Healthy Food & Healthy Living by Dr. Ayala

Do French fries and soda make you fat?

This may seem like a silly question, since all food provides calories, and you can potentially eat too much of anything and fatten up.

On the other hand certain foods and lifestyles do seem to be associated with overeating and weight gain.

And since weight loss is ever so difficult and once achieved even harder to maintain, figuring out which eating pattern is more likely to prevent weight gain over the years can offer a logical preventive plan for addressing our obesity crisis.

Which foods are linked with weight gain? To answer this question, a new study in the New England Journal of Medicine tracked changes in the eating habits of more than 120,000 professionals -- who all started out as non-obese -- while following their weight for about 20 years.  The study’s findings shed some light on weight gain over time.

Weight gain is slow and insidious

For most people, weight gain isn’t a dramatic event.  Weight, much like aging, changes so slowly that you don’t notice it at all; until one day enough change has taken place that your image in a photo puts you into a state of shock.

In this study the average weight gain was about 3.5 pounds every 4 years – just under 1 pound-a-year – which really isn’t that much, yet over the 20 years of follow-up participants gained an average of 17 pounds.

French fries and sugary drinks linked to weight gain; Fruits, veggies, nuts and yogurt linked to weight loss

Certain foods were independently related to weight gain.  The foods showing the largest effect were:

• Potato chips and French fries
• Sugar-sweetened beverages (soda and other sugary drinks)
• Unprocessed and processed meats 

Other foods were associated with weight loss:

• Vegetables
• Whole grains
• Fruit
• Nuts
• Yogurt 

Is a calorie not a calorie?

Is there something special about fried potatoes and sugary drinks that makes them especially fattening? Isn’t it surprising that adding nuts to your diet – nuts are some of the most caloric-dense foods on the planet – was associated with less weight gain?

The authors, led by Dariush Mozaffarian, from the Harvard School of Public Health, offer this explanation: Dietary quality (the types of foods and beverages consumed) influences dietary quantity.  Increasing the consumption of veggies, fruits and nuts probably reduced the intake of other, more caloric-dense foods, overall decreasing caloric intake.  Whole, unprocessed foods have more bulk, are digested slowly, and probably cause more satiety.  Drinks, other studies have shown, are less satiating than solid foods.  This study, too, showed that all caloric drinks except milk were associated with weight gain.

There’s another possible explanation: People who care about healthy weight tend to also care about healthy eating, therefore both weight maintenance and healthy eating just happen to go together, because people who are committed to not gain weight also eat healthy. Eating fruits, vegetables and nuts is also linked to being physically active, but definitely doesn’t cause it.  Good habits tend to cluster, and it’s very difficult to prove cause and effect with these kinds of things.  (It took quite a lot of research to figure out that while healthy people tend to take vitamins, taking vitamin supplements doesn’t make you any healthier.)

Nevertheless, I have no doubt that our obesity crisis is a result of overeating.  It’s a fact that most of the extra calories we’ve added over the past 30 years come from highly processed foods, refined carbs and starches and sugary drinks.  Is there something unique about these foods that makes overeating them more likely?  I think this study provides some support to the notion that the answer is yes!  There’s also plenty of evidence that these processed foods are bad for our health, and their overconsumption is linked with chronic disease.

Dietary quality probably does influence dietary quantity; it’s just easier to eat fewer calories when you’re eating well.

Dr. Ayala

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

The American Academy of Pediatrics Advises Against Energy and Sports Drinks

Energy and sports drinks are aggressively marketed to kids and teens. Not only is engaging in a sports activity – however casually and briefly – a reason to “rehydrate” with a sports drink, kids are now encouraged to consume sports drinks before, during and after thinking of moving a muscle. Sports drinks are sold in many school’s vending machines, and judging by ads for energy drinks our young ones couldn’t stay alert or study were it not for shot after shot of energy in liquid form.

Are these drinks of any benefit?

The American Academy of Pediatrics' (AAP) committee on nutrition and council on sports medicine and fitness reviewed the scientific literature and consulted with many experts for its new clinical report on sports and energy drinks. In order to clear some of the confusion around these products the report starts with a few definitions and ingredient lists:

• Sports Drinks - these contain sugars (2-20 grams of sugar per 8 oz serving, or 30-200 calories per bottle), electrolytes (sodium, potassium), minerals (calcium, magnesium), flavoring and sometimes vitamins. They are supposed rehydrate and replace water and electrolytes lost during exercise.

• Energy Drinks - these contain sugars (0-31 grams of sugar per 8 oz serving, or 10-270 calories per container) stimulants, such as taurine, guarana and caffeine, vitamins and other supplements. Energy drinks deliver stimulants, which supposedly improve performance.

Sports drinks: For serious athletes playing prolonged, vigorous sports in a the heat

For all non-prolonged less exhausting occasions the AAP report warns that the extra calories in sports drinks may lead to extra body weight, and the combined sugar and acid in them causes dental erosion.

As for the heavily marketed beneficial and functional ingredients in sports drinks: electrolytes are plentiful in food, protein and amino acids as well as vitamins are plentiful in food, and the specific amino acids added to sports and energy drinks to enhance performance (glutamine, arginine, taurine) have not been proven beneficial by good clinical trials.

Energy drinks: Totally unsuitable for kids and teens

The report stresses that energy drinks “pose potential health risks primarily because of stimulant content; therefore, they are not appropriate for children and adolescents and should never be consumed.”

Eliminate sugary drinks: Drink water!

The expert panel concludes:

“Given the current epidemic of childhood overweight and obesity, we recommend the elimination of calorie containing beverages from a well balanced diet, with the exception of low-fat or fat-free milk, because it contains calcium and vitamin D, which are particularly important for young people.”

We're very far off from the AAP's target: A recent CDC survey found that one in four high school kids drink soda every day and two in three drink a sugary drink every day. This is actually an improvement -- in previous surveys three-quarters of kids reported drinking a sugary drink each day.

When celebrity athletes drink sugary drinks in ads they do it because they’re paid handsomely to do just that. In real life star athletes usually treat their bodies like a temple. I’m pretty sure they watch what they eat quite carefully, and maximize their potential by eating well. An image that better reflects an athlete’s genuine eating habits is Rafael Nadal’s on-court water and banana combo (Nadal’s often seen snacking on a ripe banana between sets).

A sports drink with breakfast and lunch doesn’t make an athlete – it just makes kids poorly nourished and fat.

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--go join the food fight!

Forks Over Knives: Can a Plant Based Diet Reverse Disease?

“Isn't it enough to see that a garden is beautiful without having to believe that there are fairies at the bottom of it too?” Douglas Adams

There’s no doubt in my mind that the western diet – characterized as highly processed, animal product rich, sugary, fatty and salty – is bad for our health. Its spread is closely followed by a huge rise in the incidence of obesity and several “western” chronic diseases such as heart disease, hypertension and type 2 diabetes.

Traditional diets and especially plant based diets are associated with much healthier populations and lower risk of many diseases. Ample amounts of evidence show that.

Since I know that a whole foods, plant based diet is the best nutrition advice we can come up with, and I’m a lifelong vegetarian (for a multitude of reasons, the main one being animal welfare) I expected Lee Fulkerson’s documentary “Forks Over Knives” to be music to my ears.

Forks Over Knives

Forks Over Knives follows the research and personal journeys of nutrition scientist Dr. T. Colin Campbell (The China Study) and surgeon Dr. Caldwell Esselstyn. Campbell and Esselstyn independently came to the conclusion that abandoning the American diet and maintaining cholesterol levels well below those historically recommended by health policy experts on a plant based diet can prevent and even reverse heart disease and other illnesses.

The movie is peppered with engaging personal tales of people whose lives were changed by a plant-based diet: A diabetic mother, a diabetic, hypercholesterolemic meat-loving landscaping company owner, a vegan mixed martial artist, and the film’s writer and director, Fulkerson, himself – his Red Bulls and soda habit led to less than stellar lab results. Vegans, we learned, not only are healthy, some of them are really cool and really strong.

The vibrancy on the 70 something year-old vegan doctors and their plant-eating patients and the beauty of the rainbow-colored veggie fruit and grain dishes are in sharp contrast to the footage of obese, sickly, tired people and greasy super-sized unappetizing meaty food.

Forks Over Knives advocates an idea I generally believe to be true. It is a rather entertaining film, and definitely good food for thought.

However, it falls short on nuance, balance and hard facts and pushes a strict vegan way of life beyond what the science presented can support. Here are a few of my qualms:

• Where are the nuts?

The first question that comes to mind when watching a movie about food-as-cure is what’s the recipe? Forks Over Knives isn’t very clear on what the various people shown in the movie are eating. Prominent in their visual absence are the nuts – a mainstay of many plant based diets. I suppose nuts and seeds aren’t mentioned because Dr. Esselstyn’s diet, which arrested and even reversed severe coronary disease, I found out when I pulled out his study, is a very low fat vegan diet, which eliminates not only all animal products including eggs and dairy (except non-fat milk and yogurt), but also nuts, avocados and all vegetable oils. No extra virgin olive oil in this one. Perhaps sharing these details would have made this food-cure less tenable and less of a no-brainer, and that’s why the details weren’t presented.

Dean Ornish’s study, not mentioned in the movie, is an interesting comparison. Ornish’s regimen, which includes stress reduction through yoga and meditation, a low-fat vegetarian diet, smoking cessation, and regular exercise, also not only stopped the progression of coronary artery disease in the 20 patients in the treatment group, but also reversed some of it. The Ornish diet is very similar to the Esselstyn diet, but allows for some nonfat dairy products -- skim milk, nonfat yogurt, nonfat cheeses, nonfat sour cream, and egg whites. (Nuts and oils are out in the Ornish regimen, too.)

What the Esselstyn and Ornish diets have in common is not only very low intake of animal products and lots of wholesome plants – they’re both very low fat diets.

• Could food be the only medicine we need?

Although it is not explicitly said, the movie gives the notion that a plant based diet is all you need to reach a cure. The patients depicted gladly abandon all their diabetes, hypertension and cholesterol lowering meds upon adopting the lifestyle. (Dr. Esselstyn does note that in acute cases a coronary bypass is necessary).

However, in Dr. Esselstyn long term study, on which much of the movie relies, the patients* with severe coronary artery disease were on cholesterol-reducing medications as well as on a plant-based diet. The combination of diet and drugs is what got Dr. Esselstyn’s patients to a blood cholesterol of 150 mg/dL and to no repeat heart events.

• If high amounts of animal food are bad, does it prove that we should eat none at all?

If a little is good, more isn’t necessarily better (think vitamin toxicity), and I don’t think it’s self-evident that if meat consumption is correlated with disease – which is what the China Study showed – consuming any amount of animal products is harmful.

And although Dr. Esselstyn had remarkable results in his study of 17 heart patients on a low fat vegan diet, since there was no non-vegan control group, we can't really conclude that veganism cured his patient’s arteries.

• Can a plant based diet cure metastatic breast cancer?

Perhaps the most disturbing bit in Forks Over Knives was the story of Ruth Heidrich, a breast cancer survivor now in her 70s, 30 years after the diagnosis of metastatic breast cancer. Ruth, a six-time Ironman Triathlon finisher, tells a story of miraculous healing through a vegan diet and exercise. This, unfortunately, is an anecdote – there are no studies showing that a vegan diet alone can treat breast cancer. Suggesting a vegan diet can cure cancer is dangerous and irresponsible, especially when the movie features several authoritative medical doctors and scientists.

Eat food. Not too much. Mostly plants

I was glad I came to Forks Over Knives already “sold” on a plant-based diet, because the movie oversold plant-based diets to the point in which those of us not already in the choir might not think of joining.

Michael Pollan’s less assured and more moderate recipe for healthy eating, summed succinctly in “Eat food. Not too much. Mostly plants”, has, I think, much more of a chance of changing people’s mind and behavior.

Between the convenience-foods/fast-food diet and the strict vegan diet there are many shades of green. Adopting a more wholesome plant-based diet isn’t an all or nothing choice, and you can definitely eat for pleasure – and not just for health – while eating mostly plants.

Forks Over Knives reminds us of the prevention and healing powers of a healthy diet – a power that can’t be denied. I’ll need lots more proof before I believe in fairies, but the garden sure is beautiful!

Dr. Ayala

*Dr. Esselstyn’s study group initially included 22 participants, 5 dropped out within 2 years, 11 completed 5.5 years of follow-up, and at 10 years 6 were still on the diet.

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

MyPlate: A step in the right direction!

The new MyPlate icon for good eating was unveiled last Thursday.

I Like it! It’s definitely a big step in the right direction.

The most compelling features are its visual simplicity and overall message. As Michelle Obama noted in the unveiling ceremony, what can be simpler than a plate? Parents are busy, she said, they don’t have time to weigh and measure portion sizes and ounces “but we do have time to take a look at our kids’ plates”.

Here’s what I like about MyPlate:

• Half of MyPlate is fruits and veggies, with the veggies occupying more territory than the fruit. If I had to pick just one dietary change that could really make a difference and reduce the rates of obesity and several chronic diseases, I’d go with “eat more plants”. If half the plate is fruits and veggies, these automatically replace more caloric dense foods and there’s evidence that fruits and veggies reduce the risk of many ailments.

• MyPlate is memorable and easy to use. Comparing your meal to the MyPlate icon is a very simple way to judge its healthfulness. It’s easy to visualize that a muffin or donut breakfast doesn’t conform. It’s easy to envision that a bag of chips and a soda for lunch doesn’t conform. It’s easy to see that a steak and French fries dinner – with a handful of peas and a sprig of parsley garnish – doesn’t conform either. It’s also clearly apparent that fast food meals -- I dare say not even one of them -- don't resemble MyPlate.

• There’s no meat on MyPlate. Sure, protein is code for meat, and its mention is probably just enough to keep the meat industry happy. On the other hand protein can be fish, tofu nuts and beans, and MyPlate is open to personal interpretation. I agree with Marion Nestle, who says that “Protein is not exactly lacking in American diets. The average American consumes twice the protein needed. Grains and dairy, each with its own sector, are important sources of protein in American diets.” Protein, which most people will read as meat, is not something Americans need to be reminded to eat, and is definitely not necessary for a healthy diet, but for now MyPlate with its smaller portion of “protein” is a step in the healthy direction compared to previous guidelines.

• Eat from MyPlate. The food is not in a bag, not in a bucket and not in a box. A plate sends a message of old fashioned sit-by-a-table dining.

• Fork by MyPlate – fork, but no knife. Utensils, again, suggest organized eating – as opposed to eating on the go. Am I reading too much into the absence of a steak knife?

MyPlate is a major upgrade from the MyPyramid predecessor (see below) – the pretty rainbow climb-me-pyramid was so abstract and confusing it was hard not to top with any new icon – and it will be interesting to see how we eaters will react to it.

Do you think a food icon can change what we have for dinner?

Dr. Ayala

Related post: The New Dietary Guidelines: Eat Less for Better Health!

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

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 led 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!