Healthy Food & Healthy Living by Dr. Ayala

Metabolic health is awfully rare

Most people think about metabolic health in terms of leanness vs. obesity, thin vs. fat. But BMI and weight don’t tell the whole story, and it’s the internal biochemical processes that affect the risk of a wide array of chronic diseases, such as type 2 diabetes, heart and vascular disease.

How would we know if we’re metabolically healthy?

In yearly checkups physicians measure some important metabolic parameters, such as weight, BMI, sometimes waist circumference, and blood pressure. They inquire about habits that influence metabolic health, such as physical activity and smoking avoidance.

And they can also order blood work that includes other important markers known to raise the risk of disease: Impaired sugar metabolism is identified by high blood glucose or high HbA1c (a test that gauges the average level of blood sugar over the past 3 months) measurements, and the lipid panel will look at triglycerides and cholesterol, which when elevated need some attention, liver enzymes may suggest fatty liver.

The metabolic state of the union

A new study in the journal Metabolic Diseases and Related Disorders looked at the metabolic health of a nationally representative sample of the American population. The researchers included almost 9000 people, whose metabolic health was assessed by measuring 5 parameters: blood pressure, waist circumference, fasting blood glucose, triglycerides and cholesterol. The participants also reported on their physical activity and smoking status.

Metabolic health was the exception rather than the norm. Only 1 in 8 people in this study had optimal levels of all 5 parameters.

Metabolic health often correlated with weight status among the participants, and the higher the BMI the greater the chance of metabolic abnormalities, but even among the people with normal weight, less than a third were metabolically optimal.

There were more metabolically healthy women than men, and metabolic health was more prevalent among people who exercised more, never smokers, and among the younger participants.

Lifestyle and medication

A risk factor is not yet a disease, but it’s a predictor of trouble down the road, and the longer a risk factor is present, and the more metabolic risk factors one has, the more likely it is that there will be consequences such as type 2 diabetes, heart disease and stroke.

So this does sound like bad news indeed. Fortunately, metabolic health is highly responsive to lifestyle interventions.

What’s the secret? Diet and exercise are the main measures that affect metabolic health.

Most people are able to achieve some control over these risk factors with these side-effect-free measures alone. And if these aren’t enough – there are also genes and many other factors beyond our control – there are medications.

Take home message

What we eat matters. The quality of our foods affects our wellbeing and health trajectory in a profound way.

We used to pay attention to food mostly in the context of weight control and the pursuit of skinny silhouettes. But as this study and many others show, people may look thin yet have the metabolic risk markers of an overweight person; and vice versa.

Eating poorly and disregarding physical activity can catch up with the skinniest of people.

So for this New Year, if you’re planning on a diet resolution, make it one that addresses the quality of your meals – not just its caloric content. Focus on whole foods, real food, and more plant-based, less highly processed and less added sugar.

To a healthy holiday season and new year,

Dr. Ayala

The best diet to fight belly fat

People call a bulging abdomen a beer belly, but beer, clearly, isn’t the (only) culprit.

And finding the cause isn’t a silly blame game.

Abdominal fat isn’t merely an esthetic issue. Fat in and around abdominal organs is active metabolically, much more so than the fat under our skin, and it poses additional risk for diabetes, heart disease and stroke, above and beyond the risk seen with just having some extra weight. Fat around our internal organs acts like an endocrine gland, causing insulin resistance and interfering with fat metabolism.

A growing body of evidence suggests that what we eat certainly affects body shape and fat accumulation patterns – it isn’t just age and genetics. Dietary choices matter, and a more appropriate term of endearment for the rounded belly would be sugar belly.

Or perhaps soda belly, as research shows.

Drinking 25 percent of daily calories (which is quite a lot) in fructose for 10 weeks increased triglycerides and cholesterol, caused insulin resistance and belly fat accumulation, a study from the University of California at Davis showed.

Another study found that even moderate (1 can of soda a day for 3 weeks) consumption of sugary drinks led to increased belly fat, elevated glucose levels, higher inflammation markers, and worsened lipid profile.

A study in the journal Obesity, following 800 people, found sugary drinks were associated with significantly more belly fat and wider waistlines.

And a study in the American Journal of Clinical Nutrition assigned overweight people to drink cola, skim milk, diet cola or water for 6 months, with total calories staying constant. Liver fat and fat around abdominal organs and muscle increased significantly in the regular soda group, while it remained unchanged in the other study groups. Blood pressure and triglycerides also rose among the soda drinkers. 

These studies show that sugar -- especially in drinks -- increases fat accumulation in the worst possible locations of our anatomy. Similarly, saturated fat might also cause more weight to accumulate as fat in the liver and around internal organs.

But is there a weight-loss diet that can target these specific fat pools?

Losing that belly

A new study, led by Yftach Gepner and published in Circulation examines whether different weight-loss programs attack fat deposits preferentially. The 2 diets butted against each other were a low-fat one, and a Mediterranean diet – rich in unsaturated fat and low in simple carbs, with and without a moderate exercise regimen.

This was a unique, 278 participant, 18-month study, because besides the weight and waist circumference measurements, total body MRI was used to in order to measure fat quantities around all the internal organs.

The two groups lost about the same amount of weight.

The weight was loss pattern was, however, significantly different: the Mediterranean diet/low carb group lost more abdominal fat, more liver fat and fat around the heart and pancreas.

Exercise also helped shed abdominal fat preferentially.

And losing this liver and deep intra-abdominal fat helped to improve lipid profile and insulin sensitivity!

Making that belly fat the first to go

The take home message: When it comes to fat deposits it isn’t just how much we eat, but also what we eat.

Some foods – especially refined carbs – lead to fat storage in the worst-for-health places.

And the same is true for weight loss: You can preferentially target belly fat by eating a healthy Mediterranean diet with lots of fruits, veggies, nuts and unsaturated fats, and less sugar and carbs. It might work better than a low-fat weight-loss diet with the same number of calories.

Add to that all-important exercise and healthy hydration, and you’ve got yourself a good regimen that will help you avoid weight gain during the holidays – and a worthy plan if you need to lose some in the coming year.

Dr. Ayala

Is anti-inflammatory food for real?

Inflammation is the body’s useful reaction to injury and infection by outside invaders such as bacteria and viruses. Low grade chronic inflammation -- an immune system that’s a bit overactive at all times -- on the hand, is detrimental to our health and leads to serious trouble: from heart disease to cancer, depression, Alzheimer’s and arthritis, not to mention the role it plays in aging. Reduce undue inflammation and you’ll reduce the risk of these diseases.

The fascinating finding is that we can affect inflammation not just with powerful drugs but also with our fork.

What’s in our plate affects disease and health, so let’s take a look at which foods have that power, and at the latest science looking at the food - inflammation - disease connection.

The diet for controlling inflammation

To paint with a broad brush and help you remember, think of a stereotypical American diet -- low on fruits and veggies, high on meat, refined grain, highly processed foods, desserts and sugary drinks – and you’ve described the pro-inflammatory diet. Add to that obesity and sitting on a chair most of the day, and you’re imagining the perfect conditions for a pro-inflammatory state that predisposes our bodies to degenerative diseases.

To paint with another broad brush, an anti-inflammatory diet would be a classic Mediterranean diet – centered on fruits, veggies, spices and herbs, whole grains, garlic, onion, olive oil, fish and wine.

To be more specific, the tool used in most research into pro- and anti-inflammatory foods is the Dietary Inflammatory Index. To create the index thousands of scientific articles were reviewed, and each food and nutrient got a score.

Foods and nutrients that have strong anti-inflammatory activity include turmeric, fiber, tea, wine, ginger, all these wonderful phytochemichals in plant-foods, -- flavones, flavonols, flavonones, anthocyanidins, isoflavones -- vitamins such A, E, D, C, and many from the B family, magnesium, mono and poly unsaturated fats, and omega-3 fats.

Foods and nutrients with pro-inflammatory activity include total fat, saturated fat, protein, carbs and iron.

Do anti-inflammatory foods reduce disease?

 A growing body of research certainly suggests so.

A pro-inflammatory diet was associated with higher hypertension incidence in the 7000 women followed in a recent study. It was also associated with higher risk of colorectal cancer in another study that followed about 35,000 women.

Another study in the International Journal of Cardiology found that an anti-inflammatory diet lowered the incidence of heart disease in 3000 Greek volunteers followed for 10 years – at least for those of them that didn’t already have metabolic syndrome.

A brand new, large prospective study published in the Journal of Nutrition found that an anti-inflammatory diet lowered the risk of depression, especially in men.

Add to that the vast evidence linking Mediterranean diets with better health outcomes and, at least for me, it’s reason enough to pay attention to anti-inflammation foods – it’s an intriguing topic I’m sure we’ll hear more about.

The take home message: try to limit the pro-inflammatory foods – refined carbs, fried foods, soda, red and processed meat, margarine and lard, and try to include more foods that fight inflammation, such as fruits, veggies, spices, herbs, nuts and fatty fish.

Dr. Ayala

Which is worse, saturated fat or added sugar?

Which-is-Worse games can be silly, but the fat vs. sugar question might have real health implications. 

The 2015-2020 Dietary Guidelines for Americans target both saturated fats and added sugars as nutrients to limit and seem to give them equal weight: “Consume less than 10 percent of calories per day from added sugars” and also: “Consume less than 10 percent of calories per day from saturated fats”, they advise.

A new paper by James DiNicolantonio, Sean Lucan and James O’Keefe in the journal Progress in Cardiovascular Diseases examines the evidence and comes to a very different conclusion.

One in 6 Americans die of coronary heart disease. Although cholesterol plaques narrow arteries, the cholesterol in our food is not the main culprit in atherosclerosis. Our body produces most of its cholesterol, but what we eat affects cholesterol too. The theory that saturated fats increase blood cholesterol was developed by Ancel Keys, and was adopted in government guidelines. Later on, researchers found that not all cholesterol is the same. How cholesterol is packaged matters, and we came to understand that there’s good (HDL) and bad (LDL) cholesterol, and that total cholesterol doesn’t predict heart disease as much as the ratio between these different molecules.

Some saturated fats elevate bad cholesterol, others have no effect, and others actually increase good cholesterol, and fats in foods never come in isolation – they’re always a mixture. While some foods high in saturated fats, such as processed meats, are connected to heart disease, other high saturated fat foods (such as dairy) have no such effect.

Moreover, since the eat-less-saturated-fat advice has been around for decades, there has been plenty of time to put it to the test. This new article cites several meta-analyses of randomized trials that did not find a connection between saturated fats and heart disease or overall death rates.

Now they looked at sugar. Added sugar, especially fructose, which is a component of table sugar, high fructose corn syrup, and most caloric sweeteners, tends to increase total cholesterol and LDL (bad cholesterol), lower HDL (the good cholesterol) and raise triglycerides.

And here’s an instructive comparison mentioned in the article: to match the damaging cholesterol influences of the added sugar in a typical diet one would have to eat 40 percent of daily calories in saturated fat (which is highly unusual -- most people eat only about 10 percent).

Sugar’s negative heart effects don’t end with cholesterol. Diets high in added sugar are linked with insulin resistance, impaired glucose tolerance, changes in platelet function, fatty liver disease, diabetes and obesity, all linked to heart disease.

It’s often hard to pick a winner to Which-is-Worse questions, but the authors argue that excess added sugars are unhealthier.

When it comes to highly processed foods, many of them are high in one or both, which makes this question relevant, but there’s a better response to it.

If you choose whole foods, you shouldn’t have much of a dilemma. Ripe fruit are very sweet, have sugar, most of it fructose, but they are associated with good health, and lower risk of heart disease. The fats in plants are a mix of saturated and unsaturated fats, and while avocado and nuts have mostly unsaturated fats, even coconuts, which are mostly saturated fats, haven’t been associated with disease.

As long as you eat mostly whole foods, mostly plants, you won’t need to pick a lesser evil.

Dr. Ayala

Anti flat-belly foods

Does the food we eat affect our body composition? Let’s start with the obvious: caloric surplus makes you gain weight – too many calories in and too few out and fat accumulates; reverse the equation and weight is shed.

But here’s an intriguing question: can the type of food we eat cause fat to accumulate preferentially in the belly? Do diet choices affect how much muscle we build? It’s an important matter, because belly fat isn’t just an esthetic issue; fat around abdominal organs behaves like a big endocrine gland, affecting insulin resistance and heart health, while fat elsewhere has fewer health implications.

The fat you eat and the fat you store

A new study in Diabetes, led by Ulf Risérus from Uppsala University in Sweden looked at what overeating saturated fat vs. polyunsaturated fat* does to fat deposits in a neat double blind study experiment.  

39 adults of normal weight gained weight on muffins for 7 weeks. They were assigned to eat 750 calories above their normal intake in muffins made with either polyunsaturated fat (sunflower oil), or saturated fat (palm oil). The researchers chose a plant based saturated fat (rather than butter for example) in order to avoid confounding cholesterol effects, and because it’s a popular ingredient in food industry. Besides the type of fat the muffins had an identical nutrition profile (similar in sugar, protein etc.)

As expected, 7 weeks of 3 extra muffins a-day resulted in weight gain -- both groups gained about 1.6 kg or 3.5 pounds.

But the extra fat, measured by MRI scans, was stored in different body locations. The saturated fat group stored twice the amount of fat in the abdomen and had significantly larger stores in the liver. The polyunsaturated fat group spread the extra weight in more favorable ways, and had a nearly 3-fold increase in muscle mass. Bottom line, in this small study saturated fat caused more weight to accumulate as fat, and that fat accumulated preferentially in the liver and around internal organs. While participants gained just as much weight on the polyunsaturated fat muffins, they gained more of it in lean, muscle tissue, and less in metabolically active abdominal fat.

Sugar belly

This new study connects saturated fats with preferential belly fat. It is a small study, of short duration, and I’d be curious to see if studies in other populations confirm saturated fat as a fat-belly food.

The food item many people associate with a bulging abdomen is beer, but the beer belly has little scientific support.

Soda belly, on the other hand, might be for real.

A study from the University of California at Davis showed that drinking 25 percent of daily calories (which is quite a lot) in fructose for 10 weeks caused belly fat accumulation -- and increased triglycerides, cholesterol, and insulin resistance. 

A recent study found that even moderate consumption of sugary drinks led to measurable undesirable effects after just three weeks: Belly fat accumulated, fasting glucose levels and inflammation markers rose, and the lipid profile changed when volunteers drank what amounted to just 1 can of soda a day.

Another study in the journal Obesity, following 800 people, found that drinking sugary drinks was associated with significantly more belly fat and wider waistlines.

A study in the American Journal of Clinical Nutrition adds to that body of evidence with a 6 month study, in which a small group of overweight people were assigned to drink cola, skim milk, diet cola or water, while fat distribution and metabolic markers were monitored. The total caloric intake didn’t differ between the participants, and all the participants gained just about the same amount of weight (almost 3 pounds). On the other hand, the amount of fat in the liver, abdominal organs and muscle increased significantly in the regular soda group, while it remained unchanged in the other study groups. Blood pressure and triglycerides also rose among the soda drinkers. 

A calorie is a calorie when it comes to weight, but not when it comes to health, and these studies suggest that there are indeed foods that make you fat in all the wrong places.

Dr. Ayala 

*Most foods contain a combination of fats. Saturated fats are typically solid at room temperature, and include fats that come from animal sources: meat, dairy and poultry, and also from tropical oils such as palm and coconut. Unsaturated fats are liquid at room temperature, and include monounsaturated fats – olive oil and almonds are rich sources -- and polyunsaturated fats, which are typical of soybean, corn and safflower oil, fatty fish such as salmon, walnuts, and seeds such as flax, hemp and sesame.

Current nutrition understanding is that total fat in the diet isn’t the issue; the type of fat and the total calories we consume is. Present-day recommendations: limit saturated fats, eliminate trans fat, and choose foods with monounsaturated and polyunsaturated fats.