Healthy Food & Healthy Living by Dr. Ayala

Quarantine time is an opportunity to eat well

Supermarket shelves can’t be stocked fast enough as we’re hunkering down and getting ready to depend on the food in our kitchen.

A few reports interpret the booming sales of processed and packaged foods as the reversal of  healthy eating trends –people grabbing canned meat and soup, boxed mac & cheese and Oreos, rather than kale and quinoa.

This is unlikely. People’s shopping during stressful times is a very poor predictor of eating trends. The ridiculous depletion of toilet paper doesn’t signify that something has changed in our bowel movements. We’re irrational beings, and in stress, we hoard weird things. Stocking on shelf-stable products – even some that you hope you’ll never get to use – isn’t even irrational in these uncertain times.

I predict that eating habits will improve. Here’s why:

Best time to look at what you eat

A health scare often motivates the most reluctant of people to change their ways. Covid-19 is a shared transformational health threat, and it seems like suddenly we’re all focused on wellness. We are now one unit, trying our best to reduce the burden on the medical system by staying healthy.

And besides excellent hand hygiene and social distancing, our best defense against Covid-19 is to nurture our immune system. The way to do that is by eating well, getting enough sleep, keeping calm and exercising.

In time we’ll have research about the interaction between certain nutrition elements and the new coronavirus. For now, we can safely assume that what’s true for other infectious diseases is true for Covid-19. Malnutrition is a known immunosuppressant and a risk factor for infectious disease. Caloric overload can also make you less resistant to infections: During the H1N1 flu pandemic obesity was found to predict worse outcomes.

Healthy diets and exercise protect and mitigate other diseases – type 2 diabetes and heart disease to name a few – and chronic diseases are a major risk factor for complicated and severe Covid-19.

These difficult times are an opportunity to improve our diet and our health.

Home cooking will improve your health

In ordinary times many meals are outsourced. People don’t have the time, don’t have the skills, and also, just don’t feel like cooking. Many used to believe they could live happily ever after without even the most basic cooking skills.

These scary times prove otherwise.

This is the time to realize that cooking isn’t hard, it isn’t necessarily time consuming, it’s satisfying, and if you have kids at home, they’ll be happy to learn and to help. Kids are very happy to have important jobs, and very proud of their kitchen creations.

If you’re new to ways of the kitchen there’s never been a better time for basic cooking. We’re not entertaining, and your household knows that you can’t get any exotic ingredient on your wish list. Start simply and build on your successes. Like any other skill, practice and gradual learning will make it better and better.

Home cooked meals are usually healthier. You won’t be adding as much salt, fat and sugar when you’re cooking for yourself, and you likely don’t have artificial ingredients and preservatives in your pantry.

Cook from your pantry paying special attention to pulses (such as beans, lentils, chickpeas and dried peas) and whole grains (such as rice, quinoa, farro), add as many fresh vegetables and fruit as you can procure (there are luckily no shortages in the markets, and dry and frozen is also good), indulge every once in a while but try to limit added sugar, boredom- and stress-eating.

Food gratitude

For those of us who are food secure, the robust food supply chain has been such a constant, that we almost stopped noticing its parts and its whole.

Now that some shelves are empty, now that we have to go without some of the items that we need or like, now that we need to think about every trip to the grocery store, we’re realizing how lucky we were.

Now that food workers are named essential workers, now that we have to imagine our lives without the people who make our food, now’s the time to say thank you, to support them, and to never again take any of them for granted.

This is the time to reach out and express our gratitude to farmers, producers, grocers, delivery people, cashiers and the people stocking our shelves. They are working especially hard right now; they are part of the front-line in the struggle against the pandemic. They continue to show up for work, for us, despite the risk.

I have a feeling we’ll emerge from this with a renewed respect for health, for good food, and for the very many people who feed us.

We are social beings, staying away from each other is very hard; I’m confident that when this all ends we will share healthy meals together once again.

Stay strong and connected,

Dr. Ayala

Wellness lessons from the Coronavirus threat

Infectious diseases have always been around, but it takes a new one – a scary and potentially deadly one – to once again become aware of microbial threats. The new coronavirus (COVID-19) outbreak is that kind of wakeup call.

Infectious diseases are the world’s leading cause of premature death according to the World Health Organization (WHO). Nearly 50,000 people die of an infectious disease every day – 17 million each year – and the leading infectious killer is pneumonia. While threats from infectious diseases in the US have declined in the last few decades, in this season alone the CDC estimates there have already been 34 million flu illnesses, with 350,000 reported hospitalizations and 20,000 deaths (136 children among them) just from influenza.

Yet we almost forget about infectious diseases – perhaps blissfully so.

But now, the preparation for what’s to come can teach us some important life and health lessons.

Watch your hands

The centerpiece of the COVID-19 advice is to wash your hands. We’ve been washing hands since preschool, but suddenly we’re paying attention to how it should be done: Hands should be washed frequently, with water and soap, and for at least 20 seconds, especially before eating, after using the bathroom, after blowing your nose and after touching other people and places they’ve touched.

Hands and where they go have become a major focus. You’re instructed to not touch your face.

That’s because respiratory infections spread through droplets in the air, but you can transfer microorganisms directly into your eyes, mouth and nose by your own hands, hands that have touched contaminated surfaces.

Not touching your face is hard. That’s because face touching is much more than a habit, it’s simply human nature, it’s a subconscious action, much like occasionally changing your posture. A study of medical students in Australia found that they did so 23 times an hour. Another recent study of face touching found 6 such incidents in 14 minutes.

We should try our best, for sure, but perhaps rather than repeating the do-not-touch-your-face directive, we should be aware that we do touch our face, and therefore double down on excellent hand hygiene.

Washing hands frequently and well is the most important thing.

And it’s always been so. Many illnesses are spread by contaminated hands – hands carrying bacteria and viruses – and washing hands with water and soap prevents many cases of diarrhea, pneumonia and respiratory infections.

We’re all in this together

In times like this, while we each have our own preparation to take care of, we should take note that we really are all in this together. How we’ll fare relies on cooperation, keeping our cool, and taking care of each other.

It starts with being considerate: Cover your mouth and nose when coughing and sneezing, replace handshakes, hugs and kisses with non-touch hellos, keep your distance if you can – this virus can be transmitted by people that don’t have symptoms (they may develop them later or perhaps not at all).

While emergency preparedness is called for, and channeling concern towards action is soothing, stock, but don’t hoard. Get some imperishable food and a few extra-week’s supply of medication you may need. Beyond that, there’s nothing special to buy and hoarding necessary resources hurts others: the CDC doesn’t recommend masks for healthy people for protection.

We need to plan for how to organize in case daily routines (such as schools and public gatherings) are disrupted, and for that we’ll need to lean on each other.

Another important thing to remember is that although the chance of becoming seriously sick remains quite low it’s the vulnerable people in our local community, and in the end, our entire human community, that we should be worried about most. Slowing this outbreak is critical because overwhelmed hospitals won’t be able to care for very sick people if the spread is fast.

Health systems are a limited resource, a resource we share, and we should try our best to stop or delay transmission of this virus so that this limited resource isn’t depleted.

Be kind to your body and your mind

Take care of yourself: All diseases, and especially infectious diseases, are an interaction between a host and a pathogen. COVID-19 tends to be severe in people with underlying illnesses and in smokers. Now, as always, be good to yourself: eat well, exercise, get enough sleep, avoid stress, get the flu vaccine if you haven’t already.

Keep your calm. Being stressed and worried is a waste of energy and not good for your immunity. Keep informed by turning to trusted sources such as the CDC, WHO and your local municipality’s websites, but don’t overload on coronavirus coverage, especially if it makes you anxious – you don’t need to read tweets and feed updates on this trending hashtag.

Your nutritional status, fitness and calm aren’t an impervious shield from infection, nothing is, but they improve your odds, and your health should never been taken for granted.

Malnutrition is a known immunosuppressant and a risk factor for infectious disease, but caloric overload can also make you less resistant to disease: During the H1N1 of 2009 pandemic obesity was found to predict a worse outcome from the infection.

Good nutrition and exercise also protect you from a myriad of other diseases: type 2 diabetes, heart disease and stroke to name a few. Poor diets are a major cause of disease, and as such, also a risk factor for complicated and severe infectious disease. This wakeup call we’re all having is a great opportunity to shape up and look at your diet quality.

Learning these wellness lessons could be the silver lining of living through COVID-19.

Stay healthy and safe.

Dr. Ayala

Can diet news undermine your diet?

We’re drowning in information. Information overload is especially troublesome when interferes with our ability to make good decisions.

No, this isn’t about the current state of politics.

What I’m talking about is diet news, where contradictory information and the sheer abundance of material flowing from news media, social media and well meaning people you know makes your head spin.

Media messages about diet and food not only make people confused about what they should eat, they may make them distrust the system altogether. And this nutritional backlash can develop into nihilism and rejection of even the most fundamental and agreed upon nutrition recommendations, as in, if they can’t agree about cholesterol why should I eat my vegetables? Why should I believe anything I read?

Too much information

A new study in Public Health Nutrition looks at how contradictory diet information affects attitudes and leads to negative outcomes.

The researchers picked a nutrition issue that’s been hotly debated for decades: the low-fat vs. low-carb diet for weight loss.

About 900 volunteers were randomized to different exposures to news. While all the participants read two news articles, the articles differed. The articles included in the study were actual news reports of scientific studies, edited so that the length and format were uniform, with the publication and author names omitted.

One group was exposed to contradictory information: one article about the disadvantages of a low-carbohydrate diet and one article about the disadvantages of a low-fat diet in different order. The second and third groups read convergent information. One group read one article about the disadvantage of a low carb diet, and another article on the ineffectiveness of a low-carb diet. Similarly, the third group read two articles that point to the same conclusion: one article about the disadvantage of a low fat diet, and another on the ineffectiveness of a low-fat diet.

The other groups were controls: They either read two articles that had nothing to do with nutrition (one about avoiding smoking, the other about the dangers of excessive sun exposure) or nothing at all.

Not surprisingly, the people exposed to the contradictory information expressed more confusion about what they should eat than those that read the convergent articles or the controls.

Confusion and distrust

Confusion, however, wasn’t the only result.

The people who read the contradictory articles expressed nutritional backlash, i.e., negative feelings towards dietary recommendations, and were more likely to express skepticism about nutrition advice altogether. Interestingly, those who were shown the convergent articles also experienced nutritional backlash and trusted nutrition recommendations less than the controls.

The authors conclude that:

“Exposure to any information about diet – whether contradictory or convergent – led to greater backlash than exposure to established health recommendations unrelated to diet or no articles at all. This again suggests that mere attention to these topics in the news media has potential to undermine public confidence in nutritional recommendations more broadly, a concerning finding since reports of dietary studies are commonplace in the news media cycle.”

Could reading lots of nutrition news inadvertently lead to missing out on health-promoting advice?

Previous studies have shown that dietary information overload has unfortunate results, with people ignoring everything experts say, including health recommendations that are completely established, such as the benefits of exercise or of eating vegetables.

But we can’t stop the flow of news, and nutrition research is popular: We all eat, and we’d all like to know which foods to eat for optimal health, weight and fitness.

So what are we to do?

The first principle is to distinguish between guidelines and interesting studies.

Findings vs. guidelines

Guidelines are developed using a mass of scientific studies, the findings of which are weighed and considered according to the quality of the research; when the evidence is strong enough experts in the field issue a recommendation.

Study results should never be taken as guidelines for behavior.

Looking at an isolated study is as actionable as looking at the weather in Phoenix Arizona at 11:15 am on December 24 2019 and concluding that Arizona’s climate calls for umbrella and coat.

Interesting studies, especially studies showing new or contradictory results, are followed by repeated and methodologically superior ones. Scientists and people in the field are used to evidence that leads in different directions and raises new question – scientific discovery is incremental and takes a very long time.

Science is the search for truth – it’s a constant pursuit – and nutrition study is inherently hard. Isolating the effect of diet on health is very difficult because we eat all sorts of foods over a lifetime, each of us is unique, and we live in different types of environments. Nutrition research’s end result is a statistical answer, telling us what’s likely. There are no certainties.

Nevertheless, when the evidence of trials is weighed together, and further, better studies are preformed, scientists can arrive at a consensus, a guideline, which is the best advice that can be given at this time.

The constant drip of information, sometimes also mixed in with misinformation, should not erode your trust in science; we actually do know quite a lot about how to stay healthy.

Dr. Ayala

Sugars added to 68% of packaged foods – here's what can be done about it

This is the season for sweet surprises, special treats and indulgent bliss.

But the amounts of added sugar year-round, on ordinary days is staggering. Most of this added sugar is in processed foods, as food makers have learned long ago that to increase sales, just add sugar. Or high fructose corn syrup, or fruit juice concentrate, or any of the other sneaky forms of caloric sweeteners that practically act in the same way in our body.

We’ve come to understand, over the last few decades, that caloric sweeteners not only add to overall caloric intake – leading to overweight and obesity – but also have direct effects on the risk of diabetes, heart disease and other metabolic adverse outcomes.

In a new paper in the Lancet Diabetes & Endocrinology Barry Popkins and Corinna Hawkes review the current global trends in sugar intake –- especially sugary drink intake.

Here are some interesting findings:

• 68 percent of packaged foods and beverages contain added sugars

This finding comes from analyzing a representative sample of American households, looking at what they buy, and then examining the nutritional profile of these products.

• Governments around the world are looking to reduce sugar in the diet

The authors look at tactics and policies undertaken by countries, which include:

Taxation:

5 countries in Latin America and Europe are trying this: Chile, Mexico, Finland, Hungary and France. There are a few small islands (such as Samoa and Mauritius), and a city (Berkeley CA) that also passed a tax. Those taxes are rather small, well below the 20 percent recommended by scholars.

Outcomes have been positive in Hungary, France and Mexico.

A recent article in the Economist assesses that “taxes on fizzy drinks seem to work as intended” – namely, they increase the price of sugary products to consumers, and curb the sugary slurp.

Awareness campaigns, restricted availability and marketing: 

Governments have been setting standards for what should be served and sold in schools, trying to reduce exposure to soda ads and enacting public campaigns such as NYC’s Pouring on the Pounds. Getting the message out relies on sustained and continuous efforts, on multiple channels.

Labeling: 

A food label that clearly states how much sugar is in a product might affect both consumers, who want to eat less added sugar, and food makers, who’d like to declare a healthier product. Ecuador started a traffic light label, which displays sugar, fat and salt levels with red, orange and green lights. It seems to work. The UK had a similar, voluntary, traffic light label, which was revised in 2013 by the government. Chile requires a warning label on foods high in added sugar, salt and saturated fat. The authors say that the effects of these labels on what people buy and eat are not fully evaluated, but can change both habits and formulation. 

Here in the US, it’s still hard to know how much sugar is added to a product.

Naturally occurring sugar, such as what’s in fruits and vegetables, and added sugar, such as HFCS, are lumped together as “total sugar”, despite the big difference between how those behave in our body. The FDA wants to make it easier, and has proposed a label makeover that will require listing the amount of added sugar on the nutrition panel, and also, to put it in perspective, by calculating how much of the daily value this added sugar represents. Up until now, upper limits for sugar were not listed on labels at all. Since added sugar should not exceed 10 percent of total calories, a 20-ounce of soda will have to admit it supplies well over the entire daily sugar allowance.

The proposed label changes were up for public comment until the end of October, and the final decision will be out soon. If it passes, already motivated people will have a chance at making better-informed sugar choices.

Dr. Ayala

The new dietary guidelines: Outrage and yawns

Every five years the US government puts forth new dietary guidelines. The reaction tends to split between disappointment with the lack of change and outrage when recommendations actually do change – how come we were advised something that's now deemed untrue? And if experts can’t be certain and consistent why bother with dietary guidelines at all? 

The government’s guidelines are based on nutrition experts’ (The Dietary Guidelines Advisory Committee or DGAC) recommendations, and their science-based report came out last Thursday. Let’s see if we can find something to get angry about.

What’s new, what’s old?

Here’s the advice in a nutshell:

“The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meat and low in sugar-sweetened foods and drinks and refined grains."

This does sound familiar, doesn’t it? More plants, less meat, less sugar. Vegetables and fruit are most consistently identified as the food of healthy people.

Regarding sugar fat and salt:

“The DGAC encourages the consumption of healthy dietary patterns that are low in saturated fat, added sugars, and sodium. The goals for the general population are: less than 2,300 mg dietary sodium per day (or age-appropriate Dietary Reference Intake amount), less than 10 percent of total calories from saturated fat per day, and a maximum of 10 percent of total calories from added sugars per day."

The news here is that the committee departs from the vagueness of past reports and puts an upper limit on sugar consumption – 10 percent of total calories – and recommends adding a line for added sugar in the nutrition panel of packaged food to help consumers comply. 

Previously, expert advice to lower fat intake was conveniently interpreted as permission to increase carbs – many times refined carbs – to fill the gap. Well, that’s not what the doctor ordered, and to make things clearer (emphasis mine): 

“Sodium, saturated fat, and added sugars are not intended to be reduced in isolation, but as a part of a healthy dietary pattern that is balanced, as appropriate, in calories. Rather than focusing purely on reduction, emphasis should also be placed on replacement and shifts in food intake and eating patterns. Sources of saturated fat should be replaced with unsaturated fat, particularly polyunsaturated fatty acids. Similarly, added sugars should be reduced in the diet and not replaced with low-calorie sweeteners, but rather with healthy options, such as water in place of sugar-sweetened beverages.”

To eat better one needs to change dietary pattern, not reach out to the processed food whose label brags it’s free of the latest dietary villain. Low sodium and low saturated fat foods aren’t necessarily better for you.

One of the things that has changed in this report is that it’s moving away from putting an upper limit for cholesterol, stating that: 

“Available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol... Cholesterol is not a nutrient of concern for overconsumption.”

Egg lovers who limited themselves to two eggs a week may be upset. Some say the egg industry might be behind this shift. Others point to the studies cited by the committee; those show that most people don’t respond dramatically to low cholesterol diets, and that these diets don’t improve outcomes in most analysis.

What’s this advice good for?

The advisory committee’s recommendations inform the government’s guidelines, and those affect policies, action and choices. They affect everything from school lunches to SNAP to the food industry, and also the way we personally fill our plate.

We have to eat something, so we need the best, most unbiased evidence to inform what we should eat. Let’s also remember that two-thirds of the US population is overweight or obese, and healthier diets could prevent many of the chronic diseases we’re afflicted with. Yes, we do need help.

That little changes from report to report is quite reassuring. There are many ways to eat healthy, and they seem to all converge around eating more plants, less processed food and moderation.

When pieces of advice do change don’t be upset. Science is never static. Our pursuit of the truth is a journey, and new, many times better data brings us closer to it. Today’s cars are infinitely safer than the ones sold in the 80’s, despite all the recent recalls. The scientific method moves us closer to the answer, but it does take time and further study, and nutrition study is both young and very difficult.

I think it’s wise to have a healthy, enjoyable food pattern. I don’t think you have to listen to the noise and the fine details. Those change, but the essence does remain the same, and change and discovery is what makes things interesting.

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

The best silly food and silly diets of 2014

I’m very excited to share with you my end of year best of the best in diets and food innovation. Celebrating these contributions to humankind is a fond tradition and will, at the very least, take your mind off ISIS and Ebola for a bit.

An insult to kids' intelligence: Bubblegum flavored broccoli

This year, McDonald’s experimented with bubblegum flavored broccoli. The venture has been called off -- kids didn’t like it. Whoever came up with the idea of improving the taste of a food by making it taste like a non-food deserves this years’ award for underestimating kids. It’s ok – more honest even -- for fake food to taste like fake food, but can dressing up real as fake be an upgrade? Kids notice a fake from miles. 

Other contenders for this years’ silliest innovation: a park bench that weighs you, and then tells you – and the world – your weight and what you should do about it. Oh, and let’s not forget the company that offers to deliver to your home the food you’d only consider as a hungry captive at 30,000 feet. Yes, you heard that right, plane food on the ground. 

Bulletproof your common sense

Enjoying a cult-like following and celebrity endorsements, this new diet promises to make you energized, alert and focused, melt body fat, increase muscle mass without exercise and taste great. What’s this miracle food? A mixture of grass fed butter, pharmaceutical grade MCT oil, and specially selected Upgraded Coffee Beans ($18.95 for a small ¾ pound bag).  At 450 plus calories a cup it sure should fuel your day, but if you want to really bulletproof yourself, the next time you see the word ‘miracle’, ‘effortless’ or ‘melt’ connected to a diet, save time and money by following this simple step: close that tab/change that channel/throw away that ad. Here’s my prediction: 2015 won’t bring a slimness and health magic potion either. 

Party with IV hydration rescue

We all know how important it is to be well hydrated, but who knew that your vein is better than your mouth? If you’re hungover, feeling tired or sniffing a cold IVme will hook you up with fluids and electrolytes, maybe add some vitamins, and within an hour you’ll be as good as new, so they promise. Reviv offers several specialty IV formulations, the Slimboost one sounds especially tempting: it promises to increase energy levels, increase red blood cell production, help regulate sleep, mood and appetite, detoxify the body and rev up amino acids metabolism (what does that even mean?).

I’m here to defend the old fashioned mouth. I think that (provided you’re in good enough shape to step into these clinics) the mouth remains the safest orifice for fluids, it practically evolved for just that. It has a lovely mechanism that enables us to take in non-sterile, hardly even clean food and drink. It has safeguards that allow for enormous variations in intake. Oh, and instead of the slight pain of the needle you can get great pleasure from your taste buds and smell receptors that welcome the fluids.

And if someone you love is feeling fuzzy, achy and hungover, an instant redemption IV might be robbing them of the only benefit of their miserable state: the power of immediate consequences might save them from their next binge. Sounds cruel, but a big headache can be a liver’s best friend.

Wishing you a happy, healthy and lighthearted holiday season,

Dr. Ayala

The soda tax experiment, now underway

Berkeley made history yesterday by becoming the first US city to successfully pass a soda tax. The 1-cent-per-ounce tax, which will cover caloric soda, sports drinks, energy drinks and sweet teas, will take effect Jan. 1 2015. The larger the bottle, the more noticeable the price increase will be. 

The combination of cash-strapped state budgets, the obesity epidemic, and the conclusive evidence tying sugary drinks to this epidemic and to bad health outcomes brought about sugary drink tax initiatives in more than two dozen states, but up until now, all these attempts were fought off successfully by massive spending by the soda industry.

Is Berkeley’s going to pave the way for other cities, as it did before with non-smoking sections in restaurants and curbside recycling?

Time, and I hope, a few careful studies will tell.

Price generally affects purchase decisions and there are many indications that soda sales are very price sensitive. It’s expected that if a tax were high enough, sales of sugary beverages would decrease. Scholars theoretically debate to what extent taxes can affect obesity rates, with some studies concluding that even a modest one would improve public health by reducing obesity, while others contend that unless the tax is significant enough, behaviors won’t change. 

Mexico began taxing soda in January this year. Preliminary findings showed a 10 percent decline in the taxed beverages' sales, and a 7 percent increase in the sales of non-taxes drinks (water, flavored water, milk, 100% juice, diet soda). A survey in August found that the majority of Mexican participants said that they’re drinking less soda, and that they relate sugary drinks with health problems such as diabetes and obesity.

The main argument used in fights against the tax is its regressive nature: A soda tax will affect low-income people more than it would impact higher income households as soda consumption is highest in lower socioeconomic homes and minority groups. On the other hand, low-income people stand to also benefit the most: The health problems caused by obesity fall disproportionately on the poor. The programs that these taxes will fund — be it health insurance coverage, wellness programs, anti-obesity initiatives or subsidies for healthy foods — will also benefit low-income people the most. 

The battles against taxing sugary drink elsewhere were successful in preventing them from becoming law, but by fighting the fight, the soda industry has been also drawing increasing attention to this important health issue. Tax it or not, people are ever more aware that sugary drinks are harmful, and they’re already consuming less of them. 

The Berkeley sugary drinks law might be the experiment that provides the evidence that would justify similar measures in other cities. 

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.

Gut microbes might explain why diet soda is linked to obesity

Consumers are getting increasingly more worried about sugar. That’s led to consumption of ever growing amounts of non-caloric sweeteners such as Equal, Splenda, Sweet'N Low and Stevia. It’s a whole-population uncontrolled experiment, long underway, with some mystifying outcomes: Diet drinks are associated with weight gain in several long-term, large studies, even after one controls for the fact that heavier people are more likely to choose diet drinks. 

The new Dietary Guidelines for Americans diplomatically advises:

“replacing added sugars with non-caloric sweeteners may reduce calorie intake in the short term, yet questions remain about their effectiveness as a weight management strategy. ”

Increased appetite following calorie-free sweetness is one possible explanation, but now, a much discussed study from the Weitzman Institute in Israel, just published in the top tier journal Nature, has an intriguing and novel culprit for the diet soda obesity and diabetes link: our gut bacteria.

Bacteria outnumber our cells 10 to 1, and not only are most of them harmless, many of them actually play a critical role in our health, producing vitamins, aiding digestion and helping our immune system.

Unbeknownst to us until recently, each and every one of us has always been a universe, inhabited by hundreds of trillions of invisible one-cell beings. Much like invaders of unknown civilizations have learned the hard way (think Avatar), we’re finding that interfering with the natives’ inner workings -- with antibiotics and habitat change -- might cause havoc not just for them, but also for us.

The unintended consequences of artificial sweeteners 

The new study, led by Eran Elinav, fed mice several commercially available sweeteners (saccharin - Sweet-n Low, sucralose - Splenda, and aspartame - Equal) and found that the mice developed glucose intolerance, a condition that is a harbinger of type 2 diabetes. 

A series of further tests implicated an altered gut microbial flora as the reason. When these sweetener-treated mice were given wide spectrum antibiotics the glucose intolerance went away. When the fecal bacteria of the sweetener-treated glucose intolerant mice were transferred to normal mice, they, too, developed glucose intolerance. Furthermore, the gut bacteria that dominated the sweetener-treated mice’s gut are associated with type 2 diabetes in humans, and are involved in digesting and storing carbohydrates.

So far we’re talking mice.

The researchers then looked at 381 non-diabetic people, and found that using non-caloric sweeteners was associated with glucose intolerance, high glucose measurements and other signs of the metabolic syndrome. The volunteers that reported using non-caloric sweeteners had the same patterns of altered gut bacteria populations seen in the sweetener-treated mice. 

Lastly, 7 people who don’t usually use non-caloric sweeteners were fed the maximum recommended amount of Sweet-n Low for 7 days. In this very short time 4 of the 7 developed glucose intolerance, and showed alteration in the gut microbial population. When the gut microbes of these 4 people were transferred to mice, those mice developed glucose intolerance, too.

This study shows quite nicely that non-caloric sweeteners can alter gut microbes in mice -- a change that has negative metabolic consequences -- and provides preliminary evidence that it can happen in humans too. This will have to be repeated in further, larger studies (and with other sweeteners). 

We’re rightfully worried about our overconsumption of sugar, but unfortunately, there’s mounting evidence that non-caloric sweeteners are also linked with obesity and diabetes. This study offers a fascinating mechanism that explains this link, and a serious suspicion that it’s not just an association: those sweeteners might actually directly cause what we hoped they’d help fix.

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.

Added sugar replaces fat as ingredient to watch for

Michelle Obama unveiled a series of proposed changes to the food label last Thursday. These changes, she said, will help consumers make better, more informed decisions.

The nutrition label was due for an update, as the way we eat and nutrition science have moved along quite a bit, and a revision has been in the works for a decade, but given how difficult it is to change anything in the food industry, most expected little tweaks rather than bold changes.

Instead, the proposal surprised with a few very meaningful modifications. The new suggested label updates the serving sizes, admitting that people don’t drink just half a bottle of soda, leave a bagel half eaten, or serve just half a cup of ice cream. Calories will be displayed loud and clear, grabbing our attention as the largest, most prominent item on the label. But the most audacious part of the proposal: food companies will have to list how much sugar they add to a product. Up until now, when a kid had flavored milk or yogurt a parent could only know the total sugar in the drink – the sugar naturally occurring in milk, and the sugar added as sucrose, high fructose corn syrup (HFCS) or the many other sugar forms. This extra line on the food label is especially important for products that contain fruits and dairy, both of which have innate sugars, but to which manufacturers can add sweeteners for taste and appeal, and up until now we had no way of knowing how much. 

Nutrition facts label proposed revision. Source: Food and Drug Administration. Red highlights are mine.

Why is added sugar targeted?

Sugar makes food taste good. That’s why sugar’s added to everything. Does sugar just make us consume too many calories or is there something inherently fattening and unhealthy about added sugar?

Evidence is now mounting, connecting too-much-sugar directly to high blood pressure, high triglycerides (blood fats, a risk for heart disease), fatty liver and insulin resistance.

A recent study in JAMA Internal Medicine found that Americans who consume more added sugar have a higher risk of death from heart disease. A study in Public Health Nutrition, found that sugar consumption around the world was directly associated with overweight, obesity and high blood pressure. While low intake of cereals and physical inactivity were also contributors, nothing predicted how fat a country would be as much as how much sugar it consumes. Another recent article published in PLoS One looked at the relationship between sugar availability and diabetes prevalence in 175 countries. After accounting for many factors, such as obesity, exercise, poverty, age, etc., the study found that the higher the added sugar in the countries’ food supply, the higher the diabetes rates. The study's conclusion: “every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1%.”

The World Health Organization recommended in 2003 that “added sugar” be limited to 10% of a person's caloric intake. The American Heart Association (AHA) limited further, and recommended that women should consume no more than 100 calories of added sugars per day (6 teaspoons), and most men, no more than 150 calories (9 teaspoons). One 12-ounce can of Coke contains 130 calories in added sugars, which puts women over the AHA upper limit – no room for bread, sweetened yogurt, and just forget about dessert.

Yet the average American consumes about 16% of his daily calories in added sugar.

Fruit juice concentrate and honey are added sugar

Many consumers look for sugar in the ingredient list and HFCS is on many people’s list of undesirables. The new label proposal will require listing all the forms of sugars consumers don’t think about under the added sugar rubric.

“Names for added sugars include: Brown sugar, corn sweetener, corn syrup, dextrose, fructose, fruit juice concentrates, glucose, high-fructose corn syrup, honey, invert sugar, lactose, maltose, malt sugar, molasses, raw sugar, turbinado, sugar, trehalose, and sucrose.”

Fruit juice concentrate might sound good to eat, but when you strip a fruit juice of everything, all that’s left is sugar, and it really is no different from sucrose derived from cane or beets.

Another trick the food makers can apply to ‘healthify’ the ingredient list is using several different sugars, each in small amounts, and since ingredient lists are ordered by weight, a product which is mostly added sugars -- of several kinds -- might list sugar as the third or fourth ingredient. The proposed label change will help consumers identify all added sugars as one entity, and enable us to understand what proportion of the food is  sugar.

Our changing eating habits and our understanding of nutrition and health are shifting the focus from fats in the diet – we now understand that the type of fat matters more than the total fat – to added sugar. Note that "calories from fat" is omitted in the new label. Don’t get me wrong: fat, with its 9 calories per gram, is a nutrient to watch for, but that doesn’t mean that added sugar, which is the other ingredient that can make food super desirable, should get a free pass. This one line for added sugar in the new label is a big step forward.

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.

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

Genetic testing, obesity, and the false promise of 23andMe

Last week, the FDA ordered 23andMe to halt the sales of its personalized genetic test that promises to predict future health risks, saying the company has failed to show scientific backing for the claims they advertise.

I’m turning back to a piece I wrote two years ago about the ability to – and wisdom of – getting tested for genetic obesity risk.

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Simple observation suggests overweight and obesity tend to run in families. The search for genes that affect the tendency to pack on pounds has found a growing list of genes that each contribute to overall risk.  The most famous of these genes is the FTO gene on chromosome 16 – the presence of specific “risky” versions of this gene is correlated with an extra 3 pounds for each risk-increasing copy (we have 2 copies of each gene).

But overweight and obesity are clearly influenced only partly by genetics and we can also explain the tendency for familial overweight by the fact that families often share eating and activity habits. 

It’s also clear that during the past three decades, while obesity rates have tripled, the genetic makeup of the population has not changed dramatically.  Therefore environmental factors (food intake and activity levels) are clearly responsible for this rapid rise in obesity.  The genetic makeup can only take responsibility for making some people more susceptible to these environmental factors.

Genetic testing of obesity

I love the field of human genetics: It uses math, biochemistry, probability and family stories to slowly reveal deep mysteries about who we are.  Studying our genetic makeup also holds enormous medical promise. 

Is genetic testing ripe for primetime? Most people in the field are humbled by the pace of discovery in genetics, and have a feeling we know less than we think we do.   Nevertheless, the growing interest in genetic assessment has already sprouted commercial companies that offer genetic testing directly to consumers.  The future is apparently already here, and these companies suggest not only that they can calculate your risk, but also that knowledge will empower better health decisions.

Since obesity is a really important contributor to disease, one of the risks these companies assess is one’s personal likelihood of developing obesity.  A company called deCODEme tests 11 variants in 11 regions of the genome known to increase an individual’s risk of being obese; 23andMe offers an obesity risk assessment based of 2 genes; all you need to do is spit into a tube (and part with a bit of money).  The results of these genetic screens are given as lifetime risk and relative risk compared to the average person.

Genetically discovering yourself – and then what?

Let’s say we’ve reached the point at which we can really tell who’s at greater risk for obesity, is this data worth knowing?  Would recognizing you’re at risk lead to risk reduction through a better diet, or rather to hopelessness and fatalism?

A new study in the journal Obesity examined the reactions to theoretical results of genetic testing for obesity risk in two groups of British respondents: 306 overweight and obese students, and 395 normal weight students.  The participants received a result that either told them their risk is average or that it’s above average.

In both groups, telling the individual that they were at higher risk for obesity led those people to anticipate they’d be more motivated to adopt a healthier lifestyle.  Again, this is a theoretical study, as no real genetic testing was done.  The study concludes that genetic testing “may offer an opportunity for behavior change if the feeling of “at-risk” can be linked to action by providing concrete information weight gain in conjunction with the test.”

We’re all at high risk

Even without personal genetic testing, I think most of us can estimate whether our risk for developing obesity is at or above par.  A quick survey of the genetic pool during family reunions, an honest look at one’s eating habits and at personal weight trend over time are quite informative.

Perhaps genetic testing can make the assessment just a tad more informed, but does it really make sense to assign risk for a condition that is so very common? Or does the knowledge, that in all western countries the majority of people develop overweight and obesity tell us all we need to know?

The best-case scenario – the result of “you’re at average risk for obesity” – predicts that there’s a pretty reasonable chance you might become obese.  The last few decades have proven that we all have a tendency to overeat when food is plentiful, tempting and calorically dense, we all tend to store the extras – a tendency that served our ancestors very well – and given the chance, we prefer watching TV to chopping wood.

And if knowing we’re at-risk may offer an opportunity for behavior change let’s announce it right now: We’re all at risk for obesity, each and every one of us, some even more than others.  So let’s all do something about it.

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. 

Cinnamon’s for eating, not inhalation

Common sense is slow to develop in humans, and many a time young people will sit around throwing around silly ideas – and then go on to act on the silliest of them all.

And as if kids can’t come up with enough stupidity all on their own, access to a world wide web of thoughts feeds them more tricks and dares – YouTube is great at that.

The cinnamon challenge is nothing new, but I heard about it from my kids only a couple of years ago. The challenge: swallow a tablespoon of ground cinnamon in 60 seconds, without drinking fluids.

Fail to swallow a spoonful of cinnamon, and you might still have your moment of glory in this viral sensation: more than 50,000 YouTube clips, one popular clip with 30 million views (these numbers might be irrelevant by the end of today) and it’s all over Twitter. Subjecting the Cinnamon Challenge to a Google fight (fun site in which you can battle two words or phrases against each other to see which is more Internet popular) shows that cinnamon challenge with its 15 million search results is more popular than chewing gum (7 million). 

Cinnamon sounds innocent enough – every baking home has some, and what can be more natural than an ancient spice from tree bark.

So here’s an opportunity to teach kids a few basic principles in toxicology:

• Dose matters. As Paracelsus famously said: The dose makes the poison. Even water and oxygen – which we can’t survive without -- can be toxic if you have too much of them.
• Safe to eat doesn’t mean it’s safe to introduce into your body in any other way. Do you like hot peppers? So do I. They’re pleasant only by mouth. Water is fine to swallow, and to wash with, but if you inhale it it’s called drowning.

Back to the cinnamon challenge.

An article in the recent issue of Pediatrics warns that the cinnamon challenge isn’t all fun and games. Inhaling cinnamon can damage the lungs and airways, and although the effects are usually temporary, it has led to many emergency room visits, hospitalizations, and a few teens even requiring ventilator support for collapsed lungs.

You see, the cellulose fibers in cinnamon, once in the lungs, do not dissolve or break down – they stay there and are not inert. The authors, led by Steven Lipshultz, cite a study in which cellulose was introduced through the windpipe of rats. This caused inflammation and lung damage, and the results were apparent even a year after the exposure.

When a teen attempts to swallow a large mount of cinnamon there’s a pretty high risk of breathing in some of the cinnamon powder. The powder can damage the lining of the airways and lungs and even cause permanent scarring. Introducing a foreign substance into the airways is even more dangerous for people who have asthma. 

Bottom line, there are better – tastier, and more creative – uses for cinnamon.

I’m just afraid that warning kids about the dangers of the challenge – or locking the cinnamon along with the liquor as some parents have suggested – will introduce it to the few that haven’t heard about it yet, and just increase its allure.

Dr. Ayala

Is sugar making the world fat, diabetic, and hypertensive?

We’re moving towards a world with a shared diet. Pizza Hut, Taco Bell, KFC, McDonald’s, Coca Cola and Pepsi can be found worldwide and consumers around the world and in developing countries have developed a taste for our highly processed food.

The shift from traditional diets in developing countries towards a Western diet – a diet high in refined sugars, animal based foods and vegetable oils – is known as nutrition transition. While this shift affords more food security and cheaper food, the move towards a Western diet has major health consequences, chief among them being obesity, diabetes and heart disease.

What is it about the Western dietary pattern that puts populations at risk?

Sugar, obesity and disease

A new study in Public Health Nutrition, looked at the rates of overweight, obesity and high blood pressure (which are major risk factors for heart disease) in countries around the world, and these countries’ availability of foods, including cereals, sugars, vegetable oils, fruits, starchy roots, pulses, total vegetables, alcoholic beverages, total meat, animal fat, eggs, milk, and fish and seafood.

The study, led by Mario Siervo, found that sugar consumption was directly associated with overweight, obesity and high blood pressure. Low intake of cereals and physical inactivity were also contributors, but nothing predicted how fat a country would be as much as how much sugar it consumes.

Coincidentally, another article looking at what people eat around was just published in PLoS One. This widely publicized article, by Sanjay Basu, Paula Yoffe, Nancy Hills, and Robert Lustig looked at the relationship between sugar availability and diabetes prevalence in 175 countries. After accounting for many factors, such as obesity, exercise, poverty, age, etc., the study found that the higher the sugar in the countries’ food supply, the higher the diabetes rates. Their conclusion is: “every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1%.”

What is it about sugar?

In a fascinating article about the science of creating addictive food in the New York Times, Michael Moss describes the well known recipe to increase sales: “one of the cardinal rules in processed food: When in doubt, add sugar.”

Sugar makes food craveable. That’s why sugar’s in everything.

So does sugar just make us consume too many calories because it makes food tastier and more desirable, or is there something inherently fattening and unhealthy about sugar?

Dr. Robert Lustig is one of the leading voices warning that sugar is a major culprit in obesity and disease, and that sugar punishes us beyond the 4 calories per gram it sneaks in. Sugar, and especially its fructose component, Lustig claims, when consumed in excess, hits the liver rapidly, and drives a whole cascade of metabolic outcomes, and causes fat production and insulin resistance. Lustig’s new PLoS One article supports this theory.

Lustig has his critics, of course, and other obesity and nutrition experts believe sugar drives obesity and disease just because of the quantities and rates we consume of the sweet stuff.

Regardless of how we explain the sugar disease connection, there’s no doubt that to improve health we need to reduce sugar intake.

The World Health Organization recommended in 2003 that “added sugar” be limited to 10% of a person's caloric intake. The American Heart Association (AHA) went further and recommended that women should consume no more than 100 calories of added sugars per day (6 teaspoons), and most men, no more than 150 calories (9 teaspoons). One 12-ounce can of Coke contains 130 calories in added sugars, which puts women over the AHA upper limit – no room for bread, sweetened yogurt, and just forget about dessert.

Unfortunately, we don’t even know how much added sugar is in our processed food, as our food label only lists total sugars — both innate carbs and added sugar — in the sugar component of the label. 

Efforts to curb sugar consumption in the US face strong opposition from industry.  The Yale Rudd Center summarizes progress and efforts to reduce sugary drink consumption in different states in this nifty interactive map. Although sugar consumption is very high in the US and in other developed countries, it has plateaued, and even declined in the last decade. The new study in Public Health Nutrition reminds us that in developing countries sugar intake continues to rise – and will probably result in an increase in chronic conditions such as diabetes and heart disease – therefore the developing world needs policies that limit added sugars, hopefully before the train leaves the station.

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.