Healthy Food & Healthy Living by Dr. Ayala

So, is coffee really good for you?

How do we know if a food is healthy? Some of it is plain common sense, so steeped in tradition that it hardly needs proof, but for less obvious food items it usually starts with an observation.

We noticed, for instance, that people who drink lots of soda tend to gain weight and have a higher incidence of several chronic diseases, or that people who take multi-vitamins tend to be healthier.

An observation is followed by careful study to verify that there is indeed an association between the observed exposure and an outcome. If the association actually exists, we try to find out what explains the connection, and to see if the association is a result of a cause and effect connection. In the case of soda and obesity link, it has been established that drinking soda actually drives obesity; with vitamins it turns out that taking vitamins is what healthy people that engage in various other beneficial habits – they also exercise, wear seatbelts and bike helmets – tend to do. The extra vitamins are just an association and not the cause of their superior health.

Most Americans drink coffee, and it was good news to hear that drinking coffee regularly is associated with lower risk of several chronic diseases, such as type 2 diabetes, heart disease, Parkinson’s and several types of cancer. This association has been seen in many studies, and a recent review of many meta-analysis concluded that (with the exception of certain conditions such as pregnancy and women with risk of fractures) coffee is “more likely to benefit health than harm.”

The ideal next step would have been to test coffee as an intervention in a double blind, long-term study, a study in which environmental, nutrition and lifestyle parameters would be controlled. This is, of course, very difficult and expensive to do.

Coffee and health,  just an association?

When it comes to studying nutrition such studies are rarely feasible.

But there are other ways to move forward. Another method to examine a connection between two correlated findings is to see whether there’s a plausible mechanism that would make the exposure cause the outcome.

This is precisely what a new study, just published in the American Journal of Clinical Nutrition set out to do.

Chronic inflammation, insulin resistance and hormonal dysregulation are thought to be behind the development of many chronic diseases. The new study looks at biomarkers – measurable biological markers that are characteristic of biological processes and indicate particular diseases or physiological states. The researchers looked at 14 biomarkers found in blood, including some from the insulin family (C-peptide, insulin-like growth factor 1), at several sex hormones (testosterone, estradiol,) and at inflammation markers such as C-reactive protein and interleukin 6. These were studied in two very large cohorts of about 15,500 women and more than 7000 men whose coffee habits were known.

And the results: Coffee consumption was associated with favorable shifts in the levels of the biomarkers tested. There were lower levels of insulin markers – high insulin secretion markers are linked with several cancers. There were lower concentrations of inflammatory biomarkers. Estrogen levels were lower – high estrogen is associated with higher risk of breast, ovarian as well as prostate cancer – and higher levels of testosterone (testosterone can act against breast cancer cells).

This was true for the participants who drank caffeinated as well as decaf drinks.

Because besides caffeine, coffee contains very many substances, such as polyphenols, trace minerals and diterpenoids that are thought to affect health conditions.

Time for a coffee break?

If you love coffee the latest research about coffee and health is encouraging.

Drinking coffee used to come with a dose of worry. The reason for that is that older coffee studies did not account for confounding unhealthy behaviors such as smoking and inactivity, which used to be more common among heavy coffee drinkers. Newer, better studies are finding that coffee is actually associated with good health, and the mechanism of benefit is plausible. This study adds another layer of credibility and evidence.

That being said, coffee may not benefit all people: People who metabolize caffeine slowly may not find coffee helpful in the same way that people who metabolize it normally do. The reason the studies of coffee show conflicting results may be due to a genetic variability in the way people react to caffeine.

Coffee also isn’t for kids. Major health organizations, including the American Academy of Pediatrics, recommend that kids avoid caffeine in coffee and energy drinks altogether, at least until age 12. Pregnant women are advised to limit coffee to about 2 cups a day.

And when you think of coffee and health, a reminder: Coffee is in essence a calorie free, unsweetened drink. Coffee drinks with sugar, syrups and cream can become calorie bombs ­– these aren’t a healthy habit.

Dr. Ayala

Experts’ latest advice on good – and bad – foods for your heart

Love, connection and gratitude are good for your heart, on that most people agree. But when it comes to food, there’s no shortage on controversy.

Studying the effect of food on health outcomes is difficult, because unlike medications that can be prescribed, and compared to a placebo, people eat whatever they choose over a lifetime, and the narrowing of arteries – atherosclerosis – develops over many decades, so even when the best studies are devised, they’re never long enough. On top of that, there are influences from many stakeholders, adding to both controversy and hype. Nevertheless, the accumulated research, which includes studies of many designs – epidemiological, case-control, cohort studies, randomized control studies etc. – have advanced our knowledge a whole lot.

A group of experts from the American College of Cardiology Nutrition & Lifestyle Workgroup of the Prevention of Cardiovascular Disease Council studied the evidence, and debated the trending nutrition controversies last year.

And this summer, they’re back with a sequel. The new article in the Journal of the American College of Cardiology covers topics that doctors are asked about often, so the group gathered the evidence, reviewed, debated, and came up with conclusions to guide physicians' advice to their patients. Let’s take a look at some of them.

Nutrition hypes and controversies

Is dairy good for your heart?

The study of dairy products and heart health is fraught by industry-sponsored trials, and most studies are observational – which aren’t the best evidence. The bottom line:

“It appears that there is no clear consensus in the published data or among experts on the effects of dairy products on CVD (cardiovascular disease), although there seems to be a link between some dairy products and increases in LDL-C (the ‘bad’ cholesterol) concentration, fractures, and overall mortality, in addition to lowering of BP, but the magnitude of these effects is unclear. Importantly, however, there is general consensus that full-fat dairy products are major sources of saturated fat and sodium in the U.S. diet, and thus, should be limited; nevertheless, reduced fat dairy products remain a convenient source of some essential vitamins and minerals, as well as high-quality protein.”

Is sugar a problem?

People today eat 25 times the amount of sugar they did 250 years ago. Sugar is added to 75 percent of processed foods, but it’s the soda and soft drinks that supply about one half of all the added sugar in the US diet. Excess added sugar has been linked with heart disease and stroke, and this expert group joins many others with finding the evidence against added sugar conclusive, and it recommends:

“Individuals should limit added sugar to <10% of calories and preferably <100 calories daily for women and <150 calories daily for men. Clinicians should recommend consumption of a whole foods diet with a low intake of processed foods, careful selection of foods with no or low amounts of added sugars in any form, and elimination of SSB (sugar sweetened beverages).

Is coffee okay?

Coffee got a clearance from the heart experts, as long as you don’t add other things to it:

“Overall, large analyses indicate that coffee intake is correlated with a dose-response protective benefit: habitual consumption of coffee is associated with lower risks of all-cause mortality and CVD (cardiovascular disease) mortality, but not with an increased risk of arrhythmias, hypertension, or hyperlipidemia. It should be noted that coffee-based drinks may be loaded with sugars and fats that reduce their health benefits.”

How about alcohol?

The connection between alcohol and heart health is complicated, and although some studies have shown reduced heart disease with moderate wine intake, even moderate intake has been shown to increase the risk of breast cancer in women. The experts’ bottom line:

“There is not sufficient high-quality evidence to recommend specific alcoholic beverages for CV (cardiovascular) risk reduction. There is also some risk of falls, certain cancers, and liver disease. As such, it is not recommended that individuals initiate alcohol consumption for CV benefit, and for those already drinking, consumption should be limited to recommended amounts, preferably consumed with meals. Mixing of alcoholic beverages with sodas, creams, and sweeteners adversely affects their health benefits.”

Should I be eating mushrooms?

There’s growing interest in mushrooms, as, beyond their taste – delicious, in my opinion– studies have shown they can be heart protective, as they modulate the immune response, lower cholesterol levels and blood pressure. They can also provide vitamin D.

The experts’ bottom line:

“Although there is no high-quality evidence of improved CV (cardiovascular) health outcomes, mushrooms may be associated with improvement in inflammatory and antioxidative pathways and may have beneficial effects on known CVD (cardiovascular disease) comorbid risk factors. Caution should be made that some wild mushrooms are poisonous.”

What other heart friendly foods should get my attention?

Legumes. These include beans, chickpeas, lentils, peas and soybeans. They are inexpensive, rich in protein and fiber, and studies have linked their consumption with lower body weight, lower cholesterol, heart attack risk and blood pressure. The authors’ conclusion:

“Legumes are an affordable and sustainable source of protein and fiber. Consumption is associated with a reduction in CHD (coronary heart disease) incidence and improved blood glucose, LDL-C (low-density lipoprotein ‘bad’ cholesterol), systolic BP (blood pressure), and body weight. Western populations’ current consumption of pulses and derived products (bean dip, hummus, etc.) is very low despite their health benefits. Legumes should be part of any diet aimed at promoting cardiometabolic health.”

Heart disease is the leading cause of death for both men and women. Luckily the risk of heart disease is highly modified by healthy diet and lifestyle. A heart healthy diet – more plant food, whole grains, fiber and healthy fats, portion control, less added sugar etc. ­– combined with physical activity, are proven to keep your arteries and heart young, and are a remedy with no adverse side effects.

Quite the opposite: The side effects of a heart-healthy diet and physical activity include better mood, productivity, alertness and general well being.

Dr. Ayala

Love coffee? You’ll love these new studies

Coffee drinking used to come with a dose of concern. I often heard health enthusiasts announcing with pride that they quit things like sugar, red meat and alcohol; coffee would be lumped in for extra credit. And while going easy on sugar and alcohol gets broadening scientific support with the passage of time, quitting coffee – which still might be advisable for some specific people – is something research never really backed.

With time, more and better research is proving the exact opposite about the coffee habit.

A new large study, published in JAMA Internal Medicine looked at the coffee drinking habits of half a million people in the United Kingdom, not all of them moderate drinkers – participants in the study drank up to 8 cups of coffee a day.

The study found that drinking coffee was inversely associated with all cause death for all consumption levels – even for heavy drinkers. Ground coffee’s association with lower mortality was somewhat stronger than that of instant coffee, but all coffee preparations were linked to better outcomes.

The researchers also looked at what’s called slow metabolizers: people who break down caffeine slowly, and are therefore more likely to be sensitive to its effects. Might these people be susceptible to heart disease related to caffeine lingering in their blood? People were especially concerned about high blood pressure and heart attacks within this sub-population. The study looked at genetic polymorphisms that predisposed people to be slow metabolizers and it turns out, in these people too, coffee was associated with lower mortality.

This study is observational, and although it tries to account for confounders such as age, obesity and smoking, its results only prove an association. In nutritional habits that last a lifetime we’re not likely to ever see a double blind, placebo controlled interventional study that can prove causation outright.

But this analysis joins many others, and the evidence seems to repeatedly point in one direction, so a statistical fluke is not very likely.

A study of 185,000 Americans published in Annals of Internal Medicine last year showed lower risk of death in African Americans, Japanese Americans, Latinos, and whites. Another study of more than half a million Europeans from 10 countries found lower mortality and that didn’t vary among the participating countries. A meta analysis in BMJ last year reviewed 201 relevant studies, and concluded that coffee is safe, and that 3-4 cups a day are associated with health benefits rather than with harm.

The secret ingredient? It probably isn’t caffeine

Caffeine, which is the psychoactive stimulant ingredient in coffee, and one of the main reasons people turn to coffee for a pick-me-up, is just one of thousands of components in the magic bean. Coffee is very high in antioxidants, and the whole food – bean – is much more than its parts.

This new study in JAMA found that decaffeinated coffee was associated with the same reduction in mortality. So did many others.

So, should coffee be part of your healthy regimen?

How come we had coffee this wrong until recently, you may ask? It might be our misanthropic belief that if we enjoy something this much – and I personally really do – there must be something wrong with it. Early studies that did not account for known unhealthy behaviors such as smoking and inactivity, which used to be more common among heavy coffee drinkers, also gave the wrong impression.

But not everyone should be chugging coffee.

Coffee isn’t for children – major health organizations, including the American Academy of Pediatrics recommend that kids avoid caffeine in coffee and energy drinks altogether, at least until age 12. Pregnant women should limit coffee at about 2 cups a day.

Remember, also, that coffee at its essence a calorie free, unsweetened drink. Some coffee drinks have so much cream and sugar that they’re true calorie bombs, and these studies showing health benefits are not about those treats. If you want coffee to be part of a healthy routine, make sure that coffee doesn’t make you reach for a sweetener, or a cookie. Or a cigarette.

These studies provide further evidence that if you enjoy your coffee you can do so free of guilt. If you don’t like coffee or find that it interferes with your sleep or makes you jittery I don’t think the science is quite there to suggest you should adopt the habit.

Dr. Ayala

Coffee and sugar: An unhappy couple

Sugar’s on a lot of people’s minds. It’s an ingredient we love yet struggle with. Sugar is a key target on all current eat-less-of lists, and we’re all trying to cut our consumption. It’s not easy.

Coffee, on the other hand, is enjoying some good press. As a coffee lover myself, I’m on the lookout for this welcome evidence, reinforcing my habit of a daily cup. Or two, or three. Coffee by itself, research shows, may even benefit your health, providing protection from type 2 diabetes, stroke, Parkinson’s and dementia.

Now, let’s look at these two beloved foods together.

A lot of people do. They drink their coffee sweetened. Many cold coffee drinks come already sweetened – Starbucks’ Bottled Frappuccino and their Iced Vanilla Coffee have as much sugar as soda. They’re really a candy bar with caffeine.

I’ve always liked coffee without. Actually, I’ve never tried it with sugar. Adding sugar and sweeteners to espresso blunts its already gorgeous taste, in my mind. Unlike cocoa, which we fall in love with in its sweet chocolaty incarnation, I’ve accepted and fell for coffee as a slightly bitter, rich, non-sweet food.

But coffee and sugar are connected in more than one way. So today, two recent bits of research about the coffee sugar connection.

Sneaky calories

Coffee and tea are virtually calorie free. More than half of the American population drinks coffee daily, but few Americans drink their coffee plain. A study in Public Health found that two thirds of Americans add sugar, cream and other calorie-rich additives.

How much does this contribute to caloric intake? Although just a spoonful of sugar doesn’t seem like much, it adds up, and this study, that included more than 13,000 Americans, found that adding stuff to your coffee adds about 70 calories daily on average.

If these calories are unaccounted for and are just extra, they can translate to another pound of weight every 2 months.

Does coffee make you reach for a cookie?

Researchers from Cornell University showed that coffee might increase our sugar intake because it reduces the perception of sweetness. The results of their new study of 107 participants appear in the Journal of Food Science.

Volunteers drank a caffeinated and a decaf drink, unaware of the drink’s caffeine content. The caffeinated drink was perceived as less sweet that the decaf one.

Caffeine blocks adenosine receptors in the brain. This is why coffee helps with alertness; adenosine promotes relaxation and blocking it awakens us. We have adenosine receptors in our taste buds, too. Suppressing adenosine reduces our ability to taste sweet foods, potentially altering our perception of sweetness and making us reach for more sugar.

Our growing coffee habit – coffee consumption is on the rise – might be adding extra fuel to our sugar cravings.

So watch out! There’s nothing wrong with a cup of coffee. On the contrary: coffee by itself is actually part of a healthy diet and lifestyle, and much better than many other drink options.

But try to resist the temptation to accompany it with a sweet treat or a sweetener.

Let coffee speak for itself.

Dr. Ayala

Coffee and cancer?

You might have been surprised by the news coming out last week, announcing that the World Health Organization (WHO) found that coffee isn’t carcinogenic after all. If I were in the coffee business I’d want this news item to get as little publicity as possible, as I doubt anyone was worried about coffee’s carcinogenicity before they were told not to fret.

So what’s this all about?

The last time the WHO’s International Agency for Research on Cancer (IARC) evaluated coffee was in 1991, and at that time it gave it a “possibly carcinogenic to humans“ classification because of limited evidence associating coffee and bladder cancer in case-control studies (which are not the best evidence).

For this evaluation 23 scientists from 10 countries met in Lyon, France, and evaluated 1000 observational and experimental studies that have accumulated in the meantime.

Overall, cancer risk and coffee seem to be unrelated, they concluded.

The group also evaluated mate, a drink popular in South America and steadily gaining popularity elsewhere. Hot mate was classified as “probably carcinogenic to humans” in 1991 based on limited evidence. The new evaluation, based on the latest knowledge, concludes that while the high temperatures in which some people drink their tea or mate might act as a tumor promoter, the researchers think the mate itself is not a problem. Beware of very hot drinks, they advise:

“Drinking very hot beverages at above 65°C was classified as “probably carcinogenic to humans.”

Should we worry?

The WHO’s findings are a scientific evaluation, not a set of recommendations on what to eat.

The categories used by the IARC can be quite confusing.

The highest, most dangerous category, category 1: Carcinogenic to humans, includes processed meats (bacon, ham, hot dogs, sausages). And also cigarettes. Does this mean that meat is as carcinogenic as smoking tobacco? It definitely doesn’t. More than 85 percent of lung cancers result from tobacco smoking, yet according to the WHO’s report 50 grams (about 2 ounces) of processed meat daily might increase colorectal cancer by 18 percent -- smoking is much more likely to cause cancer than eating processed meat, even though both are in the same category. In this same category 1 you can also find ethanol in alcoholic beverages, secondhand smoking, engine exhaust, air pollution, and sun exposure. The sun’s rays, X rays and gamma radiation are all in the same category 1, but that doesn’t mean that beach vacations are as risky as getting a weekly CT scan.

Now, lets visit the category coffee’s in, it used to be 2B: Possibly carcinogenic to humans, and now it’s group 3: Not classifiable as to its carcinogenicity to humans. Coffee shares this distinguished category with tea.

This is science speak, so the best, most benign score you can get is category 4: Probably not carcinogenic to humans – scientists are very careful, and will never declare certainty.

Once the “can it cause cancer” question is raised to the IARC the best possible outcome can be: Probably not. When you ask a scientist: Is this – pertains to practically anything -- 100 percent safe? the answer can never be a simple: Yes.

A better place to look for practical dietary advice is the Scientific Report of the 2015 Dietary Guidelines Advisory Committee, which concluded:

“Currently, strong evidence shows that consumption of coffee within the moderate range (3 to 5 cups per day or up to 400 mg/d caffeine) is not associated with increased long-term health risks among healthy individuals. In fact, consistent evidence indicates that coffee consumption is associated with reduced risk of type 2 diabetes and cardiovascular disease in healthy adults. Moreover, moderate evidence shows a protective association between coffee/caffeine intake and risk of Parkinson’s disease. Therefore, moderate coffee consumption can be incorporated into a healthy dietary pattern, along with other healthful behaviors…However, it should be noted that coffee as it is normally consumed can contain added calories from cream, milk, and added sugars. Care should be taken to minimize the amount of calories from added sugars and high-fat dairy or dairy substitutes added to coffee.”

I wouldn’t be at all surprised if one day we’ll discover that worrying about cancer may cause cancer.

Dr. Ayala