Healthy Food & Healthy Living by Dr. Ayala

Help! My kids don't eat enough fruits and veggies!

Although many Americans know they should be eating more fruits and veggies (F&V), only 11 percent actually meet the recommended minimum of five-servings-a-day.

Many parents are worried their kids don't eat enough F&V and this concern is actually encouraging. There’s no better time to address the issue of good nutrition than in childhood. This is the time when eating habits are formed, and what we do as parents can be a lifelong gift of healthy eating and better overall health for our kids.

I think there are plenty of reasons why many American kids don’t jump with joy at the sight of F&V:

• Culinary culture and habits: In countries where F&V are central in the diet—Mediterranean countries for instance—everyone eats more produce (or at least did before the Western diet invaded). Kids eat what their parents eat, and we live in a place in which F&V are on the backstage at best.

• Advertising and marketing-: Kids are exposed to thousands of ads for foods and beverages. In fact, food and beverage companies spend $2 billion a year on marketing food to kids and some $900 million annually on television ads tailored to children under 12. Most of the ads promote foods that have low nutritional value, and almost none promote F&V.

We’d love to think our kids don’t pay attention, but the repeated messages do have an effect, and the overriding theme they’re hearing again and again is that highly processed foods are fun, will make them feel good, and taste amazing. If the same amount of money and talent targeted all of the good things about F&V, I think we’d get kids nagging for an apple (the fruit, I mean; mine are already in the habit of nagging for the other kind of Apple).

• Availability: We’re surrounded by food. There are food-purchasing opportunities everywhere. Yet what’s readily available is junk food and sugary drinks; good produce is—for too many—hard to find. Low income neighborhoods in particular are fresh produce deserts. If fresh F&V were as readily available as soda, I bet hungry kids looking for a snack would grab them.

• Quality: If kids are introduced to F&V through low-quality or poorly prepared examples, they’re unlikely to be tempted to try this food again. Day-old salads in fast food outlets (often the only F&V option) can taste so bad, one couldn’t imagine that salad could be anyone’s favorite food. Many people don't know how good veggies can taste because they’ve never eaten great produce that’s been properly handled.

• Price: The price of good quality F&V can be prohibitive. People tend to look (if only subconsciously) at how many calories or satiety their dollars buy. For $2 you can get an excellent large organic Fuji apple at Whole Foods, or a whole meal at McDonalds. Many will choose the McDonalds meal, or a bag of chips and a soda, as these will fill them up.

So what can we do?

A few tips on how to get your kids to eat more F&V

1) Serve early and often.

How early? Flavors from the mother's diet are transmitted through amniotic fluid and mother's milk. Studies show that when mothers eat fruit and vegetables during pregnancy and breastfeeding, their babies accept those fruit and vegetables more readily.
Later on, between the age of 6 and 24 months, the infant is usually most receptive to new tastes and textures, so this is the time to introduce many fruits and vegetables. Even if the initial introduction did not go very well, repeated exposure will often get the baby to like the new food.

2) Be a good role model.

Young children copy us, and for a short while (too short!) will tend to believe whatever we say. Sitting at the family dinner, and pleasurably eating a balanced diet, rich in plant-based foods, will get the message across very well. The fact that in some cultures most young children are excited about spicy and even bitter foods, shows that food preference is not a physiologic absolute, but more of a cultural, habitual behavior. While the preference for sweetness is universal, other preferences can be learned.

3) Let the F&V taste like themselves.

Celebrate F&V tastes for what they are, and good quality vegetables are quite often delicious. Cook them simply, or serve them raw. This way your child will learn to like the food for its flavor and texture.

4) Serve the best quality vegetables and fruit you can find.

One of the reasons children and adults dislike some dishes, and generalize to a whole family of ingredients, is because of an experience they’ve had with a poor quality fruit or poor preparation of a vegetable.

There is a huge difference between an organically grown local tomato, ripened on the vine and picked just today, and a winter tomato from the supermarket. Overcooked broccoli and Brussels sprouts are bitter and emit unpleasant-smelling sulphur compounds. On the other hand, there’s nothing like fresh, locally grown produce. Think about it: If the only two movies you saw were bad ones, you might think you don’t like movies.

5) Serve one family meal with no substitutions.

Making a “kids menu” is unnecessary and impractical. Beyond infancy, children can be gradually introduced to the family diet, and eat whatever we eat in smaller portions. There is no reason why a toddler should eat bland yellow foods that have cartoons on the package.

A no substitution policy is important for one simple reason: If a toddler is hungry, he will want to eat. If he has no option but the dish on the table, he is much more likely to give it a try. If he can opt for the mac & cheese instead, why would he stretch himself?

6) Involve children in making F&V dishes.

Introduce kids to the world of botany and gardening using the vegetable in their dish as a starting point. Take them to the farmers market to meet the people who grow their food. Teach them how to make a good vegetable salad, or how to prepare a nice bowl of boiled edamame for a snack. Encourage them to spend time with you in the kitchen, preparing plant-based foods.

7) Don't pressure, coax, bribe or reward your child to eat F&V.

Pressuring children to eat a particular food actually reduces their interest and intake of that food, and causes undue tension around the dinner table. Offering a reward, even if it’s just dessert, devalues the means (eating F&V) relative to the reward in the kids’ mind, while what we want them to think is just the opposite.

Encouraging everyone to eat more F&V is one point on which all nutrition experts agree. The protective effects of fruits and vegetables and a significant number of other health benefits have been confirmed by many studies. But even disregarding the health attributes of F&V, these plant foods really are tasty, pretty and colorful, and their biology is so fascinating, that there’s really no reason why we shouldn’t all enjoy them, with the proper introduction.

Good luck with what may sometimes seem to be a long journey towards better kids’ nutrition.

Dr. Ayala

I wrote the original version of this post for LittleStomaks, a great science driven child nutrition blog--go take a look.

Can Google be trusted with your health?

It’s the middle of the night. Your baby’s sick. You’re sick with worry.

Ever thought of Googling his symptoms for some free medical advice or a second opinion?

Many people use the Internet for health-related information, and used correctly it’s a great resource. But how reliable or accurate is a search engine without medical guidance?

A group of British researchers found that health information on the Internet ranges from poor to excellent, depending on the topic and the resource. They Googled UK-based websites on five common pediatric issues in which the best practice is pretty clear, and found that only about 200 of 500 sites offered correct information. The results of their study were published in the Archives of Disease in Childhood.

The five search topics chosen for the study were "MMR autism" (current practice: there’s no association between the vaccine and autism), "HIV breastfeeding" (current practice: HIV-positive moms are advised not to breastfeed), "mastitis breastfeeding" (current practice: a mom with mastitis should breastfeed), "baby sleeping position" (current practice: a baby should be put to sleep on his back) and "green vomit"(current practice: if baby vomits green, go see a doctor).

Their analysis showed that governmental sites were accurate every time. Educational sites, companies, interest groups and individual’s sites performed rather well, and were accurate around 80 percent of the time. News sites did poorly (they had a 55 percent “correct” rate), and no sponsored site gave correct advice.

The authors conclude:

“Healthcare professionals should continue to strive to be the main source of information for patients but we should be aware that most will continue to use the internet to gather information. We suggest that in addition to verbal and written information, patients and parents should be signposted to NHS (National Health Service), governmental or other preapproved websites”

Google has no clinical judgment

This study posed to Google questions to which there are only two possible answers. Most health questions are much more complicated, and a search result brings in an enormous amount of information to sift through.

If your child has a fever—perhaps the most common reason to see a pediatrician—a search engine is practically of no help at all. A study looking at advice for kids with a fever found only three out of 22 sites visited gave information which matched current "best practice" guidelines. You may wind up worrying your head off over exotic and life-threatening causes of fever which have no relevance to your child. But how would you know? A study of Internet information on lumbar disc herniation ("slipped disc") found that less than 10 percent of relevant websites were of high-quality. Try searching “headache” and see what comes up.

Doctors don’t have secret information. Even complicated medical knowledge is widely available. The Internet is full of good information—and bad information and misinformation, too. Making sense of the information is what’s become harder and harder to do.

Doctors work many years to master clinical judgment—the application of information gathered from talking to and examining patients, combined with knowledge of the science of medicine, and that impossible-to-define art of medicine—that’s what makes a good doctor.

There’s no recipe for acquiring clinical judgment. The knowledge-base needs to be there (a service Google provides fairly well), but the thoughtful application of information comes from immersion in the care of patients, experience, interaction with peers and mentors, and a constant refinement and learning process. I don’t think a machine will ever be able to learn clinical judgment.

The Internet is one of my favorite inventions of all time, but it will never be able to answer complicated health questions, nor will it ever be able to offer comfort or compassion. Surfing health issues on the Internet is a great example of how a little knowledge can be a very dangerous thing.

Nevertheless it’s a great resource for gathering information—provided you use reliable and authoritative sources—and that knowledge can be a great starting point for a discussion with a health professional who can help make sense of it all, put things in perspective and individualize it to your specific health issue.

Do you use the Internet for health related issues? Who do you trust?

I promise to share some of my favorite online sources of reliable medical information in a future post.

Dr. Ayala

Another apple-a-day may save more lives than the Toyota recall

Many health organizations, including the World Health Organization and the National Cancer Institute, recommend five servings of fruit and vegetables daily to help ward off disease.

Some people (I’m not one of them) go even further and propose that eating enough fruits and vegetables provides strong protection from cancer.

Cancer is a complex group of diseases. We still know very little about what causes some cancers, but it’s probably safe to say that increased risk for most cancer types usually stems from a combination of factors—some genetic and environmental, which are hard to control, and some that we have much more power over. Smoking, exercise, obesity, diet and sun exposure have all been shown to affect cancer risk.

A healthy lifestyle has many components, and I personally don’t believe any one healthy diet habit by itself—even if practiced religiously over a lifetime—has a hugely dramatic effect on cancer incidence in a population.

Having said that, every little bit helps, and while we shouldn’t exaggerate any intervention as the “solution” to cancer, these small measures together do add up and help prevent some disease.

That, by the way, is why I see all health claims on food as at least a little misleading. The diet-health relationship is real, but is always more complicated and variable than what a simplistic statement implies.

A new study in the Journal of the National Cancer Institute got quite a lot of coverage in the past few days; it found what the authors called only a weak association between high fruit and vegetable intake and reduced overall cancer risk. The headlines in many news publications (“Eating Vegetables Doesn’t Stop Cancer " in the New York Times, “Fruit and vegetables have little effect on cancer risk, study finds ” in The Guardian) suggested deep disappointment over fruits and veggies’ “poor performance” against cancer.

Is this a blow to the five-servings-a-day advice? Let’s first take a closer look at the study.

Paolo Boffetta of the Mount Sinai School of Medicine in New York and colleagues analyzed data from the EPIC study (European Prospective Investigation into Cancer and Nutrition), which included almost 500,000 participants from ten Western European countries. In about nine years of follow-up, more than 30,000 participants were diagnosed with cancer.

The authors found a small but statistically significant association between high intake of fruits and vegetables and reduced overall cancer risk--the higher the intake the lower the risk.

The data shows a 3 percent lower risk of cancer for every 200 grams, or seven ounces, of fruits and vegetables a day a person eats. People who ate five or more servings a day had 11 percent fewer cancers than those who ate 0-1.5 servings a day.

These results were consistent across the countries studied.

Higher intakes of fruits and vegetables in this study group were associated with other healthy behaviors, such as smoking avoidance, limited alcohol consumption and exercise, which may also be protective from cancer. But the small protective effect of fruits and veggies persisted even after adjusting for these factors.

How significant is 3 percent protection from cancer?

Numbers are often hard to understand without context—they aren’t as absolute as they sound. Is 3 percent a small number?

There is of course no one right answer to that.

Let’s take a look at the Toyota recall and compare risk/benefit ratios.

The chance of an owner of a recalled Toyota experiencing a deadly acceleration problem is assessed at 2.8 in a million. (There were 17 fatal accidents related to acceleration in 10 years, before six million cars were recalled. New complaints are now pouring in, which is quite typical after a recall and law suits are announced.) But we all expect Toyota to recall and fix all relevant cars, and we’re angry they failed to address this problem sooner.

The yearly cancer incidence in the U.S. is estimated at 4,600 in a million; one and a half million Americans are diagnosed with cancer each year, and 1,500 die of cancer daily. If, as this study suggests, eating an additional seven ounces a day of fruits and veggies can reduce cancer incidence by 3 percent we’d have 40,000 fewer Americans receiving the diagnosis of invasive cancer yearly.

In Toyota's case we demand action when the current risk is as small as 2.8 in a million, yet with cancer, where the disease risk is as high as 4,600 in a million, some suggest that a reduction of 3 percent in risk does not make much of a difference.

I wouldn’t perhaps recommend a drug with many side effects if it reduced a rare disease’s risk by 3 percent, but for an “intervention” as benign as eating an additional apple a day, and a disease as serious and common as cancer a 3 percent risk reduction looks like a decent size reward.

What if fruits and veggies offer no protection from cancer?

When a study shows only a small difference in outcome between the studied groups, there’s also the possibility that this difference can be explained by chance, and by something other than the variable studied. In this case we have to bear in mind that eating more fruits and veggies is generally associated with a healthier lifestyle, and no matter how hard the authors try to control for the other healthy lifestyle factors, some bias may remain.

So even though this study and several others show a probable small reduction in all-cancer risk, let’s bear in mind that it’s also possible that eating your veggies might offer no significant protection from cancer.

Yet, this “worst case” scenario still leaves us with many excellent reasons to continue promoting fruits and veggies. Here’s a partial list of good reasons to eat plenty of fruits and vegetables:

• They help lower the risk of heart disease and stroke (a study showed a 30 percent lower risk in people eating five servings a day, compared to those who eat only 1.5 servings a day)

• They help lower blood pressure

• They help lower diabetes risk

• They help lower risk of eye (cataract and macular degeneration) and digestive (constipation and diverticulitis) problems

• They provide lots of fiber, both soluble fiber, which helps lower cholesterol and regulate sugar, and insoluble fiber, which is important to digestive health

• They provide vitamins, minerals and many other beneficial plant molecules—phytonutrients—many of which we’re only starting to understand. (And I’m sure there are a few we have yet to discover. My mom knew nothing about lycopene, for example, when she fed me tomatoes and watermelon.)

• They have high nutritional value and low caloric density, so eating many fruits and vegetables (rather than practically any other food) helps lower caloric intake and maintain optimal weight

• They taste good, are beautiful to look at, and connect us to nature

My last item on the virtues list is completely non-objective; I’m guilty of total fascination with colorful growing things that we can also eat.

If, in all the years that fruits and vegetables have been consumed and studied, the worst we can say about them is that they’re not as thick a shield against all cancers as some had hoped, this speaks to just how good for us they really are.

So keep those fruits and veggies coming!

Dr. Ayala

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

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

Eight early-life factors that may drive obesity

Oh, how things change.

It wasn’t that long ago when I had newborns—they’re now a tween and teens—and the unspoken competition between new moms was how well our babies gain weight, how high they plot on the percentile charts and how quickly they outgrow their clothes. Chubby was cute, and—it’s embarrassing to say—many breastfeeding moms were encouraged by medical personnel to add-on some formula if the baby wasn’t gaining weight at a remarkable pace.

I was already a pediatrician when I had my first son. I did know better, yet I was still in tears—like many new moms I found tears weren’t hard to come by—when a well-meaning nurse suggested I might not have enough breast milk, as my baby was on the 25th percentile, and hadn’t gained much weight in the previous week. I didn’t heed her advice to add formula; I did know that a happy, content baby, who is growing at his own pace, probably needs nothing.

Well, someone needs to be on the 25th percentile; someone needs to be on the 10th. Kids and babies come in many sizes, and variation in size is as normal as variation in hair color. We can’t all be above average. Or actually, perhaps the obesity epidemic is proving me wrong.

Studies have shown that the path to obesity starts very early on, perhaps even before birth. Gaining too much weight in pregnancy doesn’t only affect mom’s long-term weight—it may also increase a kid’s obesity risk later in life. And we know all too well that extra weight in childhood persists all too often into adulthood. Of course, carrying significant extra weight has serious health implications, and is a risk factor in many chronic diseases—including heart disease and type-2-diabetes—and shortens lifespan.

While it’s now a fact that a third of American kids are overweight or obese, it’s especially notable that a recent study in Clinical Pediatrics suggests that the tipping point in obesity occurs before the second birthday, and weight gain may start in babies as young as three-months-old.

If that’s the case, interventions aimed at preventing childhood obesity should start well before kids start preschool. But where should we focus our efforts? Which early life factors affect weight gain the most?

Eight early-life risk factors may determine later obesity

Obesity Reviews recently detailed a study that systematically reviewed the medical literature, looking for early-life factors that affect obesity. From a plethora of more than 12,000 publications, the authors found 22 review studies that that met their standards, and they found several recurring themes:

Maternal factors

• Maternal diabetes

• Maternal smoking

Infant factors

• Rapid infant growth

• No or short breastfeeding

• Obesity in infancy

• Short sleep duration

• Less than 30 minutes of daily physical activity

• Consumption of sugar-sweetened beverages

Other factors identified as potentially associated with later development of obesity include parental obesity, very high or very low birth weight, TV viewing, food insecurity and low socioeconomic status.

These studies of course do not prove that these factors cause obesity. The associations are hard to disentangle, and many of these risk factors seem to cluster with lower socio-economic status (where smoking, parental obesity, diabetes, unhealthy foods and beverages and a sedentary lifestyle are more prevalent and exclusive breastfeeding less practiced).

Much more work will need to be done before we can say for sure which habits clearly lead to obesity. While it seems that each one on their own increases the risk only by a bit, I think it’s safe to say that some of our age-old notions—that pregnant women should eat for two, that a fat baby is a healthy baby, and that the more (baby-food) the better—were quite clearly misguided.

Sleep and early feeding patterns associated with later overweight and obesity

Nevertheless, none of the obesity-associated risk factors is in anyway controversial, or assumptions we’re likely to later regret. Breastfeeding is the first component of healthy nutrition and has a long list of advantages—to both mommies and babies—and should be encouraged and assisted as much as possible for a multitude of reasons.

As for sleep, all parents I suppose cherish their kids’ sleep. There is indeed good reason why we adore sleeping babies. Sleep is as important as food, drink and safety for kids’ wellbeing.

Sleep’s central importance wasn’t something I heard much of in my medical training. I guess telling people who are going to be on call (i.e., awake) every third or fourth night for many years that lack of sleep undermines good physical and mental health would worsen the physician shortage. Sleep’s many secrets are yet to be revealed—we still know too little about how to solve insomnia—but helping babies and kids develop good sleeping habits not only takes care of their health and well being; it also gives parents some alone-time and an opportunity to regroup. And to sleep. And that is priceless!

Dr. Ayala

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