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

European study confirms: Sugary drinks linked to diabetes risk

Type 2 diabetes rates are clearly climbing, and have tripled in just 10 years.

The rise in sugary drink consumption has paralleled the rise in obesity and type 2 diabetes, which now afflicts ever-younger patients. And while obesity is a risk factor for type 2 diabetes, researchers have wondered whether sugary drinks are an independent risk factor, regardless of weight gain.  There's something quite special about sugary drinks' sugar concentration and rate of sugar delivery. We're gorging on growing amounts of sugars, which find their way into many of our processed foods. But the major source of added sugar in the Western diet is – you might be surprised – not desserts, but rather sugary drinks, which account for as much as half the daily calories from sugar, and 10-15 percent of kids’ total daily calories.

A study in the Archives of Internal Medicine looked at the relationship between consumption of sweetened soft drinks and fruit drinks and type 2 diabetes in 44,000 African American women, and found that women who consumed two or more soft drinks a day had a 24 percent increase in incidence of diabetes relative to women who drank less than one soft drink per month, a relationship that remains valid after controlling for obesity.

A meta-analysis, published in Diabetes Care in 2010, pooled more than 310,000 participants, and found that higher intakes of sugary drinks were associated with the development of the metabolic syndrome and type 2 diabetes.

Another recent study in PLoS One 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. The article’s conclusion: “every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1%.”

Most of these studies were in North American populations. Now, a new study published in Diabetologia takes a European perspective on the sugary drink diabetes link.

The study, which followed a very large population from 8 countries for 16 years, found about 12,ooo people who developed type 2 diabetes during follow-up, and compared them to 16,000 random controls from the same large cohort. It found that after taking into statistical account confounders such as smoking, education, physical activity, diet etc., drinking what amounts to one can of sugary drink a day increased the risk of diabetes by 22 percent. When the data was adjusted for weight (BMI) and caloric intake, the association was still strong, and the extra risk was 18 percent.

The authors discuss:

“The association between sugar-sweetened soft drinks and diabetes was only slightly attenuated when BMI was included in the model, which could indicate that obesity is neither the only nor the main mediator of the association, and that other mechanisms of action might be involved, such as the glycaemic effect of sugar-sweetened drinks and consequent insulin resistance”

In other words, sugary drinks may lead to obesity, which is a risk factor for diabetes, but sugary drinks consumption is a diabetes risk in and of itself.

Their advice:

“Given the increase in sweet beverage consumption in Europe, clear messages on its deleterious effect on health should be given to the population.”

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. 

Can you eat your way out of hot flashes?

Menopause is something I rarely think about. My take is that there’s no reason to anticipate and fret over life events that haven’t yet happened. I’ll dream about my next vacation, even when it’s far off, because it’s a nice respite, but with menopause I’ll deal only when it comes.

But new research I just read makes me think that there might be some merit to planning for this life transition. The study, published in the American Journal of Clinical Nutrition looked at the connection between hot flashes and what women eat, and offers further support to the notion that diet can relieve these very annoying symptoms.

What’s a hot flash? They say that, much like becoming a parent to a newborn, until you get one, you don’t understand what it’s really like. It’s described as a feeling of increased skin temperature, profuse sweating, sometimes accompanied by facial flushing and a rapid heart rate. It’s not dangerous, and it’s extremely common, but when it happens at night it interrupts good sleep, which is the cornerstone of health and wellbeing in my opinion.

Veggies and fruit protective; fat and sugar a risk

The Australian study included about 6000 middle-aged women, who were followed for 9 years. The women were asked about night sweats and hot flashes, and about their food habits.

After adjustment for confounders such as education level, smoking, obesity, physical activity etc., two food patterns were associated with fewer hot flashes: high fruit intake and Mediterranean style diet (veggies, garlic, red wine, tomatoes). On the other hand, high fat and high sugar diets were associated with high rates of reported hot flashes.

What does food have to do with hot flashes? The exact cause of hot flashes is unknown, but it is thought that estrogen withdrawal, which happens during menopause, disrupts our body’s thermostat.  Hormone replacement is one of the most effective treatments for severe symptoms, but hormonal therapy does carry some risk, therefore lifestyle modifications that can offer relief are in high demand.

Foods for hot flashes

Some women recognize certain foods trigger hot flashes for them. General food triggers include caffeine, alcohol and spicy food.

Several years ago, soy products were heavily favored for the prevention of hot flashes. Soy has plant estrogens (phytoestrogens), which were believed to provide natural estrogen replacement. Asian women, who live in countries where soy is a big part of the diet, also report fewer hot flashes than women in western countries (there are of course many lifestyle differences that can explain this phenomenon, and complaining might be cultural, too). The effectiveness of soy for hot flashes still remains controversial, though, with some studies showing benefits, and others showing none. 

Can a more plant-based diet affect the incidence of hot flashes? There are many mechanisms that can provide a logical explanation for why that might be a real connection. Foods affect estrogen metabolism; sugar metabolism and blood glucose levels might affect blood vessel dilation and contraction, for example. The authors of this study say theirs is the first ever study to look at dietary patterns and hot flashes, and it would be interesting to see if further research can confirm these findings.

As a woman, though, if you needed another reason to eat your plants and move away from high fat and high sugar foods, here it is.

Dr. Ayala

Mediterranean potato, onion, tomato and fresh herb bake

This easy, vegan, hearty dish combines the comfort of potatoes, with the light freshness of fresh basil and parsley, and the lovely redness of tomatoes and red spices. Serve with warm rustic bread to soak up the juices at the bottom of the baking dish.

Plan ahead: prep time is short, but for best results this dish may need about 2 hours in the oven, so get things started early.

Ingredients:

• 7 medium potatoes, (preferably Yukon Gold) peeled and sliced
• 5 large tomatoes, sliced
• 4 yellow onion, sliced

• 2 scallions, sliced
• 3/4 cup chopped fresh basil
• 2 tablespoons chopped fresh parsley
• 2 teaspoons dry basil
• 1 teaspoon paprika
• Dash of cayenne pepper (to taste)
• Salt and pepper to taste (start with 3/4 teaspoon salt)
• ½ cup extra virgin olive oil
• Garnish: (optional) ¼ cup chopped fresh basil

Preparation:

Preheat oven to 400 degrees F (200 degrees C)

Combine all ingredients in a large bowl, taste a tomato slice and correct seasoning as needed.

Arrange in a large, deep baking dish, and bake covered by tin foil for 1.5-2 hours, until golden, and potatoes are nice and soft. Remove tin foil 10 minutes before the dish is ready.

Garnish with some extra chopped basil. 

Serves 6-8 

Enjoy,

Dr. Ayala

A miracle diet that prevents cancer?

If you’re ready to believe the sensational titles and overhype in mass media, miracle super foods that decrease the risk of cancer are discovered every other week.

Except miracles are just that: something that rarely happens, and many of these reported ‘proven’ food cures are based on flimsy findings, never again to be reproduced.

Nevertheless, health experts are unanimous about the effect our diet as a whole has on health, and on cancer risk. The World Health Organization estimates that 25 percent of death burden in developed countries is due to lifestyle – completely up to us – risk factors.

8 healthy habits

In 2007, a collaboration between the World Cancer Research Fund and the American Institute for Cancer Research (WCRF/AICR) evaluated the evidence and produced consensus recommendations for reducing the risk of developing cancer and for promotion of general good health and wellbeing. The WCRF/AICR report is the largest study of its kind, and its conclusions are as definitive as the available evidence allows.

The report featured eight general diet and lifestyle recommendations for cancer prevention:

“1: Body Fatness: Be as Lean as Possible Within the Normal Range of Body Weight.” Maintaining a healthy weight throughout life may be one of the most important ways to protect against cancer, and being overweight or obese increases the risk of some cancers.

“2: Physical Activity: Be Physically Active as Part of Everyday Life.”

“3: Foods and Drinks That Promote Weight Gain: Limit the Consumption of Energy-Dense Foods and Avoid Sugary Drinks.” Sugary drinks were targeted specifically in the report: “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”. Another recommendation under this heading is “Consume 'fast foods' sparingly, if at all.”

“4: Plant Foods: Eat Mostly Foods of Plant Origin.” Diets that are protective against cancer are characterized by large intake of foods of plant origin and, indeed, several cancers are responsive to increased intakes of plant-based foods.

“5: Animal Foods: Limit the Intake of Red Meat and Avoid Processed Meat.”

“6: Alcoholic Drinks: Limit Alcoholic Drinks.” (Men-to 2/day, women to 1/day).

“7: Preservation, Processing, Preparation: Limit Consumption of Salt and Avoid Moldy Cereal Grains and Pulses (Legumes).” Salt and salt-preserved foods probably contribute to stomach cancer risk, and foods contaminated with aflatoxins are a cause of liver cancer. Although salt is necessary for human health, typical levels of consumption are vastly excessive.

“8: Dietary Supplements: Aim to Meet Nutritional Needs Through Diet Alone.” Dietary supplements are not recommended for cancer prevention. According to the report the greatest danger associated with the use of dietary supplements is the possibility that consumption of supplements is serving as an alternate to good nutrition, and supplements are taken as “magic bullets” to compensate for cancer-friendly dietary and lifestyle practices.

So, not as easy as popping a supplement or drinking acai juice, but does this recipe for cancer reduction and longevity actually work?

Not a shortcut, but it will get you there

A new study in the American Journal of Clinical Nutrition, including almost 400,000 people from 9 European countries, scored participants’ compliance with the 6 first WCRF/AICR recommendations (there was insufficient data to assess recommendations 7 and 8). Women were also assessed for another WCRF/AICR recommendation specific to women: Breastfeeding. The total possible score for a man was therefore 6, and for a woman 7. The group was followed for about 12 years, and during that time almost 24,000 people died, 48 percent of them from cancer.

People with the highest WCRF/AICR score (5-6 for men, 6-7 women) had almost 34 percent lower risk of dying than those that had the lowest scores (0-2 for men, 0-3 for women). Each additional point in the WCRF/AICR score was associated with a 1.2 year increase in life expectancy, and a higher score was associated with lower risk of death from cancer, cardiovascular disease and breathing problems. The recommendations regarding overweight and obesity, and eating plant food, were the most strongly associated with risk of dying.

We like things fast and now, and the WCRF/AICR recommendations aren’t a shortcut, but isn’t it nice to know that we do have some control over our heath trajectory?

Dr. Ayala

Healthwashing with a green label

Visual cues affect our decisions, and one of the strongest, most persuasive visual elements is color.

There’s a hot debate regarding the best way to present nutrition-at-a-glance on the front of the package. At this point we don’t have a uniform labeling system, but food and beverage makers have, over the years, come up with several such schemes (Smart Choices was widely criticized and abandoned, Facts Up Front is the latest voluntary industry sponsored plan).

While the debate goes on about front of package’s label content, A new study by Jonathon Schuldt in Health Communication looks at the label’s form, and more specifically, its color, and asks an important question: Does color affect perceptions of healthfulness?

What prompted this question is the Mars front of package nutrition label, called Guideline Daily Amounts (GDA). Mars’ ‘what’s inside’ labels launched in 2010, and display the number of calories in the pack, as well as their percentage of daily value.

All well and good, and I do love chocolate, and think the world’s a more pleasant place with some sweets.

But Mars’ Guideline Daily Amounts label is green, the color of traffic light ‘go’, the color adopted by the USDA organic seal, and Schuldt asks: does green make us think it’s healthy?

Color coded food 

To test color’s effect on health perception, Schuldt randomly divided 93 students into 2 groups. All students were asked to imagine that they are hungry, waiting in a grocery checkout lane, and see a candy bar with a calorie count on the wrapper.

At this point the students saw an image of a candy bar with an identical calorie count: 260, 13 percent of daily value. Half the students saw a red calorie label and the other half a green calorie label.

The students were then asked whether the candy bar they saw, compared to other candy bars, contains more or fewer calories, and how healthy it is.

The result: the green label candy was perceived as healthier than the red.

But does green say healthy, or does red say stop? To test that Schuldt replaced the red label with a white one in an online experiment. The experiment was the same as before, but this time the 39 participants were also asked to what extent the healthiness of food is an important factor in their decision about which foods to buy and eat.

In this experiment, the more importance the participants placed on healthy eating, the more they perceived the white-labeled candy bar as less healthful. In other words, green ‘healthwashed’ the calorie worries among those who care about such things.

Not a random choice

So is green an aesthetic choice, or one that carries persuasive value? Is green associated with natural and provide a halo effect? This study gives some evidence that green labels shed some positive light on foods, and we shouldn’t be surprised. Other studies have shown that consumers view organic foods as lower in calories, and see ‘low fat’ as permission to overeat.

As the FDA and other government organizations continue to debate front of label systems, this study suggests design and color deserve as much attention as the nutrition information itself if we are to really help consumers reach informed food choices. 

Dr. Ayala

Is there a better way to 5 a day?

We’re constantly nudged to eat our 5-a-day of fruits and veggies, but never seem to quite get there. Surveys show that just 14 percent of Americans eat 5-a-day, and the numbers are lower for teens, with only 9.5 percent eating 2 fruits and 3 veggies daily.

Are people unaware of the recommendation? Probably not. The 5-a-day message has been quite successful, and surveys show that the majority of people are aware that they should eat a minimum of 5; it’s the details and portion sizes that are less clear.

Is the message poorly delivered, or is the 5-a-day so pie in the sky that many people don’t even try?

Maybe we should set a more realistic, small step goal – after all, one would assume that suggesting 30 minutes of exercise twice a week would be more doable than urging a daily session.

Big goals, or small steps?

A new study, published ahead of print in Appetite, set out to see if asking students to eat just 1 more fruit or veggie worked better than encouraging them to eat 5-a-day. The researchers hypothesized that just-1-more would have better results. Would that be your prediction?

The authors, led by Nadine Ungar, randomly divided 84 psychology students, who started off with under 4 servings a day, into 3 groups. The just-1-more group was asked to increase fruits and veggies by one more a day for a week. The 5-a-day group was asked to eat 5 servings, and the control group was told to eat as usual. After the week of treatment the participants returned their food diaries, and a week later they were asked to fill in a questionnaire again, reflecting their intake post the trial period.

This is what happened: the 84 students ate about 2.5 servings before the intervention. During the intervention just-1-more participants indeed increased their intake by almost 1 serving (0.96 serving, to be precise).  5-a-day increased intake precisely to 5-a-day – an additional 2.5 fruit and veggies servings. The control group, surprisingly, increased intake by 0.7 servings.

One week after the intervention. The just-1-more went back to almost baseline (fruits and veggies were at 0.27 above base, not significantly different from the controls), while 5-a-day were at 1 additional serving.

5-a-day was more effective, and the researchers state that setting the higher goal – and a more specific one – worked better, at least for this group.

Unfair competition

I hear a lot about the struggles people have with eating better, and with getting their kids eat more veggies.

I do feel the pain, but I don’t think it has all that much to do with fruits and veggies.

Eating veggies and fruits is not like going to the doctor for shots, or even like flossing teeth. It is not something you do just because it’s healthy. 

People ate fruits and veggies a plenty well before they knew they were healthy (indeed, people once thought tomatoes were deadly poisonous).

I think the main reason people don’t eat enough fruits and veggies nowadays isn't because they’re not tasty, or because they don’t know it’s good for them.

The main reason, I think, is the competition.

The competition, high caloric density foods and foods that are highly rewarding because of their sugar, fat and salt content, are ubiquitous. They are endlessly promoted, and often cost less than fruits and veggies. Combine our natural tendency towards densely caloric, tempting foods, with greater availability and the allure created by ads, fruits and vegetables turn pale and humble despite their bright colors, wholesome beauty and very appealing – yet mellow compared with the competition’s -- taste.

My suggestion is to inform about the importance of 5-a-day -- it’s should actually read at least 5-a-day, and has been swapped in the US by MyPlate on which half the plate is devoted to fruits and veggies – because knowing the science-based guidelines is imperative. But I wouldn’t beg and plead, or even endlessly remind; it’s annoying, and counterproductive.

Perhaps the most effective way to get the fruit and veggie habit going is to remove some of the competition. If you serve 2-3 vegetable sides, and small portions of the protein entrée, if you present a bowl of strawberries and nothing else as an afternoon snack, there’s a much better chance that the fruits and veggies will be welcomed than if you served these together with loads of pasta, fried foods, sweet and salty snacks and other highly competitive options. 

When fruits and vegetables are viewed by themselves, very few people find them objectionable, and many will name favorites. But fruits and veggies are in an unfair competition for stomach share, and since it is quite proven that a more plant based diet can benefit us all, I suggest we work on removing some of the competition, at least at home.

Competition is usually healthy, but when it comes to salad competing against a hamburger with French fries, the competition makes the healthy choice ever so difficult.

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.

Can olive oil and nuts prevent heart attacks?

A new study, just published online in the prestigious New England Journal of Medicine, was able to prove that diet – a tasty and rather easy to keep one at that – was able to reduce stroke and heart disease by 30 percent.

The study, led by Dr. Ramón Estruch from Barcelona, Spain, involved 7447 people, aged 55 to 80, all at higher risk for heart disease due to diabetes or at least 3 risk factors or heart disease, such as obesity, smoking, high blood pressure, elevated levels of bad cholesterol, or a family history of early heart disease.

Participants were randomly assigned to one of 3 groups:

• Mediterranean diet supplemented with approximately 4 cups a week of extra-virgin olive oil (OVOO);
• Mediterranean diet supplemented with an additional ounce daily of walnuts, hazelnuts and almonds;
• Control group that was counseled to eat a low-fat diet that did not include olive oil or nuts. This group received small nonfood gifts.

Both Mediterranean diet groups were encouraged to consume olive oil, nuts, fresh fruits and veggies (at least 5-a-day), legumes, white meat and wine in moderation with meals, and discouraged from soft drinks, commercial bakery goods such as pastries and sweets and red meat. Sofrito (a sauce made with tomatoes, onions, garlic and herbs, slowly simmered with olive oil) was also recommended – at least 2 servings a week. 

The control group was advised to eat low fat dairy, fruits and veggies (at least 5-a-day), lean fish and seafood, and discouraged from vegetable oils (including olive oil), commercial bakery goods, nuts, fried foods, red and processed fatty meat and fatty fish. 

To be fair, the study doesn’t really compare the Mediterranean diet to a low fat one, because the control group didn’t really adhere to a low-fat diet – they must have found it hard. So the comparison is really between a Mediterranean diet and a ‘whatever goes’ diet. 

Although people in all 3 groups had similar diets before the study started, compliance with the Mediterranean diet was good, and was verified not just by participants’ report, but also by measuring urinary hydroxytyrosol, a marker of olive oil intake, and blood alpha-linolenic acid, a marker of walnut consumption.

The participants were followed for the occurrence of heart attacks, strokes, and death from heart disease. After an average follow up of almost 5 years, 288 such events happened. Both Mediterranean diet groups experienced 30 percent less such events compared with the control group.

Quite encouraging! Especially since neither group was given a low calorie diet, or advised to lose weight – which could of course reduce heart disease and stroke risk, but isn’t easy to do. As a matter of fact the Mediterranean diet with OVOO group was encouraged to eat 4 tablespoons of the oil each day, which is 450 calories in OVOO alone! The Mediterranean diet with nuts group was supplied with about 200 calories-a-day in walnuts almonds and hazelnuts.

What’s special about this study?

The Mediterranean diet has shown its protective benefits against several diseases in many studies. A meta-analysis in the American Journal of Clinical Nutrition combined the findings of many prospective studies, pooling more than 2 million people, and showed that greater adherence to a Mediterranean diet – in line with pretty minor lifestyle changes, like eating a good amount of fruits and some nuts – was associated with 8 percent reduction in death, 10 percent reduction in cardiovascular illness and cardiac death, 6 percent reduction in cancer and 13 percent reduction in neurodegenerative diseases, such as Alzheimer’s, and to offer some protection from stroke and mild cognitive losses.

This study adds to previous evidence, and stands out due to its scientific rigor – it is a large, randomized controlled clinical trial, in which people were allocated by chance alone to eat in a certain way, were followed for a long time and were compared to a control group. Its results were also so conclusive that the trial was stopped early in order to report the results and allow the control group to enjoy the benefits of the Mediterranean treatment.

What’s the health-promoting ingredient in the Mediterranean diet?

So what should it be? Should we dip bread in olive oil twice a day or snack on almonds?

Let’s remember that this study tested the effects of a Mediterranean diet on heart disease and stroke. As much as we’d like to learn a magic trick from its findings, we cannot conclude that avoiding commercially baked goods, avoiding soda, eating sofrito, replacing red meat with fish or nibbling walnuts saves lives. The people in the study changed many eating habits during the study period.

The Mediterranean diet is an eating pattern, a total plan, and should adopted as one. We don’t know which part of the package confers the most benefit, all we know is that the pattern works as a whole; all parts of it are probably beneficial, and it very well might be that they work in combination with each other. The Mediterranean lifestyle – allowing for leisurely food enjoyment and social interaction – might be just as important.

I think the Mediterranean diet would be worth adopting for the sheer pleasure of it, and the health benefits are just another great reason to go Mediterranean.

But I’d stop short of the at-least-4-tablespoons-OVOO-daily the participants in this study were advised to eat. Way to many calories – leaves too little to play with if you’re also aiming for an energy balanced diet.

Dr. Ayala

 

Eat Healthy! Everybody’s Doing It!

What do you think is going to lead more students to the salad bar, telling them that most of their friends eat vegetables, or stating that eating vegetables is good for you?

We know that peer pressure can push people to do the right – or wrong – thing. What we think is “normal” or “typical”, and our perceptions of what others have and do, influences our decisions. Many campaigns encourage us to join the majority: “Four out of five dentists surveyed recommend…" and “billions and billions of people served” led us to believe the decision has already been made by everyone, so it must be a good idea. Social psychologist Robert Cialdini showed in a series of studies that when hotel guests were told that the majority of guests reused their bath towels, they were more likely to reuse them, too. This social norm message outperformed environmental reasoning and even a promise to donate money if guests helped reduce towel laundry.

Educational information about nutrition could appeal to those seeking to eat better, but on the other hand telling kids what’s good for them might seem like unwelcome pressure, and might backfire and cause resistance rather than adoption of the good habit.

So which approach, if any, would you use?

Your friends eat here

A new study in Appetite (online ahead of print) conducted an experiment in an on-campus food court in an eastern American university. The experiment took place in an area with two food stations: a salad bar and a grill area serving hamburgers, chicken tenders and fries. The 220 students who participated in the study saw one of three signs:

1. “Every day more than 150 [name of university] students have a burger for lunch here”, accompanied by the university’s logo and photos of the grill area.
2. “Every day more than 150 [name of university] students have a tossed salad for lunch here”, accompanied by the university logo and photos of the salad bar.
3. “Have a tossed salad for lunch”, accompanied by a picture of the salad bar and the university’s logo.

In the control condition no signs were posted.

Message 2 resulted in more students choosing salad compared with the control condition. Message 3, surprisingly, did not lead to significantly more salad choices compared to the control condition. Message 2 and 3 did increase the number of salad choices when compared to the message 1 condition.

What if the norm isn’t healthy?

The sign telling students that salad is a popular choice outperformed the message suggesting that eating salad is what they should do.

But in order to use social norm messaging people need to believe the norm described is indeed true and real. In other words, we need to reach a point in which a majority is indeed following a positive habit in order to market the healthy choice as what everyone’s doing.

When it comes to healthy eating this is rather hard to do. Eating unhealthy, calorically dense foods is very common in many social circles, and research even suggests weight gain ‘spreads’ in social groups, perhaps because people tend to follow the choices of their peers.

So how can we support an “everybody’s doing it” healthy behavior? 

Perhaps we should look at admired groups of people in which this behavior is indeed the norm. Do actresses eat a lot of veggies? Do tennis players follow a healthy diet? I’m sure we can find a trendy group of people in which “four out of five” or at least the majority are role models for healthy eating.

And let’s not forget that perceived social norms (some of them not normative at all) are also created – quite intentionally – by clever, repeated depiction in movies, TV, music and ads. I’d love to see healthy eating inserted into media in place of alcohol, junk food and sugary drinks.

Any suggestions?

Dr. Ayala

 

Are kids going to eat less junk in school cafeterias?

The days of snacking on candy, soda and chips in schools may soon be over. Last Friday, the US Department of Agriculture (USDA) announced new proposed standards for snacks sold at schools. The standards limit the amount of calories, fat, sugar and sodium of most foods sold at school, and encourage whole grains, low fat, fruits and veggies. A few examples: Yogurt, granola bars, trail mix, dried fruit and fruit bars, pizza on whole grain crust and baked potato chips are in. Candy, caloric soda, sweetened fruit juice, and most cookies are out.

Perhaps anticipating the backlash, the proposal exempts fundraisers, afterschool sports events and treats sent by parents – including birthday and holiday party goodies. It also allows for a yearlong transition.

The rules, required under the child nutrition law passed in 2010, are an effort to combat childhood obesity and close an obvious loophole: while the government-subsidized school lunch has to comply with nutrition rules, what’s sold a la carte, in school stores, snack bars, or from vending machines, and competes for kids’ stomach share and lunch money, isn’t federally regulated at all, and can be of no nutritional value whatsoever.

Is it going to make a difference?

Is there evidence that stricter rules at school will encourage kids to eat less junk? Since many states and cities have already established regulations regarding foods sold at schools, there are already some comparisons that can be made. 

California was one of the first states to implement rules for vending and selling foods in schools; these rules limit the caloric content, fat and sugar in snacks, and ban soda and sweetened beverages. Last year I reported on a study in the Archives of Pediatric & Adolescent Medicine that compared California high school students’ daily intake to the intake of students from 14 states without any school nutrition standards, and showed that California kids ate fewer calories and consumed less fat and sugar per day at school -- 170 fewer – compared to high school students in other states. And the kids didn’t load up the missed calories after school. The Californian students took in 158 fewer calories a day, overall -- a reduction of 158 calories is a big deal as we gain weight very gradually, and reducing even 100 calories a day can prevent weight gain and put a dent in the obesity crisis.

Another study in Health Education & Behavior compared 3 middle schools that implemented a healthier snack and beverage nutrition policy with 3 that had no guidelines. Removing these items not only resulted in lower consumption of junk food at school and overall (no compensatory junk eating at home), it also didn’t seem to result in negative preoccupation with weight.

The New York Times recently reported that after decades of rising rates of obesity, several cities are reporting a decline. Philadelphia, my hometown, reported a 5 percent decline, and has seen this decline among minorities, and not just among high-income families. Philadelphia has implemented broad policies to fight obesity, including a ban on sugary drinks in school vending machines, and school snack guidelines that limit calories, fat and serving size. It’s hard to credit any one public health policy for the changing trend in childhood obesity rates, but the results are encouraging.

The importance of a healthy school environment

It will take a while until the snack food regulations are installed, and even longer until we can see their effects on kids’ diets.

But I think that paying attention and debating the foods sold at schools will have immediate educational outcomes.

As Agriculture Secretary Tom Vilsack said in a press release last Friday: "Parents and teachers work hard to instill healthy eating habits in our kids, and these efforts should be supported when kids walk through the schoolhouse door".

School, or government, doesn’t determine what kids eat, but it can definitely set minimum standards that promote healthier choices, or at least not undermine healthy nutrition efforts by condoning and profiting from the sale of junk within school walls.

Discussing unhealthy snacks, and removing them from the cafeteria, has an educational purpose. I wouldn’t be surprised if it influences the bottom line of what kids actually consume (kids do eat more than half their daily calories at school), but it’s worth doing, regardless.

When the vending machine changes what’s in its belly, kids consciously or unconsciously, notice; this exposure can change minds, and hopefully also what’s in kids’ bellies.

The USDA proposal will be open to public comment for 60 days. In the meantime, I’d love to hear your comments here. 

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.

Study grades the nutritional quality of fast food menus

Proving the obvious can sometimes seem like a waste of time.

On the other hand what’s painfully clear to some seems questionable to others; that’s why experts perform research and pile evidence about seemingly evident truths, in a determined effort to gather facts. These facts can then influence perceptions and affect policies.

Fast food is a fine example; I think that many people believe fast food is the worst possible food to eat, but every once in a while I’m confronted with a nagging question: How do you know fast food’s bad for you.

What’s wrong with fast food?

So how do we know? Let’s start with the ingredient list.

From a nutritional point of view, if we were to invent the worst diet ever — one with a component list designed uniquely for unhealthy weight gain and cardiovascular and metabolic morbidity — we’d be hard pressed to imagine one worse than the typical fast food regimen. Fast food is highly processed, has lots of saturated fats, hydrogenated fats and refined sugar, salt by the teaspoons, very little fiber, very few vegetables and fruit, and many additives driving the “great taste” that keeps us coming back for more and overeating.

Now let’s go to the epidemiologic evidence.

Morgan Spurlock famously gained 25 pounds and suffered physically and emotionally after eating exclusively at McDonald's for just one month in his excellent documentary Super Size Me -- but that’s just anecdotal. The evidence comes from studying large populations and analyzing the findings in a statistical way. I’ll mention just a few of these studies.

A prospective study in the prestigious scientific journal Lancet followed more than 3,000 young adults for 15 years, and showed that those who ate at fast food restaurants more than twice a week gained an extra 10 pounds and had twice the incidence of insulin resistance (a risk factor for type 2 diabetes) compared to those who ate fast-food less than once a week. A study in the Journal of the American Dietetic Association showed that adults eating at fast food restaurants consumed 205 more calories per day than those who don’t eat fast food. Another study in the American Journal of Clinical Nutrition showed a connection between fast food and the risk of type 2 diabetes: women who ate burgers more than twice a week had an almost 60 percent higher risk of developing diabetes. And the list goes on and on.

Now, a new study in Public Health Nutrition offers a fresh assessment of the quality of fast food menus. This study compares the menus of the top 5 fast food chains (Burger King, McDonald’s, Subway, Taco Bell and Wendy’s) to the recommendations of dietary guidelines, and scores the menu on a scale of 100 possible points.

F for fail

This study uses The Healthy Eating Index: a well-established measure of diet quality that assesses conformance to the federal dietary guidance in MyPyramid.

How does this work? The components of the menu are compared in quantity to the 9 major food groups in MyPyramid, so the fruit, vegetables, grains, milk, and meat on the menu get a score by how closely they match recommendations. Other components of the diet – those items we strive to limit, such as saturated fat, salt and added sugar – get higher marks for having a smaller quantity. For example, a diet or menu would get the full 5 possible veggie points if it had 1.1 cups of vegetables for every 1000 calories, and 0 points for having no veggies at all; it would get a full 10 points for having less than 7 percent of energy coming from saturated fat, and 0 points if 15 percent of calories are from saturated fat. Everything in between gets a proportional intermediate score.

So how did fast food menus score?  The full menus in all the chains studied scored lower than 5o out of 100. The scores for fruits, vegetables, whole grains and salt were particularly low.

If it’s not shocking enough to see an under 50 score, it’ll be illuminating to see how the chains got to their under 50: they scored high on total grains, meat and beans. That’s because any hamburger served on a fluffy white bun scores a full 10 points for meat, and a full 5 for grain, but these food components are, of course, not the foods Americans have a hard time meeting guidelines on.

The researchers also looked specifically at kids’ menus, and those did score 10 points higher on average. But the scores were still consistently low, and one has to remember that although healthier options do exist on the menu, most people go into a fast food joint for hamburgers, French fries and soda, not for the salad and apple slices.

Fast food is rich in all the foods Americans struggle to eat less of, and poor in those they have a hard time eating enough of.

And that’s one reason why we should eat fast food as infrequently as possible.

Dr. Ayala

How to pick a whole grain product

White bread is out, whole grains are in, and ‘whole grain’ is one of the hottest selling health claims. The USDA’s 2010 Dietary Guidelines recommend that at least half of daily grains be whole, and school lunch programs are required to serve half of the grains offered during the school week as whole ones.

Why whole grain?

Whole grain foods have a higher content of micronutrients, polyphenols, ‘good’ fats and fiber. They also have a lower glycemic index. Whole grain food consumption is associated lower risk of heart disease, weight gain and diabetes. Whole grains are also preferred for what they’re not: refined grains have lots of pure carbs – plain sugars, which supply energy, but little else.

But how do we define a whole grain food?

You’d be surprised to learn that there’s very little standardization of the whole grain declaration. In the US, a food product can use the official whole grain health claim if it contains at least 51 percent whole grain ingredients by wet weight. But not all genuine whole grain foods carry the official claim, and a food can qualify for the whole grain claim despite containing lots of added sugar and trans-fat – so whole grain junk food certainly exists. Foods can boast “made with” and “contains” whole grains without any specifics about the percentage of such grains.

So when you’re standing next to the cereal isle, what do you look for? The Whole Grain Stamp on the front of the package? Whole grain flour as the first ingredient? Did you bring your glasses and a calculator?

Navigating whole grains

A new study from the Harvard School of Public Health in Public Health Nutrition identified 545 grain products from the virtual shelves of Wal-Mart and Stop&Shop, looked at them through 5 different whole grain criteria, and evaluated which criteria better measures the healthfulness of the product.

The 5 ways whole grains were assessed were:

• The Whole Grain Stamp: the icon created by the Whole Grains Council can be displayed if the products have at least 8 g of whole grain per serving. Companies pay $1000 to $9000 in annual dues be part of this program
• Whole grain as the first ingredient on the ingredient list
• Whole grain as first ingredient and no added sugars in the product
• The word ‘whole’ before any grain anywhere in the ingredient list
• A ratio of 10:1 or less of total carbohydrate to fiber: This is The American Heart Association’s strategy. 10:1 is approximately the ratio of carbohydrate to fiber in whole-wheat flour.

Useful criteria would be practical, identify foods that are healthier, and find enough of them to give customers (and schools) plenty of options to choose from.

The best guideline according to the authors, led by Rebecca Mozaffarian, was the 10:1 ratio. This method asks for a little bit of work: divide the total carbs by the total fiber on the nutrition label, for instance, one serving of Cheerios has 22 grams of carbs, and 3 grams of fiber, and without doing the exact calculation it’s clear that the ratio is less than 10:1 (it’s about 7), which puts this cereal in the satisfactory list. The 10:1 identifies foods with more fiber and less sugars (the neat point about this method is that if there were lots of added sugar it would add to the total carbs, changing the score for the worse).

One obvious loophole in this approach is that manufacturers can easily add bran to the product, upping the fiber content, and reaching a lower than 10:1. (Sugar-water with vitamins isn’t the same as fruit, and refined grain products with added fiber just aren’t whole grain – our body does know the difference.)

The industry supported Whole Grain Stamp helped identify products with more fiber, but many of them also had more sugar, and a higher caloric count, and many whole grain products don’t carry the stamp.

Whole grain as the first ingredient, which I think is quite popular among health conscious consumers, and ‘whole-anywhere’, were much less restrictive, and qualified more products, but they, too, failed to weed out foods with more sugar and more calories.

Whole grain as first ingredient and no added sugars was quite restrictive, and qualified only 17 percent of the tested products. Another downside is that this method requires a very careful read of the ingredient list – added sugars hide under many guises such as brown rice syrup and fruit juice concentrate, and our food label doesn’t give us any idea about how much sugar was added.

The take home message

This article will definitely make me look further into the 10:1 ratio, which, frankly, I’d never thought of before.

And it definitely sheds new light on the industry-supported Whole Grain Stamp. The symbol signifies the presence of significant amounts of whole grains, but consumers should know it looks at no other ingredients and factors affecting healthfulness.

No matter which guideline -- or combination of guidelines -- you use, you need to read the ingredient list, because as this study reemphasizes, the words ‘whole grain’ don’t necessarily mean this food’s wholesome, and in case you’re using the 10:1 ratio, make sure the product didn’t get there by adding fiber. Clearly, consumers could benefit from a clever food label makeover that can better assist them in whole grain product selection.

One of the best ways to eat whole grains is to make them yourself, and while I’m not suggesting you start baking your daily loaf from wheat you grew in your back yard, cooking brown rice, oatmeal (oatmeal is always whole grain), quinoa and wheat berries is practical, inexpensive and 100 percent whole grain!

Dr. Ayala

 

Study shows what foods supermarkets promote most

Advertisements sell and --- as much as we hate to admit it -- food ads do shape the way we eat. That’s why more than $7 billion are spent each year on food ads in the US.

Much has been said about the ubiquity of junk food and fast food ads on TV and their effect on eating habits, especially kids’ eating habits.

Newspaper and mailed circulars receive much less attention, despite the fact that they are an important advertising channel for food and grocery retailers, and food advertisers spend nearly $1.6 billion on these outlets yearly. Consumers pay quite a lot of attention to them, and a recent survey showed that shoppers change their meal plan according to which products are on promotion, with young people even more susceptible to eating-on-promotion.

A new study (published online ahead of print) in Appetite is among the first to evaluate the types of foods promoted by US supermarkets and compare them with current dietary guidance. The study analyzed sales circulars issued in 2011 by supermarket top chains and included a sample from each of the 50 states and Washington, D.C. The proportional ad area devoted to each food group was compared to the area allotted to that food group in the MyPlate icon.

Meat, soda and cereal

The most heavily promoted food group on the front page of supermarket sales circulars was meats: beef, poultry, and pork, and about 40 percent of ads were for these foods; MyPlate suggests 20 percent of the plate be devoted to ‘protein’.

Foods in the fruits and vegetables groups each were given about one-tenth of the sampled advertising space; compare that to the half-plate devoted to fruits and veggies on MyPlate.

Grains, half of these being breads, cereals, and crackers, occupied a fifth of the advertising space. This is pretty much in proportion with MyPlate.

A tenth of the ad space was allocated to sweets – mostly sugary drinks. These are not represented on MyPlate at all.

Selling soda to obesity stricken states

Supermarkets promote different foods in different regions, and the researchers looked to see how the obesity rate of a state correlated with foods on its supermarket circulars.

And indeed, in states with under 25 percent obesity (such as Massachusetts and Colorado) supermarkets devoted significantly more space to fruits than in more obese regions. (Shocking note: no state has an obesity prevalence of less than 20 percent.)

On the other hand, sweets occupied significantly more ad space in the states with over 30 percent obesity, and significantly more space was given to sugary beverages in these states. 

The south regions of supermarkets tended to allocate more ad space to sweets, predominantly sugary drinks, which were given 2 to 6 times as much ad space when compared to other regions.

Can we affect supermarkets?

Although supermarkets promote the items that give them the best profit margins, they also sell what we consumers want to buy. This is evidenced by the difference this study saw between regions. I guess it’s harder to appeal to Connecticut customers and lure them into stores with a special on soda.

Ads affect our behavior – we’d like to think we’re immune to their influence but nobody really is – but our purchasing power also affects what’s on shelf and what’s on promotion. When consumers seek healthier foods it does often lead to a decrease in the price of those foods, and to chains making shelf space for better options.

As Michael Pollan often says, we get to vote with our fork 3 times a day. Each addidional vote has the potential to change the food-world around us.

Dr. Ayala

Looking for admiration? Serve some veggies!

I happen to be one of the people that can get seriously excited about a particularly fresh, colorful vegetable, prepared just right, or even served raw, sliced just so and dressed well. Most people aren’t as eager to eat their veggies – they’re looking forward to biting into a juicy steak, or whatever’s the ‘main’ dish. Veggies are at most a sideshow.

And since most people aren’t excited about eating veggies they don’t eat enough of them.  Although the five-a-day campaign has been successful in making Americans aware they should be eating more fruits and veggies, only 11 percent actually do so, and while My Plate, the new nutrition guide from the USDA, devoted half the plate to fruits and veggies, only 23 percent of Americans have any vegetables on their dinner plate.

So how do we convince people to put more veggies on the dish?

Brian Wansink Misturu Shimizu and Adam Brumberg from Cornell University’s Food and Brand Lab have a new argument that can certainly appeal to moms, dads and any other food provider who wants to be a hero: Putting veggies on the plate gives the perception of a loving, capable cook.

Serving vegetables makes you a 'good cook'

In their new study, to be published in Public Health Nutrition, Wansink’s group asked 500 American moms who had at least two kids at home to evaluate meals. The participants assessed the personality of women who either prepared -- or did not prepare -- veggies with a family meal, and rated four different meals that either included a vegetable or had no veggies. Respondents were asked to describe the cook and to evaluate the meal itself. 

They found that having a vegetable on the side made the main dish rate higher for taste: Steak with broccoli was favored over steak alone, or steak served with a starch.

This is something restaurant owners know. In professional menus sides help the main course look good – the side helps sell the main dish -- and chefs know that dishes have more appeal if served over, under and garnished with veggies.

But here’s the most interesting part: When asked about their perception of the cook that made the meal the participants selected descriptors such as “loving” “thoughtful”, “attentive” and “capable” to the meal preparers that included veggies. Mind you, preparing the veggies in the proposed meal was no more involved than heating up a bag of frozen green beans – how’s that for return on investment. The attributes selected for the cooks who served steak, chicken or pasta without veggies were more often “neglectful”, “selfish” and “boring”.

So this is what moms thought in a sterile study environment. Does it guarantee kids would see it the same way? It’s hard to say, but I find that eventually kids tend to adopt their parents’ habits and point of view regarding food.  Being admired by other grown-ups can’t hurt either.

Pleasure, not just health

Kids hardly care about health. Making an “it’s good for you” argument doesn’t carry much clout, and asking kids to eat their veggies for the thousandth time doesn’t make for interesting dinnertime conversation.

I found this study inspiring because it demonstrates that serving veggies for hedonic reasons alone makes sense and can have a positive impact. That’s in fact, how my mom got me to love my veggies. In the end, it’s the pleasure of the food and the experience around it that create good eating habits. 

And speaking of pleasure, can you guess which veggies are most favored? Broccoli tops the list for most family members, except for young boys who prefer corn and carrots to broccoli. Are you surprised?

You may want your family to eat veggies for their health and weight maintenance qualities, but who can resist some adoration? Do you need a better motivation?

Dr. Ayala