Healthy Food & Healthy Living by Dr. Ayala

Non-caloric sweeteners on the rise: Should we be concerned?

Americans eat a lot of sugar – 15 percent of daily calories are from added sugar alone. Sugar’s high caloric price as well as its rising market cost are moving consumers and food makers to replace sugar with ever rising amounts of low-calorie sweeteners such as Equal, NutraSweet, Splenda, Sweet'N Low, Stevia and many others. Replacing sugar with no-calorie sugar substitutes potentially saves many calories, but also raises concerns about what happens when you dissociate sweetness from energy: how does non-caloric sweetness affect appetite, eating habits and weight?

And since the sugar-substitute experiment is long underway, it’s a good idea to stop and see how the trial is faring: are low caloric sweeteners helping in the obesity fight?

Food and nutrition experts met in the spring of 2011 in Washington DC to do just that in a workshop called: “Low-Calorie Sweeteners, Appetite and Weight Control: What the Science Tells Us”. The presentations of this workshop are summarized in a upcoming supplement of the Journal of Nutrition and make for some interesting reading.

Does sweetness promote overeating?

Tasting something sweet activates pleasure centers in the brain.  Do you know what else activates these neural reward pathways? Addictive drugs such as alcohol and opiates work on the same brain mechanisms. That of course doesn’t mean that drug addiction and our affection for sweet food are the same thing – but it does help explain how strong and well conserved our sweet preference is.  Loving sweet is innate and present even before birth. It probably served our species well, leading babies to crave mother’s milk and all other aged humans to seek ripe fruit.

A few interesting findings from the article about sweetness and food preference:

• Sweet taste makes pain go away: a Cochrane review showed that sweet tasting solutions reduced the reaction to pain in babies. Sweetness continues to act as an analgesic in childhood.

• We sense sweet taste through taste receptors in the mouth, but receptors are present also in our intestine and our pancreas. Stimulating these receptors leads to a cascade of physiologic reactions, including insulin and other hormone secretion, stomach emptying, appetite control and gut motility. These receptors can’t tell caloric sweeteners and non-caloric sweeteners apart -- they react to both, to a degree that isn’t completely understood. 

• Young kids prefer super sweet -- the sweeter the better. They’ll always gravitate to sweet rather than plain. Kids can also discriminate between sweet-tasting foods differing in energy content, preferring those that are more energy dense. 

• Preferring sweetness is natural, but also learned: babies and young kids exposed to sweet foods and drinks prefer sweet foods, and eat more of them. Through their experience with food kids ‘learn’ what should and shouldn’t taste sweet. Repeated exposure to sweet drinks leads to preference of sweet drinks. 

• The ready availability of sweet, highly rewarding foods, can promote overeating and weight gain. Adding sweetness (caloric or non-caloric) to foods that are not naturally sweet -- think cereal, water, yogurt or milk -- creates dietary habits of overconsumption. It’s just human nature.

The science of non-caloric sweeteners

Thanks for hanging in there up until now. I bet you’re curious to know the bottom line verdict of this workshop. Two years ago, the new Dietary Guidelines for Americans concluded that:

“The replacement of sugar-sweetened foods and beverages with sugar-free products should theoretically reduce body weight. Yet many questions remain, as epidemiologic studies show a positive link with use of nonnutritive sweeteners and BMI. Additionally, whether use of low calorie sweeteners is linked to higher intake of other calories in the diet remains a debated question.”

I’m afraid not much has changed.

The workshop concluded that the bulk of epidemiologic, observational studies, but not all of them, reported that use of low-caloric sweeteners is associated with obesity and weight gain. However, association doesn’t prove causality. Real evidence, the experts say, can only come from well-performed randomized controlled clinical trails, in which people will be assigned randomly to consume either non-caloric sweeteners for long periods of time, or serve as controls.

Until then, the large-scale non-randomized population experiment is ongoing, we’re all part of it, and I don’t think it’s going too well. I choose to be in the control group.

Dr. Ayala

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

 

Fat burning miracles?

A few years ago billboards announced the arrival of “negative calorie” food.  Drinking three 12-oz. cans a day of Enviga, the Coca Cola and Nestle carbonated tea drink, will burn an extra 60-100 calories daily, claimed the products’ packaging.

The Center for Science in the Public Interest (CSPI) filed a lawsuit against Coke for Enviga’s false weight-loss claims. Coke and Nestlé agreed to add language to the labels and marketing materials stating that the product will not promote weight loss without diet and exercise and Enviga is slowly vanishing from shelves.  But supplements and foods claiming to slim you down have not – they are alive and thriving.

A new paper in Obesity Reviews looks at the dynamic market of nutritional supplements claimed to increase fat metabolism, and explores how much evidence – or lack of it – is behind some of these popular supplements.

What is a ‘fat burner’?

A fat burner is a substance that is claimed to increase energy expenditure, make you lose weight, or somehow promote fat breakdown.  Many fat-burning supplements combine several ingredients, claimed to work in concert.  Is there such a thing as a fat burner?  The article examines some of the most popular such miracles, and I’ll discuss just a few of those.

Fat burners on the market

Caffeine

The ultimate functional ingredient, caffeine appears naturally in coffee, tea and cocoa and is also added to many foods and drinks.  Anyone who drinks coffee knows that coffee does have active ingredients that increase alertness – that’s why I love my morning cup.  It makes loose dreamy words stick into lucid sentences.  But does it increase energy expenditure and promote weight loss? 

A few studies showed that high doses of caffeine increased metabolic rate, however, longer-term studies tracking dieters taking caffeine or placebo showed caffeine performing no better than the dummy pill.  Overall, the authors conclude:

“Caffeine on its own has not been shown to be effective in reducing body weight and if caffeine increases fat metabolism, the effects are generally small”

Carnitine

Carnitine, which occurs naturally in meat, and is produced by our own liver and kidneys, is claimed to improve fat metabolism and increase muscle mass. 

Most of the carnitine in our body is in our muscles, and our muscle takes up carnitine from our blood against a huge concentration gradient (sorry for the flashback to high school chemistry, but it’s needed in order to understand how little sense this makes).  Studies have shown that the enzyme that is responsible for transferring carnitine into the muscle is at maximum capacity, and therefore ingesting extra carnitine doesn’t raise muscle carnitine at all.

The only way in which muscle carnitine could be elevated was by increasing blood levels of both carnitine and insulin at the same time – by insulin intravenous drip or very large amounts of ingested sugar.  This impractical scenario is quite counterproductive from the weight-loss point of view.

Carnitine supplementation for weight-loss just doesn’t make sense!

Tea

Tea contains catechins, which are thought to stimulate fat metabolism.  Green tea, which is non-oxidized and non-fermented tea leaves, has especially high levels of catechins, the most interesting of which is EGCG (epigallocatechin 3-gallate).  The authors review the green-tea weight burning studies and find them inconclusive:

“Green tea has the potential to increase fat metabolism at rest, also during exercise, and may help to lose body fat and body weight.  As with caffeine, the effects appear to be relatively small…”

Chromium

Chromium is added to many “functional” foods and drinks (Vitamin Water, Fuze) and is sold as part of many supplements as a fat burner and muscle builder.  Chromium occurs naturally in broccoli, red wine, mushrooms, brewer’s yeast, wheat germ and other foods, and was reported to increase lean body mass during exercise. 

The excitement was dampened by further, better studies that found chromium had no effect – overall, the majority of studies find it useless – and the authors also caution that a few studies on cell cultures found chromium can cause chromosomal damage.

Want to burn calories?

The authors, A. E. Jeukendrup and R. Randell, conclude with an overall impression that most of the supplements marketed as fat burners have little or no science to support their claims, and that among the group, caffeine and green tea have some effect, but it is small, and more consistent in habitual caffeine users.  They write:

“The ever increasing list of fat-burning supplements is industry driven, and is likely to grow at a rate that is not and cannot be matched by similar increase in scientific underpinning” 

In other words, marketers are quick to announce miracle solutions based of the flimsiest of evidence collected on a few lab mice or a cell culture; if and when the science manages to amass enough research that more often than not doubts the substance’s merit, sellers are already quick to market with the next new fat-burning sensation.

How can we end this? Silly and optimistic as I am, I’m hoping for an end to health claims on foods and supplements.  Health claims were introduced in 1994, have been so miserably abused and have become so utterly misleading that it’s just time to say goodbye. 

The other more realistic way is that consumers will start rejecting the hype and express their skepticism with their wallets.

Let’s end with the age-old solution to fat burning.  We know it works.  It’s healthy and inexpensive, too.  It’s called exercise.

Dr. Ayala

 

Can super-sizing fruits help you shed weight?

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

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 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

 

Study shows a daily can of soda has measurable harmful effects

There is very little doubt that drinking sugary drinks regularly is associated with obesity, type 2 diabetes, hypertension and heart disease. 

Since sugary drinks are the leading source of added sugar in the American diet, and it’s quite easy to take in lots of calories in beverages without much effect on satiety, a lot of the harm done by consuming sugary drinks can be explained by the weight gain associated with their consumption.

But there’s another school of thought, and growing supporting research, that believes that sugars -- and especially the fructose component of sweeteners -- are especially harmful to our health, and have direct adverse effects on fat metabolism and inflammation. 

Our metabolism on sugary drinks 

A previous study from the University of California at Davis showed that drinking 25 percent of daily calories in fructose for 10 weeks increased triglycerides and cholesterol and caused insulin resistance in people, while drinking the same amounts in glucose didn’t. And while both the fructose and the glucose groups gained weight during the study, the fructose group gained more belly fat.

Indeed, a concerning finding, but drinking 25 percent of calories in fructose is something very few of us do (although many teens do take in about 20 percent of their calories in added sugars, and do so daily for many years).

Now, a new study, led by Isabelle Aeberli, and published in the American Journal of Clinical Nutrition, looked at 29, young, healthy, non-overweight men, who drank more reasonable amounts of sugary drinks containing different levels of fructose, glucose or sucrose (which is a glucose/fructose mix). 

(Quick reminder: Our foods and drinks are usually sweetened with sucrose (table sugar) or high fructose corn syrup (HFCS); both types of sweeteners are a combination of the simple sugars glucose and fructose.) 

Each participant spent 3 weeks on each of the following 6 beverage regimens, with a 4-week washout between interventions: 

• Medium fructose: 40 g of fructose a day

• High fructose: 80 g of fructose a day

• Medium glucose: 40 g of glucose a day

• High glucose: 80 g of glucose a day

• High sucrose: 80 g of sucrose a day

• Control: No sugary drinks at all

Just to put the sugar content in perspective: The medium sugar interventions are equivalent to drinking 1 can (12 oz.) of coke/day; the high sugar interventions are equivalent to drinking 2 cans (24 oz.) of coke/day. 

The experiment lasted about 44 weeks; here are some of the main findings:

• Waist-to-hip ratio increased in the medium fructose, high fructose and high sucrose interventions (higher waist-to-hip ratios indicate abdominal obesity, which is associated with an increased risk of heart disease and type 2 diabetes)

• Fasting glucose levels increased in all five sugary drink interventions

• C-reactive protein, a marker of inflammation, increased in all 5 sugary drink interventions, with the highest values seen in the high fructose intervention.  Inflammation is a key factor in the development of both heart disease and type 2 diabetes

• There was a reduction in large, buoyant LDL particles when participants were consuming fructose drinks (high and medium fructose and high sucrose interventions).  A regular lipid profile measures only total LDL, which didn’t change between interventions; we now know that there are subclasses of LDL, and the smaller LDL molecules pose more risk and have a higher tendency to block arteries.  The large buoyant LDL is, as the name implies, flexible and bouncy, and causes less lumps and blocks.

• All sugary drink interventions lead to some increase in caloric intake

• Leptin (a hormone that regulates appetite and metabolism) increased in the medium and high glucose interventions, but not in the fructose and sucrose interventions

What can we learn from this study?

The first conclusion we can draw from this study is that fructose does seem to cause more damage than glucose – fructose leads to lipid abnormalities and more belly fat accumulation.  On the other hand all sugary drink regimens, including the moderate glucose exposure, had pretty unhealthy results: all 5 interventions increased markers of inflammation and increased caloric intake.

The practical, real-life understanding is that all sugary drinks, even in what many would consider “moderate” amounts, seem to have a measurable undesirable effect after as little as 3 weeks. 

As far as I know there are no popular drinks in the market sweetened by glucose; practically all forms of caloric sweeteners used in food processing are a glucose/fructose mixture.  Cane or beet sugar are sucrose (table sugar), which is a two-sugar molecule with exactly 50 percent glucose, 50 percent fructose. HFCS is about 45 percent glucose, 55 percent fructose. Fruit juice concentrate's sugar composition will depend on the fruit source: Apple juice concentrate is about 30 percent glucose, 70 percent fructose, while orange juice concentrate is about 50 percent glucose 50 percent fructose.  Agave syrup is about 70-75 percent fructose.

All sugary drinks contain fructose, and if this study’s findings are confirmed in larger and repeated studies, there’s reason for worry.

Dr. Ayala

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

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

The sugar wars: Is fructose the main villain?

There is very little doubt that drinking sugary drinks regularly is associated with obesity, type 2 diabetes, hypertension and heart disease.

But does drinking sugar just make us consume too many empty calories, or is there something inherently unhealthy about sugar? Is high fructose corn syrup (HFCS) the villain? Is old fashioned sugar any better or just as bad? Will agave (with its low glycemic profile) save us? And what’s all this talk about fructose being toxic?

Food sugar 101

Our foods and drinks are usually sweetened with sugars that are a combination of the simple sugars glucose and fructose. Sucrose (table sugar) is a two-sugar molecule with one glucose and one fructose bound together, and is therefore exactly 50 percent glucose, 50 percent fructose. HFCS is about 45 percent glucose, 55 percent fructose. Fruit juice concentrate's sugar composition (stripped down concentrated fruit juice is really just sugar!) will depend on the fruit source: Apple juice concentrate is about 30 percent glucose, 70 percent fructose, while orange juice concentrate is about 50 percent glucose 50 percent fructose.

Agave syrup, favored by those adhering to a low glycemic diet, is about 70-75 percent fructose.

What you need to remember is that practically all forms of caloric sweeteners used in food processing are a glucose/fructose mixes. Although only HFCS has fructose in its name, all our commonly added sugars contain both fructose and glucose. Corn syrup stands apart as a pure glucose sweetener, but since pure glucose is less sweet than HFCS or sucrose, it isn’t economic – or tasty -- to use.

Is fructose more harmful than glucose?

A study from the University of California at Davis, led by Peter Havel, made headlines a couple of years ago when it showed that drinking 25 percent of daily calories in fructose for 10 weeks increased triglycerides and cholesterol and caused insulin resistance in people, while drinking the same amounts in glucose didn’t. And while both the fructose and the glucose groups gained weight during the study, the fructose group gained more belly fat.

The study concluded that drinking lots of fructose lead to unique adverse effects on lipid metabolism, insulin resistance and abdominal obesity, effects not seen when drinking the same amounts in glucose.

What explains our body’s different reaction to these two sugars? The authors hypothesized that since fructose is metabolized in the liver, fructose sweetened beverages affect the liver’s metabolism of fats; glucose is metabolized in every cell of the body, doesn’t need as much of the liver’s attention, and therefore the adverse metabolic effects weren’t seen in the glucose beverage drinkers.

But one question lingered: Could high levels of blood sugar and blood insulin explain fructose’s adverse metabolic outcomes?

To answer that question the authors went back to study the blood samples of the people enrolled in their initial study. They published the findings of their new research in the American Journal of Clinical Nutrition (published online ahead of print). Havel’s group found that the 17 people who were drinking 25 percent of their calories in fructose were actually consuming a diet with a lower glycemic index, and their blood glucose and insulin after meals were lower than the fluctuations seen in the 15 people consuming 25 percent of calories in glucose.

To conclude, in this 10 week study, drinking fructose caused dislipedimia and insulin insensitivity unrelated to blood sugar and insulin levels. On the other hand drinking glucose caused rollercoaster peaks and troughs of blood glucose and insulin, while not causing dislipedemia.

The dose makes the poison

Fructose is metabolized by the liver, and this study supports the notion that its excess consumption plays a part in causing insulin resistance (which leads to diabetes), high cholesterol and triglycerides (all risk factors for heart disease) and the tendency to accumulate belly fat (a risk factor for a myriad of diseases, including heart disease, high blood pressure and cancer).

While drinking glucose may not affect our fat metabolism in the same way fructose does, glucose causes spikes in blood sugar and blood insulin – which are not good either.

If you’re concerned with fructose, you should be concerned with the intake of all the sweeteners that contain fructose -- that includes not only HFCS, but also cane and beet sugar (table sugar), molasses, agave, brown sugar, fruit juice concentrates and honey.

I don’t personally believe glucose or even fructose are evil. Our body, especially our brain, runs on simple sugars, and sugars, including fructose, are a natural part of very healthy foods, such as fruits and veggies.

It is excess sugar – of any kind – that is harmful. The dose makes the poison.

Excess sugar is hard to come by in nature unless you run into a beehive and the bees are willing. It takes a lot of berry picking to hit your liver with the fructose dose that is anything similar to what’s in a can of soda. Only processed foods, and especially sugary drinks, hit your liver with that much fructose at such high speed. Fructose containing foods in nature have fiber (and much less sugar) and break down slowly. On the other hand processed foods and especially sugary drinks have no fiber – just lots of fructose – and we’ve shown a tremendous capacity to chug them down real quick.

Does the study’s experiment resemble real life? On one hand, the study group drank 25 percent of daily calories in sugar. We’re bad but not that bad: A recent study shows that our teens consume 21 percent of their daily calories from added sugar.

On the other hand, the study lasted for 10 weeks. Our kids are ingesting a large proportion of their daily calories as glucose/fructose mixtures for years and years.

Considering the current evidence, this is not an experiment we should be conducting.

Dr. Ayala

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

Further reading/viewing:
• Dr. Robert Lustig explores the damage caused by sugary food in this controversial & much viewed video: Sugar: The Bitter Truth.
• Gary Taubes’ New York Times Magazine article: Is Sugar Toxic?

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

Immunity boosting foods? Really?

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

The connection between diet and health was proposed some 24 centuries ago by Hippocrates, and I can imagine he first heard of it from his mom, who heard it from her ancestors.

Today, grandmas, moms and physicians have piles of scientific evidence supporting their observations and advice. It’s true: Diet does play an important role in health. We’re learning more each day and the discovery is fascinating.

Unfortunately, scientific discoveries are being overly-interpreted to promote the sale of foods, and scientific jargon appears all too often as buzzwords on packaged goods.

Every Flu season and especially the recent spread of the new H1N1 virus have given rise to a new barrage of immunity claims shouting at us from every supermarket shelf and commercial. It’s a perfect time to look at the diet/health connection and these claims.

A short introduction to food label claims

There are several types of claims allowed by the FDA on foods.

A health claim describes a relationship between a food or food component and a disease, and it must:

• Be pre-approved by the FDA. There are currently slightly more than a dozen of these approved claims.

• Be phrased in the specific language the FDA requires. The claim must indicate that the disease may be caused by a variety of causes, and must state that the food should be consumed as part of a healthy diet.

• Appear on food that meets certain nutritional requirements.

A structure/function claim is quite a different animal.

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

A Structure/function claim:

• Requires no FDA pre-certification.

• Can be attached to any food, including junk food (there are no overarching nutritional requirements).

• Can be phrased in many ways.

• Is the manufacturer’s responsibility. While the claim “must be truthful and not misleading”, there’s no specification about how much evidence is needed to make the claim.

A few quick examples:

“Calcium reduces the risk of osteoporosis” is a health claim; “calcium builds strong bones” is a structure/function claim.

“Fiber may reduce the risk of some cancers” is a health claim; "fiber maintains bowel regularity," is a structure/function claim.

Confused? You’re in good company. Most consumers can’t tell the difference.

Even the pros in the food industry can’t necessarily make sense of structure/function claims. They consult expert lawyers whose entire practices are devoted to advising companies on the language of the label. Creative marketing devises the claim and legal counsel makes sure it’s defensible and at least somewhat based on reality.

What’s clear is that the structure/function claim has been a boon to food manufacturers. Since there are so few limitations on its use and the trusting public can’t distinguish between a health claim and a structure/function one, why not be creative, develop a claim that meets your goals and slap it on the package? Market research shows these structure/function claims really help with sales.

What's the evidence backing these “immunity” claims?

There are, in fact, no approved health claims related to immunity.

What does that mean? It means that no one has presented to the FDA enough evidence of a relationship between a food, a food ingredient or a dietary supplement and reduced risk of contracting or of treating an immune mediated or infectious disease such as the flu to warrant a health claim.

That means the immunity claims you see everywhere are all structure/function claims.

What are the claims based on? The immune system is very complicated, and its integrity depends, among other things, on good nutrition. States of vitamin, mineral or protein deficiency lead to reduced immunity and correcting the deficiency does improve immunity.

But while it’s true that if you had a vitamin C or zinc deficiency you could improve your health and immunity by eating a vitamin-fortified cereal or a vitamin supplement, it’s clear that shouting “Immunity!” from the cereal box is misleading. Vitamin deficiencies are rare, and therefore the cereal might be yummy, but it’s not doing much for your immune system.

Most food contributes to one’s health, so by that token we can add a structure/function claim to pretty much anything:

• Sleep, for example, is very important to immunity; should we advertise mattresses as immunity boosters? All mattresses or only some brands?

• Exercise improves immunity. Maybe “immunity now!” should be painted on sidewalks?

• Stress reduction improves immunity; how about an “immunity massage”?

• Why, even breathing air supports immunity.

These immunity claims are all without much substance I’m afraid, but it’s especially outrageous to see them on junk food. Cocoa Krispies is 40 percent sugar, but hey, don’t you need to maintain normal sugar levels for good immunity? Correcting potential hypoglycemia is critical for good immunity, isn't it?

Thankfully, after receiving a letter from San Francisco’s city attorney last November, Kellogg announced it would phase out the immunity claims on Cocoa Krispies.

Will misleading claims ever end?

Two scenarios I can imagine:

• Consumers will start rejecting these claims, viewing them as a hyped and misleading insult to their intelligence, and move toward products that are marketed in a more sensible and honest way.

The only reason these claims abound is because we’re buying them.

And here comes my question: Do people really believe that they can buy immunity in box? Or are they buying it knowing that an easy fix is a fantasy, but it still feels good to dream?

• The second option is the litigious route: A few really big class action suits, representing misled consumers who saw no health benefits from investing their hard-earned money in products that failed to deliver can change everything. In that respect, the recent FDA warning letters to manufacturers who post misleading or false claims could act as important evidence and actually make a difference.

I prefer the first scenario.

There’s actually a third possibility.

The FDA can overhaul the whole health-claim structure/function scene, crackdown on false and misleading claims and help consumers understand that good health (and building a strong immune system) has nothing to do with buying products that make health claims. People need to just eat well by consuming healthy, real foods over a long period of time.

Sorry, but that’s the truth—eating well is about good habits and good food, not about sprinkling vitamins, anti-oxidants and omega 3 on processed food. The Center for Science and Public Interest (CSPI) is urging the FDA to do just that in a report it recently sent. (It’s 158 pages, but well worth a read, and it includes lots of pictures.)

So, what to make of these medicinalized foods?

I think it’s best to simply leave them on the shelves and opt for good, healthy choices. As Hippocrates said, “To do nothing is sometimes a good remedy.”

Happy healthy new year!
Dr. Ayala

Silly science, silly inventions and other 2010 follies

An end of year tradition — now in its second year — I’d like to share some of the studies I failed to mention during this passing year, and pay tribute to some outstandingly ridiculous achievements in food, health and weight-loss.

Beware of the beard bugs

Fall season is celebrated with many beautiful and tasty traditions, and one fall event I really look forward to is the Ig Nobel ceremony. The Ig Nobel awards are a parody of the Nobel Prizes, and have been awarded for the past 20 years for funny, absurd or unexpected (but all too real and methodically correct) scientific research in a ceremony attended by all too real Nobel laureates at Harvard University.

As a testament to the credibility of the Ig Nobel research and researchers, I want to mention that one of this year’s physics Nobel Prize winners, Andre Geim, already has an Ig Nobel to his name — his Nobel is for experiments with graphene; the Ig Nobel for levitating a frog. We can only wonder whether both are displayed on the same shelf.

And since food safety has been on our minds this year — and for good reason — I’d like to mention the Ig Nobel 2010 Public Health Prize. Long overdue, the prize was given to Manuel Barbeito, Charles Mathews, and Larry Taylor for proving that microbes cling to beards and can be a source for microbial spread.

Their study, conducted on bearded scientists, showed that beards retained harmful viruses, bacteria and toxins despite washing with soap and water.

Perhaps that’s why we expect men (and women) working with food to be clean shaven, or for beards to be neatly covered. Can you think of famous chefs with beards? James beard had no beard. The quintessential American chef not only was clean shaven — his bald head was his trademark. Baldness is good for food.

Running to look for a clip for my long, unruly locks.

Even faster fast-food

Embarrassing, but this genius idea was not invented here – it originated in South Korea. BBQ Chicken and its South Korean sister BHC Chicken offer the ultimate hybrid, the Col-Pop: A cold drink cup topped with fast food upper layer container, ensuring maximal stuff-your-face technology at minimal effort. As reported by seriouseats: “It's perfect for handy snacking while walking, driving, talking on the phone, or—as we discovered the other day—blogging”.

Are we losing our edge? Is our lead as the fattest nation under threat? C’mon, we have to make sure we’re no 1 in at least in something. We can make a better Col-Pop. How about a cup that freshly grinds the solid part of the Col-Pop, and delivers the chewed food through the straw? Saves on chewing, frees the snacking hand.

Dieters dream come true

Girdles have been around for a while and they work! They have been boosting butts, taming tummies and shaping the shapeless, and today’s body shapers are allegedly even a little bit comfortable (let’s see men wear them!), and such an upgrade from the tight corsets that caused the fainting epidemic of the Victorian era.

But did you know that there’s clothing you can wear that can slim you down? Yes, Skineez shaping garments contain “fat fighting cream” that will “smooth, firm and soften your skin” with a “balanced combination of anti-cellulite ingredients”. The jeans, at the bargain price of 159.99 are a great deal, because: “Skineez is proven to reduce inches and firm loose skin without diet and exercise!” and “You will see results in as little as five days!”

Every time you see “without diet and exercise” an alarm bell should ring, but when a product also claims to fight cellulite, your incredulity should be at maximal alert. Girls, I hate to break it to you, there is no cure for cellulite, just like there’s no way to lose inches without diet or exercise. The only thing Skineez can add to achieve less credibility is magnetic fields and alien visits.

So how come this is on TV? I’m just as baffled. Does anyone at the Federal Trade Commission ever suffer from insomnia? Late night TV infomercials are so loaded with fraud and quackery that it boggles the mind.

Genetically modified food to the rescue

Genetic modification of food promised to make the world a better place: Increase the nutritional content of food, provide drought and pathogen resistance crops that can solve world hunger, and decrease the need for chemicals in agriculture.

What genetic modification provided, for the most part, were Round-up ready patented seeds, lots of profit for Monsanto, and lots of worry for everyone else.

And now, a great development that I have no idea how we could live without: The genetically modified apple that resists browning. A Canadian company is awaiting the USDA’s approval for its patented technology, which silences the browning reaction the apple mounts when it’s bruised or cut. Hey, it might get some fussy kids eating more apples! GMOs to the rescue of human kind.

Feel free to share what impressed you most this year.
Dr. Ayala

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

Want milk? Lactose intolerance shouldn’t stop you

Are most Americans lactose intolerant? Do all dairy products contain lactose? How critical is it to stick to a lactose-free diet?

Although most of us know someone who is lactose intolerant, and “lactose intolerance” frequently comes up in health-related conversations, there are many myths and misconceptions regarding this common digestive issue. I’d like to take a look at this malady and at the findings of a recent National Institutes of Health (NIH) consensus conference on lactose intolerance, where experts in many medical fields pored over the relevant medical literature, discussed findings and developed a state-of-the-science statement that includes a few surprises.

(This post is about the common form of lactose intolerance—primary lactose intolerance—and is not about lactose intolerance that arises from illness or intestinal injury, or the rare cases of babies born unable to digest lactose.)

Lactose and lactose intolerance

Chemistry moment (this won’t take long): Lactose is a two- molecule sugar (or disaccharide) made up of one molecule of glucose and one molecule of galactose. In order to absorb lactose our body needs to break the bond between the two simple sugars using the enzyme lactase.

Lactase is abundant in the human intestine in infancy, but its level declines with age in many people. Lactase production is a fascinating example of our body’s ability to turn genes on and off; while the genetic code for producing lactase is in the cell, the cell can turn off production partially or completely.

Those of us with lower levels of lactase don’t break up some or all of the dietary lactose, which will reach the large intestine undigested; there, bacteria will happily feast on the sugar and produce gasses: carbon dioxide, hydrogen and methane. Undigested sugars can also draw water from the intestinal walls, causing bloating and diarrhea.

But low lactase by itself doesn’t define lactose intolerance; most people who have low lactase don't experience signs and symptoms (the common ones being diarrhea, abdominal pain, gas, bloating or nausea). Only people with both low-lactase levels (measured by a health professional) and associated signs and symptoms have, by definition, lactose intolerance.

How common is it?

Surprisingly, the NIH panel concluded that we don’t really know.

Many people with low levels of lactase have no symptoms. Many people with gastro-intestinal symptoms attribute symptoms to lactose intolerance even if they haven’t demonstrated deficiency of lactase; their symptoms may very well be due to other reasons.

What we do know is that low lactase varies across ethnic groups, occurs less frequently in European Americans and more frequently in African Americans, Asian Americans and Native Americans.

Do people with lactose intolerance need to avoid lactose?

Let’s start with an explanation of the big difference between lactose intolerance and serious food allergies or gastrointestinal immune diseases such as celiac.

Food allergies can cause life-threatening systemic reactions after exposure to minute amounts of the offending food. Likewise, the intestine of a celiac patient suffers changes to its surface—changes that can lead to malabsorption, anemia and even cancer—even if exposed to very small amounts of gluten.

But not absorbing some of the sugars in our food is part of everyday life for all of us.

Beans, for example, contain sugar chains—called raffinose oligosaccharides—which no human can break down. The sugar polymers are digested by bacteria in the gut resulting in the well-know bean related flatulence—the butt of many jokes—and can also cause symptoms resembling those of lactose intolerance.

Some people experience no discomfort after eating beans while others limit their intake of beans because large amounts cause them symptoms. There are even individuals who experience such great discomfort that they choose not to eat beans at all. Our individual anatomy and physiology, our intestinal microbial flora, as well as the way we perceive pain and social awkwardness differs a lot. And by no means are beans unhealthy—they are in fact very good to eat!

Milk contains a considerable amount of lactose, much more than the undigested sugars in beans, but the bean analogy can perhaps explain some of the symptom variability we see with lactose intolerance.

So how much milk can people with lactose intolerance tolerate?

The NIH panel looked at the best studies, and concluded that most lactose-intolerant individuals can take in 12 grams of lactose (the equivalent of one cup of milk) in a single sitting with minimal or no symptoms and can tolerate larger amounts if the lactose if ingested with meals or spread over the day. A quart of milk (50 grams of lactose) ingested without food in one sitting will induce symptoms in most lactose-intolerant people. There’s also some evidence showing that the body gets used to lactose, and can tolerate more lactose if routinely exposed to it.

The most important long-term health consequence of lactose intolerance may be calcium deficiency

There are many ways to eat healthy, and dairy is by no means necessary for a balanced diet. Balanced Asian-type and vegan diets are perfectly healthy with little or no dairy. Calcium sources—both naturally occurring or in supplements—are plentiful. (Foods rich in calcium include collard greens, turnip greens, kale, bok choy, soybeans, okra, broccoli, some fish, cultured soy yogurt, tofu, almonds, and calcium-fortified orange juices, soy milks and cereals.)

But dairy products are by far the most prevalent—and least expensive—source of calcium in the Western diet. Since many people with real or perceived lactose intolerance avoid dairy products, they may consume inadequate amounts of calcium and vitamin D (which is added to milk), leading to weaker bones and osteoporosis.

Therefore the diagnosis of lactose intolerance should be made judiciously, and the treatment plan should include assuring that dairy avoidance, if necessary, won’t lead to nutritional deficiencies.

Lactose sources

Milk products vary greatly in their lactose content.

Milk itself has a lot of lactose, but aged cheeses have very little (most of the lactose is drawn away in the whey, and what’s left in the curd is fermented by bacteria and mold). Yogurt with live cultures contains bacteria that break down lactose, and therefore causes fewer symptoms. Butter and full-fat cream cheese contain almost no lactose.

Practical tips

If you think you have lactose intolerance:

Talk it over with your doctor; getting an accurate diagnosis for your symptoms can be important. Some of the causes of recurrent abdominal pain are treatable and it’s not a good idea to commit to an elimination diet for the wrong reason.

If you do have lactose intolerance:

Find a reduced-dairy eating plan that controls your symptoms, while enabling both good nutrition and enjoyment of food.

Eat dairy products with less lactose (cheese, yogurt) and spread your dairy consumption throughout the day. Consume dairy as part of a meal.

Make sure you get enough of the nutrients usually found in dairy, especially calcium.

Consider using lactase products; these are dietary supplements that help digest lactose.

Above all, listen your body—treatment and diet plans can’t ever be one size fits all. Find what works for you and stay healthy!
Dr. Ayala

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

Misleading health claims finally under fire

Is the health claim party coming to an end?

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

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

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

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

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

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

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

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

The giant loophole

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

That loophole is the structure/function claim.

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

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

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

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

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

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

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

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

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

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

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

Dr. Ayala

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

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

Related post: Are “functional” foods healthy foods?

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