Healthy Food & Healthy Living by Dr. Ayala

Is extra belly fat a health issue?

Have you ever wondered why it is that some people accumulate fat predominantly in the abdomen, while in others the fat is spread all around? Are people who are generally thin but have big bellies at high risk for chronic diseases, such as diabetes and heart disease although they have normal weight?

I’m sure we can all recognize abdominal fat when we see it, and a measuring tape quantifies what the naked eye easily identifies. Other names include “central fat”, “beer belly” and “visceral fat.” The latter term actually helps explain why abdominal fat behaves differently: The viscera are our internal organs, and visceral fat is the fat deposited between the abdominal organs in the torso, as opposed to subcutaneous fat, which is fat under our skins—the type you can pinch between your fingers. Abdominal or visceral fat is especially active metabolically and plays a part in insulin resistance and diabetes, lipid abnormalities, hypertension and cardiovascular risk.

Several studies have shown that fat distribution patters do matter.

A huge new study in the New England Journal of Medicine confirms this notion. It shows that abdominal obesity is more closely associated with the risk of chronic diseases than is general obesity, and that waist circumference or the waist-to-hip ratio, may be better predictors of the risk of disease than the body-mass index (BMI).

This study comes from the European Prospective Investigation into Cancer and Nutrition (EPIC), one of the largest long-term prospective studies in the world, which studies the relationships between diet, nutritional status, lifestyle and environmental factors and the incidence of cancer and other chronic diseases.

In this study, the researchers looked at 359,387 participants from 9 European countries. During the follow-up period, which averaged almost 10 years, 14,723 (or about 4%) of the participants died. The data suggest that both general fatness and abdominal fatness are associated with increased risk of death.

After taking general fatness into account, waist circumference and waist-to-hip ratio were strongly associated with the risk of death independently of overweight. People with the most belly fat had about double the risk of dying prematurely as people with normal amount of belly fat, and death risk increased with waist circumference whether the participants were overweight or not.

This study, essentially confirms what we already know: Excess body fat affects mortality, and the effect depends not only on the amount of extra fat (as reflected by BMI) but also on its distribution, with belly fat predicting higher risk.

This study provides important further evidence that in normal weight individuals abdominal obesity is a significant risk factor.

The authors write:

“Our finding of a positive association between waist circumference and the risk of death among participants of normal weight may also explain why studies have been unable to show a linear relationship between BMI and the risk of death across the entire range of BMI values.”

And they advise:

“The results support the use of waist circumference or waist-to-hip ratio in addition to BMI in the assessment of the risk of death, particularly among persons with a low BMI.”

As to why some people accumulate fat in the center, while others spread it around, there are no clear answers. Some ethnic groups—such as Asian Indians and Hispanics—have a higher tendency to accumulate abdominal fat, as do children born small who rapidly gain weight between the ages of 4 and 7 years. Aging, imbalanced hormones, being male, over-intake of sugars and lack of exercise have all been suggested to be factors for belly fat accumulation, too.

As to the “beer belly” theory: There’s a common belief that beer drinkers have bigger bellies than either nondrinkers or drinkers of wine. The few studies on the association between consumption of beer and abdominal obesity produced inconsistent results. Beer has plenty of calories (an average of 150 calories for a 12 oz. bottle), so drinking lots of beer regularly adds a lot of calories one needs to burn, otherwise fat will accumulate. However, I don’t think there’s good evidence to show that this fat will find its way specifically to the abdomen.

What’s clear is that, unlike banks, which give us a choice of where to deposit our money, we don’t get to choose where to put our fat. And unfortunately, no amount of sit-ups will make a fat belly go away. The overlying muscles will get stronger, but the fat inside won’t dissolve preferentially in the exercised areas.

So what to do about abdominal fat? Lose weight. That, of course, is easier said than done, but the good news is that visceral or fat is lost preferentially with even modest weight loss—belly fat is the first to go when you diet!

Ayala

Calorie posting laws spread—healthier choices follow

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

Why is calorie posting such a good idea?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ayala

Eat slowly and help lower the risk of obesity

Slow down and take time to eat your meals. You’ll enjoy your food more and you may even stay healthier.

A recent article in the British Medical Journal (BMJ) shows that the odds of being overweight were three times greater for people who reported eating quickly and until full than for people who ate slowly and stopped eating before they felt stuffed.

More than 3,000 Japanese men and women aged 30-69 participated in the study. Participants completed a diet history questionnaire about their eating habits, their height and weight were measured, and their BMI (body mass index) was calculated.

The researchers reported that around half of the men and just over half of the women said they ate until they were full, and just under half (45.6%) of men and 36% of women said they ate quickly.

The odds of being overweight were about twice greater for the “ate until full” group, about twice greater for those who ate quickly, and more than triple for participants who both ate quickly and until full.

The authors conclude:

"Eating until full and eating quickly were significantly associated with overweight in Japanese men and women after adjustment for total energy intake and other potential confounding factors. The combination of the two eating behaviours had a supra-additive effect (additive interaction) on being overweight.”

In an editorial, accompanying this article, Elizabeth Denney-Wilson and Karen Campbell write (emphasis is mine):

"Clinicians should encourage parents to adopt a child-led feeding strategy that acknowledges a child’s desire to stop eating that begins from birth. Reassure parents that well children don’t starve. Furthermore, because children find it difficult to regulate their energy intake, it is important to inform parents of the environmental stimuli that promote positive energy balance such as serving excessively large meals.

Discussion about replacing energy dense snack foods and drinks with core foods and water, appropriate serving sizes and body weight, what comprises a healthy diet, eating in non-distracting environments, eating together with an adult, and role modeling with slow and relaxed eating is likely to be useful.”

I find that eating in company really slows down my eating, and I tend to be satisfied by less food when I’m in good company, eating leisurely, and the meal is divided to several small courses. It gives time for satiety to kick in, as satiety signals need time to develop and communicate with the brain; it’s only then that the brain activates the satiety response that makes us stop eating

Most adults are ineffective at regulating energy intake, and there’s no built-in calorie counter in our body to stop us from overeating. We’re therefore overly influenced by external cues, such as an all-you-can-eat buffet, the size of a plate and the portion we’re served and “super sized” options that provide good economic value.

But babies and young kids start off with a healthier ability to regulate how much they eat. A healthy baby will stop drinking milk when satiated—there’s nothing you can do that can change its mind—and most young kids will push away the plate once they aren’t hungry.

Unfortunately, many parents encourage their kids to eat a little more, finish what’s in the plate, and “take just one more bite,” while what we should really do is appreciate and respect the kids’ natural instinct to eat just the right amount. Eating until full is actually an uncomfortable feeling the very young avoid, and we should all learn from them, not corrupt them into our unhealthy habit of eating too much.

There’s also something especially “fast” and stuffable about highly processed foods and fast food. The foods are snackable, packaged and formulated so that you can eat them while doing something else, often without a table or utensils. Drinks are designed to be chugable--gulped down in seconds. One can hardly imagine dining on these foods in a leisurely way.

I personally suspect that there’s also something about fast food that leaves people chronically unsatisfied from the culinary point of view. Perhaps fast food keeps us looking for more because the real joy of eating food that’s both good and good for you just wasn’t met.

So slow down and take the time to enjoy and celebrate food. It’s one of the pleasures we can indulge in daily. I believe that if you take the time to savor the taste of good food you’ll be less likely to overeat too.

Ayala

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

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.

Ayala