front of the TV. Exercise is very important to health, but won’t get us anywhere near an energy balance.

New research 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.

We need to be more active—no doubt about that—but that won’t exempt us from having to change our dietary habits. Even if we all met the recommendation of thirty minutes of vigorous exercise every day, we’d still need to cut our intake of sugary drinks and make them an infrequent special treat. Exercise just isn’t enough of an answer to our caloric imbalance. In order to reverse the obesity epidemic we’d need to add more than two hours of exercise every day; it’s much more realistic and logical to just cut out the soda and French fries.

The American Heart Association, American Academy of Pediatrics and many other medical authorities call for a severe reduction in the amounts of added sugar in our diet regardless of activity levels; high amounts of sugars have been linked not only to obesity and overconsumption, but also to high blood pressure, high triglycerides, diabetes and shortfalls of essential nutrients.

Many solutions are needed to address the obesity crisis--curbing the soda habit is an excellent way to start

Kent: “But a number of public-health advocates have already come up with what they think is the solution: heavy taxes on some routine foods and beverages that they have decided are high in calories.”

As noted earlier, I’ve not seen a soda tax being sold as “the solution” anywhere.

Wendell Berry said “Great problems call for many small solutions.” Obesity’s a big problem, and taxing sugary drinks can be one of the solutions.

Tax or no tax, drinking less soda has to be part of the solution—soda and sugary drinks are the number one source of added sugar in the American diet. Perhaps just talking about the soda tax informs more people about the adverse effects sugary drinks have on our waistlines and health. The conversation alone might be enough to motivate a change in habits.

But drinking fewer sugary drinks won’t be enough. Increasing physical activity also needs to be one of the solutions. On that point, Mr. Kent and I agree 100%.

Who wouldn’t?

Dr. Ayala

Related posts:
Health experts favor taxing sugary drinks in new report

Could a tax on junk food drive healthier choices?

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

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

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

Could a tax on junk food drive healthier choices?

I’m about to open a huge can of worms, but I’m pretty passionate about this idea, so here goes.

I think a “junk food” tax could help us deal with a major health epidemic.

The idea of taxing foods and drinks that have low nutritional value has been tossed around before, but the combination of cash-strapped state budgets, the obesity epidemic, and the growing evidence that sugary drinks are one of the key drivers of this epidemic may have provided for what some see as the perfect opportunity for this kind of policy to be considered.

Would it be effective? Is it fair?

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

Could it work?

Price generally affects purchase decisions, and with the exception of luxury goods, higher price reduces consumption. In this respect, if a tax is high enough, sales of sugary beverages should decrease and there are indications that soda sales are very price sensitive.

Lessons from tobacco:
Junk food and soda are not the same as tobacco, but perhaps we can learn a lesson from the role of taxes on the cigarette sales. Many believe that taxation was one of the most effective tools available to policy makers to reduce smoking, and economic research shows that every 10 percent increase in the real price of cigarettes reduces overall cigarette consumption by approximately three to five percent, reduces the number of young-adult smokers by 3.5 percent, and reduces the number of kids who smoke by six or seven percent. Every single state that has significantly raised its cigarette tax has seen smoking go down sharply.

Lessons from other states:
Most states have general sales taxes which don’t apply to food for home consumption, but there are exceptions: Some states do have a small tax on soft drinks, candy or snack foods (that includes my home state of Pennsylvania, which taxes soft drinks unless they’re purchased with food stamps--can you believe that?).

A study in the American Journal of Preventive Medicine looked at the association between the presence of a soft drink/snack tax in the years 1991-1998 and the increase in obesity rates for those years at the state level. Adjusting for age, income, race on other variables, they found that states without a soft drink tax were more than four times as likely to have a high increase in obesity prevalence, and that states that repealed a soda/snack tax between 1991-1998 were more than 13 times more likely to see a high increase in obesity.

This data doesn’t prove that a tax reduces consumption—there can be other explanations: maybe states in which a tax policy could be passed are those in which social norms act against obesogenic behaviors anyway. But it is encouraging data.

The Yale Rudd Center cites several studies in a public policy brief, and finds that:

“Based on the best estimates to date of the responsiveness of demand for soft drinks to changes in price, a 10% tax could result in about an 8% reduction in consumption. The effects could be higher for heavy users of soft drinks.
Based on November 2008 price increase and volume sales information on Coca Cola and Pepsi sales in the U.S., demand for soda is “elastic” (-1.15) meaning that a 10% tax would reduce consumption by 11.5%.”

A tax on sugary drinks will certainly help balance state budgets—given the incredible popularity of these drinks, even a modest tax will bring in lots of much-needed revenue, which states propose to use for health insurance and other health initiatives.

Is it fair?

The main argument against the tax is its regressive nature: this tax will affect low-income people more than it would impact higher income households. Consumption of soda is highest in lower socioeconomic homes and minority groups.

It’s a valid argument.

On the other hand, low-income people can benefit most from reducing their intake of soda—the health problems caused by obesity fall disproportionately on the poor. Many also argue that the programs that these taxes will fund—be it health insurance coverage, wellness programs, anti-obesity initiatives or subsidies for healthy foods—will benefit low-income people the most.

The other argument often made, and with some passion, is that the state should stay out of our plate, and not try to dictate what we should be eating.

This one’s pretty easy to deflect. Policy decisions dictate food prices and availability all the time. One of the reasons processed foods and sweetened beverages are so cheap is because of subsidies—dictated by current public policies (and not a small amount of lobbying by special interest groups). Corn is subsidized while fresh produce isn’t. There’s always been politics in food industry, and I think it’s high time new policies start to serve the health and well- being of people, and not those of “big food”.

As I mentioned before, most states have a sales tax that excludes groceries and prescription drugs (yet is imposed on prepared foods). That, again, is a policy, and I assume that the reasoning behind it that food and medications are essentials. I find it hard to call sweetened beverages an essential—quite the contrary.

The price of sweetened beverages is artificially but also ridiculously low—it doesn’t include the external costs of consuming them. Obesity and its consequences cost society huge amounts of money in healthcare costs (paid mostly by Medicare and Medicaid), absence from work and reduced productivity. This should somehow be reflected in the price of these junk foods.

If people worry about the regressiveness of such a tax, or that soda drinkers will replace the sweet drink habit with another equally unhealthy one, why not consider coupling a junk food tax with a fresh produce subsidy? a tax will also create an economic incentive for companies to produce healthy foods. It’s just mind-boggling to see that the unhealthiest foods are the cheapest, and that the more you buy of them the less you pay per ounce.

I think the argument for and against a soda tax is an interesting one (and I’m looking forward to responses to this post). It’s clear that debating the possibilities is a great way to make us look more carefully at junk food and healthy food policies.

What do you think about junk-food taxes? Do you have a better name for them? Would love to hear your thoughtful opinions!

Dr. Ayala

Social trends study shows how we compare in healthy living

A press release caught my eye this week. It stated that the French excel at two leisure activities: They spend more time at the table and in bed than any other country surveyed.

The news came from OECD (Orginasation for Economic Co-operation and Development), reputed to be the world's largest and most reliable source of comparable statistics on economic and social data. The organization collects data, looks at trends and analyzes many aspects of life, including economic development, social changes, trade, environment, agriculture, technology, taxation and health. Its Society at a Glance reports give a snapshot of how society changes, and most interestingly, how we compare to other countries.

There are 30 member countries in OECD (Australia, Austria, Belgium, Canada, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, Mexico, the Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Spain, Sweden, Switzerland, Turkey, United Kingdom and United States), and data are compiled using representative samples from each country.

Leisure time around the world

One chapter of the Society at a Glance latest edition is devoted to leisure time, and compares 18 countries’ leisure habits. Leisure is loosely defined as what people do when they’re not working.

Sleep

Most of leisure time is spent sleeping. I used to moan this “waste,” but I now recognize sleep as the cornerstone of health and sanity. The French sleep the most of any people in the report—almost 9 hours a night—but the U.S. comes in second, at more than 8 and a half hours a night. Korea and Japan are at the low end of sleep-time.

Waking leisure

The French spend the most time eating and drinking—more than 2 hours a day. The U.S. is close to the bottom end of the chart, joined by Mexico and Canada, with an average of a little over an hour spent on these activities.

A pity, really, since when people were asked what leisure activities they enjoy most, eating was near the top, right up there with relaxing and socializing. By this measure we have half the fun a Frenchman does.

A big chunk of leisure time is spent watching TV. TV takes up almost half of the leisure time in Mexico and Japan, but we in the U.S. come in third in time spent in front of the TV screen.

Visiting or entertaining friends takes up 34 percent of a typical Turk’s time, and about 16 percent of the typical Americans’ (we’re somewhere in the middle for that, and above the OECD average), and very little time is spent participating in sports—5 percent of time in the U.S., below OECD average.

Men have more fun. They have more leisure time than women, with the greatest disparity in Italy, where men have 80 minutes more a day of disposable time, while women are apparently doing housework. In the U.S., men have about 40 extra minutes of leisure a day compared to women. I wouldn’t get up in arms over this data, as it’s not clear at all how much of our leisure time is spent on “personal care,” and it very well may be that much of the disparity is because (relatively speaking) women spend so much time tending to hair and other personal grooming and maintenance. I keep telling my dear husband how lucky he is to be bald—being bald frees up enough time to pick up another serious hobby.

Health and wellness

Since we didn’t come out on top anywhere in the leisure chapter, nor did we excel in student performance or in equity indicators, I went on to the “Heath Indicators” section of the report, and there, sure enough, we’re leaders.

Although there are high obesity rates (obesity defined as having BMI—Body Mass Index— of greater than 30, and not mere overweight, defined as BMI in the 25-30 range) in many OECD countries, the U.S. is still at the top, with 34.3 percent. Our neighbor to the south is a close contender, with Mexico rating 30 percent (is obesity contagious?), while the U.K. has 24 percent and Greece comes in at 22 percent. What happened to Greece, birthplace of the healthy Mediterranean diet? The traditional ways of eating have been replaced by fast and highly processed foods, and obesity, diabetes and hypertension have skyrocketed at the same time (see here).

The least amount of obesity is seen in Korea (3.5 percent), Japan (3.9 percent), Switzerland (7.7 percent) and Norway (9 percent), with Italy and France about tied at around 10 percent.

The world is fat, but at least there’s equality among the sexes. Overall women are no more or less obese than men.

Other interesting facts about our general health, that fall in line with what advocates of a major overhaul of healthcare often cite: Life expectancy in the U.S. is 24th of the 30 OECD countries (men typically live for 75.2 years, while women live 80.4 years), and below the OECD average, yet the U.S. spends more on healthcare per capita than any other nation. Much more.

I’ll end with a few encouraging statistics:

• Cigarette smoking among teens has gone down dramatically in the U.S.; both boys and girls in the U.S. have the lowest teen smoking and repeated drunkenness rates among the countries reported in the study.

• The percentage of people aged 15 years and over reporting perceived good health in the US is very high—89 percent.

• Life satisfaction in the U.S. is above average.

• Although divorce rates are generally going up in OECD countries, they’re going down in the U.S.

We may not be doing that great in a factual sense compared to our global neighbors (especially in overall life expectancy), but we do seem quite happy with ourselves (and our spouses). And while feeling great is an important step toward being great, taking a glimpse at how people in other nations approach their lives could give us a few good ideas.

Dr. Ayala

Let the Obamas eat what they want!

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

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

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

The New York Times Kim Severson says:

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

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

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

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

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

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

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

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

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

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

The power of the health journalist’s pen

Where do you get your health and medical news? How do you know whom to trust? Should you act on news you read about health and nutrition?

The Health Correspondent Susan Dentzer recently wrote a perspective piece in the New England Journal of Medicine in which she argues that when journalists ignore complexities, or fail to provide context, the public health messages they convey are inevitably inadequate or distorted. While many seasoned reporters do a responsible, thoughtful job, she says, others—due to ignorance, an inability to interpret and convey the nuanced results of clinical studies, or a desire to hype a story to draw attention to it—deliver misleading or wrong information.

Dentzer writes:

“In my view, we in the news media have a responsibility to hold ourselves to higher standards if there is any chance that doctors and patients will act on the basis of our reporting. We are not clinicians, but we must be more than carnival barkers; we must be credible health communicators more interested in conveying clear, actionable health information to the public than carrying out our other agendas. There is strong evidence that many journalists agree—and in particular, consider themselves poorly trained to understand medical studies and statistics. But not only should our profession demand better training of health journalists, it should also require that health stories, rather than being rendered in black and white, use all the grays on the palette to paint a comprehensive picture of inevitably complex realties. Journalists could start by imposing on their work a ‘prudent reader or viewer’ test: On the basis of my news account, what would a prudent person do or assume about a given medical intervention, and did I therefore succeed in delivering the best public health message possible? “

I think that there’s no field as prone to misinformation and misinterpretation as nutrition science.

Nutrition study is inherently hard. Isolating the effect of diet on health is difficult, and in the end gives a statistical answer, telling us what’s likely. The fact is there are no certainties.

People differ from each other, eat all sorts of different foods over a lifetime, and live in different types of environments. Testing a specific food or nutrient—as opposed to testing a highly purified new drug—is impossible, as people eat in a social context, with food, lifestyle and other health influencers interacting and complicating interpretations. Many nutrition studies use study models that are not the ideal methods for obtaining proof, as there are technical and financial restraints that would make the ideal trial unattainable. Nevertheless, when the evidence of these trials is weighed together, and further, better studies are preformed, scientists can arrive at a consensus, which is the best advice that can be given at this time.

As difficult as nutrition science is, most people are very interested in learning about new developments. We all eat, and we’d all like to know how to eat best for optimal health. Therefore many scientific studies are reported in the general media.

Now, don’t get me wrong: every study has value, and publishing study results in scientific papers is the way science—eventually—gets to the truth. But publishing a surprising study result using a catchy title in a popular media outlet can lead to misinterpretation and the false belief that what a study shows is the “truth.”

I’ll give you one recent example that really upset me.

A paper titled: “Light drinking in pregnancy, a risk for behavioural problems and cognitive deficits at 3 years of age?” was published in International Journal of Epidemiology. It was a prospective study whose results indicated that at age 3 years children born to mothers who drank up to 1–2 drinks a week during pregnancy did not seem to have clinically relevant behavioral difficulties or cognitive deficits compared with children of abstinent mothers. The authors of the study concluded:

“There is no increased risk of behavioural problems or cognitive deficits at age 3 years for children whose mother drank not more than 1 or 2 units of alcohol per week or on any given occasion. It is important to acknowledge that problem behaviours or cognitive deficits may become apparent in these children at older ages, and the evidence presented should be used to guide future research and inform policy.”

Because alcohol consumption during pregnancy is a big health problem, such a study—if reported in lay media at all—must be interpreted with extreme caution.

Alcohol is a known teratogen (a chemical that can cause birth defects). Prenatal exposure to alcohol is widely accepted to be a risk factor in child development. Since it’s unclear what amount, frequency and timing of alcohol consumption during pregnancy causes damage to the fetus, the current recommendation of the U.S. Surgeon General is to not drink at all during pregnancy.

However, here are a few examples of popular media headlines in stories that presented this study:

“Light Drinking During Pregnancy May Benefit Baby”

“Pregnancy: Odd Drink May Not Hurt”

“Light drinking in pregnancy may be good for baby boys, says study”

If readers got to the end of these articles, they might have learned that experts don’t actually suggest an expectant mother should drink, but did anyone actually read the whole story? And did the same news reporters balance this catchy piece with all the bland but plentiful studies showing again and again that alcohol is dangerous to the fetus? I suspect not.

Unfortunately, there are many cases of this type of irresponsible reporting, in which the reader is drawn in with sexy headlines to seemingly relevant, applicable nutrition “news.” Studies are interpreted with great liberty while the related scientific article may be about an animal model or a cell-culture model, and be hardly relevant to anyone but the scientific community.

Study results should never be taken as guidelines for behavior. An interesting study, especially one showing new or contradictory results, will be followed by repeated and more methodological ones, and in the end, all evidence will be weighed by experts and only then might a recommendation be made.

I’m all for good health and nutrition reporting. But people are influenced by what they read in print and watch on TV, and many will act on media stories. I therefore agree with Susan Dentzer, and hope reporters take their position as influencers very seriously. There are many excellent health reporters who do and never fail to put new studies in a bigger context, examples of great health reporting would be the New York Times Health section and Tara Parker-Pope’s Well blog, and NPR’s science and health programming.

What do you think of the reporting of nutrition news? Who do you trust?

Ayala

Calorie posting laws spread—healthier choices follow

Good news! Last week, the Philadelphia City Council passed a measure requiring chain restaurants with more than 15 outlets to disclose calories on menu boards beginning on Jan. 1, 2010. My home town, Philadelphia—famous for the Philly cheese steak, all 900 calories of it—now joins New York City, several counties, and the state of California in passing such a measure.

Why is calorie posting such a good idea?

1) Knowing what you’re eating is the first step to eating sensibly.

I believe people will think twice about ordering menu items such as Arby’s Sausage Gravy Biscuit-(at 960 calories), or McDonald’s Vanilla Triple Thick Shake (at 1100 calories), products that supply half the daily caloric allowance in one meal item.

Until now we could live in ignorant bliss, because unless we went through the trouble of going to the company’s website or asking for nutrition charts, we wouldn’t know the numbers.

Will consumers lighten up their selections when presented with calorie information?

A study published recently in the American Journal of Public Health looked at 7,318 customers in 275 fast food restaurants. Of the 11 chains from which food was purchased in this study, 10 did not have calorie information at the point of purchase, and only one—Subway—did. Less than 5% of the study participants saw calorie information when it was provided only in less prominent formats, such as charts on counter mats, distant walls, posters or on a website.

On the other hand, 32% of Subway patrons saw the information, which was displayed near the point of purchase. This suggests that laws requiring calorie information be displayed on menu boards might increase the proportion of patrons seeing calorie information and taking it into consideration when making their choices.

Among the Subway patrons that reported seeing the caloric information, over a third reported that the information affected their purchase. Objective measurement of calorie content through examination of receipts confirmed that patrons who reported seeing and using calorie information purchased fewer calories than did those reporting they did not see or use calorie information.

While the average caloric reduction amongst the calorie conscious was modest—53 fewer calories—even a modest reduction on a nearly daily basis for millions of people frequenting fast food venues could be significant in slowing the obesity epidemic.

It’s estimated that three-quarters of adults use nutrition labels on packaged food, and using labels is associated with eating more healthful diets. There’s reason to believe that the same will be true for nutrition information in chain restaurants.

2) Companies will be changing their menu items to make their caloric posting more attractive.

The new measures encourage companies to reformulate or resize their menu items, find lower calorie alternatives, and abandon fat and sugar as the secret ingredient that makes all food more palatable. As New York Times’ Kim Severson writes:

“Restaurants and food companies are lightening recipes and portion sizes. Starbucks, for example, claims to have saved the nation 17 billion calories since last October by swapping 2 percent milk for whole…Dunkin’ Donuts recently added a low-calorie egg white breakfast sandwich, Così is using low-fat mayonnaise and McDonald’s large French fries have dropped to 500 calories this year from 570 last year. Quiznos is testing smaller sizes and less-caloric sandwich fillings in its New York stores.

Cathy Nonas of the New York City health department said this is all a reaction to public-health pressure…For some establishments, having their menus exposed by the New York law forced some caloric housecleaning. At Le Pain Quotidien, which has 17 outlets in New York, several items were changed or taken off the menu, said Jack Moran, a vice president. The popular Quiche Lorraine was trimmed to 6 ounces from 11, with extra salad filling out the plate. Sweets like brownies may shrink, too.”

Now, I believe we should have the freedom to eat whatever we want, no matter how unhealthy and fattening.

On the other hand, I think we have a right to know what’s in the food we’re buying. The price of our food in calories (and other nutritional information) is sometimes more important than the dollar price.

Restaurants that aren’t part of big chains, and don’t have standard menus are not subject to these laws, and I think that’s fine; it would be too costly to provide nutritional data on changing menus for these small businesses. I also think that eating at these kinds of restaurants is not an every-day thing for most people.

Since I eat most of my meals at home, I’m not concerned by the richness of the food my family eats when we go out to dine once every few weeks. We enjoy it as a special treat. I assume that the meal is indulgent in its use of ingredients that I try to use less of at home, and in these occasions, I just don’t worry about the calories.
On the other hand, if people are eating out regularly, as people often do at the fast food eateries (the average American eats out four meals a week), caloric information becomes important. Since the nutritional information exists anyway, putting it where it can be seen before selections are made, thus making consumers more informed is an incredibly useful practice.

I hope these menu labeling bills will build momentum for national legislation, making menu labeling the law everywhere people are eating fast food. We deserve easy access to this kind of information that will help us lead healthier lives.

Do you ever look at the caloric information at fast food and other chain restaurants? What do you think?

Ayala

Tainted Tomatoes and Food Safety

The recent salmonella outbreak associated with tainted tomatoes made red Roma tomatoes, red round tomatoes and plum tomatoes hard to find in supermarkets.

While this outbreak is the nation’s largest salmonella outbreak from tomatoes, and since April, more than 550 people have been infected by this specific salmonella saintpaul strain (this is a sub-type of the big family of salmonella bacteria), I’d like to put things in perspective.

Outbreaks related to a single source of contamination get a lot of media attention, and serious action is taken to identify and eliminate the foods suspected to be contaminated, yet more common sources of food-borne illness don’t get a lot of coverage or thought.

Here’s a fact about salmonella infections you might not have known, and this is a quote from the CDC’s website:

“Every year, approximately 40,000 cases of salmonellosis are reported in the United States. Because many milder cases are not diagnosed or reported, the actual number of infections may be thirty or more times greater”

If the past three months were typical, an estimated 3150 reported cases of salmonella per month would be unrelated to the tainted tomatoes, and the tainted tomatoes would be the cause for only about 5 percent of salmonella cases reported since the outbreak started.

And the bigger picture, again from the CDC:

“An estimated 76 million cases of foodborne disease occur each year in the United States. The great majority of these cases are mild and cause symptoms for only a day or two. Some cases are more serious, and CDC estimates that there are 325,000 hospitalizations and 5,000 deaths related to foodborne diseases each year. The most severe cases tend to occur in the very old, the very young, those who have an illness already that reduces their immune system function, and in healthy people exposed to a very high dose of an organism. “

How do the bacteria get into produce?

Fresh fruits and vegetables don't naturally contain disease causing bacteria.

Produce can become contaminated in the field by contaminated water, by wild and domestic animals’ fecal material, or by improperly composted animal manure. It can also be contaminated post-harvest if the workers handling, storing, transporting and preparing the produce don’t practice good hygiene.

Fresh produce can become contaminated with disease-causing bacteria when it’s in contact with raw animal products such as meat, poultry or seafood or eggs. This can happen before you buy the produce, in your shopping cart, or in your home—your fridge, counters, cutting boards and knives can all carry harmful bacteria if they’re not properly cleaned after coming in contact with raw animal products.

Indeed, the CDC warns that raw foods from animal origin the most likely to harbor disease causing bacteria:

“Raw foods of animal origin are the most likely to be contaminated; that is, raw meat and poultry, raw eggs, unpasteurized milk, and raw shellfish. Because filter-feeding shellfish strain microbes from the sea over many months, they are particularly likely to be contaminated if there are any pathogens in the seawater. Foods that mingle the products of many individual animals, such as bulk raw milk, pooled raw eggs, or ground beef, are particularly hazardous because a pathogen present in any one of the animals may contaminate the whole batch. A single hamburger may contain meat from hundreds of animals. A single restaurant omelet may contain eggs from hundreds of chickens. A glass of raw milk may contain milk from hundreds of cows. A broiler chicken carcass can be exposed to the drippings and juices of many thousands of other birds that went through the same cold water tank after slaughter.”

What should we do?

I really like the guidance given by Jorge M. Fonseca and Sadhana Ravishankar in the American Scientist (you can read the full text here, and see the helful illustration)

“Fortunately, there are several steps one can take to avoid getting sick from tainted produce. The single best piece of advice is still to wash fruits and vegetables thoroughly before eating them—a practice that can result in a ten-fold reduction in surface contamination. Wash hands with soap before beginning, but just use lukewarm tapwater and a clean cloth or scrub brush on the food…Consumers have much more control over their exposure to foodborne pathogens when cooking at home. In preparing fruits or vegetables that will be eaten raw, cut away any damage and the area around the stem scar; these are often sites of microbial colonization. Also, remember that many instances of foodborne illness caused by fresh produce actually begin with cross-contamination from raw meat. Foodborne pathogens are much more likely to survive and thrive in uncooked meat than in fruits or vegetables, which explains why it is much safer to eat raw produce than to eat raw meat. Hands, surfaces and kitchen tools should be washed thoroughly with soap before and after preparing food, and it is prudent to wash hands frequently while cooking—most especially after handling meats or using the toilet.”

They conclude with some more words of advice I truly agree with

“Overall, it's important to put the risk of eating produce in a larger context. Fresh fruits and vegetables are no riskier than other fresh foods as sources of foodborne pathogens, and eating a salad is certainly safer than driving to work. Furthermore, many forms of produce confer remarkable health benefits on people who eat them. Given these benefits, avoiding fresh fruits and vegetables is probably riskier than enjoying them—even if you still eat unwashed fruit with grubby fingers.”

The time honored advice of washing carefully—hands and produce—is the simplest and most effective way to avoid most food-borne disease. Bear in mind that reduction of the amount of harmful bacteria--and not absolute elimination of them in food--is enough to avoid illness with most bacteria (including salmonella) as a relatively large load of ingested bacteria is necessary to cause most disease in healthy people.

In the meantime since many retailers and restaurants have temporarily pulled all large tomatoes off their shelves and menus—even though many region’s tomatoes have been cleared from suspicion of being contaminated--I feel for the tomato growers whose produce is going to waste.
Ayala

Pharmaceuticals in drinking water, should we care?

Water is perhaps our most important and precious resource, and for most of us the purity of our drinking water is a serious concern. Being vigilant about our water is a lesson we learnt the hard way from history: Contaminated water spread deadly diseases like cholera and typhoid, and continues to be a major health threat in developing countries.

When Americans were asked to rate their level of worry about 12 environmental concerns in Gallup’s annual environmental survey conduced March 6-9, the top four concerns related to water quality, with pollution of drinking water the top overall concern. http://www.gallup.com/poll/104932/Polluted-Drinking-Water-No-Concern-Before-Report.aspx?version=print

Then just a few days later, on March 10, the Associated Press published the shocking results of their five-month investigation, reporting that drugs have been detected in the drinking water supplies of 24 major metropolitan areas, including Southern California, Northern New Jersey, Washington, D.C. and San Francisco. http://ap.google.com/article/ALeqM5iNgiyxxMM0erGaShF5jsL1NcfY8QD8VBDS580

Of the 62 major water providers contacted, the drinking water for only 28 was tested. Philadelphia (my home town) scored the worst, although it claims it tested for more drugs and byproducts than other utilities. It found 56 of 72 pharmaceuticals or byproducts tested for in treated drinking water, including medicines for pain, infection, high cholesterol, asthma, epilepsy, psychiatric illness and heart disease. Sixty-three pharmaceuticals or byproducts were found in the city's watersheds.

Among the 34 water providers that haven't tested their drinking water for pharmaceuticals are: Houston, Chicago, Miami, Baltimore, Phoenix, Boston, Seattle and New York City.

The presence of pharmaceuticals in the environment is nothing new, and the scientific community has been studying the issue with growing concern for several years. The recent improvements in analytical chemistry now allow detection of trace levels of chemicals and unfortunately, as a result of their growing use, these compounds have been found in aquatic systems, in sewage treatment plant effluents, aquifers deep underground, surface waters and even drinking waters in North America and across Europe.

Is it cause for alarm?

It’s definitely no cause for celebration.

The federal government doesn't require any testing for drugs in drinking water, and there are no standards for acceptable levels.

It’s going to be hard to definitively prove that these trace medications cause harm to people, and impossible to prove they don’t. Scant studies on cell cultures and animal models show negative effects. The amounts found in drinking water are indeed very small, and it would take years of drinking water to reach the dose that is taken therapeutically in one pill of any one of these drugs.

The growing concern in the scientific community centers on the chronicity of the low dose exposure (our body may deal well with a one time ingestion of a chemical, yet suffer damage from much lower exposure spread over time), the unique combinations of these low dosed drugs acting synergistically, allergic reactions that can occur even in low doses, and that these drugs can form new metabolites -- drugs can be transformed into other compounds whose effects are completely unknown.

On top of that there’s the concern for aquatic life exposed to drugs and the contribution to the rise of drug-resistant bacteria caused by the presence of antibiotics in the environment.

The AP report says most standard techniques used by municipal water treatment facilities allow many pharmaceuticals to slip through and only advanced treatments such as reverse osmosis will remove virtually all detectable pharmaceutical traces.

In the interest of full disclosure, Ayala’s Herbal Water, our company’s product, uses a multi-step purification method, including reverse osmosis, that’s intended to remove all dissolved particles.

As water becomes scarcer, the need to reuse waste water only increases. The use of prescription drugs continues to rise. The extent of this problem will only grow if it’s not addressed.

The AP report has finally turned the spotlight on this important issue, and since water has always been a major focus of consumers’ concern I’m sure we’ll be hearing more on this subject.

Ayala