Healthy Food & Healthy Living by Dr. Ayala

Cinnamon’s for eating, not inhalation

Common sense is slow to develop in humans, and many a time young people will sit around throwing around silly ideas – and then go on to act on the silliest of them all.

And as if kids can’t come up with enough stupidity all on their own, access to a world wide web of thoughts feeds them more tricks and dares – YouTube is great at that.

The cinnamon challenge is nothing new, but I heard about it from my kids only a couple of years ago. The challenge: swallow a tablespoon of ground cinnamon in 60 seconds, without drinking fluids.

Fail to swallow a spoonful of cinnamon, and you might still have your moment of glory in this viral sensation: more than 50,000 YouTube clips, one popular clip with 30 million views (these numbers might be irrelevant by the end of today) and it’s all over Twitter. Subjecting the Cinnamon Challenge to a Google fight (fun site in which you can battle two words or phrases against each other to see which is more Internet popular) shows that cinnamon challenge with its 15 million search results is more popular than chewing gum (7 million). 

Cinnamon sounds innocent enough – every baking home has some, and what can be more natural than an ancient spice from tree bark.

So here’s an opportunity to teach kids a few basic principles in toxicology:

• Dose matters. As Paracelsus famously said: The dose makes the poison. Even water and oxygen – which we can’t survive without -- can be toxic if you have too much of them.
• Safe to eat doesn’t mean it’s safe to introduce into your body in any other way. Do you like hot peppers? So do I. They’re pleasant only by mouth. Water is fine to swallow, and to wash with, but if you inhale it it’s called drowning.

Back to the cinnamon challenge.

An article in the recent issue of Pediatrics warns that the cinnamon challenge isn’t all fun and games. Inhaling cinnamon can damage the lungs and airways, and although the effects are usually temporary, it has led to many emergency room visits, hospitalizations, and a few teens even requiring ventilator support for collapsed lungs.

You see, the cellulose fibers in cinnamon, once in the lungs, do not dissolve or break down – they stay there and are not inert. The authors, led by Steven Lipshultz, cite a study in which cellulose was introduced through the windpipe of rats. This caused inflammation and lung damage, and the results were apparent even a year after the exposure.

When a teen attempts to swallow a large mount of cinnamon there’s a pretty high risk of breathing in some of the cinnamon powder. The powder can damage the lining of the airways and lungs and even cause permanent scarring. Introducing a foreign substance into the airways is even more dangerous for people who have asthma. 

Bottom line, there are better – tastier, and more creative – uses for cinnamon.

I’m just afraid that warning kids about the dangers of the challenge – or locking the cinnamon along with the liquor as some parents have suggested – will introduce it to the few that haven’t heard about it yet, and just increase its allure.

Dr. Ayala

Is sugar making the world fat, diabetic, and hypertensive?

We’re moving towards a world with a shared diet. Pizza Hut, Taco Bell, KFC, McDonald’s, Coca Cola and Pepsi can be found worldwide and consumers around the world and in developing countries have developed a taste for our highly processed food.

The shift from traditional diets in developing countries towards a Western diet – a diet high in refined sugars, animal based foods and vegetable oils – is known as nutrition transition. While this shift affords more food security and cheaper food, the move towards a Western diet has major health consequences, chief among them being obesity, diabetes and heart disease.

What is it about the Western dietary pattern that puts populations at risk?

Sugar, obesity and disease

A new study in Public Health Nutrition, looked at the rates of overweight, obesity and high blood pressure (which are major risk factors for heart disease) in countries around the world, and these countries’ availability of foods, including cereals, sugars, vegetable oils, fruits, starchy roots, pulses, total vegetables, alcoholic beverages, total meat, animal fat, eggs, milk, and fish and seafood.

The study, led by Mario Siervo, found that sugar consumption was directly associated with overweight, obesity and high blood pressure. Low intake of cereals and physical inactivity were also contributors, but nothing predicted how fat a country would be as much as how much sugar it consumes.

Coincidentally, another article looking at what people eat around was just published in PLoS One. This widely publicized article, by Sanjay Basu, Paula Yoffe, Nancy Hills, and Robert Lustig looked at the relationship between sugar availability and diabetes prevalence in 175 countries. After accounting for many factors, such as obesity, exercise, poverty, age, etc., the study found that the higher the sugar in the countries’ food supply, the higher the diabetes rates. Their conclusion is: “every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1%.”

What is it about sugar?

In a fascinating article about the science of creating addictive food in the New York Times, Michael Moss describes the well known recipe to increase sales: “one of the cardinal rules in processed food: When in doubt, add sugar.”

Sugar makes food craveable. That’s why sugar’s in everything.

So does sugar just make us consume too many calories because it makes food tastier and more desirable, or is there something inherently fattening and unhealthy about sugar?

Dr. Robert Lustig is one of the leading voices warning that sugar is a major culprit in obesity and disease, and that sugar punishes us beyond the 4 calories per gram it sneaks in. Sugar, and especially its fructose component, Lustig claims, when consumed in excess, hits the liver rapidly, and drives a whole cascade of metabolic outcomes, and causes fat production and insulin resistance. Lustig’s new PLoS One article supports this theory.

Lustig has his critics, of course, and other obesity and nutrition experts believe sugar drives obesity and disease just because of the quantities and rates we consume of the sweet stuff.

Regardless of how we explain the sugar disease connection, there’s no doubt that to improve health we need to reduce sugar intake.

The World Health Organization recommended in 2003 that “added sugar” be limited to 10% of a person's caloric intake. The American Heart Association (AHA) went further and recommended that women should consume no more than 100 calories of added sugars per day (6 teaspoons), and most men, no more than 150 calories (9 teaspoons). One 12-ounce can of Coke contains 130 calories in added sugars, which puts women over the AHA upper limit – no room for bread, sweetened yogurt, and just forget about dessert.

Unfortunately, we don’t even know how much added sugar is in our processed food, as our food label only lists total sugars — both innate carbs and added sugar — in the sugar component of the label. 

Efforts to curb sugar consumption in the US face strong opposition from industry.  The Yale Rudd Center summarizes progress and efforts to reduce sugary drink consumption in different states in this nifty interactive map. Although sugar consumption is very high in the US and in other developed countries, it has plateaued, and even declined in the last decade. The new study in Public Health Nutrition reminds us that in developing countries sugar intake continues to rise – and will probably result in an increase in chronic conditions such as diabetes and heart disease – therefore the developing world needs policies that limit added sugars, hopefully before the train leaves the station.

Dr. Ayala

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

Is organic food healthier? New study fuels the debate

What makes a food healthy? The definition of healthy food and nutritious food is absolutely essential in order to answer the question: “is organic food healthier”.

But a new widely publicized study published in the Annals of Internal Medicine this week answers this question without digging deeper into what defines “healthy”. The study reviewed research comparing organic and conventional foods and concluded that there’s “limited evidence for the superiority of organic foods”.

Let’s see what the study actually found. 

Fewer pesticides, more phenols, no more vitamins

The researchers, led by Dena Bravata and Crystal Smith-Spangler identified 237 of the most relevant organic vs. conventional studies. Those included 17 studies (six of which were randomized clinical trials) of humans consuming organic and conventional diets, and 223 studies that compared either the nutrient levels or the bacterial, fungal or pesticide contamination of various products including fruits, veggies, grains, meats, milk, poultry, and eggs grown organically and conventionally. There were no long-term studies of health outcomes of people consuming organic vs. conventionally produced food – these would be difficult and expensive to do, and have not yet been attempted.

There were two types of nutrients organic food had statistically higher levels of: total phenols in organic produce, and beneficial omega-3 fatty acids in organic milk.

As expected, organic food had fewer pesticide contaminants: conventional produce has a 30% higher risk for pesticide contamination than organic produce. Another study found kids switched to an organic diet for 5 days had significantly lower levels of pesticide residue in their urine.

As for vitamins, overall there wasn’t a significant difference in the vitamin content of organic and conventional plant or animal products.

There was no difference in the risk for contamination of produce or animal products with pathogenic bacteria (yes, organic produce does need to be washed!), but conventional chicken and pork had a higher risk for contamination with bacteria resistant to antibiotics than were organic alternatives.

Obsessed with vitamins 

So is the meta-analysis’ conclusion that organic has little health benefit correct? 

If eating healthy is about getting as much vitamins as possible I guess you can conclude just that. But if eating healthy is about maxing on vitamins your route to health can easily be a vitamin supplement with a fast food meal (an abundant source of protein!). 

Our obsession with vitamins has been fueled for years by nutritionists and marketers. But getting enough vitamins is hardly a central health issue in modern societies. Eating healthy isn’t about getting your vitamins.  Even devoted junk eaters gets plenty of vitamin C and don’t need a vitamin boosted organic strawberry to save them from scurvy. 

What is healthy eating? This is a complicated question. It’s hard enough to even define health; is health the absence of detectable disease, or a state of physical, mental, and social wellbeing? I can’t really answer this question (especially not in a blog post), but healthy food has to be more than the sum of all its vitamins.

Why organic

More and more people are choosing organic. One popular reason is avoidance of chemicals. Conventional food is grown using a multitude of chemical fertilizers, pesticides and herbicides. We now know that these remain in the food, and are absorbed by and present in our body. Although conventional growers and food producers make every effort to convince us that these chemicals are safe and harmless in these amounts, common sense says that they definitely add nothing good to our health, and we’re probably better off without them. This study shows that organic food does have fewer pesticide residues and fewer antibiotic-resistant bacteria -- organic delivers on its promise!

But organic farming is about so much more than our personal health and safety. Organic agriculture is an ecological production management system that has deep environmental implications. Organic production is about respecting the land and all its inhabitants. 

An organic farm doesn’t contribute to the growing problem of chemical fertilizers’ run-off contaminating our rivers, lakes, oceans and drinking water. This contamination is persistent, and affects us as well as wildlife.

An organic farm doesn’t contribute to our worrying dependence on dwindling oil supplies (fertilizers are fossil fuel products). Farm workers on organic farms aren’t subjected to a work environment heavily contaminated by pesticides. Soil fertility is maintained for future generations by organic practices. An organic farm recycles its waste, and doesn’t fill landfills with hazardous waste.

An organic farm promotes biodiversity. Organic practices lead to crops that are more resistant to drought and pests, and probably are more complex in phytochemical composition. (Phytochemicals are chemical compounds derived from plants and fruits; there is evidence from epidemiological studies that phytochemicals in fruits and vegetables can reduce the risk of disease. This is one of the findings this study demonstrated by the higher level of phenols in organic produce). 

And the list goes on and on.

Organic food delivers products with fewer chemicals, preservatives, additives, antibiotics and hormones, and the environmental reasons to go organic are compelling. I doubt informed buyers opt for organic strawberries for their superior vitamin C level anyway.

Dr. Ayala

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

Moms oversharing their kids’ most personal stories

The mommysphere was abuzz over Dara-Lynn Weiss's Vogue article that detailed her effort to get her 7-year-old daughter to lose weight.

Criticism of Weiss spread like wildfire, especially after Katie J. M. Baker posted her scorn in Jezebel and described Weiss’ self-reported intense regimen of calorie restriction and public shaming as “abrasive, often irrational weight-loss strategies” and accused Weiss of projecting her hatred of her own body onto her child, and of writing the “worst Vogue article ever”.

Was Weiss wrong to put her daughter on a diet? Was the diet regimen inappropriate? Was its message misguided? Is being tough on your kid a parenting mistake?

There are situations in which action needs to be taken to prevent kids from further weight gain, and it’s definitely a parent’s job to educate kids about healthy eating and active lifestyle, and to provide for healthy food. There’s more than one way to obesity prevention and treatment in kids, and the discussion about what to do when a kid is diagnosed with overweight or obesity is an important one.

But here’s why I’m absolutely appalled by Dara-Lynn Weiss's piece: the Vogue article not only gave the child’s full name, it also displayed her photos.

A few days after witnessing the media party around the 7-year-old-on-a-diet, I read Elizabeth Weil’s Puberty Before Age 10: A New ‘Normal’? in the New York Times. This article opens with a story told by another mother, Tracee Sioux, whose daughter started growing pubic hair at the age of 6. Again, full name of the child, hometown and picture all included.

Outing kids

Reality TV seems to have dampened our instinct for privacy.

Adults willing to share tears and fears and humiliation with strangers are one thing, but dragging your kids exposed into the village square is an entirely different story.

Could anyone really imagine that a girl could benefit from the world knowing when her breasts budded?

So here’s an easy trick for moms with oversharing tendencies: Ask yourself this: if someone else revealed the information about your kid, would you feel comfortable? If your kid wanted to expose the information on the Internet, would you advise him to go ahead?

I’m sure most parents would be outraged if their kid's weight struggles, breast budding or pubic hair appearance were exposed by a reporter or a friend. They’d sue them!

Why did these moms do it? Weiss’ diet might have been designed to help her kid. Sioux might be thinking that she has an important story to tell.

But revealing the names and images served only mom’s interest – and was done for publicity and financial gain. Apparently, Weiss scored a book contract with Random House following her article. Sioux got to plug her “No Craptastic Ingredients” cosmetic line in the Times article as the solution to early puberty.

Every parent will make mistakes. I believe that kids are pretty resilient, and usually turn out fine despite the fact that perfect parents don’t exist. Our kids might be angry with us over what they see as our wrongdoing, but will forgive us – because most kids realize their parents do the best they can, and mean well.

I really can’t see exposing your kids’ private life for financial or any other gain as an act done in the kids’ best interest.

Dr. Ayala

 

Halftime in the school cafeteria

Last month Michelle Obama and Agriculture Secretary Tom Vilsack announced some very welcome and long awaited changes to the government subsidized school meals. These are the first changes made in the program -- which feeds 32 million kids each day – in 15 years. Under the new guidelines kids will be doubling their fruit and veggie intake, will be eating more whole grains, all milk will be low fat, and there’ll be upper limits to salt, trans-fat and calories in the school meal.

Yes, the program is far from perfect, kids will continue to eat lots of highly processed foods – very few schools actually cook food from scratch – and tomato paste on pizza counts as a vegetable. But it’s a laudable change in the right direction, and considering the mighty fight the food industry wages against any proposed change, and the fact that the new rules will add 3.2 billion to the yearly cost of the program it’s reason for a mini celebration.

The next critical change is yet to come 

Competing with the subsidized school lunch are the foods sold in schools, which make a big part of what kids actually eat while they’re in school. These are foods and beverages sold in the cafeteria or in a school store, from a vending machine or in fundraising events. The lunch money parents give their kids may very well be spent on these offerings rather than on the school lunch.

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

The USDA administers and regulates the school lunch program, and is developing nutrition guidelines for the foods and drinks available at schools. (The Healthy, Hunger-Free Kids Act, passed in 2010, gives the Agriculture Department authority to set health standards for all foods sold on school property — including those in vending machines). Right now, the only existing federal restriction is that foods of “minimal nutritional values”, such as candy and soda, won’t be sold in the cafeteria during meal times. That of course doesn’t mean they can’t be sold right outside the cafeteria doors.

Vending junk 

A new study published in the Archives of Pediatrics & Adolescent Medicine showed that even in elementary school half of the students could buy potato chips, ice cream or similar snacks from vending machines and at snack bars during school.

Other studies show that a la carte foods sold in the cafeteria are common in all school levels. Vending machines are available in 87 percent of middle schools and virtually all high schools. Forty percent of kids consume competitive foods on any given day, eating 280 calories daily in mostly junk food (the most commonly consumed competitive foods are desserts, snacks and sweetened beverages.

The new age of vending

Getting rid of the vending machines is perhaps a fancy aspiration and a non-starter, especially during tight budget times.

Instead, states and schools have put in place policies guiding the nutritional content in schools’ vending machines, and now offer healthier vending options.  Several vending companies specialize in healthy vending. 

But the neatest idea I’ve seen yet is the LiVe vending machine Intermountain Healthcare installed at Rose Park Elementary School in Salt Lake City. The talking machine will make its rounds in Utah schools spending a few weeks at each. 

 

I want one of these in my kids’ school!

Let’s hope the upcoming USDA regulations for competitive foods in schools will be sensible and have teeth. 

Dr. Ayala

 

Reposted as part of Food Renegade's Fight Back Fridays.

NYC's latest effort to wean New Yorkers from sugary beverages

Following last year's "Pouring on the Pounds" campaign, NYC's Health Department debuted a new series of subway billboards that urge New Yorkers to consider what goes into a large serving of sweetened soda. The answer: a shocking 26 packets of sugar. Who knew? Apparently, many New-Yorkers are aware already. In fact many New Yorkers are starting to cut back on sugary drinks, and the Health Department is trying to encourage that trend.

The spoonful of sugar we started off with a few decades ago has exploded into dozens of spoonfuls a day, and sugar and high fructose corn syrup (HFCS) are added to many processed foods, making food very palatable, but quite detrimental to our health.

Too much sugar 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. Too much sugar may also raise blood pressure and can elevate blood triglycerides levels (a risk factor for heart disease).

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

The new ads take a more rational approach to the matter. The previous ad campaign went straight for the gut, and created quite a stir:

Which approach works best in your opinion?

Dr. Ayala

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

Kombucha: Health elixir or risky experiment?

Kombucha tea is a popular complementary remedy, which after many decades of small-scale home brewing made a commercial debut in the marketplace and got off to a flying start. Kombucha drinks are a multimillion business, and these beverages are marketed as the elixir of health in both specialty and mainstream stores. Many people—including celebrities—swear by them.

But commercially brewed raw kombucha will be harder to find this summer. Last week Whole Foods Market pulled all raw (live) kombucha bottles off the shelf due to a concern that their alcohol levels may exceed the 0.5 percent ceiling allowed by law in non-alcoholic beverages. Other retailers are following suit. Products with alcohol levels exceeding 0.5 percents are subject to special regulations regarding permits, labeling, advertizing and taxation. Most importantly, alcoholic beverages must bear a health warning statement, as alcohol poses special risks for kids, pregnant women and people on certain medications. The Alcohol and Tobacco Tax Trade Bureau received several complaints about kombucha teas’ alcohol content, and is now looking into the matter.

What is kombucha? Where’s the alcohol from?

Kombucha tea is prepared by fermenting sweetened black or green tea with a symbiotic culture of yeast and bacteria. The resulting liquid contains acids, B vitamins and a number of other chemical compounds. Alcohol is another natural product of the fermentation process. In live kombucha drinks fermentation can continue in the bottle, and therefore the alcohol levels may rise with time, providing an extra kick.

Is kombucha truly magical?

Kombucha tea is promoted in some alternative therapy circles as a cure-all for a wide range of conditions, from memory loss, baldness, insomnia and intestinal disorders, all the way to cancer and AIDS.

Unfortunately, there is no scientific evidence that kombucha is an effective treatment for any condition. In fact, a systematic review of scientific literature found no clinical trials of kombucha in humans. The limited studies on rodents yielded conflicting results: kombucha had antioxidant activity in some studies, but caused liver and spleen enlargement in others.

Although there are no proven health claims that can be made regarding this drink, the well established commercial kombucha brands tell an artful story that suggests eternal health and freedom from disease without actually saying anything that can get them in trouble with current labeling laws—rules which leave plenty of room for confusing consumers into believing a product is a healing elixir.

Is alcohol the only concern? Should we be concerned?

Despite the dearth of scientific support for kombucha’s health benefits in humans, there are several case reports in the medical literature of adverse reactions associated with the consumption of home-grown kombucha tea, including abdominal complaints, allergic reactions, jaundice, toxic reactions, metabolic acidosis, and occasionally even death.

The fact that there are only a few case reports of bad outcomes after kombucha consumption is perhaps somewhat reassuring—it means that the described outcomes are an unusual occurrence. On the other hand these case reports suggest kombucha’s safety profile needs further study.

The Food and Drug Administration cautions that because of the method of preparation, home brewed Kombucha can easily become contaminated if brewed in unsanitary conditions. Medical experts warn that Kombucha may reduce the absorption of certain pH sensitive drugs and caution people with a compromised immune system against drinking it. Evidence-based practitioners advise prudence with this unproven drink, and even open-minded, holistic and alternative therapy embracing Andrew Weil M.D. counsels: “I don't recommend kombucha tea at all”.

What’s next?

Kombucha has a dedicated following—people say it gives them energy (perhaps easily explained by kombucha’s caffeine and sugar content) and makes them feel good, which is hard to argue with. It’s going to be interesting to see whether attention to kombucha’s alcohol levels will also raise interest in its other controversial features—there are no scientific studies to back the health claims made for it, there are concerns about its safety, and the health claims touted on these products are baseless and misleading.

Taste is a personal matter, but in a quick survey among my kombucha consuming friends and acquaintances I couldn’t find even one who drinks it because it’s a culinary delight. In the mind of most of its consumers kombucha is a healing elixir, and as such should be judged on its healing merits—proof of which is seriously lacking.

Will raw kumbucha makers shift to pasteurizing their brew? Pasteurization—a process that wipes out most bacteria and mold—stops fermentation, ensuring stable alcohol levels, and also prevents microbial contamination. On the other hand pasteurization takes away kombuchas biggest claim to fame—its live cultures.

Dr. Ayala

Full disclosure: I’m vice president of product development for Herbal Water, where we make organic culinary 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.
Reposted as part of Food Renegate's Fight Back Fridays--go join the food fight!

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

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

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

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

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

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

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

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

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

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

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

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

These results were consistent across the countries studied.

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

How significant is 3 percent protection from cancer?

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

There is of course no one right answer to that.

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

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

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

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

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

What if fruits and veggies offer no protection from cancer?

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

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

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

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

• They help lower blood pressure

• They help lower diabetes risk

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

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

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

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

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

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

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

So keep those fruits and veggies coming!

Dr. Ayala

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

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

Michelle Obama to food makers: Make healthier food, now

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Finding common ground

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

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

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

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

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

Dr. Ayala

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

Misleading health claims finally under fire

Is the health claim party coming to an end?

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

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

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

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

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

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

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

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

The giant loophole

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

That loophole is the structure/function claim.

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

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

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

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

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

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

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

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

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

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

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

Dr. Ayala

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

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

Related post: Are “functional” foods healthy foods?

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

”Let’s Move” to reform school food

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

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

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

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

A short introduction to school food

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

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

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

What kind of meal can you get for $1?

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

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

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

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

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

School candy-land

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

Availability:

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

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

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

Consumption of competitive foods :

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

Energy contribution of competitive foods:

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

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

The most commonly consumed competitive foods:

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

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

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

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

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

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

Dr. Ayala

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

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

Just a pinch of salt for health

Salt runs in the veins of language. There are reminders everywhere of salt’s former glory. The word “salary” is derived from salt (Roman soldiers were paid in salt), and salt is at the root of “sauce”, “salsa” and “salad”.

Ancient wars were waged over the control of salt.

Today, a modern war on salt—salt reduction—is looming in the horizon. And for good reason.

While salt is a dietary mineral we can’t live without, most of us take in two or three times the daily recommended upper limit of salt. Extra salt is typically sneaking into our meals unnoticed through processed and restaurant foods—and too much salt threatens the health of many people.

Recently, New York City’s mayor Michael Bloomberg announced an initiative encouraging food manufacturers and restaurant chains to reduce salt in their products by 25 percent over the next five years.

His call joins the voices of many health advocates: For example, in 2007, the American Medical Association (AMA) published a report calling for a major reduction in the salt content of processed and restaurant foods. They’ve been urging the FDA to revoke salt’s “generally recognized as safe” classification and to develop regulatory measures that limit the amount of sodium used in processed and restaurant foods.

But let’s start with a few words of respect for salt, because I’d hate to see salt described as the new villain, on par with cigarettes and trans-fats.

In defense of salt

Like anyone who loves food and spends lots of time cooking, salt is one of my (little) friends. Salt is the primordial condiment—it is absolutely essential to cooking and flavoring. Salt enhances and modifies other flavors and is indispensable in the traditional preparation of many foods, including bread, cheese and pickles.

Salt also is an essential mineral that our body absolutely needs to function properly, albeit in very small amounts. Sodium is needed for fluid balance, nerve transmission and muscle function; it helps many organs work properly.

Our fondness of salt is probably innate, and has served us well as a species. Salt is an essential nutrient that was very rare until modern times, so having a biological cue to seek salt was a good thing. However, the preference for certain levels of saltiness is acquired and isn’t fixed. Repeated exposure to higher levels of salt habituates our taste receptors to seek saltier foods.

How much salt do we need?

Chemistry time: Table salt is sodium chloride, a combination of one chlorine atom for each atom of sodium. Every gram of salt is 40 percent sodium. (The conversion formula of sodium to salt is milligrams of sodium X 2.5 = milligrams of salt.)

The Dietary Guidelines for Americans recommends we consume “less than 2,300 mg (approximately 1 teaspoon of salt) of sodium per day.” For African Americans, older people or people with hypertension the advice is to consume no more than 1,500 mg of sodium per day.

But in terms of what our bodies require, there’s a far lower limit: unless we’re running in sweltering heat we need only about 500 mg of sodium daily, which is very, very little.

Contrast this with what you’ll get in a Burger King Whopper with cheese: 1,450 mg of sodium. And that’s in just one part of one meal.

A Caesar salad with grilled chicken at McDonalds packs 1,390 mg of sodium. Dunkin’ Donuts’ breakfast egg and cheese on a bagel gives you 1,120 mg sodium when your day has hardly begun.

Science in the Public Interest paints a worrisome picture with their sodium chart.

Where’s all the extra salt coming from?

Roughly 10 percent of the salt in our diet comes from the salt we add ourselves (the salt we season with while cooking or sprinkle at the table) and 10 percent is naturally occurring. The vast majority of salt—amounting to about 80 percent of daily intake—comes from processed foods.

Salt is added to processed foods to achieve a (very salty) taste profile. In many situations adding salt is what makes cheap, un-tasty food palatable. Salt also is added for stability and preservation reasons. But the amount of salt added is clearly above and beyond what’s required for the safety and function of the food supply.

The simple math leads to the conclusion that going easy with the salt shaker is hardly going to put a dent in the unhealthy amount of salt in the typical American diet.

It’s also hard to trust our taste buds when salt is involved. Some foods taste quite salty because the salt is on the surface, while other sodium-saturated dishes don’t taste salty at all because other flavors and textures (namely, lots of fat and sugars) cover up the salt.

The health risks of excessive salt

The amount of salt in modern diets is having a profound effect on our collective health.

Our kidneys generally excrete extra sodium, but this mechanism isn’t perfect; too much sodium can cause or aggravate hypertension in some people. Roughly a quarter of Americans have hypertension.

The evidence connecting higher intakes of salt to higher blood pressure is pretty strong, and relies on many types of studies, including studies that neatly take away the possibility that people who eat lots of salt might have other lifestyle and diet variables that cause blood pressure to rise. Studies comparing two Nigerian rural communities, identical in all but the fact that one community had access to a salt lake and the other community did not, showed that higher intakes of salt tend to result in higher blood pressure. Similar studies of the Iranian Qash’qai and Pacific Island communities showed similar results. Several treatment trials have shown that a reduction in salt reduced blood pressure.

High blood pressure is a major risk factor for heart disease and stroke. It therefore makes sense to assume that high salt intakes will increase the risk of stroke and heart disease, and studies support this link.

A new paper in the New England Journal of Medicine used computer models to predict the effect of relatively small reductions in salt intake on Americans’ health and found that if everyone consumed half a teaspoon less salt per day, there would be between 54,000 and 99,000 fewer heart attacks each year, between 32,000 and 66,000 fewer strokes and between 44,000 and 92,000 fewer deaths. This small change could save from $10 billion to $24 billion in health care costs annually!

A call to reduce salt in processed food -- worldwide

Since 80 percent of the salt in the American diet comes from processed food, the effective way to reduce salt consumption is by reducing the—really high—salt content of restaurant and processed foods.

In fact, a program quite similar to New York City’s proposed one was initiated by the British government in 2003-2004, and has already achieved a 20-30 percent reduction in the sodium content of processed foods, and further gradual reductions are on the way.
Finland has a systematic approach for salt reduction, and foods high in salt carry a high salt warning. Portugal recently approved a law restricting the sodium content of processed foods. The European Union has salt-reduction initiatives underway with reformulation of processed foods as a major priority.

These public health initiatives are a sensible idea, and it’s good to see similar efforts finally underway in the US.

An editorial accompanying the NEJM article calls for implementing policies to reduce the salt content of processed food, describing these actions as “inexpensive, yet highly effective public health intervention for the prevention of disease.”

We can all take these simple steps to monitor and limit our own salt consumption:

• Select processed foods with less sodium. This could be painful; keeping count of sodium isn’t a practical or enjoyable way to eat. But we can pay attention to the amount of salt in processed foods and make low-sodium choices whenever possible.

• Reduce the amount of prepared and highly processed food we eat (as if we needed another reason to do just that). The best way to control our salt content is by preparing our own food.

I promise to devote another post to advice and tips on how to easily stay within the recommended salt recommendations without sacrificing taste. It isn’t hard!

Kudos to New York City for—once again—being the trailblazer in public health; I think we’ll be hearing a lot more about salt very soon!

Dr. Ayala

Why do we care what the Surgeon General weighs?

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

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

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

I have two things to say about this:

First: Where are our manners?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Ayala

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

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?