Healthy Food & Healthy Living by Dr. Ayala

Our health report card for 2009: Are we making progress?

As 2009 winds down and the season for gratitude is upon us, this is a great time to reflect on our progress and contemplate the road ahead. This year especially, with the ongoing debate over public-policy directions for the U.S. health-care system, the collective state of our health deserves our attention.

America`s Health Rankings’ 2009 report came out just recently, and as a two-decade continuous assessment of our nation’s health, it’s a great tool for checking how we’re doing and—I hope—springing us into some action.

The longest-running annual assessment of the nation`s health on a state-by-state basis, the rankings urges all populations and communities to take action to improve health.

There are some bright spots in the report: Over the past 20 years, our nation has seen improvements in the reduction of infant mortality (a 33 percent drop), infectious disease (down 53 percent), prevalence of smoking (down 33 percent), cardiovascular deaths (29 percent fewer incidents), violent crime (a drop of 23 percent), air pollution and children in poverty (8 percent reduction), and there has been an increase in immunization rates of 42 percent.

We deserve a very light tap on the back for these advances since our progress has been slow. Even smoking cessation efforts, which have been the focus of a very large public health effort, has left nearly one in five Americans still smoking. Childhood poverty—which had been going down consistently—has gone up in the past year by a percentage point.

The past 20 years have also been very challenging in two important measures of public health: Obesity prevalence has increased by 129 percent since 1990, and the rate of uninsured Americans has increased by 14 percent, and now stands at about 15 percent. And yes, obesity rates are still climbing and have gone up since 2008.

Let’s take a closer look at obesity.

Obesity rates are climbing fast. The average American man has added about 17 pounds in the past 20 years and the average American woman has gained about 15 pounds. About a third of Americans are obese, and if obesity continues to grow at the same rate, the report predicts 43 percent of Americans will be obese by 2018, and since excess weight drives health-care costs, our collective weight gain will add $344 billion to our health bill bottom line.

There’s also great disparity among different ethnicities, with minority groups showing overall higher rates of both obesity and smoking compared to non-Hispanic whites.

National and international comparisons

The report ranks states’ healthfulness taking into account a multitude of measures from high school graduation, violent crime rates, health funding and prenatal care to obesity, smoking, binge drinking, and cancer and cardiovascular deaths.

The state-by-state assessments add a nice sense of competition, and I’m sure you’d like to see how your state ranks in health compared to others (after you finish reading my post!). Ranks go from 1 (healthiest) to 50 (least healthy). The winner is Vermont, up from 4th last year, with its low rates of kids in poverty, low obesity rates ('only' 23% of the Vermont’s population), a high rate of high school graduation, and low smoking rates (8th in the nation). Vermont’s downside: a high rate of binge drinking and low immunization rates.

At the very bottom of the list is Mississippi, which has won the dubious rank of least healthy state in the nation eight times in a row. Mississippi remains uninsured, poor, uneducated, the most obese of the states and one of the highest consumers of cigarettes (44th in the nation).

The thinnest state is Colorado.

My home state of Pennsylvania is ranked 28th—making us totally in the middle and unremarkable—with a 2 point improvement from last year. Pennsylvania’s main strengths are a high rate of high school graduation (7th in the nation) and a relatively low rate of uninsured (7th in the nation). The challenges are air pollution and a high rate of infectious diseases, and of course obesity (36th in the nation)—that goes without saying, as all American states suffer from high rates of obesity. Even Colorado.

Besides encouraging a healthy sense of rivalry, these comparisons are a great resource to draw upon, and see how we can learn from other states and implement best practices for good health.

But the comparison to other developed countries is what deserves our greatest attention.

When we measure ourselves against other countries, the conclusion is obvious—and there’s no softer way to put it—we simply aren’t the best.

Healthy life expectancy is the number of years a newborn can expect to live a healthy and productive life. The Japanese are at the top, and enjoy 76 healthy years on average. We in the US rank 30th, are on par with the Czech Republic and Chile, and our average healthy lifespan is 70 years. We rank #37 in infant mortality among 193 countries rated.

We spend more on health care than any other country in the world yet have a lower life expectancy, less access to care, less patient safety and definitely less equity than many other countries.

A short quote from the report:

“Based on two decades of consistent tracking, the 2009 Rankings calls for the nation to change unhealthy behaviors that are contributing to preventable, chronic diseases as the key to improving our nation`s health. Trends cite smoking as the greatest health challenge of the past 20 years and warn obesity is likely to be the next national health battle. When it comes to our national pursuit of health, Americans have benefited from disease treatment while preventable illnesses continue to decrease quality of life for many. With focused attention, change is possible.”

The way ahead

As the U.S. health care-reform debate continues, we’re becoming increasingly aware of the staggering cost of treating disease.

But prevention and improving public health are still very much missing in the general conversation.

I’m not referring to screenings (and I definitely don’t want to get into the mammograms schedule issue); screening is usually aimed at early detection and timely treatment of disease, which is a very important, but quite different from prevention.

What I’m talking about is modification of risk factors and prevention of disease through simple and proven changes in lifestyle. Smoking, poor eating habits and inactivity contribute to chronic diseases in a big way, and we’ll have to put some serious effort toward modifying these risk factors in order to slow the rise in chronic illness and truly reform our health-care system.

The incidence of diabetes has doubled in a decade, and we know that improved diet, obesity prevention and physical activity are the key to reversing this trend in type 2 diabetes, which is costing us both unnecessary suffering and lots of money.

The late Ted Kennedy said this in 1994 about health-care reform: "What we have in the United States is not so much a health-care system as a disease-care system."

Not much has changed in the past 15 years. Although disease treatment has progressively improved, preventable illnesses prevalence is still rising, causing a lot of suffering and impairing the quality of life for many.

Please check out the useful Take Action resource section in the report, which can help individuals, employers, community leaders and health care professionals take concrete steps toward the goal of changing unhealthy behaviors and preventing disease.

There’s much we can do, both individually and as a nation, to improve our health and prevent disease.

Dr. Ayala

How do low-carb diets affect mood?

The promise of many popular diets often includes not just weight loss, but a happier outlook. Yet, a new study shows that the expected mood improvement—the added perk usually seen when losing weight—seems to be short-lived in successful dieters on a low-carb diet.

The low-carb diet debate is one that doesn’t seem to want to fade away. The diet itself is an old one. The idea that eliminating most carbs as a weight-loss strategy is an idea that preceded Dr. Atkins by more than a century. There are many types of low-carb diets with varying restrictions on the types and amounts of carbohydrates permitted. Just like other diets, they work as long as you eat fewer calories.

Their relative popularity is at least partially because proponents find low-carb diets easier to follow: It may be that a low-carb diet produces more satiety and reduces appetite, and the initial weight loss might be greater than with other diets (although some of that initial weight loss advantage is probably explained by greater water loss).

Whether a low-carb diet is a sustainable plan is a whole different issue.

In order to lose weight on low-carb diet one needs to reduce total calories and do so over the long-term. Unfortunately, low-carb diets generally aren’t easier to stick to over the long run and the long-term weight outcomes of low-carb diets are no different than those of other diets. In fact, a large study published in the New England Journal of Medicine compared low-carb and low-fat diets and found that after a year, people dropped out of both diets at similar rates.

Many experts also worry that a low-carb diet, which replaces carbohydrates with foods containing a higher percentage of proteins and fats and especially saturated-fats, isn’t a healthy way to eat over a long period of time. Studies of low-carb diets continue to examine their effect on a multitude of end results, from heart health, atherosclerosis and kidney function, to Alzheimer’s, cognition and now—mood.

A recent study in the Archives of Internal Medicine compared participants’ long-term mood and cognition when undertaking low-carb and low-fat diets.

A total of 106 overweight and obese participants were randomly assigned to either a low-carb or low-fat diet for one year. Both diets were similar in calories and only moderately energy-restricted, with an average of about 1,400 calories for women and about 1,700 for men.

Mood was checked four times throughout the study year using validated questionnaires and looking at many aspects of mood, including tension, anxiety, depression, dejection, anger, hostility, vigor, fatigue and confusion. Cognitive function was also tested.

And the results:

• Eight weeks into the diet both groups reported similar marked improvement in mood.

• After the initial eight weeks, mood scores started to differ significantly and the low-fat group clearly outperformed the low-carb group in mood scores.

• In the low-fat diet group the majority of mood measures, including the measures for anger, depression and confusion improved long-term and mood was generally better than it was at the beginning of the diet.

• In the low-carb diet group, after an initial improvement in mood the majority of mood measures, including the measures for anger, depression and confusion returned to baseline level (before weight loss), and the positive mood lift was short lived.

• Both groups achieved similar weight-loss results.

• Cognitive functioning tested working memory and speed of processing, and both groups scored similar scores at one year.

Psychological well-being is one of the many health perks one gets from dieting, and at least in this long-term study, the low-carb diet didn’t achieve the sustained elevated mood that the regular low-fat one did.

The authors offer a few hypotheses to explain their finding:

Western diet eating patterns rely on carbs—bread, pasta, rice and fruit are quite central to our cuisine. Low-carb diets are far removed from our normal eating habits, and may create a sense of food preoccupation, social eating impairment and isolation, and may therefore result in a bad mood.

The other explanation is quite intriguing: low-carb diets may change the brain’s chemistry. Low serotonin levels in the brain are known to be linked to depression and anxiety (many antidepressant drugs work by making serotonin more available in the brain). A high-carb diet may increase serotonin production, and a fat- and protein- rich diet may reduce serotonin concentrations in the brain. Therefore, a low-carb (which is also high in protein and fat) diet may decrease serotonin levels and have a negative effect on moods. Serotonin may be only one of the brain chemicals affected by a low-carb diet.

Who is the fairest of them all?

The weight-loss industry is huge—we spend $40 billion a year on weight-loss and diet advice just in the U.S.; the diet business, unlike the American people, is always in great shape.

Each diet boasts its superior results, ease of use and testimonials from happy thin people, exemplifying the most positive outcome possible with no mention of the average results achieved by most dieters, so I think some reality checks are always welcome.

Whenever I see so many products on the market, it’s a clue that maybe none of them has a clear advantage. While all diets that prescribe an energy deficit—fewer calories consumed than calories expended—should work, the problem remains that only five percent of dieters manage to maintain their lower new weight for very long; most dieters typically slowly return to baseline weight in three to five years. In other words—all diets work but actually none of them really does. Our old eating habits are comfortable, and we are prone to fall back on them.

So which is the best diet? You’ll get many different answers and plenty of advice from experts. My point of view isn’t based on personal experience—I don’t diet—but rather on general health advice and common sense: I prefer diets that promote healthy eating habits, moderation, are balanced nutritionally, and resemble habits you can see yourself adopting long-term.

A better diet plan is one that’s both healthy in the long-term and sustainable. The more the weight-loss diet resembles the weight-maintenance diet habits you need to adopt in order to remain at your new weight, the better it is, as acquiring new eating habits is the ultimate challenge.

These general rules of course exclude fad and crash diets, such as the cookie, milkshake and cabbage soup diets, as well as extremely low-calorie diets. Any diet with “miracle” or “easy” label on it should be highly suspect—there are no miracles (sorry!) and losing weight and keeping it off is never easy.

And because losing weight and keeping it off is so difficult, we need to emphasize obesity prevention. Good eating habits, physical activity and a healthy food environment are the best tools to minimize the chances of ever needing to diet.

Dr. Ayala

Are we exercising less or eating more?

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

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

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

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

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

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

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

Are American adolescents getting enough physical activity?

And

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

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

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

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

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

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

There were also a few encouraging trends:

• Physical education class attendance and engagement have improved.

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

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

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

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

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

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

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

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

Dr. Ayala

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

Healthy neighborhoods can reduce the risk of diabetes

Do you live in a healthy neighborhood?

Is there such a thing as an unhealthy neighborhood?

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

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

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

Can a neighborhood influence health?

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

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

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

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

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

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

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

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

The authors conclude:

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

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

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

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

A closer look at an unhealthy neighborhood

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

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

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

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

• The average purchase supplies kids with about 360 calories.

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

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

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

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

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

Related posts: When Healthy Food is Hard to Find

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

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?

Can super-sizing fruits help you shed weight?

I’m very skeptical of promises that sound too good to be true.

No field is as rife with these as the diet industry, where new dream diets are invented daily and claim to have found a magic trick allowing us to eat as much as we want yet lose weight.

But here’s one worth checking out: Can eating more fruit help you shed weight?

This diet is worth a second look because we have many other good reasons to increase our fruit consumption—fruit and vegetables are an important component of a healthy diet and have a protective effect against many chronic diseases, such as heart disease, cancer and diabetes.

There’s also a plausible explanation for why eating fruit may protect against weight gain: Fruits have a relatively low-energy density, they have a lot of water and dietary fiber, and add lots of bulk. Studies show that food intake may be regulated by the weight of the food, and how long it takes to consume, therefore filling your plate with fruits would lead to greater satiety and less consumption of other foods.

A recent paper in Obesity Reviews analyzes the published studies on the association of fruits and weight loss. The authors specifically sought studies which look at fruit only, and not fruit and vegetables as one category (there are many studies showing that fruit and vegetable intake has an inverse relationship with overweight and obesity).

Of the sixteen human studies that met the inclusion criteria, eleven showed that increased fruit intake facilitated a significant reduction in body weight, decreased the risk of overweight or obesity or was associated with less overweight. The remaining five studies found no significant association, and no studies showed increased weight related to increased fruit consumption.

The studies included in this review were of three different types: Intervention studies, in which a study group is randomly assigned to receive an intervention—in this case increased fruit—and compared to a control group which receives a placebo or no intervention, prospective observational studies, in which a cohort with known exposures (in this case fruit intake) is followed for a health outcome over time (in this case weight), and cross-sectional studies, in which a population is observed at a certain point in time, looking for possible connections between, in this case, fruit consumption and weight. Each kind of study has its strengths and weaknesses.

Results from all three types of studies pointed towards an association between high fruit intake and lower weight. The authors call for large behavioral, randomized, controlled intervention studies to further clarify this issue.

Can supersizing the fruit serving increase fruit intake?

I think we’re all sold on the idea of including more fruit in our daily diet for a multitude of reasons, but many parents struggle with just how to do it—less than ten percent of kids consume their daily recommended number of fruit and veggie servings.

This brings me to another recent fruitful study, this one from the scientific journal Obesity.

Many studies show that increasing the size of the serving of food—entrees, snacks or soda—leads to increased intake, and supersizing the portion leads to supersized eating and supersized people. The authors asked the interesting question: Will supersizing the fruit and vegetables portion lead to higher intake of those in kids?

Forty-three Philadelphia-area kids aged five and six years were included in the study. They were twice fed dinner consisting of pasta with tomato sauce, broccoli, carrots, unsweetened applesauce and milk, with the portions of broccoli, carrots and unsweetened applesauce doubled in one of the meals randomly, while the pasta and milk portions stayed the same.
The results are pretty interesting:

Doubling the portion of fruit and vegetables side dishes resulted in a significant increase of 43 percent in the intake of the fruit—applesauce—but not the vegetables.

Doubling the portion of fruit and vegetables side dishes resulted in a significant decrease in the intake of the pasta dish, with the extra fruit displacing the more energy-dense pasta.

Overweight kids showed a bigger response to over-sizing the fruit and vegetables portion than normal weight kids; they ate more of the fruit and vegetables offered.

The study shows doubling the size of fruit and vegetables portions as a valid method for increasing fruit intake, but also maybe of controlling weight gain, as the fruit displaced a higher calorie food (pasta).

What about the vegetables?

A more careful look at how the vegetables were presented might offer an explanation: the broccoli and carrots were thawed from a frozen pack and served plain, with no seasoning or fat. I think even the most ardent vegetable lovers wouldn’t get too excited by those. Perhaps a more appealing preparation (broccoli sautéed with some olive oil, garlic, fresh ground pepper and salt anyone?) would have gotten a different result.

I think that if you’re plating a meal for yourself or for others increasing the size of the vegetable and fruit component is worth trying. It may very well be that the most obvious way to increase fruit and vegetables consumption is by making them show up in plenty! If they’re on the table, prepared in an appealing way, ready to eat and constantly available they’ll be what we eat when we’re hungry. That’s part of the way manufacturers of sugary drinks and junk foods make sure we consume more—they’re just everywhere and in plenty.

Food for thought!

Dr. Ayala

Health experts favor taxing sugary drinks in new report

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

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

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

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

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

Sugary drink consumption is rising, as is obesity

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

Why would sugary drinks lead to poor health?

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

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

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

Economic rationale to taxing sugary drinks

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

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

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

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

The proposed tax and its projected effects:

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

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

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

Objections, industry reactions and growing public support

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

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

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

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

The authors conclude:

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

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

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

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

How can “cutting added sugar” drive better health?

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

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

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

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

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

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

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

Primary source

Now on to the number one source of added sugar.

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

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

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

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

The article reviews evidence showing that added dietary sugar:

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

Agreement from other authorities

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

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

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

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

What do you think of this image?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

Dr. Ayala

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

Are “functional” foods healthy foods?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Watermelons: A Healthy Taste of Summer

I am taking a summer break for a few weeks to spend time with my family and travel. Meantime, I'm reposting some of the more popular posts I’ve written over the past almost two years (wow, how time flies!) so that new readers have a chance to catch up. Enjoy this post! - Ayala

One of the best things to enjoy on a warm summer day is a cold watermelon. What could be better? Sweet, crisp, refreshing, red and nutritiously healthy.

My husband sees it as a personal failure when we open a watermelon and find a pinkish disappointment that tastes like a cucumber. He feels there must be a fool-proof way to pick the perfect fruit.

Alas, there’s no secret method, but I can offer a few tips for choosing a good watermelon:

Tapping: Tap the watermelon with the pads of your fingers. A winning watermelon will typically have a slight hollow sound, more like the sound you get when tapping your head rather than tapping your chest.

The yellow spot: At the bottom of the watermelon -- where it rested on the ground -- you want to find a yellow or cream-colored spot. If the spot is still white, the watermelon isn’t ripe.

Hardness: Press your fingers and thumbs into the watermelon’s skin. A good one should be hard all around with no soft spots.

Heaviness: A good watermelon feels heavy for its size.

I’ve been using these methods for years. Still, I have to admit I’m not convinced that digging through the watermelon bin using these tricks gets you a better success rate than randomly picking the first watermelon your hand touches with your eyes closed. I occasionally end up with disappointing watermelons no matter how hard I try. It just happens!

The good news though if you get a bad one: a not-so-sweet watermelon makes a wonderful and easy-to-prepare cold soup. (The cucumber in the recipe masks the cucumberness of the not-so-great watermelon.) It looks like a gazpacho, but is even more refreshing.

Watermelon and mint cold soup

Ingredients

6 cups seedless watermelon, diced
1/3 cup finely chopped fresh mint
1 cup cucumber, peeled and finely diced
1 small jalapeño pepper, seeds removed, minced
1 red onion, diced
1/2 cup young celery stalks, diced
2 tablespoons fresh lime juice or to taste
2 tablespoons balsamic or red wine vinegar
salt and fresh ground pepper to taste

Preparation

Puree the watermelon in a food processor, using the “pulse” setting; pulse several times until the watermelon is still chunky and not too smooth.

Transfer the puree to large bowl. Add the remaining ingredients. Refrigerate until cold (at least an hour).

Garnish with a few leaves of fresh mint and serve.

What’s so good about watermelons?

First and most important – it’s a fruit and it tastes good. And of course its color brightens up the table.

Watermelon is a low calorie nutritious treat: a one-cup serving of watermelon has only about 50 calories.

It’s an excellent source of vitamins C and A. It’s also a good source of vitamins B6 and B1, and minerals such as potassium and magnesium. Red watermelon (yes, there’s a yellow-orange type too!) is also a good source of lycopene (a carotenoid antioxidant). In fact, watermelons are a richer source of this beneficial antioxidant than tomatoes.

Watermelon is 92 percent water so it’s very good for hydration.

While we mostly eat the flesh of the watermelon, all parts are actually edible. The rinds can be stir-fried, stewed or pickled. Watermelon seeds are rich in fat and protein, and can be eaten as a snack (roasted), or made into an oilseed.

How big can they get?

Very, very big!

Hope, Arkansas, the birthplace of President Bill Clinton, is known for producing the world's largest watermelons.
The last world record was set at 268.8 pounds as far as I could find. I wonder what a watermelon this big tastes like.

Is watermelon a favorite fruit in your home?

Dr. Ayala

New evidence that simple healthy lifestyle choices can thwart chronic illness

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

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

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

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

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

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

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

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

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

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

• Normal weight (BMI of less than 25).

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

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

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

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

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

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

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

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

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

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

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

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

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

Roger writes:

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

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

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

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

Dr. Ayala

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

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

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

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

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

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

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

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

Ingredients:

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

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

• ½ cup freshly grated parmesan cheese

For the sauce:

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

• 5 tablespoons extra virgin olive oil

• 1 clove garlic

• A pinch of hot pepper flakes

• Salt and pepper to taste

Preparation:

• Heat the oven to 350 degrees F.

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

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

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

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

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

Enjoy,

Dr. Ayala

Can Pac-Man help kids make healthier choices?

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

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

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

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

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

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

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

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

The results of this small study are very clear:

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

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

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

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

The authors, Tiffany Pempek and Sandra Calvert, write:

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

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

"Reduce Your Child’s Media Use

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

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

Media Literacy

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

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

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

Countermarketing

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

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

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

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

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

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

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

Dr. Ayala