Healthy Food & Healthy Living by 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

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

Feeding young minds for a successful school year

It’s back to school time, and to get the school year off to a good start kids need not only school supplies and enough sleep – they need the right foods to fuel their studies.

There’s no doubt that hunger interferes with learning. Skipping breakfast hurts academics, and studies link missing that important morning meal with less alertness, diminished memory and slower processing and problem solving.

But eating for best school performance goes beyond having enough calories to keep young tummies from rumbling. Previous research has tied getting enough fruits and veggies with better school performance, and the Mediterranean diet, hailed for its heart health benefits, has also been shown to be good for academics. On the other hand, highly processed foods and a Western diet pattern ­– soda, fast food and sweets ­– are associated with less favorable school performance.

Why would fruits and vegetables and Mediterranean Diet help with math and grammar, and French fries hurt kids’ academic skills? One possible mechanism is inflammation.

Anti-inflammatory foods and school performance

Inflammation is linked with many disease processes, from heart disease, aging, arthritis and cancer, to depression and Alzheimer’s. Could foods that promote inflammation affect young brains at school?

Researchers from Portugal examined the diet of 524 sixth graders, considered the inflammatory properties of the foods and drinks the kids ate, and correlated those to school performance. Their findings appear in a new paper published in Public Health Nutrition.

To assess the inflammatory potential of the kids’ diets the researchers used the Dietary Inflammatory Index (DII), a tool that gives foods a score, and rates them as pro-inflammatory, neutral or anti-inflammatory. To create the index thousands of scientific articles were reviewed, and each food and nutrient received a score.

Foods that have strong anti-inflammatory activity include fruits (such as strawberries, blueberries, grapes, oranges etc.), green veggies (kale, broccoli, spinach), nuts, olive oil, spices and herbs. Foods and nutrients with pro-inflammatory activity include fried foods, soda and sugary drinks, foods high in saturated fat, refined carbs (white bread, pastries), red and processed meat and foods with lots of iron.

The kids in the study score ranged from -4.27 to 3.21. the kids’ school performance was assessed using school records.

The results show that an anti-inflammatory diet clearly correlated with school performance. This was true after adjusting for confounders such as socioeconomic status and BMI. Kids who ate a diet rich in fiber, fruits and veggies, and a more Mediterranean diet, had better academic scores, while kids who ate a more Western diet – refined sugars, soda, saturated fats, highly processed foods – had lower scores.

Starting the year right

While this is the first study to examine foods’ inflammatory index effect on studies, there’s already plenty of evidence to justify eating fruits, veggies a wholesome breakfast and healthy hydration in order to start the school day right.

And let’s not forget the other thing that helps maximize the capacity to learn: physical activity. Students who are fit and who exercise regularly have better grades, better memory and concentration and behave better in class. And that’s one more reason why recess is ever so important.

To a happy and healthy school year!

Dr. Ayala

To sell kids on veggies do what the food industry does

Advertisements sell. Companies wouldn’t be spending so much money on them had they not delivered. To parents’ dismay – and to public health advocates’ alarm – most of the ads and marketing efforts targeted at our kids and teens promote fast and junk foods.

According to a report from the Yale Rudd Center for Food Policy & Obesity the fast-food industry spent $4.6 billion on ads in 2012, mostly for their unhealthiest products, and most of it targeted to kids and teens. Kids are encouraged to snack by a plethora of ads: According to another report from the Rudd Center preschoolers (2-5 years) see 1.6 ads each day, that number only increasing as kids grow older, and kids' exposure has increased by double digits from 2010 to 2014. Again, most of the ads are for sweet or savory highly processed snacks, but on a positive note, ads for nuts and fruit doubled from 2010 to 2014 -- but still made just 6 percent of what kids saw.

School food in undergoing a significant transformation and better options and more fruits and veggies are being served in cafeterias, with the hope that serve-a-healthier-meal-and-they-will-come. Which I actually believe will happen, eventually.

But what if healthy food could get a little help -- of the kind that unhealthy food gets by the bucket load?

Market, don’t nudge

This is the premise of a new study just published in Pediatrics. The researchers, led by Andrew Hanks, randomized 10 elementary schools to 3 types of veggie marketing exposures: A banner ad with veggie cartoon characters wrapped around the base of the salad bar, a short TV ad with those veggie characters, or both of the above experiences.

The salad bars were a hit during the 6-week field experiment, with an overall increase of 135 percent in veggie selection. Looking more carefully at the 3 types of interventions, the kids exposed to just the salad-bar banner increased their veggie selection by 90 percent, while those exposed to both a TV ad and the banner increased it by 240 percent!

Which really proves what marketing experts already know: Exposure across several types of media increases its effectiveness, and branded characters make food more attractive to young kids.

Unless we can make junk-food marketing to kids disappear altogether – good luck with that – we should try to somewhat level the playing field by giving veggies a bit of a marketing boost.

Dr. Ayala

Learning from others: How to make school (lunch) great

Steve Jobs famously said: “we have always been shameless about stealing great ideas.” In his latest documentary, Where To Invade Next, Michael Moore “invades” country after country, looking for lifestyles worth appropriating – so that he can plant the American flag upon them and bring them home.

Of particular interest to me were his school visits.

The French school dining experience

Moore sits for a 1-hour lunch in a French school cafeteria and is served a 4-course meal, in real plates, with water in a real glass. He brings a can of Coke with him, and asks the kids if they ever drink that. None of them do, and none are interested in trying. There are no sugary drinks or vending machines in French schools. Meals are planned by a chef and a planning committee and cooked from scratch. There’s always a cheese course – the favorite cheese in that particular school is Camembert. There are no “kids' foods” served and French fries are a biannual dish.

Moore visits an ordinary school, he claims, in a lower-income neighborhood. I do believe that he didn’t cherry pick a French school lunch, as there are multiple such reports, and the nutrition standards of the school lunch are set by government policy. French kids do eat better, and that they get a culinary education at school that lasts a lifetime, and results in better health and lower obesity rates. Their school cafeteria reflects widespread French values, and the school environment is consistent with what many parents do at home.

The question is can we import this, and how.

Forget homework, be happy!

Moore also visits a school in Finland, a small country with one of the best education systems in the world. According to the movie the secret to the Finns’ success is little or no homework, no standardized tests, and that play, freedom and happiness are the teachers’ top priority. The kids spend only 3-4 easygoing hours at school, where they learn a variety of skills, such as cooking, arts and crafts.

According to the film all you need is to set kids free – less is apparently more.

Could it really be so simple? This sounds too much like a miracle diet – the kind that promises that fat will melt away while you’re eating lots of cookies.

Well, the Finnish school system did vastly improve its reading, math and science scores but ditching homework was hardly the only or the main thing on the road to success. You don’t need to dig deep to find that editing out things-kids-hate is not the only difference between the US and Finland. Teachers in Finland are professionals, selected from the top of the nation’s graduates, and all have a master’s degree in education. Teaching is a very prestigious and selective job that’s highly sought-after and is well paid. Classes are small. Schools are small, and most teachers know all the kids not just in their class, but also in all others. There are no private schools -- all schools are equal. There are no hungry or homeless kids, and everyone has the same, free, healthcare. Parents get a year of paid leave to care for their new baby.

And it took 40 years to turn Finland’s schools around – 40 years of sustained effort, prioritization, planning and funding. The international science scores rose only in the last decade. Finland’s education overnight success was decades in the making.

Unfortunately, this is the real nature of change. It’s usually hard, protracted, sometimes ugly work. It also doesn’t make for great entertainment and would leave little screen time for the invasion of other countries – I found Moore’s Germany and Iceland invasions especially compelling.

But it can be done. Others have done it. The movie ends kind of optimistically with the thought that positive change sometimes takes a leap; Moore reflects on the fall of the Berlin Wall, pointing that advances sometimes surprisingly accelerate all of a sudden. But even the drama of November 9th 1989 was actually preceded by a gradual collapse behind-the-scenes.

Leaps can hardly be expected. School food is improving bit by bit, in small incremental changes, and although the kids of today deserve a perfect school lunch, we can take some solace knowing that things are moving in the right direction. I’m all for big dreams, as long as we don’t get discouraged by how long it usually takes to implement change and improve things in a big old system.

I’m hopeful. And I think Moore wants us to be jealous, angry, ashamed enough to do something -- but in the end optimistic.

Dr. Ayala

We’re finally eating more veggies, even at school

I was heartened to hear that one of the big trends for 2016 is vegetables. According to NPR’s Bonny Wolf vegetables have moved from the side to the center of the plate. The National Restaurant Association surveyed chefs on what’s hot, and vegetable-centric dishes are becoming the highlight of many menus.

But the more plant-centric movement isn’t limited to restaurants. The Healthy Hunger-Free Kids Act went into effect in 2012. Its goal was to improve the nutritional value of school meals by increasing the availability of fruits, veggies and whole grains and every school meal now includes a choice of a fruit or a veggie that also got a portion size boost.

Change isn’t easy, and many predicted that serving more fruits and veggies, and requiring all kids to have some plants on their tray would just lead to more waste.

It’s still early days, but a new crop of studies suggests that serving a better lunch does change the way kids eat. In a study that compared school meals in 12 Connecticut schools before and after the implementation of the new standards by weighing a photographing these meals, researchers found that kids ate almost 20 percent more of their veggies in 2014 compared to 2012. A study conducted in 4 schools in Massachusetts showed that after the implementation of the healthier lunch program kids ate 16 percent more of their veggies. Another study that took place in 8 Texas elementary schools found that in 2013, after the menu change, significantly more students selected fruits and veggies, and this did not lead to greater waste – putting more plant foods on the tray led to greater consumption. A brand new study didn’t look at fruits and veggies directly, but rather at meal nutrients such as vitamins A and C, and fiber that – in the case of these Washington State school lunches – come from them, and found significant increases after the new standards kicked in.

Again, change isn’t easy nor is it fast, and I’m not suggesting that we’ve solved childhood obesity or school lunch’s overly processed nature, but it’s encouraging to see that if you give fruits and veggies a chance, and serve them in an environment with fewer junk-food distractions, hungry kids will bite. Generally, larger portion sizes make us eat more, and this is also true for fruits and veggies. And the doomsday predictions and anecdotal stories about kids dropping out of the school lunch programs in droves, or dumping their tray intact, didn’t materialize according to more cool-headed investigations.

If vegetables do become a food trend it will definitely help us eat and enjoy more of them. We’ll surely see better produce, new and superior preparation techniques and tie-ins with celebrity and popular culture. It will be easier to eat better.

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

Whole wheat-ifying school lunch

 

I’ve been playing with grains and flours for many years and replacing white with whole grain is one of my favorite experiments, so I’m often asked: will kids eat whole wheat? 

Whole wheat pizza to the test 

That’s the question a new study in Public Health Nutrition investigates, and in order to do that they compared about 500 kids’ reaction to whole wheat and refined grain pizza in restaurants and in a Minneapolis/St Paul elementary school cafeteria. Kids’ acceptance of the pizza was measured by how much of it they consumed – the amount they sent to the trash after the meal revealed that quite nicely – and by what they had to say about their slice. The whole-wheat crust was 55 percent whole wheat, made with white whole-wheat flour, which is a grind of a wheat type that has a lighter bran hue and milder flavor.

The researchers, led by Aimee Tritt, found that the crust type made no difference to how much the kids ate, or to how much they liked the pizza. 

The Dietary Guidelines for Americans advise us to eat at least half of grains as whole, and the updated school lunch program benchmarks require school menus to move in that direction. Reformulation of popular foods is an easy way to reach that target, and pizza seems to be an ideal target – 1 in 5 kids eat it on any given day, reformulating it isn’t hard, and the results satisfied the kids in this study.

This is good news for schools adapting to the new school meal standards. Whole-wheat pizza didn’t end up in the trash, as many objectors to the reforms fear. 

Whole wheat-ifying the menu

Can we use this approach for everything? Should we?

Not all flour-based foods lend themselves as well to recipe substitutions, and while I find that breads are easy (and honestly, whole wheat ones are tastier, richer), great whole-wheat pasta is quite hard to make (please tell me if you’ve found it.)

Flour can be substituted discreetly, and kids will improve their fiber and nutrient intake without any cognitive effort and without changing their habits, but some of the best ways to eat whole grain are by introducing the unground whole grain: brown rice, oats, quinoa, corn, bulgur, farro and wheat berries are very tasty, and we need to give kids a chance to enjoy them, and overcome the default towards white and soft foods. I hope school lunches will feature some of that, and not just substitute the flour in tortillas and biscuits.

On the other hand, for some grain based foods – for me at least -- it doesn’t make a lot of sense. A donut made with whole-wheat flour is just slightly healthier that the refined wheat one, but that doesn’t make it into a healthy food, and the whole wheat-ification might confuse us into forgetting it’s a food to consume rarely. Whole wheat desserts are first of all desserts, to be consumed in moderation – the whole grain halo changes very little. Personally, I’d rather indulge in a piece of cake in its best possible incarnation than bother with making it just a little more nutritious.

Hopefully schools won’t just be looking for the easy, processed foods shortcuts to 50 percent whole grain, but also for ways to improve kids’ eating habits and to add variety to the grain offerings. 

Dr. Ayala

Back to school: 5 easy tips to improve kids’ health

I can’t believe the summer vacation is over and kids are going back to school this week. Summer went by too fast!

The new school year is a chance for new begginings, or at least a few minor adjustments, so here are a few suggestions for simple steps that can add up to better health this coming school year. These steps are indeed small, certainly doable, but can have real impact, especially if they lead to the next small step towards wellness:

• Eat breakfast - Many know that breakfast may be the most important meal in the day. Studies show that eating breakfast is not only associated with better nutrition, better concentration and performance in school but also with less obesity. Yet up to a third of teenagers skip breakfast regularly. Make sure your kids leave home after they’ve had a nutritious breakfast! I’ve written more about the importance of eating breakfast in my post here.

• Teach your kids how to cook - Preparing simple healthy meals is a life skill that is a gift that keeps on giving. Give your kids age-appropriate healthy shopping and healthy cooking lessons, and if you feel you’re in need of a few lessons yourself, you can learn together from books, websites and cooking shows.

• Take the junk-food out - While a little junk every once in a while will probably do no harm, having it available at home on a regular basis enables bad habits and teaches the wrong lesson. Make home a safe haven of healthy, nutritious food. Take the soda, sweet drinks, fatty sweet and salty highly processed snacks out, and replace them with readily accessible fruits, vegetables, nuts and other healthy snacks.

• Find out what’s served in the school cafeteria - School lunch nutrition standards have been updated in the last few years, but there still room for improvement. What’s more, competing with the school lunch are junk foods sold through vending machines and other sources. Find out what is served in your kids’ school, and if it doesn’t meet your standards, do something about it: Send your kids to school with a lunchbox and healthy snacks from home; speak up and try to effect change in the school lunch program in a practical and positive way. 

• Get them moving! - A third of our kids are overweight or obese, childhood obesity has tripled in the past thirty years, and although these skyrocketing rates are mostly a result of the food environment we live in, kids’ inactivity also plays a role. If your kids aren’t getting their daily dose of vigorous exercise, encourage them to join a sports team, pick a new hobby that will get them moving, and incorporate more movement in daily life. If school and other activities are close to home, consider walking rather than driving when weather and time permits. Choose family activities that are active, and get the whole family exercising and out in the fresh air! Many neighborhoods are quite safe, yet kids don’t play outdoors often enough; find a way to get the kids on your block back in the playground or on the open field playing unorganized sports the old fashioned way, with supervision if you see the need, or without. 

A happy, healthy start to the new school year to all of us!
Dr. Ayala

Do French kids really eat better?

It’s impossible to characterize an entire nation’s eating habits, on the other hand it is safe to say that the patterns offered in the American preschool and school system leave much to be desired.

Pamela Druckerman’s Bringing Up Bébé has lots of admiration for the French parenting style. Druckerman, who is raising three kids in Paris, describes a nationwide framework of politeness, patience and knowing-one’s-place, which sounds, well, like a gross generalization. I’ve lived in three countries, and in each, parents were as varied as Noah’s Ark. Parenting is a messy, imprecise art, and despite parents’ best efforts we all make many mistakes. I’m sure we have plenty to learn from French parents – but there’s also plenty to learn from your next-door neighbor and from your aunt, too.

Yet when it comes to food education in school – a government supervised program – we actually can compare the systems with some accuracy.

Lunch at a French preschool

Druckerman scores a spot for her daughter in the nearby daycare (crèche), a government-run, all day, affordable program for 3-month to 3-year-olds. Druckerman is won over by the food and describes the “dining experience” at the crèche in detail. The week’s menu is posted near the entrance, and every lunch is served in four courses: a cold vegetable starter, a main dish with a side of grains or vegetables, a cheese course with a different cheese each day, followed by dessert of fruit or fruit puree. Lunch is a 30-minute affair, even at the daycare age group level, and it is cooked in house, from scratch.

Druckerman attends the Parisian menu committee to better understand how these daycare menus are constructed. A few principles are apparent: variety is important, and there are very few repeats; each ingredient is prepared in several different ways, so kids will try the full range of what spinach can taste like and have many occasions to give new foods a chance; there are no “kid’s foods” – food isn’t dumbed down and there are no chicken nuggets. 

Karen Le Billon used to post the school lunch menu from different areas in France in her blog, French School Lunch Menus and her observations are similar. The menus demonstrate the veggies first principle, – first course is when kids are most hungry, and will appreciate almost anything – there are no sweetened drinks or flavored milks and there are no vending machines at schools. The meals are usually cooked at the school kitchen, but some schools outsource the cooking to private companies, who, nevertheless, make the food from fresh ingredients – food is never prepared in a factory. 

Now take a look at the June menu of the Philadelphia School District. I don’t want to pick on any specific item, but it does read like a fast-food menu, not like a freshly made meal.

I devoted many posts to our School Lunch Program and to the fight to improve nutrition at school. The 2010 Healthy Hunger-Free Act was a step in the right direction: Under the new guidelines menus doubled fruit and veggie servings, increased whole grains, and set upper limits to salt, trans-fat and calories.

Yet even the improved lunch is one of highly processed foods – very few schools actually cook food from scratch – and tomato paste on pizza counts as a vegetable. And now there’s a threat of a step back: members of the House of Representatives want to provide exemptions from these standards and lower the quality of food if the school is losing money.

kids and snacks

The French eating pattern, which Druckerman says is observed from very early on, consists of three meals and one goûter (late-afternoon snack, quite similar to the British Tea Time). There are no snacking times or snacks at daycare, preschool or school. 

How one divides daily calories can be a matter of preference, so if snacks consist of good food should it matter that American kids are trained to eat all day? That most preschools feed kids every 2-3 hours and that there’s a vending machine in most schools? 

The answer, I think, is that it does matter. Arriving at the meal hungry makes the introduction of new and healthy foods much easier. Knowing that if you skip breakfast there’s nothing to eat until lunch encourages kids to eat breakfast. And unfortunately, snacks, even the healthified ones, are usually not exactly food.

So yes, there is wisdom in the way French schools feed kids. Perhaps that’s part of the reason why 14 percent of French kids are overweight (still, way to many) while a whopping third of kids in the US are overweight or obese.

We can definitely learn from others. 

Dr. Ayala

Does healthy food sell?

What can be more wholesome than an athletic event at school? I’ve been to many, and my frequent regret is that the foods and drinks offered during these games almost undo the message and purpose of sport’s healthfulness.

“It’s what kids eat”, is the recurrent response, “and we need the money.” 

For those of you dreaming about healthier concession stands that don’t bust the budget, here’s an interesting experiment. 

Better-for-you tested

The parent booster club of Muscatine high school, Iowa, partnered with researchers from the University of Iowa Medical School, led by Dr. Helena Laroche, to test how healthier options affect student’s food choices and purchases.

Rather than restricting unhealthy options, the makeover focused on adding a few healthier options: apples, baby carrots with dip, chicken sandwiches, granola bars, pickles, soft pretzels, string cheese, and trail mix. They also substituted canola oil for coconut oil bars in the popcorn (reducing saturated fat and trans-fat) and the cheese in the nachos was replaced with one without trans-fat.

There was no push for the healthier options, but those nevertheless sold, and comprised 9.2 percent of the revenues at the school’s subsequent football games and swim meets. What’s more, sales of healthier items increased game after game, suggesting that with growing awareness healthier choices became more popular. The modified popcorn and nachos sold just as well as the old versions. Revenues did not suffer and there were also no complaints: students surveyed were satisfied with the concession stand’s offerings, and welcomed the new healthier additions, and parents were happier with the overall changes.

Offer better choices and they will come!

School food is undergoing a significant transformation. The subsidized school lunch has to comply with improving nutrition standards. Last year, the US Department of Agriculture also announced new proposed standards for snacks sold at schools that limit the amount of calories, fat, sugar and sodium of most foods sold there, and encourage whole grains, low fat, fruits and veggies.

Perhaps anticipating the backlash, the proposal exempted fundraisers, afterschool sports events and treats sent by parents.

So while laws do not apply to concession stands – at least not yet – this pilot study is encouraging. For parents and schools that want better foods: kids will eat them, and for those worried about the bottom line: healthier options do sell. 

Dr. Ayala

Eat Healthy! Everybody’s Doing It!

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

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

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

So which approach, if any, would you use?

Your friends eat here

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

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

In the control condition no signs were posted.

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

What if the norm isn’t healthy?

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

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

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

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

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

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

Any suggestions?

Dr. Ayala

 

Are kids going to eat less junk in school cafeterias?

The days of snacking on candy, soda and chips in schools may soon be over. Last Friday, the US Department of Agriculture (USDA) announced new proposed standards for snacks sold at schools. The standards limit the amount of calories, fat, sugar and sodium of most foods sold at school, and encourage whole grains, low fat, fruits and veggies. A few examples: Yogurt, granola bars, trail mix, dried fruit and fruit bars, pizza on whole grain crust and baked potato chips are in. Candy, caloric soda, sweetened fruit juice, and most cookies are out.

Perhaps anticipating the backlash, the proposal exempts fundraisers, afterschool sports events and treats sent by parents – including birthday and holiday party goodies. It also allows for a yearlong transition.

The rules, required under the child nutrition law passed in 2010, are an effort to combat childhood obesity and close an obvious loophole: while the government-subsidized school lunch has to comply with nutrition rules, what’s sold a la carte, in school stores, snack bars, or from vending machines, and competes for kids’ stomach share and lunch money, isn’t federally regulated at all, and can be of no nutritional value whatsoever.

Is it going to make a difference?

Is there evidence that stricter rules at school will encourage kids to eat less junk? Since many states and cities have already established regulations regarding foods sold at schools, there are already some comparisons that can be made. 

California was one of the first states to implement rules for vending and selling foods in schools; these rules limit the caloric content, fat and sugar in snacks, and ban soda and sweetened beverages. Last year I reported on a study in the Archives of Pediatric & Adolescent Medicine that compared California high school students’ daily intake to the intake of students from 14 states without any school nutrition standards, and showed that California kids ate fewer calories and consumed less fat and sugar per day at school -- 170 fewer – compared to high school students in other states. And the kids didn’t load up the missed calories after school. The Californian students took in 158 fewer calories a day, overall -- a reduction of 158 calories is a big deal as we gain weight very gradually, and reducing even 100 calories a day can prevent weight gain and put a dent in the obesity crisis.

Another study in Health Education & Behavior compared 3 middle schools that implemented a healthier snack and beverage nutrition policy with 3 that had no guidelines. Removing these items not only resulted in lower consumption of junk food at school and overall (no compensatory junk eating at home), it also didn’t seem to result in negative preoccupation with weight.

The New York Times recently reported that after decades of rising rates of obesity, several cities are reporting a decline. Philadelphia, my hometown, reported a 5 percent decline, and has seen this decline among minorities, and not just among high-income families. Philadelphia has implemented broad policies to fight obesity, including a ban on sugary drinks in school vending machines, and school snack guidelines that limit calories, fat and serving size. It’s hard to credit any one public health policy for the changing trend in childhood obesity rates, but the results are encouraging.

The importance of a healthy school environment

It will take a while until the snack food regulations are installed, and even longer until we can see their effects on kids’ diets.

But I think that paying attention and debating the foods sold at schools will have immediate educational outcomes.

As Agriculture Secretary Tom Vilsack said in a press release last Friday: "Parents and teachers work hard to instill healthy eating habits in our kids, and these efforts should be supported when kids walk through the schoolhouse door".

School, or government, doesn’t determine what kids eat, but it can definitely set minimum standards that promote healthier choices, or at least not undermine healthy nutrition efforts by condoning and profiting from the sale of junk within school walls.

Discussing unhealthy snacks, and removing them from the cafeteria, has an educational purpose. I wouldn’t be surprised if it influences the bottom line of what kids actually consume (kids do eat more than half their daily calories at school), but it’s worth doing, regardless.

When the vending machine changes what’s in its belly, kids consciously or unconsciously, notice; this exposure can change minds, and hopefully also what’s in kids’ bellies.

The USDA proposal will be open to public comment for 60 days. In the meantime, I’d love to hear your comments here. 

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.

Study proves school nutrition standards work

School meals are far from perfectly nutritious, even after the long awaited and very welcome changes put in place earlier this year.

The good news is that under the new guidelines kids will hopefully double their fruit and veggie intake, will be served more whole grains, all milk will be low fat, and there’ll be upper limits to salt, trans-fat and calories in the school meal. The not so great reality is that kids will continue to eat lots of highly processed foods – very few schools actually cook food from scratch – and tomato paste on pizza counts as a vegetable.

But school food isn’t just the subsidized school lunch; competing with it are the foods sold in schools -- in vending machines, school stores, and a-la-carte in the cafeteria -- which make a big part of what kids actually eat while they’re in school.

The USDA administers and regulates the school lunch program, and is developing nutrition guidelines for the foods and drinks sold at schools. (The Healthy, Hunger-Free Kids Act, passed in 2010, gives the Agriculture Department authority to set health standards for all foods sold on school property — including those in vending machines). Right now, the only existing federal restriction is that foods of “minimal nutritional values”, such as candy and soda, won’t be sold in the cafeteria during meal times. That of course doesn’t mean they can’t be sold right outside the cafeteria doors.

In the meantime some states have developed their own regulations. Studying the effects of different sets of regulations and their enforcement can teach us what’s been successful – and what doesn’t work.

Vending machines with fewer calories

California was one of the first states to implement rules for vending and selling foods in schools; these rules limit the caloric content, fat and sugar in snacks, and ban soda and sweetened beverages.

A new study in the Archives of Pediatric & Adolescent Medicine compared California high school students’ daily intake to the intake of students from 14 states without any school nutrition standards. 

California kids ate fewer calories per day at school -- 170 fewer – compared to high school students in other states. California kids also consumed less fat and sugar.

Did the kids load up the ‘lost’ calories on their way home or once they got there? It doesn’t seem so. Although California students ate more of their daily calories out of school when compared to the kids from the “no rules” states, the Golden State’s students took in 158 fewer calories a day, overall.

And a reduction of 158 calories is a big deal. We gain weight very gradually, and reducing even 100 calories a day can prevent weight gain and put a dent in the obesity crisis.

Fewer calories, perhaps no better nutrition 

California students ate fewer calories from fat and sugar, but the study found that their intake of nutrients such as vitamins and minerals was unchanged compared to the students from the other states. 

The authors suggest that the reason lies if the food laws themselves: the laws limit sugar fat and salt, they don’t require whole grains, fruits or vegetables. Replacing full fat chips with baked low-salt ones can only do so much.

Providing truly healthy substitutes is obviously the next step, but since obesity – too many calories -- and the abundance of sugar, fat and salt in kids’ diets are the main nutrition problem facing us, I’d conclude that California kids seem to enjoy better nutrition according this study.

Does public policy impact kids’ health?

While there are plenty of studies that show policies have a positive impact on kids’ eating habits, there are definitely studies that show that they don’t. I shared a recent study that showed that in schools that banned only soda, kids bought the other vended sugary beverages instead.  In schools that banned all sugary drinks kids indeed consumed fewer sugary drinks at school, but their consumption did not decrease overall; kids were able to find sugary drinks out of school, and filled the sugar gap before and after school. In other words, school vending policies only changed the school environment, and didn’t seem to be enough to change kids’ access and behavior overall.

I’d argue that even if the regulations don’t have the immediate nutrition-improving outcome we’d hoped for, it’s still imperative to apply nutrition rules for educational reasons. It’s impossible to advocate for safe driving while holding a cellphone with one hand and the wheel with the other.

School should have a central role in nutrition education, and you can’t teach healthy nutrition while benefiting from the sale of junk food within school walls.

Kids spend half their waking hours in school and consume much of their daily calories while on campus. Changing school food should be a critical part of the effort to combat obesity.

Dr. Ayala

 

Halftime in the school cafeteria

Last month Michelle Obama and Agriculture Secretary Tom Vilsack announced some very welcome and long awaited changes to the government subsidized school meals. These are the first changes made in the program -- which feeds 32 million kids each day – in 15 years. Under the new guidelines kids will be doubling their fruit and veggie intake, will be eating more whole grains, all milk will be low fat, and there’ll be upper limits to salt, trans-fat and calories in the school meal.

Yes, the program is far from perfect, kids will continue to eat lots of highly processed foods – very few schools actually cook food from scratch – and tomato paste on pizza counts as a vegetable. But it’s a laudable change in the right direction, and considering the mighty fight the food industry wages against any proposed change, and the fact that the new rules will add 3.2 billion to the yearly cost of the program it’s reason for a mini celebration.

The next critical change is yet to come 

Competing with the subsidized school lunch are the foods sold in schools, which make a big part of what kids actually eat while they’re in school. These are foods and beverages sold in the cafeteria or in a school store, from a vending machine or in fundraising events. The lunch money parents give their kids may very well be spent on these offerings rather than on the school lunch.

Kids love the vending machines and the school stores, but that’s not the only reason these outlets exist. Schools depend on the revenues that vendors bring in to fund much-needed programs. This creates an unusual and worrying conflict of interest.

The USDA administers and regulates the school lunch program, and is developing nutrition guidelines for the foods and drinks available at schools. (The Healthy, Hunger-Free Kids Act, passed in 2010, gives the Agriculture Department authority to set health standards for all foods sold on school property — including those in vending machines). Right now, the only existing federal restriction is that foods of “minimal nutritional values”, such as candy and soda, won’t be sold in the cafeteria during meal times. That of course doesn’t mean they can’t be sold right outside the cafeteria doors.

Vending junk 

A new study published in the Archives of Pediatrics & Adolescent Medicine showed that even in elementary school half of the students could buy potato chips, ice cream or similar snacks from vending machines and at snack bars during school.

Other studies show that a la carte foods sold in the cafeteria are common in all school levels. Vending machines are available in 87 percent of middle schools and virtually all high schools. Forty percent of kids consume competitive foods on any given day, eating 280 calories daily in mostly junk food (the most commonly consumed competitive foods are desserts, snacks and sweetened beverages.

The new age of vending

Getting rid of the vending machines is perhaps a fancy aspiration and a non-starter, especially during tight budget times.

Instead, states and schools have put in place policies guiding the nutritional content in schools’ vending machines, and now offer healthier vending options.  Several vending companies specialize in healthy vending. 

But the neatest idea I’ve seen yet is the LiVe vending machine Intermountain Healthcare installed at Rose Park Elementary School in Salt Lake City. The talking machine will make its rounds in Utah schools spending a few weeks at each. 

 

I want one of these in my kids’ school!

Let’s hope the upcoming USDA regulations for competitive foods in schools will be sensible and have teeth. 

Dr. Ayala

 

Reposted as part of Food Renegade's Fight Back Fridays.