Healthy Food & Healthy Living by Dr. Ayala

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 developed 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?

Food, nutrients and relief from the common cold

Medical science has no cure for the common cold; symptomatic relief is the best we can offer as we wait for our body to overcome the viral illness.

Although the common cold is generally a mild disease and poses no real threat to overall healthy people it can be quite unpleasant. As a mom and a physician I really like having some helpful, natural, inexpensive common sense therapies to prescribe.

A good number of the methods used today haven’t changed much since my grandma’s time: Her advice was drink lots of liquids, get plenty of rest and eat chicken soup, but every grandma’s different and home remedies change from culture to culture.

Most of these home remedies pose no harm, and are well worth a try, even if there’s only an anecdotal notion of benefit. But I wanted to see if any of the remedies have attained enough scientific support through rigorous research so that we can now firmly say these kitchen-based medicines work better than a placebo, and there’s more than suggestion in their mechanism of action.

So, I headed to the online Cochrane library looking for reports on some of these natural remedies.

Before I get into the details of what I found, I’m sure you’ve been wondering how we make sense of study results when one study shows one finding while another study refutes those results. The experience can leave everyone quite confused, not knowing what to believe. But this is how the scientific method works. It’s only through refining and repeating studies that we can arrive at a tentative conclusion. The Cochrane reviews aim to do just that—take into account only the best of studies, and see if there’s enough evidence to prove efficacy.

The global Cochrane Collaboration is an independent network of volunteers that doesn't accept conflicted funding, and whose mission is to gather the best available evidence, summarize and interpret the results and make them readily available as a resource for evidence-based medicine on which to base scientifically grounded health-care decisions. (The full reports require a subscription, but the abstracts and summaries are free.)

Now, here are some interesting findings from the library:

Garlic

Garlic’s is a common-cold remedy handed down for generations in my husband’s family, and while I love garlic in cooking and use plenty of it, the result of a spouse consuming half a head of raw garlic is offensive to my nose. I just hate it! I admit I’m biased here; I really wanted this one to be proven ineffective.

The Cochrane report authors looked for randomized controlled trials of common-cold prevention and treatment comparing garlic with placebo, no treatment or standard treatment, and found five such studies with only one fulfilling their criteria. The study included 146 people and found that people who took garlic (in supplement form) every day for three months had fewer colds and fewer days of illness with a cold than people who took a placebo. They found no information from randomized, controlled trials about whether taking garlic at the time of a cold reduces either symptom severity or the number of days of illness.

They conclude:

“While this one study was positive, there is a need for large, high-quality randomised controlled trials to support these findings. Possible side effects in this small trial included odour and a skin rash. More information is needed about the possible side effects of garlic.”

Honey

Honey has been used from ancient times for many medical purposes, from wound healing to respiratory relief. Mixing honey into warm milk, tea or juice is a time-honored sore throat soother and cough suppressant.

The Cochrane reviewers looked for randomized, controlled studies comparing honey to placebos for the treatment of chronic cough, and found none that were applicable for review. In other words, there are no good studies out there, therefore no proof for or against honey for a four- week-old cough.

Honey for acute cough has shown promise in some studies, in which it outperformed both no treatment and cough syrup, and this treatment modality is currently evaluated by the Cochrane group.

A word of caution: Honey should not be given to kids younger than one year due to the risk of infant botulism.

Plenty of fluids

Drinking plenty of liquids makes sense: the water replaces losses due to rapid breathing, reduces the viscosity of mucus (therefore reducing congestion) and prevents dehydration. Alas, the reviewers found no evidence for or against increasing fluid intake during the illness—no randomized controlled studies have been conducted.

Vitamin C

Vitamin C was popularized by Nobel Laureate Linus Pauling in the 1960s and has been used widely as both a preventive and therapeutic agent for the common cold for decades. It’s still very controversial.

The Cochrane review was restricted to placebo-controlled trials testing at least 0.2 grams per day of vitamin C. Thirty studies involving more than 11,000 participants were analyzed and they showed:

• Regular ingestion of vitamin C has no effect on preventing the common cold in the ordinary population.

• Vitamin C reduced the duration and severity of common cold symptoms very slightly, and the magnitude of the effect was so small its clinical usefulness was doubtful.

• Six trials included participants exposed to short periods of extreme physical or cold stress or both (including marathon runners and skiers). In these people vitamin C reduced the common cold risk by half.

• Trials of high doses of vitamin C administered to treat the common cold showed no consistent effect on either duration or severity of symptoms. The authors call for more therapeutic trials (especially ones including kids who weren’t studied in trials) to settle the question.

Echinacea

Echinacea is a plant widely used for the common cold, but preparations vary greatly (there are many Echinacea species, and different parts of the plant are utilized in different ways). The Cochrane review found 16 clinical trials investigating the effectiveness of several Echinacea preparations for common-cold prevention or treatment.

Two trials using Echinacea for 8 to 10 weeks for common-cold prevention showed no clear effect.

Most of the trials investigated Echinacea for treatment of common-cold symptoms, and it seems that some preparations may be effective in adults, but the results were inconsistent. There’s no evidence of efficacy in kids. Side effects were rare, and included rashes in one trial in kids.

Zinc

Seven trials of variable quality were included in the review, and no strong evidence was found to show that zinc lozenges reduce the duration of the common cold. Side effects included mouth irritation, unpleasant taste and diarrhea.

As for chicken soup, I couldn’t find it in the Cochrane reviews. A study in CHEST (the cardiopulmonary and critical-care journal) looked at mucus velocity and airflow through the nose of 15 healthy people after they drank cold water, hot water or chicken soup. The results showed that both hot fluids increased the flow of mucus for about 30 minutes, with the chicken soup outperforming the hot water significantly. Another study in CHEST showed that chicken soup inhibited the movement of neutrophils (a subset of white blood cells) in the lab. So there is some evidence supporting my grandma’s regimen.

Writing this post and going through these studies reinforces my respect for the wisdom of traditional methods for symptom relief. Many of these old-fashioned remedies show some benefits, are worth a try, and won’t hurt. I think the current evidence on Echinacea, vitamin C and Zinc tend to show little or no efficacy, and zinc can have some nasty side effects, so I’d personally stay with the food remedies, and not the supplement ones—their safety profile’s better.

As to the garlic: I’m hoping my husband won’t read this post and decide on garlic as a preventive regimen, taken continuously. Personally, I think the secret to garlic’s success is that no one ventures near you when you eat that much raw garlic. Isolation is perhaps the best way to prevent the spread of communicable diseases, including the common cold. Washing hands frequently and well is probably the best preventive measure of them all.

Have a healthy fall,

Dr. Ayala

Whole wheat banana bread with mint sauce

I’ve always wondered why banana bread is called banana bread and not banana cake.

Is it because it’s baked in a bread pan, and not in a round pan? Is the name designed to make us feel better about eating it—bread’s a necessity and cake’s an indulgence?

To be honest, this recipe, although a more nutritious version than your ordinary banana bread, still should be filed in the dessert section due to the sugar and fat content. (To me, bread is flour, yeast, salt and water, with maybe trace amounts of added fat and sugar.)

Having said that, I do love banana bread. Like most banana-loving families, I find over-ripe bananas in my fruit bowl quite often. Bananas are a tricky fruit: They’re at their best when just ripe, and if you happen to look away for a few hours and neglect to consume them in time, you’re in banana bread territory with over-ripe bananas—still delicious, but not lunchbox material.

I write and speak often about the poor eating habits most of us have, especially related to fruit and vegetable consumption. The Centers for Disease Control and Prevention reported this week that fewer than ten percent of U.S. high-school students eat the combined minimum five-a-day daily recommended servings of fruits and vegetables, with some states such as Arkansas and North Carolina faring significantly below those averages and some New England states, particularly Vermont, doing notably better.

Combining bananas and mint into a bread or cake isn’t the answer to our kids’ low intake of fruits and veggies—not at all. But it is another fine use for these plant-based foods we should have in plenty at home and in our kids’ lunchboxes, available for snacking and ready to eat. And, just to be clear, I recommend eating most fruit raw.

However, this bread/cake is a delightful exception-—moist, scented, full of fruit and really delicious! Try it.

INGREDIENTS

For the mint sauce:

1 cup packed fresh mint leaves
1/4 cup almonds
1/4 cup honey
1/2 tablespoon vanilla extract

For the banana bread:

3 or 4 very ripe mashed bananas
1½ cups of whole wheat flour
2 tablespoons melted butter
½ cup sugar
½ cup dark raisins
2 eggs
1 teaspoon ground coriander
1 teaspoon vanilla extract
1 teaspoon baking powder
Pinch of salt

PREPARATION

• Make the mint sauce: puree all ingredients to a thick paste using a food processor (or blender) fitted with the steel blade.

• Preheat the oven to 350°F.

• In a large bowl, combine all of the banana bread ingredients. You don’t need a mixer, but feel free to use one.

• Pour the banana bread mixture into the buttered 4x8 inch loaf pan.

• Swirl the mint sauce into the banana bread (Transfer the mint sauce into a small plastic bag with a corner snipped off. Drizzle it on in parallel lines and then run a knife through the lines from the other direction to swirl.)

• Bake for 30-40 minutes until a toothpick inserted into center of the loaf comes out clean and the bread is golden brown.

• Cool on a rack. Remove from pan and slice to serve.

Tip: The mint pesto will keep in a tight container for a week or so, and will pair up nicely with any chocolate dessert. Double the quantity and you’ll look like a pro when you serve chocolate ice cream or cake with a few dollops of this home-made mint sauce on the side.

For more of my whole wheat recipes go here and here.
Enjoy,
Dr. Ayala