Healthy Food & Healthy Living by Dr. Ayala

How many calories should a kid eat?

Many of us are familiar with the caloric information on nutrition labels, stating that nutrition facts are based on an average daily budget of 2000 calories.

Have you ever wondered where this 2000 number comes from? Does this number refer to men? Women?

And how about kids?

“Kids should eat more because they’re growing,” some say. “Kids should eat less, small bodies need less fuel,” say others. So which one is it?

If this issue mystifies you you’re not alone.

As more kids struggle with overweight and obesity, this question becomes more relevant, especially since kids are eating many of their meals out of home. When a meal is plated for us, the serving implies, at least subconsciously, that this is a normal amount to eat. And now that calorie counts are popping up in fast food restaurants, and we can see the calorie count of a kids’ meal, parents need some context for this number -- is an 800 calorie kids’ meal reasonable?

A new study in Public Health Nutrition looked at what parents make of these numbers.

How much should my kid eat?

The researchers asked about 1200 parents of 5-12 year olds how many calories a kid should consume in a meal – that includes all courses and drinks.

Only one third of parents correctly estimated that a child should have 400-600 calories per meal, but even those considered their answer kind of a guess – most parents admitted that they were far from confident about their answer.

A third of the parents overestimated kids’ needs, while a third underestimated them.

(An average 5-year-old boy or girl needs about 1200 calories. An average 12-year-old boy needs 1800. Caloric needs vary greatly, and depend on activity level and individual metabolic rate, among many other variables, but if we take these averages into account, and assume that daily needs are divided to 3 meals, it brings us to 400-600 per meal.)

A good kids’ meal

Back to the original question, do kids need more calories because they are growing, or less, because they’re small? Both arguments are correct, and need to go into account when thinking about what a child should eat.

Since caloric need is a moving target, and changes by activity level, and in a child, also by his developmental stage and growth, the best way to eat is by self-regulation determined by satiety and hunger. Which is easier said than done nowadays. Given our stimulating food, endless choices, and the powerful marketing and sugar, fat and salt combinations that entice kids to eat even not hungry, many kids have lost that kind of control.

A good kids meal should have as few as possible of these distractions. A plate with real food, half of which is fruits and veggies, makes kids less likely to overeat. And when it comes to drinks, with a 400-600 calorie budget, one could hardy afford a sugary drink – even the smallest ones have more than 100 calories, and add nothing to health or good habits.

Fast food joints offer different options in kids’ meals. I’d argue that none are ideal, but if you look at the calorie postings, you can see that choosing the apple slices (30 calories) as opposed to the small bag of fries (260 calories) brings the meal down to a more reasonable total calorie count.

A rule mandating that all chain restaurants have to post calorie counts on their menus was supposed to go into effect this month, but it was given a last-minute one-year delay by the Food and Drug Administration. Many places are posting calorie counts voluntarily already, and I think this information could be very helpful and of interest to many people, but to make the best use of it we need to be able to put it into context.

My general advice to kids, including my own, is to eat real food, seated at a table, eat when hungry, only until they’re no longer hungry, and minimize the junk. Kids should learn about nutrition and about food, but counting calories should not be part of a kid's routine. Nevertheless, a casual glimpse of a calorie board leaves an impression — it shows us which foods are calorie-dense and which are lighter. Kids and teens notice these numbers, and over time a general picture emerges that helps a more informed decision.

Dr. Ayala

The diet for clear, acne-free skin

Don’t eat chocolate. That was the advice dispensed – unsolicited of course – to pimply teens in my time. Dermatologists disagreed. The chocolate acne connection was debunked by studies – albeit weak and flawed ones -- and the thinking back then was that diet doesn’t affect acne in any significant way.

A recent article in the New York Times reminded me how much has changed in the last decade. Anahad O’Connor interviewed Dr. Daniel J. Aires, a researcher and dermatologist at the University of Kansas Hospital in Kansas City, who recommends a low glycemic diet for acne, and points to research that shows that foods that cause spikes in insulin, such as those with added sugars and refined carbs, exacerbate the skin affliction. “I’ve had a lot of patients who get their acne under control just by changing their diet,” says Dr. Aires.

In skin disorders, much like in other fields of medicine, further research shows that what we eat, unsurprisingly, affects our wellbeing. We’re not back to chocolate prohibition for acne sufferers; today’s lists of bad-for-your-skin is a little more involved.

Acne’s main food suspects

Carbs:

A curious finding of a study led by Loren Cordain sparked the suspicion that something in the Western Diet promotes acne. The study examined 1315 15-25 year olds from Papua New Guinea and Paraguay, all from non-Westernized societies, who ate traditional diets. They found zero cases of acne. To put this in perspective: 80–90 percent of American teens have some degree of acne. The researchers hypothesized that the glycemic load – a measure of carbohydrate foods’ effect on blood glucose and insulin levels -- see previous post for a short explanation of the concept – causes a cascade of endocrine changes that make acne worse.

This notion was given support by several studies. In a 2007 randomized controlled study, 23 Australian 15-25 year olds showed significant improvement of acne under a low- glycemic load diet. Another randomized controlled study of 32 20-27-year-old Korean volunteers found pretty much the same. These are small studies, but there are several other -- less rigorous ones -- that point in the same direction.

Milk:

Studies that relied on people’s recall of their diet in their teens, and the severity of their acne, suggested that milk affects acne. Looking further into milk type studies showed that only skim milk showed a statistical correlation with acne.

Foods to avoid if you have acne

Given the new information gleaned from the latest research it seems that diet does play a role in acne. It probably doesn’t cause it, but it can aggravate or improve it, at least to a certain degree.

In guidelines published by the American Academy of Dermatology in 2016, the group of 17 experts concluded that, regarding diet, “emerging data suggest that high glycemic index diets may be associated with acne” and that “limited evidence suggests that some dairy, particularly skim milk, may influence acne,” but “given the current data, no specific dietary changes are recommended in the management of acne.”

They did not find that the evidence was strong enough to warrant a recommendation.

Guidelines aside, since high glycemic load foods are generally to be minimized anyway – they are typically highly processed foods, foods with white flour, added sugar, and low fiber – I can see no reason to why people with acne shouldn’t give it a try.

Eating more fruits, non-starchy veggies and whole grains is good for you anyway, and it so happens that this eating pattern has low glycemic load. Minimizing added sugar helps curb weight gain and chronic diseases such as diabetes and atherosclerosis.

This kind of eating plan will also add color and glow to your skin.

No reason not to give it a shot.

Dr. Ayala

Light therapy for your food choices

In food choices everything matters. This is the premise of Brian Wansink and the Cornell Food and Brand Lab’s work. Their research has unveiled some of the many occasions in which environmental cues such as plate size, packaging, label claims and placement influence our eating. Terms such as "mindless eating" and "health halos" are also the fruit of Wansink’s team’s work.

Now, let’s think of lighting. We know if affects our mood: People may feel more optimistic on sunny days, and the light and color of interiors may affect the state-of-mind of those inhabiting brighter rooms.

The smell and the music in a restaurant affect our feeling and food choices. Could light be doing the same? A new study, to be published in the Journal of Marketing Research examined the food choices of diners in a series of experiments, and found that in well-lit rooms people were 16-24 percent more likely to order healthier food (grilled/baked fish, veggies) rather than unhealthy items (fried food or dessert). When the researchers looked at sales receipts they found that the caloric content of meals ordered in dim rooms was almost 40 percent higher.

The authors, led by Dipayan Biswas conclude:

“In terms of consumer wellbeing, dining in brightly lit ambient settings might be a good option if the goal is to enhance choice likelihood for healthy options. Since dim (vs. bright) ambient light reduces mental alertness level, dining in dimly lit environments might lead to greater likelihood of yielding to the temptation of going for the sumptuous, but unhealthy, chocolate dessert.”

According to this study, a dimmer switch may influence the food choices – and the bottom-line – in a dining establishment.

But then, being alert and cognizant when we select food would make us less vulnerable to environmental manipulations. Mindfulness and food knowledge could shine a permanent, independent light on our choices.

Dr. Ayala

Does restaurant food raise blood pressure?

It is possible to eat healthy when eating out – but it certainly isn’t easy. Tempting foods, countless choices and large portions are just some of the reasons we’ll tend to overdo it when eating out. The fast food to healthy food restaurant ratio definitely also skews to the greasy, salty, sugary side of things. 

Eating out more often is known to be associated with overweight, but a new study in the American Journal of Hypertension found that even for young people, just one more meal out is linked to higher blood pressure. 

High blood pressure your food and your health

High blood pressure, or hypertension, is a risk factor for heart disease and stroke, and the earlier in life it starts the greater the danger. The researchers, from the Duke-NUS Graduate Medical School in Singapore, recruited about 500 healthy students aged 18-40, and collected data about their physical activity, dietary habits and also measurements of blood pressure, weight and height.

In this young group 27.4 percent had prehypertension (defined as systolic blood pressure of 120–139 mm Hg and/or diastolic blood pressure 80–89 mm Hg) and 2.2 percent had hypertension (systolic blood pressure above 140 mm Hg and/or diastolic blood pressure above 90 mm Hg). Not surprisingly, higher blood pressure was associated with higher BMI, older age and particularly with being male and with lower levels of exercise.

But the new finding in this study was that each additional meal out of home increased the odds of high blood pressure by 6 percent, and the association was stronger the older you got.

Controlling blood pressure is important for prevention of future disease, and while circulating androgens (the probable cause for men’s higher blood pressure) and our genetic makeup are a given, there are plenty lifestyle factors that are up to us. Exercise and controlling our weight are important for ideal blood pressure – as well as for countless other health conditions. And while eating out is fun, and a necessity for many of us, we can definitely try to eat more home cooked meals, and to eat out in a way that‘s more like eating in.

A few tips:

Choose the restaurant, choose the dish: After picking a restaurant with healthier food, opt for the dishes that offer simply prepared healthy options. Stay away from crispy and fried foods and creamy sauces and soups.

Control portions: Beware of all-you-can-eat buffets. If the portions are large don’t be shy – try to order a half portion or share the dish with your dining partner. Boxing half of the entrée for tomorrow is another option.

Pay attention to the drinks: Alcoholic and sugary drinks can add lots of unnoticed calories. Mixed alcoholic drinks can be calorie bombs: they contain both alcohol and sugary additions. Instead, drink water throughout the meal.

Pretend you’re home: Well, I wouldn’t suggest such killjoy steps if you’re eating out as an occasional indulgence – in that case I'd personally dress nicely and eat whatever my heart desires. But if you’re a student and have to subside on cafeteria food, if you’re traveling for a while and therefore eating a restaurant breakfast daily, I do suggest you pick the meal that most resembles a healthy home-meal. Those big muffins do look good and everyone seems to eat them, but the yogurt and bowl of fruit will leave you with fewer regrets.

Dr. Ayala

Distracted driving, distracted eating

A few weeks ago, an Alabama man was stopped by a policeman for eating a cheeseburger while driving and cited under the distracted driving law. The charges were later dropped.

The story got remarkable attention, and although I have no idea whether the driver should have gotten a ticket, I’m glad that it brought the issue of distracted driving into discussion.

The other issue that we should think about more is distracted eating. We seem to be eating most of our meals while doing something else. And while eating might take your mind off the road, traffic also takes your mind off your food. 

A study in Public Health Nutrition that looked at people’s food-related time use over 30 years revealed that besides the dramatic shift in how much and what Americans eat, there’s also been a big shift in the way we eat. 

The study found that we now do almost 50 percent of our eating while concentrating on something else, up from just 20 percent 30 years ago.

Eating is now done while driving, watching TV, walking down a street and working — as we all know, it’s now perfectly acceptible to eat while doing pretty much anything — and food’s available for nibbling and sipping everywhere.

We’re eating most of our calories while distracted. Does preoccupied eating explain overconsumption and the upward trend in our collective weight? I think so, at least in part. Mindful eating is an important technique that helps people modify their food intake and we should give some thought to how we eat, and perhaps try to multitask a little less during the time we have food in our mouths. Food that’s eaten at a table, slowly, attentively, is more effective at filling you up. Food that’s celebrated is more satiating. 

Mind you, I’m as guilty as anyone of eating lunch at my computer. But I do have some rules that I’ve been able to stick to: We eat a family dinner every day, unrushed, no electronic distractions allowed, and I limit eating-while-distracted to low caloric density, highly nutritious foods, such as veggies and fruit.

A good start would be eliminating eating while doing these two things: watching TV (huge amounts of calories can be consumed mindlessly in front of a screen) and obviously driving. Eating slows your reaction time to dangers on the road. Driving slows your reaction time to food. 

Dr. Ayala

Two different paths to obesity, and what they have in common

The naturally thin often have a hard time understanding the struggles of the very many who battle with overweight and obesity. Why is losing weight – and especially keeping it off – so very hard? What is it that drives us to obesity, and what can we do about it? And why has obesity spread like an epidemic in the last few decades?

A new article in Obesity Reviews explains that obesity is caused by two distinctive mechanisms, and understanding these different causes might help with targeting a more tailored solution.

Body weight regulation 

Our body likes stability. It regulates its temperature, blood pressure, blood sugar and electrolytes, and for the most part also our adult weight. Most people fluctuate around a “set point”. You may lose weight due to stress or illness, gain some over the holidays, but usually these pounds come back and go away once life goes back to normal. 

Researchers have been studying how weight is regulated for several decades, and it’s a very complex system of hormones (the most famous are leptin and insulin), neurons, nutrients and feedback mechanisms from the gut that keep this steady state. In order to keep weight stable we regulate intake and energy expenditure, so that when weight is lost we’ll eat and/or lower our activity; when we gain weight appetite will diminish and our cells might burn more energy, even at rest.

The set point helps explain the two types of obesity this review proposes.

Overeating for hunger

In what’s called metabolic obesity, that set point is in play, just at a higher point. The body “defends” this higher set point, and will drive hunger and energy expenditure so that when pounds are shed they slowly creep up towards that elevated set point unless a lot of effort is put in to fight the body’s basic tendency.

An elevated set point is inherited and determined by our genes, but if that were the entire story metabolic obesity couldn’t explain the tripling obesity rates we’ve experienced in the past decades – the population’s genetic makeup hasn’t changed in this time period. 

And indeed, early childhood influences and environmental factors can tune the weight set point in susceptible individuals. Experiments in rats show that when they are forcefully overfed or underfed with regular food for a while, they gain and lose weight respectively, but once they return to eating at will their weight goes back to normal. But if the same rats are fed tasty, high calorie food for a significant while, about half of them will become obese, and their set point will set at a higher weight. They will now defend this higher weight point even when returned to a regular rat diet.

The same mechanism seems to be present in humans. Some people’s set point will change in an obesogenic environment, while others are resistant to it.

Overeating for pleasure

The other mechanism for obesity isn’t regulated by hunger and satiety, but rather by emotions, desires and rewards. Hedonic obesity is governed by liking and wanting food, and by seeking pleasure from it. Whether people overeat because food is more highly rewarding and pleasurable for them, or rather because they need more food stimuli in order to feel the same amount of pleasure thin people get with less food, the end result is that they eat above what their body needs metabolically, and their eating has less to do with energy balance. Satiety signals are overridden and the body’s set point doesn’t matter.

How can we tell the two overeating patterns types apart?

A person with metabolic obesity would have normal metabolic rates and would burn no more than the expected number of calories appropriate for his body size. On the other hand, with hedonic obesity, metabolism is revved up – the body is above its weight set point and will try to burn off the extra energy. Behavior around food might also differ, with food addiction and compulsive over-eating more typical of hedonic obesity.

In reality it’s very hard to test for such differences, it’s tough to tell the two types apart, and both patterns often interact and interplay in the same person. 

The authors believe that knowing the underlying mechanism would help with treatment. Hedonic obesity would be treated with behavioral and lifestyle interventions, while those would not work as well for metabolic obesity, in which drugs (of which, sadly, there are very few) and other forms of intervention would be of more benefit. Bariatric surgery works well for both types. 

High-calorie processed foods are the common pathway

It’s hard to tease apart metabolic vs. hedonic causes for obesity, and impossible to change the underlying genetics leading to each susceptibility. Both mechanisms explain why it’s so hard to lose weight and keep it off – body and mind fight really hard, with multiple redundant defense layers – to protect from weight loss.

But both of these causes flourish in the modern food environment in which we’re surrounded by foods that are sweet, salty and fat, attractive and addictive and at the same time so easy to get. Exposure to these foods affects our metabolism and can up-regulate the internal homeostat that determines body weight; having these foods around, seeing ads and marketing for them wherever we go, also affects our desire and craving for food.

The processed food diet is a common pathway to both types of obesity and its spread explains why obesity has soured. 

Dr. Ayala

Working off a Coke: Warped logic at its finest

Coke has a new online ad, beautiful, happy, clever, and logically twisted.

The ad (see below) imagines what would happen if people paid for their can of Coke by working off the calories it contains. It shows that people are different, but on average, working off a can of soda takes just 23 minutes of cycling.

In this imaginary world soda makes thin people exercise -- and imaginary worlds are a nice respite. But it also distorts human physiology on many levels.

You don’t really burn 140 extra calories in 23 minutes

The time it takes the riders to burn their 140 calories varies, and depends on the speed of their pedaling and their weight (the heavier and larger a person is, the more they burn). These of course are just estimates – calorie trackers don’t really measure the calories you burn.

But the important thing to remember is that that estimate on the treadmill or the bike is for the total you burned during those 23 minutes, not for what you burned extra during the exercise session. If you were sitting at your computer you’d burn 40 calories during that time. If you were shopping you’d expend about 54 calories. The amount of extra calories you burn, what you really ‘earned’,  is the number of calories you exerted minus what you would have spent on an ordinary day, and we burn quite a few calories even in our sleep (50 per hour). In the best case scenario, I’d say those 23 minutes of biking add to the daily expenditure tally just 60-100 calories, and that’s if you're careful not to compensate by a little more couch time that day -- and you'll really have to be careful, as our body aspires to a steady state and resists change in energy.

140 calories aren't the problem, soda is

Let’s put numbers in context: 140 calories are just 7 percent of the daily caloric allowance for an average person. A large banana has as many calories as can of soda, and a handful of nuts have more, and most health experts highly recommend you do eat those. Soda isn’t on the ‘don’t’ list because it’s a calorie bomb, but because its calories are entirely empty. One can of soda has more sugar than what we should consume in an entire day. And there is something unique about liquid calories, as they don’t count towards satiety; we’re therefore advised to cut these specific calories to a minimum.

Soda is linked to obesity and disease not because it’s the most calorically dense food of them all – it isn’t – but because these are added-sugar calories that are conducive to overconsumption and poor metabolic health.

Exercise won’t solve obesity

Most people will not lose weight when they start an exercise program. To lose weight they’ll need to also watch what they eat, i.e., eat less.

Researchers have puzzled over why this is the case and I won’t go into it right now, but at this point it’s clear: there’s no way ordinary people whose day jobs don’t involve physical labor can exercise to the level in which they could eat as much as the food industry suggests they do.

We need to be active for our health and well being, not so that we’ll be rewarded with eat-less-of food. Exercising for a sweet reward usually leads to weight gain, because we tend to overestimate caloric expenditure, and underestimate intake.

The math just doesn’t work, and neither does the myth. Exercise will not solve our obesity crisis, nor will it allow us to eat whatever we wish. 

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. On top of that, I really enjoy Coke ads, and wish the talent behind them would be used to further health.

What’s a normal restaurant portion size?

We tend to eat what’s on our plate. Most of us have a hard time stopping at satiety or assessing caloric count, we therefore rely on outside cues and eat the unit offered, believing that that unit is what normal people eat.

So restaurants influence how much we’ll eat just by deciding the serving sizes, and those are unpredictable and range from petite to colossal. A study published last year surveyed 245 restaurant chains and found that entrees averaged 674 calories, appetizers 813 calories, sides 260 calories, salads 496 calories, drinks 419 calories, and desserts 429 calories. Combine just two portions and you’re way over the Institute of Medicine’s recommended 640 per meal, and these calorie counts are averages – Olive Garden’s Chicken Alfredo has 1540 calories a plate.

A new commentary by Deborah Cohen and Mary Story in the American Journal of Public Health has an interesting suggestion: let’s standardize portion sizes in restaurants.

Portion distortion 

There are standards for screws, nuts and bolts, argue the authors. Portion sizes are established for packaged foods. Alcohol is standardized: A standard drink contains about 0.6 ounces of ethanol in the US (the US alcohol unit is more generous than the UK one), and would therefore amount to a large 12-ounce glass of beer, 5-ounce or half a glass of wine or a tiny 1.5-ounce shot of vodka. This enables people to gauge their alcohol consumption, knowing that it takes about an hour to metabolize each unit of alcohol. Most states outlaw all-you-can-drink sales of alcohol – you’re free to order as many drinks as you wish, but it’s illegal to automatically refill your glass.

Yet when it comes to restaurant food serving sizes are all over the place, making it very difficult to practice portion control unless you can consult calorie charts and bring along measuring cups and scales. Palm-of-your-hand tricks for estimating the meat portion hardly work for amorphous foods in deep plates. Portion control relies totally on consumer education, but why not enlist the provider – who after all has much better access to measuring cups – for assistance?

Cohen and Story suggest using some combination of the USDA and FDA’s portion sizes – those were developed for the Dietary Guidelines for Americans and for packaged foods – and coming up with a standard size that would, for example, standardize an entrée without sauce at 3 ounces, and with sauce at 5 ounces. They suggest all prepared foods should be available in single portions, and family size portions, whole fish and cuts of meat would clearly state they contain 3 or 4 portions. This way the default is one serving, and the diner has the choice of ordering as many portions as he wishes, while being better informed about the size of the serving he’s ordering.

Would restaurants be willing?

Let me guess: Of course not. Remember the outcry when Mayor Bloomberg suggested capping sugary drinks at 16 ounces per serving? Nobody likes regulations, but Cohen and Story remind us of the response preceding the clean indoor air laws. Restaurants objected fiercely and claimed they’d lose customers and money, yet no such thing happened, and if a few smokers stopped frequenting a bar, people who previously avoided the smoky establishment replaced them. I bet one of the most frequent questions servers get is “how big is your portion”; this new system might bring in diners that were previously cautious of overeating when dining out.

Will customers like this? Would you?

Dr. Ayala

Crazy diets, silly food science and absurd food inventions 2013

This year had its remarkable share of senseless diets, bizarre research and odd inventions. Here’s what you might’ve missed. Feel free to add your chuckle-worthy items to the comments below.

Lose weight; stop eating

The Breatharian Diet holds much promise. For one: It can solve world hunger. According to believers, much like plants, humans can live on fresh air and sunlight’s vital life forces if they work on it. The British Dietetic Association lists this diet as the number one “Top 5 Worst Celebrity Diets to Avoid in 2014”; ridiculous as this might sound, there are people who actually tried this, and some who lived to tell the tale. 

Why do onions make us cry?

The silliest of research is celebrated yearly at the Ig Nobel awards.  The ceremony, held at Harvard University each fall, spoofs the Nobel prizes and is presided over by real Nobel winners.

Among this year’s achievements were the discovery that people who think they’re drunk feel more attractive, and that the longer a cow lies down, the more likely she is to stand up. The important food chemistry prize went to Shinsuke Imai from Japan, who discovered why onions make us cry – it is actually more complicated that previously thought.  Imai’s group discovered a previously unknown enzyme, lachrymatory-factor synthase, which apparently has nothing to do with onion’s taste profile or nutritional value. So there you have it: we can potentially develop a perfectly tasty onion that doesn’t protect itself with tear gas. 

Must have: watermelon stroller

I love watermelons and really miss them right now – I won’t touch watermelons out of season. Would you like to take your watermelon for a walk in a fitted cooler, or are you going to carry this heavy baby in your arms forever? Head over to this site and you can purchase this lovely Japanese device for about $200. What do you do with twins?

A tablet on every table

Applebee’s announced it will install tablets on every table by the end of 2014, enabling diners to read the menu, pay the bill and play games. Chili’s will be doing much the same, empowering customers to order drinks and desserts and to play interactive games. Both companies deny this will cut jobs. If you are to believe the chains, the computers will enhance rather that replace human servers, who are poised to get larger tips due to better customer satisfaction.

Yippee! With TV screens already in every corner, Instagram, Facebook and text luring us to our personal smartphones, and now a tablet to fill odd-moments-when-family-finds-silence-unbearable with video streaming and social media interaction, we can finally fully enjoy a leisurely meal. This really brings these so-called family friendly eating establishments to new levels of kindliness to what it means to eat and to be in company. Next: your meal will be delivered by drone.

Looking forward to see what 2014 brings.

Dr. Ayala

Do star athletes eat the junk they endorse?

What do star athletes eat? I’d bet they view their bodies as a temple and treat it with great care.

Yet for the right price role models of health and fitness will recommend junk food. 

A new study in Pediatrics shows the extent and reach of athlete-endorsed junk food. The study looked at the 2010 Bloomberg Newsweek 100, a list that ranks top athletes on the basis of prominence in their sport and the earning potential of their endorsement contracts. The researchers, led by Marie Bragg, then generated a list of the brands these athletes endorsed, and sorted the brands to 11 categories, including food and beverage, automotive, finance, airlines etc. 

Best endorsers for worst foods

Of the 512 brand endorsements, 122 were for food and beverage, and these made up about 24 percent of all the deals. LeBron James (Sprite, Vitaminwater, McDonald’s, Powerade), Peyton Manning (Gatorade, Wheaties, Pepsi) and Serena Williams (Oreo, Gatorade, Nabisco) had more food and beverage endorsements than any other athlete. 

Sports drinks toped the list of food and drink deals, followed by soft drinks and by fast food. And here’s the nutritional profile of athlete endorsed food: About 80 percent of the foods were energy dense and nutrient poor, and 93 percent of the beverages were sugar water, receiving 100 percent of their calories from added sugar.

What do athletes eat?

LeBron James might not need to care about calorie counts –  he probably burns 3 times the energy most men his age do -- but his food doesn’t come from a factory; it is carefully prepared by his personal chef, Brandon.

When asked about her diet Serena told Body & Soul “My goal is to have a healthy lifestyle so I can live a long life. I don’t eat a lot of meat. I eat a lot of natural food – a lot of green stuff like spinach and cucumber. And I drink lots of water.” 

Marketing junk leads to eating lots of junk. Junk endorsed by sport idols -- the very picture of health and fitness -- removes barriers of judgment, and leads to eating even more junk. And the most talented marketers and endorsers are promoting the worst foods.

Yet in the real world, eating fast food and drinking sugary drinks leads to obesity and disease, not to winning super bowls and grand slams.

An athlete isn’t just a celebrity. His endorsement carries with it a healthy halo, associating the food and drink he’s supporting with fitness, strength and vigor, and creating a confusing mixed message. Although junk food and cigarettes are not the same, the Pediatrics article reminds us that Babe Ruth, Joe DiMaggio and Lou Gehrig appeared in tobacco ads, and it was only public pressure that did away such practices. Until such pressure is applied to junk food, we’ll continue to see the world’s premiere sports competitions like the Olympics, brought to us by McDonalds and Coca-Cola, and the athletes our kids admire suggesting to them that junk food makes you strong.  

Dr. Ayala

Should salt shakers be removed from the table?

Setting the table was my first contribution to the family food making effort as a little girl, and the first task my kids participated in in my own home (I hate calling it a chore – makes a job that can be delightful and creative sound so boring.) A basic set table to me has plates, glasses, cutlery, napkins salt and pepper.

But now, many restaurants are omitting the salt shaker. The New York Times brought in chefs, health experts and others to debate this trend.

I suppose that most restaurants that do away with the salt shaker do so because they feel the food’s already properly seasoned, and that the chef is responsible for the final taste and deserves full control over the finished product -- I don't think hypertension is on their mind.

Chef Kevin Sbraga does not put salt on the table in his Philadelphia Sbraga. He thinks that the guests should expect to get the food properly salted and says:

“Ultimately, it might be a control thing. I want to have as much say in our guest experience as possible, even when it comes down to the salt.”

Mary Sue Milliken of the Border Grill restaurants offers the same reasoning and doesn’t automatically provide salt at the table.

On the other hand, Marcus Samuelsson of Red Rooster Harlem thinks it’s not for him to force his salt preferences on his diners.

None of the chefs in this piece took the salt shaker off the table for health reasons. Indeed, Thomas Farley, New York City’s Health commissioner – who has waged a war on the salt excess in our diet and is a big proponent of salt reduction – is on good terms with the salt shaker:

“The salt shaker is not the culprit. Only about 10 percent of the sodium in our diet comes from salt we add to food while cooking or eating. Most of the salt we consume is already in food when we buy it. In fact, foods that don’t even taste salty, like bread, are among the top sources of sodium in our diets.”

Salt to taste

Too much salt can have detrimental effects on blood pressure, especially in vulnerable populations, and there is no doubt that the American diet contains excess salt – added for a multitude of reasons some unrelated to taste – and salt clearly belongs on the ‘foods to reduce’ list.

Salt, on the other hand, is an amazing ingredient. It is an essential nutrient we can’t do without; it not only flavors food, it is also a taste enhancer and taste modifier, and a natural preservative that keeps foods from spoilage.

But how much salt is just enough salt for perfect flavor? To that -- I beg to differ from the salt-controlling chefs -- there is no right answer.

Salt sensitivity and preference varies from person to person, and depends on the foods we regularly eat. Evidence shows that we develop a preference to a certain level of saltiness through repeated exposure. Raise a kid on very little added salt, and his taste buds will sense just a few flakes; raise him on fast food and food will taste bland unless it’s generously salted. Evidence shows we are born liking some saltiness, but salt level preference depends on exposure.

So chef isn’t necessarily an authority on the perfect salt level. No one is.

I rarely add salt at the restaurant table, but when I want another grain of salt I hate having to ask – and wait – for it, and for me, a table is not set without it. Salt just belongs at the table, and has been part of how we welcome guests for a very long time. Please, do stop this saltless trend. And if I can, one more pet peeve: please don’t clear plates when other diners are still eating; it is rude, and interrupts the mood and the conversation.

Do you miss the salt shaker when it isn’t there?

Dr. Ayala

Immunity boosting foods? Really?

I have a summer full of travel (mostly work but also family time and pleasure) and will be writing new posts infrequently. Meantime, I'll be reposting a version of some of the most popular posts I’ve written over the past years so that new readers have a chance to catch up. Wishing you a happy and healthy summer!

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The connection between diet and health was proposed some 24 centuries ago by Hippocrates, and I can imagine he first heard of it from his mom, who heard it from her ancestors.

Today, grandmas, moms and physicians have piles of scientific evidence supporting their observations and advice. It’s true: Diet does play an important role in health. We’re learning more each day and the discovery is fascinating.

Unfortunately, scientific discoveries are being overly interpreted to promote the sale of foods, and scientific jargon appears all too often as buzzwords on packaged goods.

Every Flu season has given rise to a new barrage of immunity claims shouting at us from every supermarket shelf and commercial. It’s a perfect time to look at the diet/health connection and these claims.

A short introduction to food label claims

There are several types of claims allowed by the FDA on foods.

A health claim describes a relationship between a food or food component and adisease, and it must:

• Be pre-approved by the FDA. There are currently slightly more than a dozen of these approved claims.

• Be phrased in the specific language the FDA requires. The claim must indicate that the disease may be caused by a variety of causes, and must state that the food should be consumed as part of a healthy diet.

• Appear on food that meets certain nutritional requirements.

A structure/function claim is quite a different animal. 

Structure/function claims describe a role of a nutrient, a substance in food or a food supplement in affecting the normal structure or function in the body. Unlike a health claim, it doesn’t relate to a disease or a health-related condition. The verbs “support”, “improve”, “boost” and “maintain” are often a telltale sign of a structure/function claim.

A Structure/function claim: 

• Requires no FDA pre-certification.

• Can be attached to any food, including junk food (there are no overarching nutritional requirements).

• Can be phrased in many ways.

• Is the manufacturer’s responsibility. While the claim “must be truthful and not misleading”, there’s no specification about how much evidence is needed to make the claim.

A few quick examples: 

“Calcium reduces the risk of osteoporosis” is a health claim; “calcium builds strong bones” is a structure/function claim. 

“Fiber may reduce the risk of some cancers” is a health claim; "fiber maintains bowel regularity," is a structure/function claim. 

Confused? You’re in good company. Most consumers can’t tell the difference.

Even the pros in the food industry can’t necessarily make sense of structure/function claims. They consult expert lawyers whose entire practices are devoted to advising companies on the language of the label. Creative marketing devises the claim and legal counsel makes sure it’s defensible and at least somewhat based on reality.

What’s clear is that the structure/function claim has been a boon to food manufacturers. Since there are so few limitations on its use and the trusting public can’t distinguish between a health claim and a structure/function one, why not be creative, develop a claim that meets your goals and slap it on the package? Market research shows these structure/function claims really help with sales.

What's the evidence backing these “immunity” claims?

There are, in fact, no approved health claims related to immunity.

What does that mean? It means that no one has presented to the FDA enough evidence of a relationship between a food, a food ingredient or a dietary supplement and reduced risk of contracting or of treating an immune mediated or infectious disease such as the flu to warrant a health claim.

That means the immunity claims you see everywhere are all structure/function claims.

What are the claims based on? The immune system is very complicated, and its integrity depends, among other things, on good nutrition. States of vitamin, mineral or protein deficiency lead to reduced immunity and correcting the deficiency does improve immunity.

But while it’s true that if you had a vitamin C or zinc deficiency you could improve your health and immunity by eating a vitamin-fortified cereal or a vitamin supplement, it’s clear that shouting “Immunity!” from the cereal box is misleading. Vitamin deficiencies are rare, and therefore the cereal might be yummy, but it’s not doing much for your immune system.

Most food contributes to one’s health, so by that token we can add a structure/function claim to pretty much anything:

• Sleep, for example, is very important to immunity; should we advertise mattresses as immunity boosters? All mattresses or only some brands?

• Exercise improves immunity. Maybe “immunity now!” should be painted on sidewalks?

• Stress reduction improves immunity; how about an “immunity massage”?

• Why, even breathing air supports immunity. 

These immunity claims are all without much substance I’m afraid, but it’s especially outrageous to see them on junk food. Cocoa Krispies is 40 percent sugar, but hey, don’t you need to maintain normal sugar levels for good immunity? Correcting potential hypoglycemia is critical for good immunity, isn't it?

Thankfully, after receiving a letter from San Francisco’s city attorney last November, Kellogg's announced it would phase out the immunity claims on Cocoa Krispies.

Will misleading claims ever end?

Two scenarios I can imagine:

• Consumers will start rejecting these claims, viewing them as a hyped and misleading insult to their intelligence, and move toward products that are marketed in a more sensible and honest way.

The only reason these claims abound is because we’re buying them.

And here comes my question: Do people really believe that they can buy immunity in box? Or are they buying it knowing that an easy fix is a fantasy, but it still feels good to dream?

• The second option is the litigious route: A few really big class action suits, representing misled consumers who saw no health benefits from investing their hard-earned money in products that failed to deliver can change everything. In that respect, the recent FDA warning letters to manufacturers who post misleading or false claims could act as important evidence and actually make a difference.

I prefer the first scenario.

There’s actually a third possibility.

The FDA can overhaul the whole health-claim structure/function scene, crackdown on false and misleading claims and help consumers understand that good health (and building a strong immune system) has nothing to do with buying products that make health claims. People need to just eat well by consuming healthy, real foods over a long period of time.

Sorry, but that’s the truth—eating well is about good habits and good food, not about sprinkling vitamins, anti-oxidants and omega 3 on processed food. The Center for Science and Public Interest (CSPI) is urging the FDA to do just that in a report it recently sent. (It’s 158 pages, but well worth a read, and it includes lots of pictures.)

So, what to make of these medicinalized foods?

I think it’s best to simply leave them on the shelves and opt for good, healthy choices. As Hippocrates said, “To do nothing is sometimes a good remedy.”

Dr. Ayala

Would the Bloomberg soda ban unfairly target poor people?

Portion sizes have grown and so have we.  Today’s kid-size soda at McDonalds (12 oz., 110 calories) is 70 percent larger than the regular size (7 oz.) of the ‘50s, and 32 oz. big gulps (310 calories) and food buckets wouldn’t be fathomed several decades ago.

Are portion sizes to blame for our overeating? The obesity epidemic has multiple roots, but there’s very little doubt that when presented with larger portions people tend to eat more, and that social norms affect what we perceive as acceptable behavior. So yes, most experts do see portion sizes and the attractive prices they’re offered at as a culprit in the obesity crisis.

Last year, in an effort to shift the default portion size to something a little more logical, New York City proposed to cap the size of sugary drinks sold in food service to 16 oz.  It’s been a bumpy road for this proposed law, which was blocked this spring a day before it was supposed to take effect.

The free-choice and stay-out-of-my-business opposition to the proposed law is understandable, and I’m not going to get into it here. Will the cap reduce waistlines? If such a law ever passes, we’ll get to see if the predicted reductions in consumption play out.

The interesting question a new study set out to answer focuses on the argument that the so-called soda ban isn’t fair because it disproportionately affects low-income people.

Soda cap would target the overweight

The new study in the American Journal of Clinical Nutrition from the Columbia University School of Health looked at the dietary records of almost 20,000 people, and found that about 60 percent of people consume sugary drinks on any given day, and of those, about 7.5 percent order a larger than 16 oz. cup. Two thirds of the large size cups are bought at fast food restaurants.

The large size purchases were more common in teens, young adults, overweight and obese people. Although low-income people did buy more sugary drinks, they weren’t more likely to buy large ones.

This analysis suggests that capping soda at 16 oz. could disproportionately affect young people who are overweight or obese. The researchers calculated that if the cap led 80 percent of the people that order larger drinks to downsize to a 16oz it would shave about 60 calories daily.

They of course don’t have to. Under the NYC proposal anyone’s free to order as many 16 oz. drinks as they wish. The cap would just change the beverage landscape a little bit, and give people pause to consider whether the second 16 oz. is addressing thirst or habit.

Then, of course, even without the law in place, the endless debate and uproar against it is already doing that, so even without passage the sugary drink cap is, I think, already a success.

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. 

A miracle diet that prevents cancer?

If you’re ready to believe the sensational titles and overhype in mass media, miracle super foods that decrease the risk of cancer are discovered every other week.

Except miracles are just that: something that rarely happens, and many of these reported ‘proven’ food cures are based on flimsy findings, never again to be reproduced.

Nevertheless, health experts are unanimous about the effect our diet as a whole has on health, and on cancer risk. The World Health Organization estimates that 25 percent of death burden in developed countries is due to lifestyle – completely up to us – risk factors.

8 healthy habits

In 2007, a collaboration between the World Cancer Research Fund and the American Institute for Cancer Research (WCRF/AICR) evaluated the evidence and produced consensus recommendations for reducing the risk of developing cancer and for promotion of general good health and wellbeing. The WCRF/AICR report is the largest study of its kind, and its conclusions are as definitive as the available evidence allows.

The report featured eight general diet and lifestyle recommendations for cancer prevention:

“1: Body Fatness: Be as Lean as Possible Within the Normal Range of Body Weight.” Maintaining a healthy weight throughout life may be one of the most important ways to protect against cancer, and being overweight or obese increases the risk of some cancers.

“2: Physical Activity: Be Physically Active as Part of Everyday Life.”

“3: Foods and Drinks That Promote Weight Gain: Limit the Consumption of Energy-Dense Foods and Avoid Sugary Drinks.” Sugary drinks were targeted specifically in the report: “Such beverages appear to exert little influence on total daily self-selected energy intakes and their habitual consumption can lead to rapid and sustained weight gain even in the face of restricted solid food intake”. Another recommendation under this heading is “Consume 'fast foods' sparingly, if at all.”

“4: Plant Foods: Eat Mostly Foods of Plant Origin.” Diets that are protective against cancer are characterized by large intake of foods of plant origin and, indeed, several cancers are responsive to increased intakes of plant-based foods.

“5: Animal Foods: Limit the Intake of Red Meat and Avoid Processed Meat.”

“6: Alcoholic Drinks: Limit Alcoholic Drinks.” (Men-to 2/day, women to 1/day).

“7: Preservation, Processing, Preparation: Limit Consumption of Salt and Avoid Moldy Cereal Grains and Pulses (Legumes).” Salt and salt-preserved foods probably contribute to stomach cancer risk, and foods contaminated with aflatoxins are a cause of liver cancer. Although salt is necessary for human health, typical levels of consumption are vastly excessive.

“8: Dietary Supplements: Aim to Meet Nutritional Needs Through Diet Alone.” Dietary supplements are not recommended for cancer prevention. According to the report the greatest danger associated with the use of dietary supplements is the possibility that consumption of supplements is serving as an alternate to good nutrition, and supplements are taken as “magic bullets” to compensate for cancer-friendly dietary and lifestyle practices.

So, not as easy as popping a supplement or drinking acai juice, but does this recipe for cancer reduction and longevity actually work?

Not a shortcut, but it will get you there

A new study in the American Journal of Clinical Nutrition, including almost 400,000 people from 9 European countries, scored participants’ compliance with the 6 first WCRF/AICR recommendations (there was insufficient data to assess recommendations 7 and 8). Women were also assessed for another WCRF/AICR recommendation specific to women: Breastfeeding. The total possible score for a man was therefore 6, and for a woman 7. The group was followed for about 12 years, and during that time almost 24,000 people died, 48 percent of them from cancer.

People with the highest WCRF/AICR score (5-6 for men, 6-7 women) had almost 34 percent lower risk of dying than those that had the lowest scores (0-2 for men, 0-3 for women). Each additional point in the WCRF/AICR score was associated with a 1.2 year increase in life expectancy, and a higher score was associated with lower risk of death from cancer, cardiovascular disease and breathing problems. The recommendations regarding overweight and obesity, and eating plant food, were the most strongly associated with risk of dying.

We like things fast and now, and the WCRF/AICR recommendations aren’t a shortcut, but isn’t it nice to know that we do have some control over our heath trajectory?

Dr. Ayala

Eat Healthy! Everybody’s Doing It!

What do you think is going to lead more students to the salad bar, telling them that most of their friends eat vegetables, or stating that eating vegetables is good for you?

We know that peer pressure can push people to do the right – or wrong – thing. What we think is “normal” or “typical”, and our perceptions of what others have and do, influences our decisions. Many campaigns encourage us to join the majority: “Four out of five dentists surveyed recommend…" and “billions and billions of people served” led us to believe the decision has already been made by everyone, so it must be a good idea. Social psychologist Robert Cialdini showed in a series of studies that when hotel guests were told that the majority of guests reused their bath towels, they were more likely to reuse them, too. This social norm message outperformed environmental reasoning and even a promise to donate money if guests helped reduce towel laundry.

Educational information about nutrition could appeal to those seeking to eat better, but on the other hand telling kids what’s good for them might seem like unwelcome pressure, and might backfire and cause resistance rather than adoption of the good habit.

So which approach, if any, would you use?

Your friends eat here

A new study in Appetite (online ahead of print) conducted an experiment in an on-campus food court in an eastern American university. The experiment took place in an area with two food stations: a salad bar and a grill area serving hamburgers, chicken tenders and fries. The 220 students who participated in the study saw one of three signs:

1. “Every day more than 150 [name of university] students have a burger for lunch here”, accompanied by the university’s logo and photos of the grill area.
2. “Every day more than 150 [name of university] students have a tossed salad for lunch here”, accompanied by the university logo and photos of the salad bar.
3. “Have a tossed salad for lunch”, accompanied by a picture of the salad bar and the university’s logo.

In the control condition no signs were posted.

Message 2 resulted in more students choosing salad compared with the control condition. Message 3, surprisingly, did not lead to significantly more salad choices compared to the control condition. Message 2 and 3 did increase the number of salad choices when compared to the message 1 condition.

What if the norm isn’t healthy?

The sign telling students that salad is a popular choice outperformed the message suggesting that eating salad is what they should do.

But in order to use social norm messaging people need to believe the norm described is indeed true and real. In other words, we need to reach a point in which a majority is indeed following a positive habit in order to market the healthy choice as what everyone’s doing.

When it comes to healthy eating this is rather hard to do. Eating unhealthy, calorically dense foods is very common in many social circles, and research even suggests weight gain ‘spreads’ in social groups, perhaps because people tend to follow the choices of their peers.

So how can we support an “everybody’s doing it” healthy behavior? 

Perhaps we should look at admired groups of people in which this behavior is indeed the norm. Do actresses eat a lot of veggies? Do tennis players follow a healthy diet? I’m sure we can find a trendy group of people in which “four out of five” or at least the majority are role models for healthy eating.

And let’s not forget that perceived social norms (some of them not normative at all) are also created – quite intentionally – by clever, repeated depiction in movies, TV, music and ads. I’d love to see healthy eating inserted into media in place of alcohol, junk food and sugary drinks.

Any suggestions?

Dr. Ayala