Healthy Food & Healthy Living by Dr. Ayala

This is how weight is gained

Although people blame vacations, holiday meals and older age, weight is actually gained slowly and steadily over a lifetime. Much like you don‘t notice the slow bodily transformation from teenager to young adult to middle aged, as there’s no clear demarcation, weight stealthily adds up unnoticed – until it is.

More than 40 percent of the adult US population is obese, and since obesity is a risk factor for a multitude of chronic diseases – including stroke, heart disease, diabetes and several cancers – understanding how weight is gained can help mitigate this raging epidemic.

A new study in the Journal of Obesity looks at weight gain over a decade of almost 14,000 statistically representative Americans. The results are concerning.

Over 10 years more than half of the people followed in the study gained 5 percent or more body weight, more than a third gained 10 percent body weight or more, and a fifth added 20 percent.

Weight gain over the decades

The study shows an inverse relationship between age and weight gain. The greatest weight is gained by young people – between 20s and 30s – in which an average of almost 18 pounds of weight is added on.

Between 30s and 40s weight gain averages about 14 pounds. It slows further down to about 10 pounds for the 5th decade of life, and to 5 pounds for the sixth.

This pattern adds up to 47 pounds over four decades.

People usually think that older age and slower metabolism leads to the accurate observational finding that the older the population the greater the obesity incidence. This is not the case according to these findings. 

In fact, people gain the most weight when they’re young, but despite gaining 18 pounds by the mid 30s many young people are not obese – it takes further weight gain to push you into the obese category.

Obesity rises with age because the older you are the more years you have to steadily gain weight, a process that actually starts early on.

Why would weight gain slow down with age? One reason is that the bigger the body, the more energy it needs, so if you gain significant weight in your 20s and 30s, if you continue eating the same amounts you’ll gain less weight in subsequent years. 

Habits over time

We’ll all age with time – it’s inevitable. But we don’t have to get fatter over the decades – that’s avoidable with better eating and exercise habits.

It's mostly eating habits – lifelong habits – that determine weight gain trajectory.

Studies in overfeeding, in which people were fed 1000 excess calories daily for three weeks led to more than 4.5 pounds gained. But the excess weight was lost within 6 weeks after the overfeeding experiment ended. Extend that to 100 days – which is what was done in another study – and weight gain was on average 18 pounds, and although much of the weight was lost when the experiment ended, 3 extra pounds lingered, and the participants continued to gain weight over the years. 

It's what you do day in and day out that matters the most.

It’s wise to take inventory of your eating habits early on (and it's never too late), add highly nutritious healthy foods such as fruits, vegetables and whole grains, and cut out unhealthy, seductive calorie bombs, such as highly processed foods, foods with lots of added sugar, and sugary drinks.

Dr. Ayala

Are you in denial about overeating and your weight?

Denial is a powerful coping mechanism. When it comes to eating and weight issues many of us seem to be living in ignorant bliss. 

In much the same way many of us believe ourselves to be above average drivers, studies show that weight misperception is widespread. People don’t recognize overweight in themselves or in their loved ones, and even health professionals fail to identify overweight and obesity when just observing a patient. 

About 48 percent of overweight men and 23 percent overweight women considered themselves about the right weight in a study including about 16,000 people, and even among obese people only about 10 percent were aware of the extent of the extra weight they carried. About 8% of obese adults considered themselves to be "about the right weight” in another study.

We often don’t see the expanding weight on ourselves, and we don’t see it in our own kids: A meta analysis of more than 64,000 kids shows that 50 percent of parents did not identify that their kids were overweight or obese, and seriously underestimated their kids' weight status.

It may be that our eyes have acclimated to heavier bodies because so many of us are now overweight. Looking at mid 20th century footage of the movie-star-thin general public from that era surprises us, and contrasts clearly with our two-thirds-overweight/obese population. 

We’re unaware of how much we eat

We not only see ourselves as smaller than we actually are, we also underestimate how much we eat. Intake tends to be underreported by 10-40 percent according to a recent review of 59 studies, which compares people’s reports of intake to objective measures of the calories people need to eat to maintain weight (energy expenditure measured by doubly labeled water, which is the gold standard for assessing how many calories are spent).

Calorie undercounts are widespread, but studies show that overweight and obese people undercount to a greater extent.

Calories expenditure, however, is related to body mass – the larger you are the more calories you need, regardless of physical activity.

A new study including 221 people compared reported caloric intake with objective measures of energy expenditure using doubly labeled water, and also compared it to body size.

Overall, underreporting was very significant, and by as much as 1000 calories a day – had that been true people would be losing weight rather than staying the same weight or gaining some.

Obese people underreported caloric intake by as much as 42 percent. More active people also tended to underreport by almost as much: 41 percent. In comparison, thinner and more active people underreported – but by less.

But when you take into consideration body size and therefore resting energy expenditure, the absolute discrepancy between reported caloric intake and expenditure was equal: thinner people under-reported calorie intake less, but their caloric need is lower, therefore the absolute discrepancy between actual intake and caloric need was about the same.

Dietary patterns rather than calorie counts

Given the tediousness of counting calories, and the inaccuracy our self-assessed intakes, eating while counting perhaps isn’t serving us well. Regardless of the reasons why we tend to imagine we’re eating less and better than we actually are, our self deception allows us to gain weight over time.

The authors suggest that perhaps focusing on obesity-risky foods, such as high energy density foods, ultra-processed foods, foods with low fiber that cause little satiety, and sugary beverages, might better serve as dietary guidelines. Recommending a dietary pattern rather that focusing on specific foods and quantities can help curb overeating, especially since most of us are only partially aware of ourselves doing it.

Denial, again, is a natural coping mechanism, but it’s especially un-useful when interventions such as healthier eating and activity habits could have helped turn the tide.

Dr. Ayala

Artificial intelligence in the service of food brands

Do we really have free will when it comes to food choices? 

When we’re at the highest level of focus and control we may feel totally in charge, but as food choices and eating are everyday habits, and are made mostly without thought, much of what we ingest isn’t really because we applied judgment or even listened our hunger cues – much of our consumption is mindless.

That’s not necessarily bad. Automation of daily activities can free your mind to pursue other important tasks.

But when the tendency to follow cues and triggers is manipulated in favor of consuming unhealthy foods it can become a problem.

End caps and eye level placement

We already know that food manufacturers use efficient marketing tricks to promote sales. These nudges could have promoted the sales of any number of foods, but since highly processed foods are profit centers for big food manufacturers – who are the powerful players in the supermarket – these are the foods that enjoy strategic placement.

Supermarkets and food outlets are carefully designed to move you about, leading you to places you wouldn’t necessarily go. The necessities aren’t concentrated in one area, which forces shoppers to cover ground even if they’re in for just bread and bananas. The necessities are occasionally shuffled around to prevent us from getting into a speedy shopping rhythm. Since most customers tend to look to the right when entering a supermarket, special offers and promotions will be at the immediate right as you enter.

And then there’s the shelf: Most shoppers are right handed, so placement on the right makes for better sales. Eye level products sell better, that’s where you’ll find what makes more money for the store. Kids’ offerings will be lower, at kids’ eye level. Displays near checkouts and end-caps attract your eye while you’re waiting for the cashier driving impulse shopping.

None of this is by chance.

And now, artificial intelligence and machine learning can apparently upgrade these methods to the next level.

A new study in Public Health Nutrition looks at the way international food companies use artificial intelligence (AI) to nudge consumers to buy more of their products. Nudges are a strategy to affect people’s behavior, they can be employed in the service of improving health (when the kitchen counter displays cut carrots and apples regularly for instance), and they can also be used to promote consumption of less healthy foods. 

The researchers included 12 leading companies, including Danone, McDonalds, Pepsico, Coca-cola, Nestle, Yum Brands etc. They read through the companies’ reports for evidence of use of AI to influence customer behavior.

The use of AI is widespread, according to the study. It’s used for social listening: Comments on social media are analyzed for trends and hone in on what customers want. Ordering algorithms and data-driven demographics make sure products are precisely stocked for each location. Weather-related preferences are also digitally analyzed.

Position of the product on menu boards is just as important as its location in the supermarket. The researchers found that many companies use AI to manipulate the visibility and significance of offerings on their menu boards. McDonald’s for instance, describes using decision technology to adjust drive-through menu boards according to weather, time of day and trends. Yum Brands uses facial recognition and manipulates the position of products on the menu according estimated age, sex and mood.

Since much of food ordering is done on screens, companies use AI and other emerging tech to increase sales when customers are on their website or app. They deploy recommendation algorithms offering add-on suggestions, and use bots and voice assistants to augment sales.

Ads and products are targeted based on data that includes location and other information collected through cookies.

Realizing the promise of big data?

Is AI in the hands of food companies of concern?

The authors suggest that by altering the availability, position, functionality and presentation of their offerings companies ultimately increase consumption, and since what these companies sell is predominantly unhealthy food, an increase in consumption affects the population’s diet negatively. McDonalds gains are public health losses.

Using big data to create personalized options, and the ability to to test multiple versions of ads varying copy, images and placement, brings nudging to the next level, and resisting the lure of tempting food becomes even harder. The authors raise another concern: “data can be used to target unhealthy food and beverage marketing to certain populations, with the potential to exacerbate existing disparities in diets and health. Data related to engagement with unhealthy food marketing could also potentially be used to make inferences about long-term health risks, which could then be applied in insurance, financial services, differential pricing or other discriminatory applications.”

Big food often argues that they’re just giving people what they want. Data driven products indeed give the food industry the ability to appeal to our craving for sugar, fat, salt, convenience, availability, and low price. What most people are tempted to do is munch junk food sitting on a couch in front of a screen. 

Employing ever more sophisticated ways to make us do what’s easy and tempting is hardly what big data promised to add to mankind.

Dr. Ayala

Does playing with fruit get kids excited to eat them?

Unhealthy foods are marketed to kids wherever kids can be found, and since kids spend a lot of time on screens, marketing messages permeate their online destinations, including games, shows and social media. This creates a virtual food environment of tempting processed foods full of sugar, fat and salt, that fuels real world unhealthy eating and obesity. 

Eating habits established at a young age tend to stick, that’s why it’s so important to build good ones. That – and kids’ susceptibility to entertaining advertisements and games’ hidden messaging – is why marketers target young audiences. There are many studies that show that advergames that promote unhealthy foods make kids fond of the brands behind the games, and lead to consumption and appetite for sweet and salty junk foods.

For that reason, public health advocates call for stricter regulation of marketing of junk foods.  

Can we also fight fire with fire? Can the same marketing techniques be used to make kids reach for apples and carrots?

Digitally marketing fruit 

A new study in the journal Appetite examines whether playing a fruit advergame affects fruit intake. 123 kids played games that featured either fruit (whole fruit, fruit drinks or cups of fruit), toys, or no game at all. The games integrated advertising features such as sounds, timers, and brand logo visuals. After playing, the kids were seated at a table with bowls of pieces of fruit, and the same logos as in the advergame they played.

The researchers expected fruit intake to rise after playing the fruit game, but that did not happen – the electronic fruit game did not lead kids to eat more fruit.

Not all studies show this disappointing result. Another study in the Archives of Pediatric and Adolescent Medicine that had kids playing a Pacman-style advergame with healthy or a less healthy snack showed that the healthy advergame promoted the healthy snack much the same as it “sold” the junk food.

But if the same methods that promote junk food don’t apply to healthy ones what would explain that?

The authors suggest that our brain is much more sensitive to highly palatable and energy dense foods – they’re evolutionarily conditioned to push the buttons that move us to consume calories in preparation for the next famine. Low-calorie foods just don’t have as much of an effect. Unhealthy calorie-rich food that’s designed to taste good has an unfair advantage. 

The other factor, they suggest, is that the cumulative effect of years of priming and branding of unhealthy foods stimulates junk-food intake in a way that a short term game doesn’t. Food companies spend about $14 billion a year on ads, with more than 80 percent of that marketing budget promoting fast foods, sugary drinks and unhealthy processed foods. 

Another worry is that there’s evidence that exposure to advergames promoting unhealthy foods leads to a generalized increase in appetite and caloric intake, regardless of what’s promoted. Seeing so much food in our digital worlds is enough to cause craving and overeating.

Playing with fruit in real life

Playing with food virtually may not lead to better eating habits, but handling real food may very well do the trick.

Involving kids in food preparation not only teaches them valuable life skills, it’s also proven to increase their intake of fruits and vegetables. Involving kids in growing and preparing vegetables — through garden-based programs improves veggie consumption. The more kids handle a food the more likely they’ll grow fond of it.

And what works even better, according to the scientific literature, is setting an example. Eat nutritious food, show genuine excitement for healthy and delicious fruits and healthy dishes, and kids will likely adopt your habits eventually.

Dr. Ayala

Why does losing sleep make you overeat?

We’ve all missed a good night’s sleep at one time or another, so we know first hand how important sleep is. Chronic lack of sleep is a bigger issue, it can make us moody and anxious, it reduces mental acuity, and it’s associated with increased likelihood of several diseases – such as viral infections, diabetes and heart disease.

Insufficient sleep is also associated with weight gain and overeating. 

A recent meta-analysis including 11 interventional studies – in which people with partial sleep deprivation were compared to controls who slept normally – found that shortened sleep is associated with eating an extra 385 calories.

Lack of sleep is now considered an established risk factor for childhood obesity, even though the data is mostly observational. An analysis of seven studies, including 14738 participants finds that from infancy into adolescence, sleeping less is linked with the development of obesity.

Sleep and weight gain are linked, but that doesn’t explain how one affects the other. What is it about sleeplessness that triggers weight gain? 

It may be that the lack of sleep activates hunger through a cascade of hormones. Lack of sleep may also just move people to eat in the absence of hunger – an emotional kind of eating that has more to do with comfort or mindlessness, not with real hunger urges.   

Not hungry, still eating

A new study in the American Journal of Clinical Nutrition including 105 kids aged 8-12 looks at what sleep deprivation does to eating in the absence of hunger, ie: eating for the sake of eating.

The kids, who all had normal sleep (8-11 hours a night), were assigned to 2 weeks of sleep restriction in which they went to bed one hour later, and the same kids were also tested with 2 weeks of sleep extension, in which they went to bed one hour earlier, the sleep settings done in random order. On the last day of each week the kids were given a buffet style meal, and told to eat until they were full. After a 15 minute break the kids were asked back into the dining room and given a free range of things like ice cream, chips, cookies and chocolate. Each kid’s consumption was measured in both the meal and the after meal by weighing what’s missing from the serving plates.

The authors found that the kids – who are basically compared to themselves – didn’t increase caloric intake when they lost an hour of sleep compared to when they gained one. What they did find is that after the first meal experiment the kids lowered their consumption during the first course, leaving more room for the dessert session for the remaining 3 weeks of their experiment. In other words, the kids learned that there’s sweet and salty stuff coming later, and adjusted accordingly.

When the researchers looked at all the kids together, after just the first week, before kids could learn that dessert was coming, they found that the mild sleep deprivation did increase the eating-while-not-hungry intake by a little, but the study sample wasn’t big enough to prove this point.

In this respect, this experimental model failed to prove that sleep deprivation leads to a greater tendency of eating while not hungry.

Eating while sleep deprived

This is, however, just the way science moves on. The observational data finds that sleep deprivation is clearly linked with overeating. Designing and implementing randomized controlled studies and manipulating sleep to further understand the mechanism and to establish causality is still needed, and obviously challenging. And we can never completely control for biases such as screen time and socioeconomic factors even though the statistical models take those into account. Questions remain.

But we can already say with some confidence that chronic sleeplessness is a common trigger for overeating.

It may simply be that being awake longer gives us more time to engage in our favorite activity.

And being tired may also make us more susceptible to the temptations of the kinds of foods that make us overeat: fast and energy dense ones – tired people aren’t likely to chop kale and dress it in lemon juice in the middle of the night.

Solving sleep isn’t easy, but being aware of the connection between sleep deprivation and overeating can make us a little more mindful of what we do when we don’t get enough sleep.

Dr. Ayala

Student health: Why cooking matters

Healthy eating is mostly about habits. It’s the recurring actions that are repeated mindlessly day in and day out, month after month, year after year, that matter the most. What you eat on vacation or at a wedding party isn’t going to change things that much, but overeating just a bit each day makes for significant weight gain over the years, and poor diets take a toll on health if sustained.

So habits really matter – establish a healthy routine and you’re on autopilot towards a healthy destination. There are critical times in life in which habits are formed, and for young adults the transition from home to independent living is such a period.

Unfortunately, for many college students who are at that exact juncture, fast food courts, alcoholic drinks, junky snacks and midnight deliveries are the default. The lure of convenience, low price, student food culture and maybe also no parental food oversight (at last!) make unhealthy eating real easy for college students. Lifestyle habits shaped over these formative years may last a lifetime and can be hard to root out.

College students are reportedly on the lowest end of fruit and vegetable consumption in a world in which most people don’t get their 5-a-day. A recent review of 71 scientific papers from around the world found that on average only 40 percent of students ate vegetables daily and that being female was the most reliable predictor of higher vegetable intake, as was living at parents’ home and higher socioeconomic level.

Gender and economic background aren’t changeable and need to be controlled for when understanding the barriers towards better nutrition at this important life phase. But there’s another really important parameter that influences what people eat: the ability to cook.

When it comes to whole plant-based foods and especially vegetables, knowing what to do with these leaves and roots, and having the equipment, time and wherewithal to do it is what it all hinges on.

A new study in the journal Appetite looked at the veggie consumption and cooking skills of university students in Brazil. Less than half the students ate vegetables regularly. Knowing how to cook was significantly associated with eating veggies daily. These results are in agreement with another recent study in more than 1000 freshmen in the US that found that confidence in the ability to cook from basic ingredients and to follow a recipe was associated with eating more fruits and vegetables. “Cooking more frequently, cooking with greater skills, and practicing meal planning behaviors are associated with greater fruit and vegetable intake and lower BMI in first-year college students. Interventions aimed at improving health in college students may be enhanced by incorporating cooking and meal planning components,” the authors conclude.

And it make sense: Although eating a baby carrot from a bag requires no skill at all, making kale delicious requires equipment, skill and other pantry staples, such as oil, vinegar and seasoning.

Life skills

Kids are never too young, nor too old, to start cooking. Learning how to cook is a valuable life skill that will enable kids to eat healthier — no matter what you make at home it will usually be healthier than what you buy — and it can also be a great tool in helping them eat their veggies. 

Whether this summer is the last one before your kid leaves the nest or not, it’s never too late to dig into veggie and fruit prep skills. And I do know that it’s not just kids that don’t cook: Many of them are second and third generation non-cooks, but again, it’s never too late.  

This is the summer to fall in love with salads: It really takes very little skill to make a delicious green salad from scratch, and a green salad is a basic recipe that can include any number and variety of grains, seeds, fruits and nuts – the things that we should be eating more of daily.

Practice salads.

Another basic technique that will add lots of veggies to the diet is stir frying. It’s fast, you only need a few tools, and you can include many vegetables and protein sources.

The third one isn’t a summer dish (at least not in my home) but it’s another basic technique that any budding vegetable cook needs in their arsenal: vegetable soup. A big pot of vegetable soup can sustain a hungry student for many days, supplying lots of vegetables, as well as whole grains and pulses.

Cooking isn’t hard, it isn’t necessarily time consuming, it’s fun, and it’s something everyone should be able to do.  You wouldn’t imagine releasing kids into the world not knowing basic money management, or what to do with dirty laundry.

It should be the same for food skills.

Dr. Ayala 

Who should remind kids to eat their fruit?

Most kids don’t eat enough fruits and vegetables. On the other hand, they’re all too happy to eat junk food, candy and sweetened drinks. The allure of sweet foods is understandable. We humans have an innate preference for sweet flavor and high-calorie foods – a fondness that served us well a long long time ago when food was scarce and we had to hunt and gather it. It’s biological.

But it’s not just the inborn preference that’s leading kids to the cookie jar. Kids also see lots of unhealthy food in media content directed at them, and marketers present these unhealthy foods in a way that’s cleverly persuasive. Food products are placed in entertainment directed to kids, in ads online, on billboards, in games and practically everywhere their eyes go.

So on one hand, parents might be modeling healthy eating behavior and placing fresh produce on the counter, yet on the other, kids see celebrities, athletes and cartoon heroes drinking soda and eating candy bars. Do parents and the people who care about kids’ health even have a chance against cute animals pushing the opposite message?

Whose behavior do kids most emulate?

Kids imitate behaviors encountered in real life, as well at what they see on screens and in fictitious characters. 

A new study in the journal Appetite tests three social endorsers making an argument for fruit. Based on previous studies, endorsers are categorized as either experts (such as a dietician or medical doctor), celebrities (famous or admired people) or peers (a child-like character).

The study recruited 340 6-11 year olds through schools. Kids were shown a cartoon promoting grapes and mandarins, in which the presenter was either an expert (physician), a celebrity (actress or football player) or a child. The arguments for eating fruit were the same in all conditions, and were things like: “it is important to eat a lot of fruits because they help you stay fit,” and “to stay healthy, it is important to eat a lot of healthy foods, such as grapes.” A control group saw no videos.

After viewing the cartoon (or no cartoon in the control group), the kids could select just one of four types of snacks: grapes, mandarins (both appearing in the video), fruit gummies and fruit chews. These snacks were chosen because they are similar in size, shape and color to the fruit.

And the results: The kids in the expert condition – those who saw a doctor making an argument for eating fruit – selected fruit over candy significantly more than in the celebrity, peer and control groups.

The authors conclude that the effectiveness of a health-related message depends on the source who’s presenting the information, and experts perform better than other social endorsers. 

Ads sell. That’s why companies spend so much money on them, and most of the marketing efforts targeted at our kids promote junk foods and sugary drinks.

But persuasion and reasoning work, too. Kids do care about their health, weight and fitness. And this is where input from experts, as well as the parties interested in kids' health – parents, family and friends – come in. Kids are in front of screens like never before, due to Covid-19, so inserting reasoned nutrition public service announcements can help. 

And what works best, in my experience, as well as according to the scientific literature, is setting an example. Eat your fruits and vegetables, show genuine excitement for these truly delicious foods, and kids will – eventually – follow.

Dr. Ayala

 

Covid-19 may worsen childhood obesity – unless we do something about it

Covid-19 is mainly a disease of adults, and kids’ infections tend to be mild, nevertheless, children are greatly affected by the pandemic, the indirect impact of the pandemic touching their physical, mental, developmental and educational lives. Schools around the world have been closed for months, and kids have been spending most of their time indoor, much of it in front of screens.

Kids’ diets changed as a result. There’s a lot to be desired about school cafeterias’ offerings, and physical activity at school is often insufficient – let’s agree that the school food environment is not ideal. Closed schools, however, hurt those that are most at risk of poor diets, weight gain and obesity.

How do we know that? Several studies show that kids gain more unhealthy weight over summer break, and that weight gain is even more pronounced among Hispanic, African-American and children that are already overweight. Social and racial disparities widen over summer break not just academically but also nutritionally. The pandemic is like a greatly extended summer break, only a more sedentary one.

School closure worsens diet

In a recent paper in the Journal Obesity, public health experts led by Andrew Rundle warn that Covid-19 can be much worse that the average summer vacation. “The closing of schools and the shelter‐in‐place orders create food environment and physical activity challenges for children,” they write.

Why’s that? Kids are missing out subsidized school lunches, and food insecurity is linked with risk of obesity and weight gain. Households also appear to be stocking up on ultra-processed, and calorie dense foods. On top of that, sports activities and leagues are closed, as are playgrounds, and it takes more of an effort to stay active.

The authors call for and commend innovative approaches, such as the continuation of school meals as grab-and-go, bussing of meals to kids’ homes along their usual pickup route, and remote physical education.

Childhood obesity spikes

One of the first studies of kids’ weight gain trajectory under Covid-19 comes from Verona, Italy. The study included 41 overweight children and teens that are part of an ongoing long-term study. Compared to their behavior in the same months in 2019, lockdown in March and April 2020 resulted in an additional daily meal, 5 extra hours of screen time, 2.5 fewer hours of exercise per week, and a dramatic increase in sugary drink, junk food and red meat consumption. The study does not include weight and height measurements, and it’s a small sample. It nevertheless alerts us to what lockdowns and school closures can do, especially to people struggling with obesity.

It’s cruel irony that the illness caused by the new coronavirus is exacerbated by obesity, yet fighting viral spread may increase this very risk factor for severe disease. Poor eating habits not only increase the risk of overweight and obesity, they’re also associated with chronic inflammation, which worsens our immune response.

Junk food shamelessly promoted

Another recent paper in Obesity titled Good deeds and cheap marketing–The food industry in the times of Covid-19 praises the generous donation of food and money by fast-food corporations.

Covid-19 has also been used as a marketing strategy. The article describes a few examples: Coca Cola released an image with spaces between the letters of its name to imply social distancing. Some companies offer ideas for coping with boredom, such as Jumex, a Mexican juice company, that created a “bowling alley” out of its used cans on Facebook. Others promote their products with activities for children. Hostess Snacks posted an ad on Twitter showing a woman running towards a bag of donuts with hashtags such as #AtHomeWorkout and #TreatYourself.

Taking advantage of a crisis is perhaps what companies need to do to survive and remain competitive, the authors, Mariel White, Claudia Nieto, and Simon Barquera admit, however, marketing unhealthy foods promotes an obesogenic environment, and exploits our harmful relationship with unhealthy foods. There’s no doubt that marketing affects kids' and teens' choices even more than it influences adults, and lastly, they note, we’re probably exposed to more marketing than ever, that with all that the extra screen time and less to do.

“If we wish to treat obesity seriously by promoting healthier environments and societies that can better respond to health challenges – such as the Covid-19 pandemic – then there is no doubt that the food industry’s strategies are working against this goal and should be effectively regulated,” they conclude.

Covid-19 is a tragic reminder that what we eat is crucial to our health. It will take a long time to fully understand the full spectrum of risk factors for severe disease, but we already know that unhealthy diets are the major driver of underlying conditions such as type 2 diabetes, high blood pressure, heart disease and obesity, which are clearly associated with increased rates of hospitalization and death from Covid-19.

The pandemic should renew our commitment to improve the quality of our diet, we need to make healthy food more accessible especially to those of us who are vulnerable and food insecure. Now more than ever, we need to commit to a healthy lifestyle: eat well, exercise, keep a healthy weight.

Dr. Ayala

Walking the streets, not just on Halloween

One of the pleasures of Halloween is that on and around this day kids are out and about, walking from home to home, trick-or-treating. They fill the streets.

Other days of the year, not so much.

Childhood obesity tripled in the last few decades, and if we were playing the blame game the obesogenic environment would be my target.

An obesogenic environment is one that makes it easy to take in lots of calories and spend fewer of them.

Its components include a setting with lots of high calorie tempting food around, mass media that promotes that food, and role models such as parents, friends or influencers engaging in eating habits that lead to weight gain.

But on top of the high-calorie food excesses, obesogenic environments support sedentary lifestyle and make it the default.

Kids are affected by their families, friends, home environment and their virtual – online – reality.

But they’re also a reflection of the place they live in.

Does a walkable neighborhood make you thin?

People in Manhattan and Paris are thinner than average. Does walking have anything to do with it? 

Neighborhood design can affect the way people behave, and when it comes to kids’ time outdoors, the ability to walk, bike and play outside may predict how often this actually happens.

What’s a walkable neighborhood? It’s pedestrian friendly – with safe sidewalks, well-connected streets, fewer busy intersections, and tree-shaded lanes. A walkable neighborhood has destinations to walk to: friends’ homes, parks, shops, schools, jobs, transit stops. A walkable neighborhood has safe streets to stroll.

Walkable neighborhoods have many benefits: They are happier, better for the environment (your feet don’t emit), help build a community, and they’re also healthier.

Unfortunately, many new suburbs were built as a subdivisions, around a cul-de-sac, with streets that empty into a busy road that’s hard to cross, and not within walking distance to schools, shopping or entertainment.

Does that affect the lives of suburban kids? Several studies show a correlation between neighborhood walkability and physical activity, obesity, as well as the incidence of type 2 diabetes.

But here’s the thing: People who enjoy walking and who are health conscious may chose to live in a walkable neighborhood – where you live isn’t random. Several studies which use sophisticated matching techniques find that the residential selection bias is modest, though, and when correcting for it, the link between walk-friendly neighborhoods and weight status still stands.

A new meta-analysis in Obesity Reviews examines how streets’ characteristics affect physical activity in kids, and to do so the researchers collected and analyzed all 47 relevant studies on the topic. The analysis found that living in streets that connect to other many other streets and create a network – as opposed to subdivisions and cul-de-sacs that empty into a major artery – is associated with kids engaging in more physical activity.

Walk safe

Our food environment has changed, but so have our neighborhoods. Too many neighborhoods aren’t walkable, and walking them isn’t always safe.

And here’s another disturbing statistic: While driving a car in the US is becoming safer and safer, year after year, walking is becoming less so. Pedestrian deaths rose by 50 percent in the last decade – in 2018 pedestrian deaths rose again by 3.4 percent, cyclist fatalities by 6.3 percent, continuing this alarming trend.

We need to fight for a better food environment.

But an environment that promotes health is also one that enables and entices kids to be active, to use their feet; it requires safe sidewalks, safe streets, parks and public green spaces where a kid can run and play in real life.

Yeah, I know, both these challenges are no small feat.

As to Halloween, a few tips: Make yourselves noticed by carrying a flashlight, walk on a sidewalk or path, and if there are none, face oncoming traffic, cross safely, and stay alert – distracted walking due to cell phones is an epidemic.

Dr. Ayala

Can better hydration help kids think?

How much fluids do you really need?

It’s an old question about one of the most essential components of our diet, yet the answer is surprisingly debatable. Eight glasses a day? To satisfy thirst? So that your urine is clear?

Our body is 60 percent water, and water’s needed for every system and every cell to function. Water keeps our temperature stable, clears waste through our kidneys and urinary system, it pumps blood through our vessels – there’s no function in our body that doesn’t rely on water.

Since water is so critical to bodily functions our body maintains the same blood concentration over wide variations of fluid intake. It’s only when our body is missing significant amounts of water that we’ll see abnormalities in blood tests – and in our ability to function normally.

Dehydration, the state in which water is depleted to the point our body can’t maintain its normal functions is clearly dangerous.

But does being optimally hydrated make a difference? Do smaller variations in fluid intake – the kinds of variations we experience in everyday life and ones that are no way close to clinical dehydration – make a difference?

Although blood samples show little variation in concentration across wide differences of fluid intake, our urine becomes more and more concentrated the less fluid we have – that’s why urine might be a better marker of hydration. Studying urine samples suggests that half the kids in the US have highly concentrated urine, which suggests they’re not drinking much.

Mild fluid deficits, do they matter?

What are the health implications of milder fluid deficits?

A few studies suggest that mild dehydration affects short-term memory in school-aged kids, and on the other hand, when kids are given plenty of water, their memory and attention improves.

A new study, led by Naiman Khan and published in the Journal of Nutrition tests the effect of hydration on cognitive performance. 75 kids aged 9-11 years from Illinois were tested in three conditions for 4 days each: They were drinking as usual (no intervention), were prescribed low water intake (16 oz. a day or about 2 glasses), or high water intake (84 oz. a day or about 10 glasses). On the fourth day of each condition urine was collected to measure its concentration and cognitive tests were performed to assess performance, thought flexibility and inhibition.

And the results: As expected, urine got less concentrated the more fluids the kids took in. Better hydration, benefited kids' working memory and cognitive flexibility according to the the mental tests.

These findings are consistent with findings from other studies that show better hydration improved exercise ability and cognitive flexibility.

Going back to the data that shows that half the kids have concentrated urine signifying insufficient hydration, this study suggests that increasing fluids may be a simple way to help kids think a little better.

Just add water

Our brain is even more water than the rest of our body: it’s 70 percent water. Missing some of it may affect mood, thinking, memory and overall health.

Mood and attentiveness decline first, and while mild changes in body fluids certainly don’t put kids in danger of dropping blood pressure or shutting off their kidneys, proper hydration can help kids perform best at school.

Giving kids access to clean and safe drinking water – safe water fountains in every school! – and prompting them to drink is a really simple way to make sure studying’s a little bit easier and happier.

Optimal hydration may improve overall wellbeing and clarity of mind, and can be a cost- and calorie-free mental boost.

Hydration tips:

How much: 8 (glasses-a-day) isn’t a magic number – so no need to keep count – but is pretty good approximation for an average person in average conditions. The Institute of Medicine (IOM) doesn’t set exact intakes, but recommends about 91 ounces of total water a day for women, and 125 ounces daily for men – and no upper limit for water. Eight glasses is about 64 ounces, add to that the water in food, and you’re not far off from the IOM recommendations. Water needs depend, of course, on activity level, outdoor temperature etc.

What counts: All fluids count, including coffee, tea, soup and the plenty-of water in fruits and veggies.

Assessing hydration: One should rarely feel thirsty, and your urine should be almost colorless. 

Drink More: Provided you’re healthy, your kidneys know how to take care of your fluid levels. Drinking too little can lead to headaches, dehydration, constipation and maybe crankiness, while extra fluids are simply excreted through your urine – it’s difficult to overdrink. Only in unusual circumstances – such as extreme endurance exertion while overdrinking water – can drinking too much water become a problem for healthy people.

Dr. Ayala

 

Full disclosure: I co-founded Herbal Water, which makes 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.

Childhood obesity, an app for that too?

The prevalence of childhood obesity is truly alarming: One fifth of American kids are obese.

When an adult is obese their doctor might recommend a weight loss diet. Their health professional’s advice will be just a drop in the bucket of counsel: Weight loss plans of all stripes materialize from every bookshelf, digital screen and food outlet. Weight loss is a 72 billion industry, which in and of itself might suggest that we don’t yet have a reliable solution – most weight loss plans work to a certain degree when people reduce caloric intake, and ultimately have miserable long term success rates in avoiding weight regain.

Should the same approach be used for kids?

A few weeks ago WW, previously known as Weight Watchers, launched an app called Kurbo, intended to help kids (as young as 8 years old) and teens “reach a healthy weight”. It tracks food intake, physical activity and weight loss. The app categorizes foods into Green (fruits and veggies), Yellow (bread and pasta) and Red (candy, soda and French fries), encouraging kids to eat according to the traffic light system, and asking them to select a goal, such as ‘lose weight,’ ‘feel better in my clothes,’ ‘make parents happy’, ‘boost my confidence’ and ‘eat healthier.’ For a fee, it will set kids up with coaches. The app follows a previous encroachment into young audiences: Last summer WW offered free membership to teens aged 13-17.

The newly launched app was met with widespread criticism from consumers and dietitians, and a petition in change.org has collected tens of thousands of signatures. Why the outrage?

Should kids diet? What are the risks?

Kids and teens, unlike adults, are growing, and caloric restriction, if not done carefully, may interfere with their growth and development.

Another concern is the link between food restriction and eating disorders, which are extremely prevalent among teens, and are in fact the third most common chronic condition in teens – right after obesity and asthma. Although eating disorders usually appear in teens who are not overweight or obese, quite often, teens who try to lose weight develop eating disorders.

The American Academy of Pediatrics issued a clinical report several years ago in which it reviews the studies and states that dieting – caloric restriction with the goal of weight loss – is a risk factor for eating disorders, and, un-intuitively perhaps, to obesity. Pediatricians are advised to discourage dieting.

So, if dieting is counter-productive and risky what should health professionals and parents do? The obesity, nutrition and eating disorder experts writing the paper suggest an integrated family-based and lifestyle approach (emphasis is mine):

“An integrated approach to the prevention of obesity and EDs [eating disorder] focuses less on weight and more on healthy family-based lifestyle modification that can be sustained. Pediatricians can encourage parents to be healthy role models and supportively manage the food environment by creating easy accessibility to healthy foods (eg, fruits, vegetables, whole grains, beans and other legumes, and water) and by limiting the availability of sweetened beverages, including those containing artificial sweeteners, and other foods containing refined carbohydrates.”

Leaving it to the kids?

Early prevention and intervention – before habits of overeating set in – is key, but when it comes to obesity treatment proven successful plans are hard to find, and most success is short lived. A 2017 Chochrane review estimated that childhood interventions that included diet, physical activity and/or lifestyle changes achieved only a very small, short-term reduction in BMI.

A recent analysis in Obesity Reviews looked at 182 nutrition-related randomized trials in kids aged 2-11 years for successful interventions. Only 14 trials were effective in reducing body weight, the results in these were small (but still encouraging), and those successful trials centered on environmental changes, such as water fountain installations at school and cafeteria menu changes.

Childhood obesity has tripled in the last three decades. The epidemic’s cause is multifactorial, but I don’t think kids of the 70’s liked candy and soda any less than today’s kids. They certainly needed much less self control – they didn’t live in an obesogenic environment in which the default is to gain weight, one on in which junk- and fast-food is endlessly available and tirelessly marketed to them wherever they go.

We owe it to our kids to fight this fight for them and with them. The last thing they need is more of time alone on an app.

Dr. Ayala

How to get babies to love their veggies

Parents know how important vegetables are to their kids’ health, yet only 1 in 10 kids eat enough of them, leading to another worrying statistic: Only 1 in 10 US adults eat enough fruits and veggies to support good heath. How do you create good vegetable-eating habits? How do you get kids to like vegetables and eat them out of choice, without a struggle?

All habits are easier to form earlier in life, but that’s even more pertinent when it comes to food preferences. Generally, a baby’s first 20 months are the time he or she is most open to new flavors and textures – bear in mind that babies are fed nothing but milk until age 4-6 months. Acceptance of new foods diminishes after that, food neophobia peaks at age 5 years, after which interest in new food usually recovers.

So how do you take advantage of this window to get kids into broccoli, tomatoes and spinach?

A new review, published in the journal Appetite, collected all 46 relevant scientific studies on promoting intake of vegetables in kids under 3 years of age. Among these there were 25 interventional studies and 21 observational ones.

Strategies that work

Repeated exposure

There were 27 studies exposing babies to the same vegetable repeatedly, for 8-10 repeats. All 21 experimental studies find that recurrent exposure increases intake, usually by at least about an ounce a day, and that the younger the baby, the greater the increase in veggie consumption. The 6 observational studies confirm the same trends. Some of these studies had up to 6-month follow up, demonstrating that repeated exposure let to a stable increase in veggie consumption.

How many exposures are needed to change a baby’s initial aversion? Some studies showed an effect already at the third exposure, and by the eighth exposure about 70 percent of babies liked a veggie they previously disliked.

Variety

Exposure to a variety of veggies seems to increase veggie intake in young kids in the 15 studies examining this strategy. When variety is piled on to repeated exposure the advantages are magnified.

Start early

Mom’s diet during pregnancy and after birth if she’s breastfeeding may expose her baby to the flavor of veggies very early, well before they eat their first mashed carrot. All the observational studies reviewed in this paper support a relationship between breastfeeding and veggie acceptance.

As to the age in which babies were fed their first veggies, this seems to have just a small effect on veggie affection, hardly detectable when the kids are 4 years old, so no rush  feeding eggplants to a 4-month-old.

Visual exposure 

Does showing a picture of a veggie in a book increase a baby’s affinity to the veggie? Four studies investigated this question and suggest that exposing babies to unfamiliar veggies through books, play and touch moves them to try that veggie.

Setting an example

Parents who eat vegetables in the presence of their kids tend to have kids that eat vegetables. Three observational studies in this review confirm that setting a good example of eating and enjoying vegetables is associated with higher frequency and intake in their young kids.

Things that don’t seem to work

Acclimatizing to a veggie’s taste

Parents may combine a veggie that their kid doesn’t readily want with a flavor they like, for instance, sugar can be added to green beans, masking its flavor. Although young kids initially prefer a sweetened veggie puree or a high calorie veggie soup the effect doesn’t last.

Bottom line

Repeated exposure to a variety of veggies and fruit is the most effective way to get babies and young kids to eat them. This method is the most proven scientifically, and makes intuitive sense – we’re all subject to the persuasive power of repetition, that’s why we’re served the same messages and ads again and again.

Don’t give up!

Serve veggies in a positive, calm, no pressure way – another clear takeaway from other research is that pressuring kids to eat is counterproductive and it certainly isn’t fun for anyone involved. It also follows common sense that better-tasting, nicely prepared veggies will be better liked.

Dr. Ayala

Are school cafeterias too noisy for healthy eating?

Many restaurants are so noisy that you need to raise your voice to be heard across the table, hardly the peaceful conversation you’d like to have when dining out.

I often wonder if this is an oversight or by design – there are many ways to make a dining room quieter, and many restaurants seem to choose blaring music, bare surfaces and stripped down finishes that bounce back noise in a way that makes the room loud as if on purpose. Once the room is loud and diners need to shout it becomes a vicious cycle; soon enough everyone’s at high pitch and once ears are on fire you’re itching to leave – which may be good for quicker guest turnover.

Not good for relaxation. Certainly not good for your ears.

But does it affect food choices?

School cafeteria noise and kids’ choices

Very few kids in the US eat enough veggies and fruit. Since 30 million kids eat lunch at school through the National School Lunch Program, the school cafeteria can be an important tool to fill in that deficit. Indeed, an effort has been made to serve healthier food at school, and to give kids enough time to take advantage of it.

Ambiance can also make a difference, and some school cafeterias are very loud.

To see if the noise level in the cafeteria affects fruit and veggie consumption researchers led by Matthew Graziose looked and second and third graders in 293 schools. Fruit and vegetable intake was assessed visually and with the aid of photos of the lunch tray before and after the meal, and altogether there were almost 2,600 lunches assessed. Noise level was measured by a Sound Level Meter throughout the lunch period. The findings of the new study appear in the journal Appetite.

The average noise level in the cafeteria was 79.7dBa.

Just to put this in context, this is loud, and just shy of 80dBa, the noise level that may cause hearing loss when kids are exposed to it over extended periods of time.

And the noise level mattered: With each decibel increase in the cafeteria sound level kids ate less fruits and veggies.

Other things that made a difference in this study, by the way: Kids ate more fruit and veggies when more fruits and veggies were offered to them, and having recess before lunch also increased fruit and veggie consumption.

This study just shows an association, it cannot prove that noise makes kids eat less veggies. The researchers hypothesize that kids enjoy a noisy cafeteria less and abandon their fruits and veggies sooner. Noise is distracting, and at some point even uncomfortable. Noise is known to impair our ability to smell, taste and enjoy food. It certainly impairs our ability to have a good conversation.

Another recent study of 382 6-8 year olds found that kids ate more veggies in quieter cafeterias – dining halls in which staff didn’t need to yell in order to communicate with one another.

Need to raise your voice?

Restaurant goers often complain about noise. According to the latest Zagat Survey, noise was the most irritating thing about eating out, more bothersome than bad service, crowds or high prices. Noise is such a big issue that restaurant critics often include sound level in their reviews. It makes you wonder why restaurants don’t try to make the place less loud. Well, several studies claim that beyond the buzzy atmosphere, loud environments make guests drink more, eat faster, spend more, and then leave sooner.Save

A school cafeteria isn’t a library, and the sound of kids chatting and laughing is welcoming and happy. But it shouldn’t be so loud that kids need to shout to be heard. It shouldn’t be so loud that exposure to it harms kids’ hearing, and damages the hearing of the people that work in that space and are exposed to this noise continuously.

It isn’t clear why most of the cafeterias in the study were so loud; might they be very crowded? I suppose there are ways to make cafeterias pleasantly hospitable to conversation without shushing kids.

Loud cafeterias aren’t good for kids’ hearing, and apparently, not good for their nutrition either.

Dr. Ayala

Does Instagram make kids overeat?

Can you imagine photography-free dining? It isn’t easy. I’d bet that the food-photo to phone-call ratio on many teens’ smartphones favors food images. Food dominates much of social media; we are fed with food images as often as mama bird shares real food with her newly hatched chicks.

And while so many of us document our meals and snacks for a multitude of unclear reasons, there are professionals making a living off their stylized, gorgeous photos. Food manufactures and brands seek influencers with engaging content in order to reach their fanbase. Products are integrated into the feed of influencers in a way that makes it hard to discern that’s marketing and what’s content.

It’s already established that ads on TV and other traditional media affect kids’ food choices, and play a part in the obesity epidemic.

Instagram marketing may have just the same effect.

First with your eyes, then with your mouth

A new study in Pediatrics examined the effect of Instagram influencer marketing. 178 British kids, aged 9-11 years were randomly assigned to one of three influencer-marketing conditions: healthy food images, unhealthy food images, or non-food images as the control.

The influencers were a 26-year-old female video blogger and a 23 year-old male YouTube video blogger with millions of followers and subscribers. Each child was exposed to both the male and the female influencer, and was shown mock, photo-edited images that looked like a real Instagram feed with 6 images, 3 test ones, and 3 fillers. Test images had the celebrity holding an unhealthy snack – cookies – or healthy snacks – a banana – or a branded control that isn’t food – sneakers.

After looking at the images the kids were treated to snacks. They could choose from jelly candy, chocolate buttons, carrots or grapes, and eat as much as they wanted.

Exposure to marketing affected the kids’ immediate intake:

Kids shown the unhealthy Instagram feed consumed 26 percent more calories overall than those shown no food, and 15 percent more than those shown healthy foods.

Kids shown the unhealthy Instagram feed consumed 32 percent more calories from unhealthy snacks than those shown no food (control), and 20 percent more than those shown healthy foods.

Could Instagram make you overeat?

I think that nobody will be surprised to learn that marketing a product increases its sales – why else would brands invest money in it?

But another growing concern is just the sheer abundance of junk food offline and online, because junk food marketing, we’re learning, not only lifts the sales of the advertised brand: it has an overall effect of making us eat more.

Junk food abundance, both in real life – offered wherever kids go, sold in every corner, vended from machines placed strategically – and in images, may be central to our obesogenic environment.

It turns out that just having appetizing food around, even in a picture, might push kids to eat just a little bit more. And years of just an extra half cookie can be enough to launch a kid into overweight or obesity.

As kids shift their media consumption towards mobile and social media it’s imperative that we learn how new technologies and content impact their habits and health.

Dr. Ayala

Quick tip for picky eaters: Serve a veggie by itself

Feeding kids thier veggies is a common struggle for many parents and the scientific community is on it with new research. Whether your kid’s a picky eater or an adventurous one, some methods are proven to increase the chances that he’ll grow fond of veggies and fruit.

Repeated exposure

The most important piece of advice for parents who want to get their kids eating more fruits and veggies is to serve them again and again. Repeated exposure works for many things in life – anything you’ve done several times becomes easier to do, turning eventually into a mindless routine, and familiarity itself can breed fondness. We do what we’ve already done, and we’re all creatures of habit.

But it works especially well with food.

Fear of unfamiliar food might be a natural evolutionary tendency that kept us humans safe from ingesting poisonous plants – eating only what we already knew to be risk-free worked well for us as gatherers.

But what’s the best way to repeat food exposure? Should parents prepare the vegetable in several different ways? Serve a variety of vegetables? Variety is something that is known to increase food intake in adults; does it also work for young kids?

Solo or together?

Researchers from the UK recruited preschoolers aged 2-5 years in five nurseries. Their new study appears in the journal Appetite (online ahead of press).

The tested veggies were served as a single snack, with repeated exposure, or mixed with other vegetables: The kids were served about 3 ounces of either baby sweet corn, celery or red peppers alone 5-6 times, or combined with the other target veggies plus radishes and green peppers.

Exposing kids to single vegetables repeatedly worked its wonders – confirming many previous studies. The effect was seen as early as the third exposure.

To the researcher’s surprise, however, serving the vegetable alone worked much better than offering variety. Serving the variety didn’t increase veggie intake, and surprisingly still, kids who were exposed to a single vegetable and increased its intake after several exposures didn’t eat more of it when it was served mixed with other veggies. In other words, getting these young kids to accept and eat more red peppers when served as a snack didn’t lead them to eat more red peppers when they were in a bowl with other veggies.

The paper discusses the “contamination effect” – kids will reject a food they like if it’s touching or mixed in with something they don’t like.

It very well might be that young people prefer new foods served as stand-alones.

Similarly, another new study shows that giving young kids (age 2-6 years) a choice of vegetables didn’t increase their intake and even decreased it when comparing to just giving them the veggie, with no choice at all.

The take home message: 

Young kids who object to new foods might react better to new veggies presented separately and of course repeatedly. Kind of good news, as this is also the easiest way to do it.

This is a relevant strategy for the caregivers of children averse to new flavors and textures.

Not all kids present these challenges. For the rest, I’ve always been a proponent of streamlining food prep, and for serving kids the family meal as soon as they are able to eat it; by the age of 2 years most kids can eat anything adults eats, don’t need any special meals, and smaller portions of good food that parents enjoy are just fine.

Many young kids will love salad.

Just serve the veggies time and time again, in a positive, calm, no pressured way – a real clear takeaway from research: pressuring kids to eat is counterproductive and it certainly isn’t fun – and fear not, kids outgrow this phase.

Dr. Ayala