Healthy Food & Healthy Living by Dr. Ayala

Can we really blame diabetes on diet choices?

Many chronic diseases are attributable, at least in part, to diet, among them are type 2 diabetes, heart disease and several forms of cancer. 

Type 2 diabetes is an enormous burden on human health and longevity worldwide, It’s has wide consequences for the people suffering from it, and on healthcare systems, as type 2 diabetes affects most organ systems including the heart, kidney, eye, brain, and liver, it increases the chances of cancers, infections, and dementia. 

Type 2 diabetes may run in families, but its rapid rise makes it clear that there’s much more than genetics at play. In the last 40 years type 2 diabetes incidence has risen 5 fold, 1 in 10 adults live with the disease and this is occurring worldwide. It’s clear that diet plays a big role, whether through weight gain and obesity or directly: by affecting sugar metabolism, inflammation, and changes in the gut. 

To what extent does your diet drive the incidence of diabetes, and which foods are most to blame?

To assess that researchers from Tufts University looked at data from 184 countries from 1990-2018. They looked at diet components, as well as age, sex, education, and where people lived. Their model relies on information from the Global Dietary Database, population demographics, global type 2 diabetes incidence estimations, and published research on how food choices impact type 2 diabetes. The findings appeared recently in Nature Medicine.

And the conclusions: about 70 percent of new cases of type 2 diabetes are attributable to a suboptimal diet and could have been avoided with a better diet. Eating too much of the wrong foods – such as refined rice and wheat, sugary drinks, processed and unprocessed meats – can explain 60 percent of the harm. Not eating enough of the protective foods – such as fruits, vegetables, nuts, seeds and whole grains – explains the 40 percent rest of the risk.

Poor diet drives type 2 diabetes in men more than in women, according to the study, in younger people more than in older ones, and in city dwellers more than in rural ones. And although men and city-dwellers with higher education tended to have a greater burden of type 2 diabetes caused by their diet, the opposite was seen in wealthier countries where living in urban areas and a higher education was predictive of a healthier diet. Interestingly, the link between a country's economic development and its diet-attributable type 2 diabetes burden has become weaker over the years – which suggests that as highly processed foods spread worldwide and expand so does type 2 diabetes.

The assessment that 70 percent of type 2 diabetes is diet related is astounding. It’s higher than previously assessed: Another study estimates 40 percent of cases are due to a suboptimal diet. This study, however, looks at 11 dietary factors instead of just six in other studies. Either way, many people could change the trajectory of their health by making healthier food choices and the biggest culprit is refined/highly processed foods – and especially refined carbs.

The diet to prevent diabetes

To lower your risk of type 2 diabetes it's important to control weight gain, which is a major risk factor for the disease. Other important lifestyle risk factors include inactivity and smoking.

Pay special attention to these diet principles to lower your risk:

Skip the sugary drinks: Excess added sugar is an established risk for diabetes, sugary drinks are the leading source of added sugar in our diet, and many studies show a clear link between soda consumption and the development of type 2 diabetes. These include randomized controlled studies that showed that sugary drinks aren’t just associated with diabetes – they cause obesity, insulin resistance and chronic inflammation, which are the harbingers of type 2 diabetes. 

Choose whole, unprocessed foods: Select whole grain over refined grains, eat nuts, beans, legumes, make sure you eat plenty of fruits and veggies (non-starchy vegetables, a potato isn’t in this category).Limit meat, especially processed meat.

Dr. Ayala

Is soda bad for your brain?

One of the biggest fears we face – especially if we’re lucky enough to live a long life – is dementia. Despite great efforts to treat Alzheimer's and other dementia forms, there is no cure for this malady. Prevention is crucial.

Important modifiable risk factors for dementia are poor nutrition, binge drinking, lack of physical activity and mental stimulation and smoking.

A new study in the American Journal of Clinical Nutrition looks at a large population of almost 180,000 people in England, with no signs of dementia at the start of the study, and follows them for an average of almost 10 years. The diet of the participants was reported, and their sugary drink consumption tallied. The genetic risk of dementia was assessed for each participant looking at common genetic variants related to the risk of Alzheimer’s disease. 

During follow-up almost 1300 of the participants developed dementia. After adjusting for socioeconomic status, lifestyle factors, such as alcohol intake, smoking, exercise and weight status, and underlying health conditions that may affect dementia risk, the researchers found that those who consumed more than 2 sugary drinks a day had greater odds of developing dementia: their risk rose by some 35 percent. Excessive intake of added sugar was also linked with dementia risk.

The added risk was seen with sugary drinks, but also with artificially sweetened ones. On the other hand, those consuming moderate amounts of fruit juices did not have a higher risk of dementia. These links were not modified by genetic predisposition.

A similar study of almost 3000 people over the age of 60 years showed almost doubling of dementia risk among those with high intake of artificially sweetened drinks, and another study of 1865 people showed greatly increased risk of dementia with an intake of on average 7 sugary drinks a week.

How could sugary drinks impair the brain? It might be that the excessive sugar and rapid rise in insulin impair the brian, and for artificially sweetened drinks the authors suggest that aspartame could disrupt energy production and increase oxidative stress.

Why are sugary drinks singled out?

The western diet contains plenty of added sugar, but while sugar’s added to many foods, most of the added sugar hides in drinks – soda, sports drinks, energy drinks, flavored milks and fruit juices – the sheer amount of sugar in sugary drinks can explain why they are linked so tightly with obesity.

But studies show that there is something distinctive about getting calories in liquid form. Solid sugars suppress hunger somewhat, while liquid sugar – in sugary drinks – doesn’t affect satiety.  Sugary drinks’ calories are just added, and the meals eaten with them will be just as large, if not larger. And several studies have suggested that sugary drinks are an independent risk factor for diabetes and hypertension irrespective of obesity. 

Liquid sugar lends itself to overconsumption, and it might very well be that sugar in liquid form poses an especially tough burden on our body’s metabolism and on our brain’s function.

Dr. Ayala 

Is honey really better than sugar?

We’re encouraged to limit sugar and sweeteners in our diet. The American Heart Association advises no more than 6 teaspoons a day for women, 9 for men, and for added sugar to provide no more than 5-10 percent of daily calories. Excess added sugar is linked with obesity, and many chronic diseases such as type 2 diabetes, metabolic syndrome and heart disease.

And since we like sweet food –  to prefer sweet foods is to be human – are there healthier ways to sweeten food? Are honey, maple syrup, agave and date syrup any better?

Sugar is sugar?

Honey is made by honeybees from the nectar of flowers, and contains, besides sugars, a whole array of organic acids, enzymes, proteins, amino acids, minerals, vitamins, and bioactive substances. It has been shown that honey has beneficial effects on sugar control, weight maintenance, inflammation, lipid profile, and as a common cold remedy.

A new systematic review published in Nutrition Reviews including 18 controlled clinical trials set to examine honey’s health effects.

It found that a median dose of 40 grams (about 2 tablespoons) daily over 8 weeks reduced blood fasting sugar, cholesterol, and triglycerides levels. Raw honey was more effective than honey that was heat treated – most of the benefits demonstrated are from studies that use raw honey.

This review is in line with animal studies: several studies in rats show that regular honey intake results in better sugar control and lipid profiles.

Honey’s wellness benefits are plausible: Honey is 80 percent sugar, mostly fructose and glucose, but there are also “rare sugars” in honey, those include monosaccharides and their derivatives (such as isomaltulose), which have effects on fats on gut microbes. Honey contains phenolic compounds and flavonoids and other important antioxidants. Raw honey contains probiotic beneficial bacteria that are known to regulate the immune system and improve lipid profiles.

The flower source of the honey also matters – clover honey, and robinia honey were especially beneficial for fasting blood sugar control and cholesterol reduction.

Swapping sugar with honey

Honey is still in the “added sugar” category, and as such, should be enjoyed in moderation. Replacing sugar with honey can help with moderation, as you’ll be skipping most processed foods – which are made with refined sugar and high fructose corn syrup. Honey’s price point and nuisance value can help limit your consumption.

A “no refined added sugar” principal that allows for natural sweeteners can make sense if it helps you keep a lid on your sweet tooth. 

The added nutrients in honey can also add a bit of wellness.

The authors of the study also suggest that honey should not be lumped with the other refined added sugars which provide nothing but energy (empty calories): “as honey, when taken in moderation, may offer a variety of benefits for glycemic control and lipid levels.”

The key is moderation. I do believe that sweets and dessert have a place in a healthy diet. But a cake doesn't become “health food” because it’s sweetened by honey – cake is still cake.

Dr. Ayala

How much junk food is too much?

There’s a place for everything that’s tasty and enjoyable to eat in a healthy diet, that’s what I believe. I can also support this declaration with plenty of scientific literature showing that long lived communities as well as large cohorts in studies maintained health and avoided excessive weight gain without abstaining from dessert – traditional diets don’t declare abstinence from sweet or fried foods.

It’s the proportions that matter. If 90 percent of what you eat is nutritious you can play with the rest. If 80 percent of your days are reasonably active, hibernating couch-potato style on a lazy day will do no harm.

But here’s the problem: Our proportions have turned upside down, completely. 

Junk all around

A new study in the Journal of Nutrition assesses the amounts of junk food in the American diet using two nationally representative data sources, including more than 10,000 people.

What is junk food? The academic literature struggles with this question. Salty snacks, candy and soda are the hallmark representatives, but there are many other products – such as bakery products, sweet breakfast cereals, fast-food and processed meats – that should be in the eat-less/junk category.

This study uses the 2016 Chilean law for food labeling and advertising definitions of junk food. This law identifies foods with high caloric density, high added saturated fat, sugar and salt, and imposes marketing and advertising regulations upon them, including warnings on the front label and a ban from sales in schools.

And the results: Between 2015-2018 almost half of daily calories US adults consumed were derived from junk food. Sugary drinks composed almost half of the sugar from these junk food.

This study paints a picture concordant with another study in kids, that finds that 56 percent of the calories US kids consume come from junk food.

This current study also found that there are disparities in junk food intake among ethnic groups, with non-Hispanic black adults consuming more junk food, and with the highest income group consuming the lowest amount of sugary drinks.

You are what you eat 

Obesity, type 2 diabetes, hypertension and many other chronic conditions are nutrition associated diseases – they could be avoided or ameliorated by a healthy diet and lifestyle.

We know that the more junk food in a society’s diet the greater the obesity rates. A recent large prospective study found that a 10 percent increase in ultra-processed food is associated with a 10 percent increased risk in overall cancer and breast cancer rates. A study following 12,000 Americans with no underlying illnesses for more than two decades found a 30 percent higher risk of dying in the group consuming more junk food.

If people just replaced junk foods they’d likely gain less weight and perhaps shed some.

A study in the BMJ simulated what would happen if kids reduced their junk food intake, and estimated that childhood obesity rates would drop from 20 to 11 percent, and there’s be 16 percent fewer overweight kids. This simulation extrapolates from a randomized controlled trial in which people alternated between highly processed and less processed diets which were matched for total calories, energy density, carbs, protein and fat, fiber, sugars and salt and instructed to eat as much as they wanted. People on a junk food diet consumed on average an additional 500 calories daily than they did on an unprocessed diet.

You know it when you see it

As to the definition of junk food, no system of categorizing food will be perfect, and we can debate whether warnings on the front of the package are the best way to reduce the intake of what’s inside.

Although academics may struggle with the definition of junk food, for the most part, we know junk food when we see it. The problem is that we see so much junk that it's normalized. Mainstream supermarket’s shelves sell more highly processed and junk food than wholesome ones, pharmacy and convenience store shelves stock almost nothing but junk, and advertising efforts focus almost only on these products. 

It’s really no surprise that half of what Americans eat is junk when so much of what’s offered to them in reality and digitally is these highly processed sugary drinks, candy, fast food, mass produced chips, highly sweetened cereals and cured meats.

Dr. Ayala

What to eat to protect your liver

When too much fat is stored in the liver it can damage this vital organ, leading to liver inflammation, which may cause liver scarring, liver failure and liver cancer in some susceptible people. In the past most fatty liver disease was caused by heavy alcohol use. Nowadays the most common cause of excessive fat accumulation in the liver is nonalcoholic fatty liver disease – it’s unfortunately extremely common and affects about a quarter of the world population. Among people who are obese the incidence is an astounding 70 percent. The obesity epidemic is fueling the rapid rise in liver disease.

There are no FDA approved medications for nonalcoholic fatty liver disease but the good news is that this liver affliction is reversible. Diet changes and physical activity are known to improve this condition. Studies have shown that vegetables and fiber are associated with less risk of fatty liver disease, and a Western diet, high meat consumption, and soft drinks are linked with elevated risk.

A new study in the Journal of Nutrition looks at the diets of a large multiethnic group of 1682 people, whose liver composition was measured using the gold standard: MRIs quantifying fat in the organ.

The foods and nutrients linked with higher liver fat are total fat, saturated fat, cholesterol and meat.

On the other hand, fiber, vitamin C and vitamin E are significantly linked with leaner livers.

People obviously don’t eat vitamins and cholesterol as such, they eat food, and these findings suggest that the diets that are linked with liver fat storage are those high in fat, rich in animal products; those that are associated with less liver fat are more plant based (that’s where the fiber and vitamins come from). The authors conclude: “we found strong positive associations between liver fat and intakes of total fat, percentage energy from fat, and saturated fat, with meat intake a likely contributor.”

The study’s findings confirm those of previous ones. A study of 1128 Dutch people found that people with fatty liver ate more animals, soft drinks and snacks, and less fiber, and several studies show that dietary fiber is associated with lower incidence. A meta-analysis shows a dose-dependent connection between sugary drinks and non-alcoholic fatty liver disease – the more sugary drinks the higher the risk of nonalcoholic fatty liver disease. 

How do you know if you’re developing fatty liver disease?

Nonalcoholic fatty liver disease is usually silent and manifests no symptoms. People may come to medical attention if their liver enzymes – those are measured in blood tests done routinely as part of a regular checkup – are abnormal. These liver enzymes (including ALP, ALT, AST, GGT) can be an indication that the liver is inflamed or injured, and fatty liver disease is one of the common reasons for that. These tests can be followed up with imaging studies of the liver, such as an ultrasound, CT or MRI.

Lifestyle measures to protect your liver

To protect your liver avoid stressing it out: Excessive alcohol damages the liver, as can some medications. The pandemic has unfortunately led to a significant spike in alcohol consumption.

A healthy diet rich in fruits, vegetables and whole grain is as good for your liver as it is for pretty much every other part of your body. Avoid excessive added sugars, especially in drinks. Same goes for exercise. The diet-exercise holy duo also helps with avoiding weight gain, controlling cholesterol, triglycerides and abnormal sugar tolerance – which all increase the risk of extra fat deposits in your liver. 

Dr. Ayala

Two thirds of kids’ calories come from highly processed food

Rates of childhood obesity have skyrocketed over the last decades, and there’s little doubt that the main culprit is our diet. Caloric intake has risen, as did the consumption of ultra-processed foods. Ultra processed foods make overeating incredibly easy: there’s very little you need to do in order to prepare them – they’re ready to eat or need a brief moment in the microwave or a little mix-in – they’re usually calorically dense, they provide lower satiety, and the flavors and mouthfeel are seductive. They’re also relatively inexpensive.

The more ultra-processed food in a society’s diet the greater the obesity rates. A recent large prospective study found a 10 percent increase in ultra-processed food was associated with a 10 percent increased risk in overall cancer and breast cancer rates. Another study following about 12,000 Americans with no underlying illness for more than 20 years found that consuming more ultra-processed food is associated with a 30 percent higher risk of dying.

A new study in JAMA looked at the diets of American kids and found that two thirds of calories now come from highly-processed foods. 

The study looked at a nationally representative sample of almost 34,000 2-19 year olds, and found that although sugary drinks intake decreased somewhat in the last two decades, those sugar calories were more than made up for by greater intake of bakery products and sweet snacks. Ultra processed food consumption increased especially among ethnic minorities, such as non-Hispanic Black kids, who are especially targeted for junk food marketing. Highly processed food use is rampant and pervasive in the entire population though, in all parental education levels and across all income levels.

What are the negatives of ultra processed foods? Most have low-quality carbs, coming from added sugar. Most are low in fiber. They contain additives, such as emulsifiers, stabilizers, preservatives and artificial sweeteners, which have been linked to unfavorable metabolic outcomes.

Beyond that, the authors note that: “processing itself may convey adverse health effects by changing the physical structure and chemical composition of food, which could elicit elevated glycemic response and reduced satiety.”

A recent study in the BMJ simulated what would happen if the use of ultra processed foods were to be reduced, and estimated that the prevalence of childhood overweight would go down from from 37 to 21 percent and obesity rates would move from from 20 to 11 percent. This study is just a simulation, extrapolating from a randomized controlled trial in which volunteers alternated between highly processed and less processed diets which were matched for total calories, energy density, carbs, protein and fat, fiber, sugars and salt and instructed to eat as much as they wanted. People on an ultra processed diet ate a daily average of 500 calories more than they did on an unprocessed diet.

But phasing out ultra-processed foods when they’re already a habit isn’t easy.

The Covid-19 pandemic brought about a return to home cooking for many families, but it seems like the rush to bakers’ yeast and kitchenware was temporary – people have reverted to ordering in and to ready-made foods. Childhood obesity rates, which we hoped had already leveled off, may be rising again during the pandemic.

Watching out for over-processed food

Think of ultra-processed foods as the polar opposite of whole foods, which should comprise the majority of what we eat. 

But cooking from scratch using whole foods isn't always practical, and let’s not over romanticize the era in which people spent all their waking hours preparing a meal – we do need someone else to do our food prep at least to a certain degree.

To enjoy the best of both worlds, when purchasing packaged food ignore marketing claims on the front of the label, and instead, read the ingredient list watching out for these indicators:

Artificial ingredients: 

If you can’t pronounce an ingredient, it’s probably a chemical, added for flavor, color, texture or preservation.

Lots of sugars/sweeteners:

Look at the “added sugar” quantity or look for sugars among the top three ingredients of non-dessert foods.  Watch out for sugar’s many versions, such as dextrose, evaporated cane juice etc. Foods with lots of added sugar are the embodiment of highly processed food, and the worst are sugary drinks. Desserts and treats are ordinarily made with plenty of sugar and sweeteners, whether they’re highly processed or made from scratch, and those are best eaten in moderation, regardless of processing level. High-fructose corn syrup is the embodiment of high processing and industrialized food.

Highly processed category until proven otherwise:

Fast food, most fully prepared and frozen meals, most mass produced chips, crackers, and highly sweetened cereals, cured meats (ham, salami, bacon, some sausages.)

What are your tips for minimizing highly processed foods?

Dr. Ayala

 

The inconvenient science-based truth about the upper limit of sugar and alcohol

Covid times have brought two conflicting realizations to the fore. We’re ever more aware that our general health is key to the way our body deals with a medical challenge – such as an infection with a virus. On the other hand, it’s been hard not to double down on the very things that undermine our wellbeing, which is understandable, given the stress and isolation of the recent year, and how hard it is to change our habits. 

As pubs and restaurants closed, people stocked up on alcohol at home. According to Neilsen, alcohol sales from stores grew 21 percent, while online alcohol sales skyrocketed and are up 234 percent. People gravitated to larger sizes and to higher alcohol content. Alcohol consumption is up especially among people prone to alcohol abuse, and binge drinking rose about 20 percent for every week on lockdown according to a recent study.

Unhealthy eating patterns also rose, especially in already at-risk populations. In a recent study about a third of participants reported that they’re eating less healthfully and have gained weight, 44 percent reported increases in unhealthy snacking, as well as increased intake of sugary drinks and candy. 

A guiding hand

Unrelated to the pandemic, the 2020-2025 Dietary Guidelines were recently published. These recommendations are developed using a report by a scientific advisory committee of 20 nationally recognized experts in the field of nutrition and health. After reviewing the relevant science, the committee’s advice, published last summer, was to cut back further on sugar and on alcohol. Alcohol intake is on the rise the committee notes “excessive alcohol consumption is a leading behavioral risk factor for a variety of morbidity and mortality outcomes, social harms, and economic costs”, and “consuming higher average amounts of alcohol is associated with increased mortality risk compared to drinking lower average amounts.” Men who drink alcohol, the expert panel advises, should limit their alcohol intake to 1 drink a day – the upper limit for women – down from the 2-a-day upper limit in the 2015 guidelines. 

Likewise, the scientific committee had new advice regarding the upper limits of added sugar. Previous dietary guidelines had the upper limit at 10 percent, a tall order by itself, as per the committee’s data, the average American consumes about 13 percent of daily calories as added sugar. The committee’s added sugar conclusion: “Evidence suggests that adverse effects of added sugars, particularly from sugar sweetened beverages, may contribute to unhealthy weight gain and obesity-related health outcomes... the Committee suggests that less than 6 percent of energy from added sugars is more consistent with a dietary pattern that is nutritionally adequate while avoiding excess energy intake from added sugars than is a pattern with less than 10 percent energy from added sugars."

The committee’s advice regarding cutting back on alcohol and added sugar was not incorporated into the 2020 guidelines, however.

Although the 2020 guidelines admit that added sugars, and especially sugary drinks, can add to our alarming obesity rates, and that alcohol is linked with certain cancers and cardiovascular disease, the guidelines remained unchanged.

Drinking less sugar and alcohol is better

To which one can say, who listens to the guidelines anyway? Well, it’s true that years of recommending 5-a-day of fruits and veggies achieved the common knowledge that we should eat more veggies and fruit, but not the actual practice of doing so – only 1 in 10 Americans eat enough fruits and veggies. Most Americans don’t follow the guidelines, and the average American scores 59 out of 100 on the Healthy Eating Score.

But the Dietary Guidelines for Americans are the basis of educational materials and policies, such as the federal nutrition assistance and school lunch programs, so the guidelines do have real-world consequences. People are also aware, like never before, that poor diets are linked with chronic diseases and bad outcomes, so communicating the science matters.

And for people struggling to improve upon an unhealthy habit, vague or ambivalent advice, especially from a voice of authority, is permission to struggle less. It’s all too easy to read the current guidelines as entitling men to 14 drinks a week under the guise of moderate drinking, and shooting for a diet of 10 percent added sugar as a recipe for health – and we know we're already cheating ourselves when we count our dietary indiscretions.

So yeah, alcohol and junk food can give some comfort, and a little indulgence shouldn't be denied, especially when we’re deprived of many other things we used to enjoy. Alcohol sales have also been a bright spot for many retailers and food service businesses struggling in these hard times.

But the truth is still the truth.

The fact that health food stores like Whole Foods Market have several aisles devoted to alcohol doesn’t mean that alcohol is a whole food that nourishes you. It reflects consumers’ desire to buy the retailers' need to sell. Wine is delicious, so is cake, but these, evidence shows, should be consumed in moderation; moderation can't be defined by our desire to consume or by the wishes of those who profit from sales, but by evidence. 

I, too, wish that ice cream could become the new kale nutrition-wise, unfortunately, this is not the case.

Dr. Ayala

What to eat to save your teeth

Beware of sticky candy and starchy foods that get trapped between your teeth, brush and floss. You must have heard this annoying advice endless times. 

It’s good advice, though. That much of the advice is targeted at sugar and carbs makes sense. Sugars have long been established as a major contributor to the formation of cavities. Bacteria in tooth plaque ferment sugars and produce acids that lead to tooth damage.

But to keep teeth healthy diet advice goes well beyond just sugar control.

Because beyond cavities, there’s a more serious dental disorder: periodontitis. Periodontitis is a chronic inflammatory disorder that slowly destroys the gums and the tissues that support the teeth. Untreated, it eventually leads to tooth loss. Severe periodontitis affects more than one in ten people worldwide, while mild disease may affect up to 90 percent. Gum disease starts with gingivitis: Plaque along and under the gum line can get gums infected, red, tender and prone to bleeding. Gingivitis, left untreated, can advance to periodontitis. The inner layer of the gum and bone pull away from the teeth to form pockets, which collect debris and become infected and activate an immune response, which together with the bacterial excretions, breaks down the supporting structures of the teeth, leading to their loss.

Periodontitis is a major public health issue, and preventing its development can help avoid a lot of suffering and expense. Gum disease is influenced by many factors beyond dental hygiene, including genetics, smoking, and alcohol consumption. An association between a balanced diet and periodontal health has been observed for centuries.

Sailors leaving the ports of Europe felt just fine, but after a few months at sea their gums were bleeding and inflamed, so painful that they couldn't eat. They became extremely fatigued, their limbs swelled up and bruised easily, and soon after, their teeth fell off like the leaves of autumn. The discovery that fresh citrus prevented this deadly syndrome led to the recommendation that sailors on the Royal Navy drink lemon or lime juice on long journeys at sea. Many other fresh fruits and vegetables prevented this clinical syndrome, called scurvy; later on the etiology of the syndrome was revealed: vitamin C deficiency. Vitamin C is critical for gum health, but isn’t the only one: vitamin D and B-12 deficiencies also increase the risk of periodontitis.

Fortunately, vitamin deficiencies – and vitamin C deficiency especially – are now uncommon in the developed world. Despite that, rates of periodontal disease and its severity continue to rise.

We know that other chronic inflammatory conditions – such as cardiovascular disease, type 2 diabetes and cancer – are influenced by diet. Is periodontal disease linked with dietary patterns in the same way? We also know that periodontitis is correlated with the chronic inflammatory conditions listed above, among others. Is diet-related inflammation a common mechanism for all of these diseases?

Ideal dental diet isn't just about candy and soda

A new study in the American Journal of Clinical Nutrition looked at the connection between whole diet – not just specific nutrients such as sugar and vitamins – and periodontitis.

The researchers looked at a large cohort of 10,000 people and investigated the association between their overall diet and periodontitis, which was evaluated with a full-mouth periodontal exam. They didn’t look at any one single nutrient, but rather at foods and general dietary themes. The dietary pattern associated with healthy gums was a varied diet, rich in fruits, vegetables, salad, plain water and tea. People who adhered to this pattern most had less than half the periodontitis occurrence than those who followed this pattern the least. 

Could it be that people with periodontitis avoid fruits, vegetables and green salad in response to their weakened chewing ability? The authors think it’s highly unlikely, since periodontitis is symptomless until very late in the process – when teeth are falling off – and adjusting the study population to exclude people with advanced tooth loss did not change its findings.

Why would these foods matter? 

“One hypothesis is that high intake of carbohydrates, especially sucrose and fructose in added sugars, may influence periodontal health through chronic systemic inflammation,” the authors suggest.

So refined sugar may not just act locally inside your mouth, but systemically, raising inflammation and thus increasing the risk of periodontitis in the same way that it raises the risk of heart disease and stroke.

That periodontitis tracks with heart disease is pretty well established. It very well may be that the same risk factors that increase the risk of heart disease increase the risk of severe gum disease.

Studies like this should of course be followed by prospective, careful trials to further investigate the diet-periodontitis link. 

But since this dental diet is in concordance with what’s recommended to eat anyway, why wait? We already have too many reasons to limit added sugar and eat more salad.

Dr. Ayala

 

Is diet soda better for your heart?

There’s a long standing debate over diet soda and weight loss. 

Non-caloric sweeteners came to the scene decades ago, offering the intense sweetness we naturally prefer, without the caloric price tag. Sweeteners such as aspartame (NutraSweet, Equal), sucralose (Splenda), saccharin (Sweet'N Low) acesulfame K (Sweet One) and neotame are practically calorie free, so replacing added sugar with them should cut calories from our daily intake, and fewer calories should translate to weight loss, right?

Short-term clinical trials were promising: Artificially sweetened soft drinks may indeed produce short-term weight loss when they replace sugary drinks. However, there are very few long-term studies looking at what artificially sweetened beverages do to weight, and since body weight regulation is super complicated, it very well may be that over time the calories saved by switching to artificial sweeteners are replaced by other foods; in other words, diet soft drinks may not help you lose weight after all. Several studies actually suggest that these artificially sweetened sodas fuel, rather than fight the obesity epidemic.

Sugary drinks pose risks beyond weight gain though; they increase the risk of heart disease, type 2 diabetes and other chronic diseases. Are diet sodas better? 

Is diet soda safe?

While the weight loss benefits of diet sodas are still questioned, several safety concerns are being raised.  On the one hand, despite recurring worries about sweeteners and cancer risk no such link has been found. Artificial sweeteners in the market are approved by the FDA and considered safe.

However, there’s disturbing evidence showing a correlation between the consumption of diet soft drinks and the metabolic syndrome as well as type 2 diabetes, even when obesity is controlled for. Sweet tasting drinks without calories may send signals that trigger hunger, increase cravings and interfere with weight regulation, and lately, studies have indicated that artificially sweetened soda may induce glucose intolerance by altering gut microbes.

A new study reported in the Journal of the American College of Cardiology looks at artificially sweetened drinks and heart health. The study includes 100,760 people, who reported on their beverage intake every 6 months. Incidents of cardiovascular disease, including heart attacks and strokes, were marked from the fourth year of study, to control for reverse causality (cardiovascular disease pushing people to quit sweet drinks rather than sweetened drinks driving cardiovascular disease).

And the results: After taking into account confounding factors, people who consumed drinks sweetened by added sugar as well as people who drank artificially sweetened soft drinks were at significantly higher risk of cardiovascular disease, the higher the consumption the greater the risk. The authors conclude that artificially sweetened beverages “might not be a healthy substitute for sugary drinks.”

A temporary fix

For sure, excessive added sugar isn’t good for our health – and it’s especially harmful in liquid form – but even if artificial sweetened soft drinks are better, it may not be by much. 

A science advisory from the American Heart Association advises against long term consumption of diet soda, especially for kids. For adults who consume large amounts of sugary drinks, they suggest that diet drinks may be a useful strategy to reduce soda intake while moving towards more desirable options. Ultimately, though “other alternatives to SSBs (sugar sweetened beverages), with a focus on water (plain, carbonated, and unsweetened flavored), should be encouraged.”

Overcoming the soda habit is the best option. Treats are one of life’s joys, but intense sweetness with everyday hydration isn’t good for you – even when no calories are involved.

Dr. Ayala

 

The inequities of soda

There’s a double digit gap in life expectancy between the richest and poorest Americans. Chronic diseases, such as diabetes, stroke and heart disease are more common and start earlier in poor communities. One of the key drivers of this inequity is diet quality.

And one of the hallmarks of an unhealthy diet is sugary drinks, which are clearly linked with a whole host of chronic diseases and obesity.

The pandemic has focused our attention to our personal and collective health like never before. The CDC advises that to better cope with the pandemic, good nutrition is essential; “Getting the right amount of nutritious food like plenty of fruits and vegetables, lean protein, and whole grains is important for health.” Access to good nutrition, however, is unequal.

The income connection

A new study set out to look at the relationship between income and sugary drinks consumption. 

The study analyzed data from more than 24,000 adults in the US, looking at health, income, wealth, diet and attitudes, year after year. This study is unique in its attention not just to income, but also to wealth, which is the accumulation of resources. 

The study finds that the number of sugary drinks people drink a week declines as income rises. This is also true for wealth, and even more pronounced. It finds that people in the richest 10 percent of families drink about 2.5 fewer sugary drinks a week than those in the poorest 10 percent. The link between income and sugary drink consumption holds even after you control for education, race, gender, and interest in nutrition.

The researchers then tried to see if a change in income and wealth changes sugary drink consumption. They had data of just 4 years for this part of the study, and in these 4 years they didn't see changes in sweet drink consumption as people moved up the income or wealth ladder. 

It seems like soda habits, once formed, don’t change much, or at least not that quickly.

Health disparities and soda

The inverse relationship between socioeconomic status and sugary drink intake may help illustrate some of the health disparities we see, now more than ever, with Covid-19.

Healthy diet patterns depend on access, cost, as well as the ability to cook. Disparities in diet quality are driven by how cheap and easy it is to consume fast and highly processed foods, and how much harder it is to purchase and prepare meals from whole, fresh foods.

But when it comes to drinks, the least expensive and most accessible option is available to most of us. Sugary drinks are an unhealthy alternative to plain water -- they’re no more than an unexamined habit, instilled in us through clever marketing, wide accessibility and our innate fondness of sweet food. 

What makes it even more unfair is that soda marketing is specifically targeted towards people already suffering from higher risk of disease. Lower income neighborhoods have more outdoor ads such as billboards and bus shelter signs featuring soda and junk food, African American kids see more TV ads promoting sugary drinks, and disproportionate soda ad money is targeted at Spanish language media. 

The health disparities in nutrition and obesity correlate with the racial and ethnic disparities in Covid-19, according to a recent perspective in the New England Journal of Medicine. Improving access to better food is imperative, but isn’t easy; removing the drivers of the soda habit, especially in the most vulnerable communities, is just the decent thing to do.

Dr. Ayala

Does food affect susceptibility to Covid-19?

Six months into the Covid-19 pandemic, and the astonishing variability in disease severity remains an enigma. The same virus causes an infection so mild in some that it passes without notice, yet in others it manifests catastrophically. While older age clearly increases the risk for severe disease and death, at times younger people also need intensive care, and a whole host of underlying conditions are presumptive risk factors.

According to the WHO, the CDC and other leading health agencies, conditions that make a person more likely to suffer severe Covid-19 include cardiovascular disease, diabetes, lung disease such as asthma and COPD, hypertension, obesity and history of smoking, among others.

Unfortunately, underlying health conditions are common. According to modeling recently presented in the Lancet about one in five people worldwide are at increased risk of severe Covid-19, due to underlying health conditions, and 4 percent of those infected worldwide would require hospitalization. The situation in the US is even more concerning: 60 percent of Americans have an underlying condition. Even young adults ­– late teens to late twenties – in the US are more vulnerable than one might imagine. A new study by UCSF researchers, in the Journal of Adolescent Health predicts that 32 percent of young adults are at risk of severe Covid-19 based on risk factors.

But although time goes in only one direction, and not every underlying disease can be reversed, many risk factors are highly modifiable. And since it looks like we’re in for a long battle it’s time to step up our efforts.

Eating to support immunity and measured inflammation

Our knowledge of Covid-19 is evolving, but it’s safe to assume that a sound nutritional status supports immunity, and lowers the chance of severe, out-of-control inflammation.

More importantly, many of the chronic diseases, which put us at risk of severe Covid-19, can be mitigated by a healthy diet. A healthy diet supplies us with all the essential nutrients – malnutrition causes immune deficiency – and also promotes health, reduces undue inflammation, and lowers the risk of chronic diseases.

There are many ways to eat healthy. There’s one particular diet pattern, however, that’s clearly not good, and it’s unfortunately popular, inexpensive and prevalent. The Western diet, characterized by excessive consumption of highly processed, sugary and fatty foods, refined grains and cured and red meats, and low intake of fruits and vegetables, is associated with impaired blood sugar and insulin, metabolic disease and obesity. It’s linked with inflammation and many chronic diseases, including diabetes and heart disease, even in people with normal weight.

One example of a healthy diet – one I’m especially fond of due to its flavor and ease of preparation – is the Mediterranean diet. It’s characterized by high intake fresh whole foods, fruits and veggies, fiber and only moderate intake of other foods; it’s associated with lower incidence of chronic diseases. Any diet that emphasizes fresh plant-based foods such as vegetables and fruits, whole grains, legumes, and nuts may improve the inflammatory response, fight insulin resistance and metabolic disorders.

An interesting new paper in ACS Chemical Neuroscience looks at the correlation between herb and spice consumption and Covid-19 cases, deaths and recovery in 163 countries. It found that countries with lower consumption of spices per capita had a higher number of deaths per million citizens as a result of Covid-19, and more importantly, that the recovery rate was higher in nations with higher consumption of spices. Could ginger, turmeric, garlic, clove and thyme help fight infections? The authors cite studies that support the notion that “herbs and spices are well-known to boost immunity,” perhaps due to their antiviral, antioxidant and anti-inflammatory actions.

Or perhaps, people from countries that utilize large amounts of spices simply cook more from scratch, rely less on highly processed foods, and therefore just have better diets.

Now, more than ever, healthy eating habits should be a top priority; they may reduce our susceptibility to severe Covid-19 and its complications. Now, more than ever, is the time for cooking simple meals from scratch, and filling half the plate with veggies. Spices and herbs will enhance the flavor of the dish, add to its nutritional value, and maybe even help with fighting illness.

Dr. Ayala

The proven flat belly diet

It’s all about location. Much like in real estate, where fat's located determines its importance: Fat under the skin and fat around abdominal organs behave differently. Fat in and around abdominal organs is active metabolically and acts like an endocrine gland, causing insulin resistance, blood sugar spikes, and interfering with fat metabolism, and is much more of a health issue than fat under our skin.

A bulging abdomen used to be called a beer belly, but sugar belly's more fitting. Studies show that sugar – especially in drinks – increases fat accumulation in the worst possible locations of our anatomy.

Fructose overconsumption – as in drinking 25 percent of daily calories in fructose for 10 weeks – increased triglycerides and cholesterol, caused insulin resistance and belly fat accumulation, a study from the University of California at Davis showed. Another study found that even moderate consumption of sugary drinks (1 daily can of soda for 3 weeks) led to increased belly fat, elevated glucose levels and inflammation markers, and abnormal lipid profiles. A study in the journal Obesity, following 800 people, found sugary drinks were associated with significantly increased belly fat and wider waistlines. And a study assigning overweight people to drink cola, skim milk, diet cola or water for 6 months, with total calories staying constant, found that liver and abdominal fat increased significantly in the regular soda group, while it remaining unchanged in the other groups.

Added sugars are likely culprits of excessive liver and abdominal fat, but are there foods that promote less of it?

Plant-based = smaller belly?

A new study in the American Journal of Clinical Nutrition looks to see if plant based diets affect fat distribution.

The study included almost 600 older people – median age was 62 years. Their diet was assessed by a validated questionnaire, and further, plant based foods were assessed for their healthfulness. For instance, under the healthy plant foods fell fruits, vegetables, nuts, seeds, legumes, whole grain foods, olive oil etc. Less healthy plant based foods included sweets and desserts, refined grains and sweetened drinks. Animal based foods included meats, milk and eggs.

Fat deposits were assessed by MRI, which looked at fat around the abdominal organs, as well as at fat under the skin. The study adjusted its results for age, sex, BMI, education, smoking, alcohol, and exercise as well as for underlying medical conditions.

Overall, people eating higher on the plant-based index – with more plant-based foods and fewer animal products – tended to be thinner, they had slightly lower BMIs, less fat both under the skin and around abdominal organs, and had lower rates of Fatty Liver Disease than those lower on the plant based index.

But for the same level of overweight and obesity, fat distribution wasn’t associated with adherence to plant-based foods overall – only a healthy plant based diet was associated with lower chances of abdominal fat after adjusting for BMI, which is to say, for the same BMI, people on a healthy plant based diet had less fat in the dangerous – abdominal – locations.

These findings are supported by several other studies:

A study in Circulation examined the effect of two weight-loss diets – a low-fat diet, and a Mediterranean diet, rich in unsaturated fat and low in simple carbs –on fat deposits. The 278 participants were followed for 18-months, and besides the weight and waist circumference measurements, total body MRI was used to in order to measure fat quantities around all the internal organs. Although the two groups lost about the same amount of weight, the Mediterranean diet group lost more abdominal fat, more liver fat and more fat around the heart and pancreas. Losing this liver and deep intra-abdominal fat improved participants’ lipid profile and insulin sensitivity.

Another recent study in the Journal of Nutrition examining the diets of 6671 45-65 year olds and correlating them with MRI findings of abdominal fat, found that high fruit and veggie intake are linked with low liver and belly fat.

Ab exercises and workouts

Further research may clarify whether a healthy plant-centered diet helps fight belly fat accumulation ­– its fiber, high antioxidant levels, anti-inflammatory activity and plant proteins may facilitate benefits – or that healthy plant-based eaters minimize consumption of sugary offenders.

Exercise also helps. I’m not talking about abdominal crunches – those are excellent to strengthen your abs, but focusing on abs doesn’t preferentially attack the belly fat under them – all aerobic and strength training reduces the chance of visceral fat, even if you don’t lose weight.

No matter what your genetic disposition, you can affect the distribution of your fat through healthy food choices and keeping active.

Dr. Ayala

A tasty addition may help fight inflammation, even when you indulge

Immunity’s on our minds as we’ve altered our lives to deal with the Covid-19 pandemic. Inflammation is critical to the immune response to this virus, but we’re also hearing about cytokine storms and exaggerated immune reactions. We’re learning that sometimes an overactive immune reaction causes severe illness – that can be even worse than the virus itself. Inflammation is both friend and foe.

Inflammation isn’t just at the center of our reaction to infectious diseases though. Chronic low-grade inflammation can happen when we’re not attacked by invaders, and it recruits chemicals and cells that damage arteries and build plaque; it’s a likely major mechanism of many chronic diseases including heart disease, cancer, depression, Alzheimer’s, arthritis, and it can age you prematurely.

One of the ways you can help your body mediate inflammation is through your food choices. An anti-inflammatory diet resembles a classic Mediterranean diet – it’s rich in fruits, vegetables, spices and herbs, whole grains, legumes, garlic, onion, olive oil and fish, it’s low in red meat, refined grains, highly processed foods and sugary drinks. Metabolically healthy people can deal with nutritional indiscretion quite well, but people at risk of metabolic syndrome are already prone to chronic inflammation, and eating a pro-inflammatory meal exacerbates the situation. Unfortunately, metabolic health isn’t common – just 12 percent of US ­adults are in optimal metabolic health.

So what if you still want that occasional burger with French fries? Can you make it less inflammatory by adding anti-inflammatory foods to the pro-inflammatory ones is the meal?

Improving an inflammatory meal

A new randomized controlled study from Penn State University, published in the Journal of Nutrition, tests this idea.

The study recruited twelve men aged 40-65 years who were overweight or obese, and had at least one risk factor for heart disease. The participants ate three versions of 1000 calorie meals of coconut chicken curry, a corn muffin, and a cinnamon biscuit for three days and in a random order: one had no spices and herbs added, one had two grams of the spices and herbs, and the third meal had 6 grams, amounting to 1-2 teaspoons of the blend. Blood was drawn before the meal, and hourly in the 4 hours after the meal, and tested for inflammatory cytokines. (Cytokines mediate our immune reactions, recruiting inflammatory cells, stimulating the movement of cells towards sites of inflammation, and changing the behavior of blood vessels.)

The spices and herbs blend contained basil, bay leaf, black pepper, cinnamon, coriander, cumin, ginger, oregano, parsley, red pepper, rosemary, thyme, and turmeric.

White blood cells were also cultured and stimulated to respond to an inflammatory stimulus, resembling what could happen if the body’s attacked by a pathogen such as a virus.

And the results: Inflammatory cytokines were significantly reduced with the addition of 6 grams of herbs and spices.

This is a small study, but the antioxidant and anti-inflammatory activities of certain spices and herbs have been shown before, for instance: A study of turmeric in adults with obesity reduced the cytokines IL-1β and IL-4, and ginger has been shown to reduce circulating inflammatory markers in people with type 2 diabetes. Additional studies will help test this hypothesis.

But we already have excellent reasons to add herbs and spices to our food: they add flavor (without adding calories, sugar, fat and salt), make food more interesting, and transport us to faraway places – at least in our mind. 

Dr. Ayala

Should you skip dessert in 2019?

Do you have a sugar problem? For most of us, the answer is yes.

The average American consumes 17 teaspoons of added sugar a day. Well above the 6 teaspoons upper limit for women, or 9 teaspoons limit for men that the American Heart Association recommends, or the 10 percent of daily calories that the Dietary Guidelines for Americans advocates as the upper limit. Sugar is added to many foods, and staying within this limit isn’t easy. One can of regular soda already exceeds a child’s daily allowance.

The reason these upper limits were suggested by the American Heart Association as well as the World Heath Organization is that studies show that high consumption of added sugar, especially in sugary drinks, is associated with increased risk of heart disease, metabolic disorders and type 2 diabetes.

A new study in the American Journal of clinical Nutrition set out to examine the link between added sugars and mortality. The researches, led by Stina Ramne, looked at two Swedish cohorts, which together included about 50,000 people. The dietary information collected considered and registered all types of sugars and highly sweetened foods, such as sugary drinks, pastries, ice cream, jams, candy and chocolate.

The lowest mortality was among those consuming 7.5-10 percent of calories from added sugar – the common recommended allowance.

Eating 20 percent of daily calories as added sugar was associated with a 30 percent greater risk of death.

How low (sugar) should you go?

Surprisingly, the lower end of sugar consumption – those eating less than 5 percent of calories as added sugar– were also at higher risk of dying.

When looking at the different sugar sources, sugary drinks were clearly linked with early death. Treats, such as cookies and cakes were not – they were actually inversely associated with bad outcomes.

This study joins many others in showing a clear link between sugar in liquid form, and bad outcomes. The solid forms of added sugar – dessert and chocolates for instance – are not linked to obesity and disease in the same way, perhaps because although these are more calorically dense than soda, they satisfy hunger and ‘register’ in our body as food.

What could explain the higher mortality rate among those eating almost no added sugar? It could be a mistake in reporting; it could be that people who eat very little sugar are avoiding it because they already have an underlying illness necessitating abstinence. It also could be that enjoying a coffee and pastry break is a custom enjoyed by people who have social connections and is otherwise associated with healthy lifestyles.

This association has been shown before. In the NIA-AARP Diet and Health Study, which included about 350,000 Americans, people who consume very high and very low added sugars were at higher risk of death. This might be another hint that there’s great wisdom in moderation, and no reason to deduce that if less sugar is better none is best. Never-do-it is the proven recommendation for some behaviors, such as cigarette smoking, but not for sugar. In many health habits, the dose makes the poison.

Doing something for your wellbeing this new year doesn’t need to entail a full diet reset – just a few tweaks will do the trick, and a good target is sugar reduction.

You don’t need to declare Sugar-Free-January, or go full Keto to enjoy the benefits of a reduced sugar diet, nor do you need to suffer the deprivation – and to me personally, the cruel punishment of – complete dessert abstinence.

Easiest places to cut sugar

The easiest sugar-reduction target is also the most important: sugary drinks.

There’s no other food that is as clearly linked with overweight, obesity and chronic diseases as soda and sweetened beverages. Sugary drinks are also the largest contributor of added sugar in the American diet, they practically add nothing but empty calories, and there’s something unique about drinking your calories – drinking calories bypasses satiety and appetite controls, causes spikes in blood sugar and metabolic mayhem.

Another easy target is salad dressing. Making your own will upgrade your salad, save you money and cut added sugar. The basic salad dressing is very simple: 2/3 oil (extra virgin olive oil, or any other vegetable oil/s you like) 1/3 acid (balsamic or any vinegar, lemon juice etc.) add to that any flavoring you like (fresh herbs, garlic, mustard), and just a drop of sweetness from agave or honey for balance.

A third good target is breakfast. Sweetened cereal (Froot Loops and Frosted Flakes), sweet yogurt, morning pastries and pancakes are really a dessert, a treat. Nothing wrong with sweet treats every once in a while, but there are better ways to start the weekday.

Dr. Ayala

 

Love coffee? You’ll love these new studies

Coffee drinking used to come with a dose of concern. I often heard health enthusiasts announcing with pride that they quit things like sugar, red meat and alcohol; coffee would be lumped in for extra credit. And while going easy on sugar and alcohol gets broadening scientific support with the passage of time, quitting coffee – which still might be advisable for some specific people – is something research never really backed.

With time, more and better research is proving the exact opposite about the coffee habit.

A new large study, published in JAMA Internal Medicine looked at the coffee drinking habits of half a million people in the United Kingdom, not all of them moderate drinkers – participants in the study drank up to 8 cups of coffee a day.

The study found that drinking coffee was inversely associated with all cause death for all consumption levels – even for heavy drinkers. Ground coffee’s association with lower mortality was somewhat stronger than that of instant coffee, but all coffee preparations were linked to better outcomes.

The researchers also looked at what’s called slow metabolizers: people who break down caffeine slowly, and are therefore more likely to be sensitive to its effects. Might these people be susceptible to heart disease related to caffeine lingering in their blood? People were especially concerned about high blood pressure and heart attacks within this sub-population. The study looked at genetic polymorphisms that predisposed people to be slow metabolizers and it turns out, in these people too, coffee was associated with lower mortality.

This study is observational, and although it tries to account for confounders such as age, obesity and smoking, its results only prove an association. In nutritional habits that last a lifetime we’re not likely to ever see a double blind, placebo controlled interventional study that can prove causation outright.

But this analysis joins many others, and the evidence seems to repeatedly point in one direction, so a statistical fluke is not very likely.

A study of 185,000 Americans published in Annals of Internal Medicine last year showed lower risk of death in African Americans, Japanese Americans, Latinos, and whites. Another study of more than half a million Europeans from 10 countries found lower mortality and that didn’t vary among the participating countries. A meta analysis in BMJ last year reviewed 201 relevant studies, and concluded that coffee is safe, and that 3-4 cups a day are associated with health benefits rather than with harm.

The secret ingredient? It probably isn’t caffeine

Caffeine, which is the psychoactive stimulant ingredient in coffee, and one of the main reasons people turn to coffee for a pick-me-up, is just one of thousands of components in the magic bean. Coffee is very high in antioxidants, and the whole food – bean – is much more than its parts.

This new study in JAMA found that decaffeinated coffee was associated with the same reduction in mortality. So did many others.

So, should coffee be part of your healthy regimen?

How come we had coffee this wrong until recently, you may ask? It might be our misanthropic belief that if we enjoy something this much – and I personally really do – there must be something wrong with it. Early studies that did not account for known unhealthy behaviors such as smoking and inactivity, which used to be more common among heavy coffee drinkers, also gave the wrong impression.

But not everyone should be chugging coffee.

Coffee isn’t for children – major health organizations, including the American Academy of Pediatrics recommend that kids avoid caffeine in coffee and energy drinks altogether, at least until age 12. Pregnant women should limit coffee at about 2 cups a day.

Remember, also, that coffee at its essence a calorie free, unsweetened drink. Some coffee drinks have so much cream and sugar that they’re true calorie bombs, and these studies showing health benefits are not about those treats. If you want coffee to be part of a healthy routine, make sure that coffee doesn’t make you reach for a sweetener, or a cookie. Or a cigarette.

These studies provide further evidence that if you enjoy your coffee you can do so free of guilt. If you don’t like coffee or find that it interferes with your sleep or makes you jittery I don’t think the science is quite there to suggest you should adopt the habit.

Dr. Ayala