Healthy Food & Healthy Living by Dr. Ayala

Are some calories worse than others?

Energy is a word with positive vibes. We’d all like to be brimming with energy, to rise every morning full of vigor.

A calorie is no more than a unit of energy, yet its undertone is much less positive.

Calories became the enemy only once we started to have too many of them – as tempting food became abundant and cheap excess calories became the most critical nutrition problem of our time.

All food has calories, which are the energy coin that our body uses for all its processes, and all living organisms run on energy and can’t do without it. The makers of fast and snack foods often argue that a calorie is a calorie, take in more energy than you expend and you’ll gain weight, and thus increase your risk of heart disease and type 2 diabetes.

But although all calories store exactly the same amount of energy, just counting calories doesn’t tell the whole weight gain and weight loss story, and definitely not the wellness story, because we don’t eat calories the way a car fuels with gas. We are complex organisms that eat food, not just for energy, and 200 calories from a kale salad with beets, topped with a sprinkle of nuts and a tahini dressing has a different metabolic effect from the same 200 calories derived from a large cup of soda. The salad is nutritious and leads to greater satiety, and since ours is not a gas tank that senses when it’s full, the intricate mechanisms that signal us to eat may totally ignore the 200 calories from soda.

A group of experts met to discuss whether certain dietary components increase the risk of cardio-metabolic disease beyond extra calories and weight gain. The summary of the conference was just published in Obesity Reviews.

Are calories from sugar worse than calories from other food? 

Kimber Stanhope and Jean‐Marc Schwarz reviewed the evidence linking sugar and cardio-metabolic disease. The discussion doesn’t pertain to the sugars that occur naturally in fruits and vegetables – fruit and veggie consumption is associated with lower risk of heart disease, diabetes and obesity.

On the other hand, added sugar has been linked with unfavorable outcomes.

Several recent meta-analysis of prospective studies consistently linked sugary drinks with heart disease, type 2 diabetes and high blood pressure. The scientific evidence has been reviewed by the Nutrition and Chronic Diseases Expert Group, which concluded that sugary drinks cause heart disease and type 2 diabetes directly and independently from the weight gain they usually cause.

In other words, even if you don’t consume extra calories, and don’t gain weight, there are metabolic downsides to consuming soda and sugary drinks.

While the evidence about sugary drinks is pretty conclusive, added sugar in the solid diet has been less studied, the results are less conclusive, and this is an area in which the authors urge more research.

Another interesting topic is the study of specific sugars. Most sugars in use are a combination of glucose and fructose. Fructose has been shown to dys-regulate metabolism more than glucose, as fructose is metabolized in the liver, overloads it, and increases liver fat. But in all practicality, since table sugar (sucrose), honey, high fructose corn syrup, agave, and pretty much all caloric sweeteners contain fructose, the bottom line is that added sugar poses metabolic risk, beyond its caloric count.

Does a high added sugar diet promote weight gain – in other words, does sugar pack on extra fat beyond what we’d expect from counting the calories?

The authors presented evidence suggesting that certain dietary patterns – namely, the high-sugar, high-fat highly palatable Western, highly processed diet – have the potential to promote weight gain. Refined carbs, i.e. added sugars, may affect some people who are susceptible to them, and have lower glucose tolerance, more than others.

Bottom line

Sugar calories aren’t just empty of any nutrients; excessive amounts of them, especially in liquid form, can cause chronic diseases and metabolic mayhem. That’s why current guidelines urge us to limit calories from added sugar to no more than 10 percent of daily intake, and emphasize minimizing sugary drinks.

Dr. Ayala

Serving up real food in the coming new year

It’s the season to celebrate – December festivities bring a little too much to eat – but come January, it’ll be time to get back on track for a healthy 2018.

And there must be a better way than counting carbs, fats, calories and sodium.

The nutrient discussion isn’t just old and tiresome; it also shifts our attention away from what’s perhaps the most important attribute defining what’s good to eat.

What if it’s not the nutrients, not even the foods, so much as what’s done to these poor foods? What if processing is the main issue? What do I mean by what’s done to food? Let’s take cereal; it can be intact wheat in a wheat-berry salad, a 4-ingredient whole-wheat bread freshly baked, or a packaged breakfast cereal. Nutrients aside, the processing of these three types of cereal is very different. Does it matter? Nutrition research certainly suggests it does.

Public Health Nutrition will devote a whole special issue to the subject in the coming January.

All food is processed to some degree; even raw-food vegans and Paleo enthusiasts don’t graze in fields.

But foods range from minimally processed all the way to ultra-processed foods – foods made mostly or entirely from substances derived from foods and additives, with little intact food.

Visit a supermarket in the US (or any other developed country), and you’ll find that ultra-processed foods dominate the shelves, especially the central aisles. Ultra-proceed foods are heavily marketed and dominate ads in old media and in social media. Fast food franchises are everywhere, and vending machines sell salty and sweet ultra-proceed stuff in every building, every corner. Ultra-processed foods now supply almost 60 percent of calories in the American diet.

What is highly processed food?

As mentioned above, all food is processed. It has been processed for hundreds of years. And some of the processing is not only tasty and convenient, it’s also important for safety and health. Drying, fermentation, cooling, freezing and pasteurization protect food from spoilage. On the other hand, adding sugar (as in sugary drinks and so many other foods), and partial hydrogenation (as in trans-fat) are clearly harmful.

NOVA is a widely used classification of food processing; its definition of highly processed food is an eye opener to those unfamiliar with modern food manufacturing:

“Ultra-processed foods, such as soft drinks, sweet or savoury packaged snacks, reconstituted meat products and pre-prepared frozen dishes, are not modified foods but formulations made mostly or entirely from substances derived from foods and additives, with little if any intact Group 1 (unprocessed or minimally processed) food.

Ingredients of these formulations usually include those also used in processed foods, such as sugars, oils, fats or salt. But ultra-processed products also include other sources of energy and nutrients not normally used in culinary preparations. Some of these are directly extracted from foods, such as casein, lactose, whey and gluten. Many are derived from further processing of food constituents, such as hydrogenated or interesterified oils, hydrolysed proteins, soya protein isolate, maltodextrin, invert sugar and high-fructose corn syrup.

Additives in ultra-processed foods include some also used in processed foods, such as preservatives, antioxidants and stabilizers. Classes of additives found only in ultra-processed products include those used to imitate or enhance the sensory qualities of foods or to disguise unpalatable aspects of the final product. These additives include dyes and other colours, colour stabilizers; flavours, flavour enhancers, non-sugar sweeteners; and processing aids such as carbonating, firming, bulking and anti-bulking, de-foaming, anti-caking and glazing agents, emulsifiers, sequestrants and humectants.

A multitude of sequences of processes is used to combine the usually many ingredients and to create the final product (hence ‘ultra-processed’). The processes include several with no domestic equivalents, such as hydrogenation and hydrolysation, extrusion and moulding, and pre-processing for frying.

The overall purpose of ultra-processing is to create branded, convenient (durable, ready to consume), attractive (hyper-palatable) and highly profitable (low-cost ingredients) food products designed to displace all other food groups. Ultra-processed food products are usually packaged attractively and marketed intensively.”

What’s the harm?

Ultra-processed food has been associated with poor diet and obesity, as well as with hypertension and metabolic syndrome.

New research in this issue reinforces this point.

A review of 26 studies finds that eating ultra-processed food is associated with obesity in kids and teens. Another study finds that availability of ultra-proceed foods at home ranged from 10 percent in Portugal and 13 percent in Italy to about 50 percent in Germany and the UK. There was a significant positive association between household availability of ultra-processed foods and obesity rates. A study from Lebanon looked at 302 adults’ diets, and found that those consuming the highest amount of ultra-processed diets had the highest rates of metabolic syndrome, high blood sugar and a risky lipid profile.

New year, new pantry

If you’re looking for an easy to follow, realistic,  positive,  healthy living goal for 2018, try eating real.

I’m not suggesting you make all your food from scratch. It would also be highly impractical to mill your own wheat, or press your own oil. Just try to avoid the highly-processed stuff.

And the best way to do that is to make it less available. Don’t keep it at home, in your car or your desk.

Make this the year in which you notice highly-processed food – it’s usually beautifully packaged, and often even has health claims on it, which is particularly confusing – and call it by name.

I’ve been reading the definition above again and again; it really makes me look at sugary drinks, snacks and prepared meals in a whole different way.

Happy holidays, and to a happy and healthy 2018!

Dr. Ayala

The best diet to fight belly fat

People call a bulging abdomen a beer belly, but beer, clearly, isn’t the (only) culprit.

And finding the cause isn’t a silly blame game.

Abdominal fat isn’t merely an esthetic issue. Fat in and around abdominal organs is active metabolically, much more so than the fat under our skin, and it poses additional risk for diabetes, heart disease and stroke, above and beyond the risk seen with just having some extra weight. Fat around our internal organs acts like an endocrine gland, causing insulin resistance and interfering with fat metabolism.

A growing body of evidence suggests that what we eat certainly affects body shape and fat accumulation patterns – it isn’t just age and genetics. Dietary choices matter, and a more appropriate term of endearment for the rounded belly would be sugar belly.

Or perhaps soda belly, as research shows.

Drinking 25 percent of daily calories (which is quite a lot) 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 (1 can of soda a day for 3 weeks) consumption of sugary drinks led to increased belly fat, elevated glucose levels, higher inflammation markers, and worsened lipid profile.

A study in the journal Obesity, following 800 people, found sugary drinks were associated with significantly more belly fat and wider waistlines.

And a study in the American Journal of Clinical Nutrition assigned overweight people to drink cola, skim milk, diet cola or water for 6 months, with total calories staying constant. Liver fat and fat around abdominal organs and muscle increased significantly in the regular soda group, while it remained unchanged in the other study groups. Blood pressure and triglycerides also rose among the soda drinkers. 

These studies show that sugar -- especially in drinks -- increases fat accumulation in the worst possible locations of our anatomy. Similarly, saturated fat might also cause more weight to accumulate as fat in the liver and around internal organs.

But is there a weight-loss diet that can target these specific fat pools?

Losing that belly

A new study, led by Yftach Gepner and published in Circulation examines whether different weight-loss programs attack fat deposits preferentially. The 2 diets butted against each other were a low-fat one, and a Mediterranean diet – rich in unsaturated fat and low in simple carbs, with and without a moderate exercise regimen.

This was a unique, 278 participant, 18-month study, because besides the weight and waist circumference measurements, total body MRI was used to in order to measure fat quantities around all the internal organs.

The two groups lost about the same amount of weight.

The weight was loss pattern was, however, significantly different: the Mediterranean diet/low carb group lost more abdominal fat, more liver fat and fat around the heart and pancreas.

Exercise also helped shed abdominal fat preferentially.

And losing this liver and deep intra-abdominal fat helped to improve lipid profile and insulin sensitivity!

Making that belly fat the first to go

The take home message: When it comes to fat deposits it isn’t just how much we eat, but also what we eat.

Some foods – especially refined carbs – lead to fat storage in the worst-for-health places.

And the same is true for weight loss: You can preferentially target belly fat by eating a healthy Mediterranean diet with lots of fruits, veggies, nuts and unsaturated fats, and less sugar and carbs. It might work better than a low-fat weight-loss diet with the same number of calories.

Add to that all-important exercise and healthy hydration, and you’ve got yourself a good regimen that will help you avoid weight gain during the holidays – and a worthy plan if you need to lose some in the coming year.

Dr. Ayala

Chocolate became a health food; is it really good for you?

Chocolate, long associated with indulgence, romance and guilty pleasures has become a health food. A large expose in Vox last week traces the transformation.

Apparently, over the past three decades Nestle, Mars and Hershey, among others, have poured millions into scientific studies and research grants that support cocoa research. The research has been fruitful, flooding the scientific journals with many peer-reviewed papers. The media relishes on these studies and coats them with extra chocolate syrup – there’s nothing as appealing and eye-catching as revealing that vices are actually good for you.

Cocoa, these studies found, lowers the risk of heart disease, autoimmune disorders, cognitive decline and diabetes, and is linked with lower body weight. And industry funding warped our perception of chocolate, Vox reports.

Let me demonstrate with an example. Consider this trio of studies about cocoa and our brain.

In a study published in Nature Neuroscience, 37 middle aged people, who drank a mixture rich in cocoa’s flavonols for three months, improved their cognitive function. Functional MRI imaging after ingesting the cocoa drink found greater activity in the area of the brain called the dentate gyrus, an area associated with memory.

Another study in the American Journal of Clinical Nutrition in 90 elderly people who didn’t have cognitive impairment tested 3 cocoa drinks: with high, medium or low flavonol content. The people who drank the intermediate and high flavonol drinks showed improved cognitive performance and improvement in some mental tasks. Blood pressure and insulin resistance also improved in the high cocoa flavonol group. 

The same researchers conducted a similar study with older people that already suffered mild cognitive impairment. The study demonstrated that the 90 people that were randomly assigned to drink the intermediate and high cocoa flavonol drinks improved verbal fluency and increased the speed of mental processing when compared to the volunteers on the low flavonol drink.

These are encouraging, interesting findings, about cocoa. The titles in the popular media, however, took these findings all the way to “Chocolate Protects Against Alzheimer’s” and “Chocolate Makes You Smarter.”

Spending money and time on cocoa

Concentrating on cocoa’s merits creates distortion in perception, even if all the research is done diligently and honestly. Engaging researchers’ time and focusing it on one – food industry sponsored – food, diverts attention from other topics and foods they could and should be studying.

And by the time the results are reported in popular media, they’re hyped to the point that an association with lower risk is understood as a cure – no less – for the associated condition.

Is chocolate really good for you?

Chocolate research centers on cocoa flavonols. Flavonols are plant molecules, abundant in many foods. Cocoa beans are seeds, and seeds are generally packed with important phytochemicals to protect the seed and enable its development into a full-grown plant. Tea, onions, kale, grapes and apples also contain similar flavonols. That's why we should eat lots of and mostly plants.

Had we been eating pure cocoa the positive findings would have been somewhat applicable.

But eating chocolate for its flavonols is like putting young kids in front of the TV for language skill development, or promoting video games for fine motor skills. Yes, there’s some educational value in TV programing, and there are flavonols in chocolate.

Those beneficial specks are bundled, however, with lots of other stuff.

In chocolate’s case the flavonol package includes added sugar, lots of it. And fat.

Investing in research on any whole plant food usually leads to encouraging results.

I’ve confessed to my love for chocolate before. It’s my favorite treat. But a treat is exactly what it is. To deliver enough flavonols from chocolate to make a difference you’d need to consume lots and lots of calories and sugar. I eat chocolate for pleasure, and don't intend to give it up.

If you're seeking the benefits of cocoa flavonols, however, I suggest a handful of cacao nibs. These are pure, crunchy crushed bits of cocoa beans; they’re great in salads, smoothies and on yogurt, and are slightly bitter – because they have no sugar added. The taste of pure cocoa is not sweet. 

Dr. Ayala

Coffee and sugar: An unhappy couple

Sugar’s on a lot of people’s minds. It’s an ingredient we love yet struggle with. Sugar is a key target on all current eat-less-of lists, and we’re all trying to cut our consumption. It’s not easy.

Coffee, on the other hand, is enjoying some good press. As a coffee lover myself, I’m on the lookout for this welcome evidence, reinforcing my habit of a daily cup. Or two, or three. Coffee by itself, research shows, may even benefit your health, providing protection from type 2 diabetes, stroke, Parkinson’s and dementia.

Now, let’s look at these two beloved foods together.

A lot of people do. They drink their coffee sweetened. Many cold coffee drinks come already sweetened – Starbucks’ Bottled Frappuccino and their Iced Vanilla Coffee have as much sugar as soda. They’re really a candy bar with caffeine.

I’ve always liked coffee without. Actually, I’ve never tried it with sugar. Adding sugar and sweeteners to espresso blunts its already gorgeous taste, in my mind. Unlike cocoa, which we fall in love with in its sweet chocolaty incarnation, I’ve accepted and fell for coffee as a slightly bitter, rich, non-sweet food.

But coffee and sugar are connected in more than one way. So today, two recent bits of research about the coffee sugar connection.

Sneaky calories

Coffee and tea are virtually calorie free. More than half of the American population drinks coffee daily, but few Americans drink their coffee plain. A study in Public Health found that two thirds of Americans add sugar, cream and other calorie-rich additives.

How much does this contribute to caloric intake? Although just a spoonful of sugar doesn’t seem like much, it adds up, and this study, that included more than 13,000 Americans, found that adding stuff to your coffee adds about 70 calories daily on average.

If these calories are unaccounted for and are just extra, they can translate to another pound of weight every 2 months.

Does coffee make you reach for a cookie?

Researchers from Cornell University showed that coffee might increase our sugar intake because it reduces the perception of sweetness. The results of their new study of 107 participants appear in the Journal of Food Science.

Volunteers drank a caffeinated and a decaf drink, unaware of the drink’s caffeine content. The caffeinated drink was perceived as less sweet that the decaf one.

Caffeine blocks adenosine receptors in the brain. This is why coffee helps with alertness; adenosine promotes relaxation and blocking it awakens us. We have adenosine receptors in our taste buds, too. Suppressing adenosine reduces our ability to taste sweet foods, potentially altering our perception of sweetness and making us reach for more sugar.

Our growing coffee habit – coffee consumption is on the rise – might be adding extra fuel to our sugar cravings.

So watch out! There’s nothing wrong with a cup of coffee. On the contrary: coffee by itself is actually part of a healthy diet and lifestyle, and much better than many other drink options.

But try to resist the temptation to accompany it with a sweet treat or a sweetener.

Let coffee speak for itself.

Dr. Ayala

How many calories should a kid eat?

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

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

And how about kids?

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

If this issue mystifies you you’re not alone.

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

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

How much should my kid eat?

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

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

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

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

A good kids’ meal

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

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

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

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

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

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

Dr. Ayala

Is soda bad for your brain? How about diet soda?

Soda ads feature young, vibrant, clear-eyed, athletic people. It has already been proven that in fact, soda is actually associated with the opposite: obesity and a myriad of chronic diseases that are the stark contrast of athleticism.

And now, researchers from Boston University, led by Matthew Pase, have shown that it may also dull your mind. It is already known from animal studies that excess sugar leads to Alzheimer’s findings in mice brain tissue. Its effect on human brains hasn’t been examined extensively until now.

The researchers used data from the Framingham Heart Study – a large cohort that is followed every 2 years for decades.

In the first study, published in Alzheimer’s & Dementia, more than 4200 people with different levels of soda intake underwent neuropsychological assessment as well as MRI scans. And the results: The more sugary drinks the participants had, the lower their brain volume and the poorer their memory scores – these findings are consistent with early Alzheimer’s. This held true even after adjustments for diabetes, smoking, exercise and weight.

How about diet soda?

The second study, just published in Stroke examined the connection between sugary and artificially sweetened drinks in almost 3000 people for stroke and in about 1500 for dementia. The volunteers were followed for about 10 years.

It found that diet soda was associated with both stroke and dementia. This was true after adjustment for age, education, smoking, caloric intake and physical activity.

This isn’t the first time diet soda has been correlated with stroke: The Nurses Health Study and the Health Professionals follow-up study both found that diet soda was correlated with stroke. This new study for the first time implicated diet soda with dementia.

Bottom line

Although association, as shown in these studies, isn’t definitive proof – yet – that soda is detrimental to our your brain, there certainly is absolutely no upside to drinking soda, regular or diet.

Sugar is a clear target for reduction in the latest Dietary Guidelines for Americans, and there’s no better place to start than your drinks. Drinking your added sugar it the worst possible way to consume it, as sugary drinks do not lead to satiety, go in unnoticed, at a really fast rate, and cause spikes in blood sugar and insulin.

The motivation to change habits differs from person to person, for some a warning that soda will ruin your figure is powerful, for others, hearing about the risk of diabetes is scarier.

For me, there’s nothing as alarming as the risk of losing my mental capacity.

These new studies offer yet another finding that can help convince people to rethink the way they drink.

Dr. Ayala

Low-sugar, low-fat, reduced-salt, but is it healthy?

What you eat will affect your health. You must have heard this first from your mother, who learned it from her ancestors; ancient physicians knew it (“let food be thy medicine and medicine be thy food”), and modern medicine continues to support this finding with scientific research.

What exactly makes for a healthy food is still something we debate, but we’ve targeted sugar, fat and salt as things our food clearly has too much of. Health conscious consumers seek foods that have less of these ingredients and fewer calories, and highly processed foods with a reduced-sodium, reduced-sugar and reduced-fat claim on their from label seem healthier, or at least less unhealthy.

But is that really so? Are these low-content claims on packages helping our food choices and waistlines, or are they just pushing our buttons, persuading us to buy products that are not really any healthier?

A new study from the University on North Carolina at Chapel Hill, published in the Journal of the Academy of Nutrition and Dietetics, looks to see if these nutrition claims actually lead to healthier purchases.

What’s inside?

A staggering 35 percent of beverages and 13 percent of foods bought by 40,000 US households in this study had low-content claims.

In what seems like good news these products tended to have lower caloric density, less sugar, salt and fat compared to the full-calorie, full-sugar, full-salt and full-fat version.

So, a low-fat Oreo cookie has lower fat that a regular Oreo. But that doesn’t mean it’s healthier that another brand’s cookie – which might have less fat in its original, claim-less product to begin with. Nor does it mean that it’s healthy – it actually has just as much sugar. In other cases, such as low fat chocolate milks, the low-fat versions had higher sugar. Some of the ready-to-eat cereals claiming low-calorie were more calorically dense than other cereal brands with no such claim.

Unhealthy products can easily reframe themselves as better by comparing themselves to something even less healthy. If a potential basketball recruit is faster and taller, or a profile states would-be date is smarter and kinder it means nothing unless we know what the reference point is.

“In many cases, foods containing low-sugar, low-fat or low-salt claims had a worse nutritional profile than those without claims,” the lead investigator Lindsey Smith Taillie, said in a press release.

What the claim promises is that it’s less than something. Fewer, less of, and healthier don’t mean much when compared to a very low standard. If the label said “healthier than a donut”, would you consider it healthy?

Another worry is that when consumers see low-anything-bad it gives them conscious or subconscious permission to eat more of this product – and by increasing the serving size of this food they outdo any potential healthier-for-you benefit that food could offer.

The bottom line is, to know the nature of what’s in that package there’s no avoiding reading the nutrition label and going through the ingredient list. The claims on the front label are for marketing. It’s the back label that has the facts.

Dr. Ayala

When you cut soda, what replaces it?

San Francisco, Oakland, Chicago and Philadelphia, my fair city, recently passed soda taxes. But the first to enact such a policy was obesity-ridden Mexico. The sugary drink tax was enacted there in 2014, and it seems to work. In its first year sales of sugary drinks fell by as much as 12 percent, and a recent study showed that it wasn’t just a blip -- they continued to fall in the second year, with a decline of about 10 percent.

Public health advocates hope that a reduction in sugary drink consumption will lead to a reduction in chronic diseases such as diabetes and heart disease, and to slimmer waistlines -- which makes a lot of sense, but still needs to be proven. Time will tell if that is indeed the case.

But here’s some encouraging evidence.

A new study published online ahead of print in the American Journal of Clinical Nutrition has some heartening findings that suggest that the soda habit is a keystone one, and when you work on changing it, other healthy behaviors follow naturally.

The soda cluster

When people sign up for a weight loss program they follow a whole set of guidelines, targeting many aspects of their diet and physical activity. But what would happen if people were advised to just cut sugary drinks?

Researchers, led by Valisa Hedrick, looked at 149 participants in a program called SIPsmartER – a study that targets only sugary drinks. Most of the volunteers (~80 percent) were overweight or obese, and they were followed for 6 months.

Cutting soda, the study showed, led to other positive dietary changes.

Guided to just cut sugary drinks the volunteers cut soda and sweetened coffee, and without further instruction also decreased trans-fats, artificial sweeteners, salt and total calories. They ate more veggies. The sugary drinks that were omitted were not replaced by a compensatory sweet dessert; they were replaced by water and non-caloric drinks.

The participants, in fact, ate 285 fewer daily calories, and the sugary drinks they skipped accounted for just half of this reduction.

One of the arguments the sugary drink and snack industry puts forward whenever health advocates suggest that their products should be consumed with moderation is that the energy imbalance can be addressed by expending more energy -- moving more. If we just exercise enough, they suggest, we could continue the soda and chips binge.

Here’s the thing: In this study the researchers compared the SIPsmartER participants to 143 volunteers in another single intervention study that focuses only on physical activity, called MoveMore. Moving more the study showed, didn’t lead to eating better. There was minimal reduction in soda drinking in this group, too, suggesting that exercise is a potential gateway to better health.

But the less-soda gateway is much more promising.

Changing habits is hard, and although a comprehensive healthy lifestyle intervention for all would be ideal, it’s not really feasible. Health experts agree that if you drink soda and sugary drinks, that’s the first habit to target – because these drinks are just empty calories that account for much of the excess added sugar in our diet and don’t lead to satiety.

This approach is also promising because soda drinking clusters with other unhealthy eating habits. Delete the soda, and good things start to happen.

Drink better, and better eating becomes easier.

Dr. Ayala

Healthy food trends to take advantage of in 2017

Eating your veggies is suddenly hip.

You might accuse me of being biased – and for full disclosure, yes, I’ve always been a huge veggie and plant-based food fan and proponent – but look around you and see the signs.

In restaurants, veggies are taking center plate; menus are listing more plant-based offerings as many Americans declare they are trying to eat less meat. Pinterest reports a 336 percent rise in the search for veggies in comfort foods.

And this trend will only expand next year.

The market research agency, Mintel, recently announced 2017's food trends, predicting further expansion of vegetarian, vegan and other plant-focused interest.

The Baum and Whitman consultancy's trend predictions follow the same lines:

“Vegetables in 2017 will extend their domination of the dinner plate, shoving animal protein to the edges ... or off the plate altogether… It is no secret that Americans are eating less meat (26% of consumers said so last year) ... that vegetarian/flexitarian diets going mainstream ... and that vegans increasingly are gaining respect.”

Trends shape health

These current trends are sure to please health and sustainability advocates – and grandmas -- who have been drumming the fruit and veggie advice into everyone’s head forever. Plant-centered diets are not only healthful and nutritionally adequate, they have also been shown to prevent and treat many diseases, and people practicing them are among the longest lived and most vibrant people on this planet.

Yet nothing seemed to move for the longest time. And that’s understandable: habits are very hard to change.

It seems that a message needs to come from many different directions, in several modalities and forms, in order to affect action, and in that respect trends help greatly. Just look at what the cool factor – or lack of it – did to cigarettes, spinning, yoga and running.

Greens are in, and 2017 is the perfect time to jump on this trend and adopt healthier habits.

To a healthy 2017

New year resolutions are often broken by the end of January, but a trend, by definition, is something that people are ‘dragged’ into without much resistance, or with minimal effort.

If you’ve been trying to eat a little bit better, chances are, this will be a good year to clinch a few good habits.

A few tips:

• As you continue to hear the “eat more plants” message from health experts, notice how attractive this option is becoming, by looking at recipes, menus and Instagram posts.

• Make plant-centered options convenient, tasty and attractive; this will make this choice easier for you and for your family. Place that pretty, ready-to-eat fruit bowl a little closer and it will be as convenient as a bag of chips.

• Remember: Making small steps in the right direction helps a lot, and this isn’t an all or nothing game. By eating more fruits and veggies you'll be benefiting your health, and displacing less healthy items – such as added sugar, highly processed food and processed meat -- from your dish and cup.

Wishing you happy and healthy holidays, and a peaceful 2017.

Dr. Ayala

Can diet soda lead to weight gain?

Artificial sweeteners were designed to keep food and drinks’ sweet taste while doing away with excess sugar’s unwanted effects, such as weight gain, diabetes and metabolic syndrome.

Sweet tasting drinks without calories seemed like a win-win.

And off we went on this large-scale experiment, which sounded quite promising. But our body is a very complex machine, and simple calorie counts fail to predict what food inventions will do in our body, especially in the long run.

Obesity rates continued to rise, and studies started to indicate that diet soda might not assist with weight loss.

What was even more alarming was the emergence of evidence showing a connection between the consumption of diet soda and metabolic syndrome and type 2 diabetes; another study showed that people who drank diet soft drinks on a daily basis were at increased risk of stroke, heart attack, and vascular death.

These counterintuitive results were a total surprise only to people who don’t appreciate the intricacy of our biology.

Emerging explanations for the diet soda-obesity connection 

Aspartame’s downside

A new study helps explain why diet soda hasn’t yielded the expected weight loss. The researchers, led by Richard Hodin from Massachusetts General Hospital, hydrated mice with aspartame, a sweetener commonly used in diet soda, and compared them to mice that drank plain water. The mice on the aspartame water gained more weight and developed metabolic syndrome.

Further experiments pinpointed the mechanism for weight gain. Aspartame breaks down to phenylalanine in the body, and phenylalanine interferes with intestinal alkaline phosphatase, a beneficial enzyme that helps prevent diabetes and metabolic syndrome.

The researchers demonstrated that when you add intestinal alkaline phosphatase to diet soda and regular soda in a test tube, the activity of this beneficial enzyme was significantly lower in the diet soda solution.

They then looked at the effect of aspartame in the intestine of living mice, and found the same effect inside the body: The mice given aspartame had low activity of intestinal alkaline phosphatase – the ‘good’ enzyme that fights obesity and metabolic syndrome.

Microbiome havoc

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

Further tests implicated an altered gut microbial flora as the reason.

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

These are mice studies, though. Is this relevant to people?

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

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

This study shows quite nicely that non-caloric sweeteners can alter gut microbes in mice -- a change that has negative metabolic consequences -- and provides preliminary evidence that it can happen in humans too.

Unexpected consequences

To further appreciate how complicated our handling of diet soda can be, here’s another little example: Our intestine (or bowel) is covered with cells that secrete hormones. These cells react to the presence and composition of food by secreting peptides such as glucagon-like peptide 1 (GLP-1), peptide YY (PYY) and cholecystokinin – these names are not important – that work on the brain, signal satiety and control glucose by influencing the secretion of insulin. Guess what: Artificial sweeteners seem to not affect these hormones the way real food does.

So although at this point we can’t be sure that diet soda directly causes obesity and metabolic syndrome, I think it’s fair to say the experiment isn’t going too well.

These latest studies offer a few fascinating mechanisms that can explain the link between diet soda and untoward outcomes.

An explanation, and perhaps also a lesson.

We have co-evolved with the traditional foods that come from nature; we have survived and thrived on them from the beginning of human time. They combine into endless possibilities – culinary boredom isn’t even a possibility.

As much as I like technology, innovation and progress, food might not be the place to experiment with new materials. Replacing soda, a drink with nothing but empty calories, with a drink equally lacking in nutritional value but with calorie-free sugar substitutes, isn’t likely to advance our wellbeing – both are silly inventions.

Dr. Ayala

Full disclosure: I co-founded 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.

Soda news: election results, diabetes and the art of misinformation

Election results

Soda taxes were on the ballot in 4 cities on November 8th. The fact that these measures were even there is meaningful: Every time soda is discussed as a public health issue, people are reminded that the evidence tying them to obesity, diabetes and heart disease is piling up. Fifty million dollars were spent on persuasion efforts according to the New York Times, with Big Soda -- opposing the tax -- heavily outspending the tax supporters.

Yet the citizens voted for the tax in all 4 cities; San Francisco, Oakland, Albany CA, and Boulder CO will join Philadelphia and Berkeley, who passed such measures recently.

The anti-soda movement is gathering momentum.

Sugary drinks linked to autoimmune diabetes, too

Sweetened beverages are linked with type 2 diabetes – where typically, the body becomes resistant to insulin.

A new study now finds that drinking soda is also associated with autoimmune diabetes – in which the immune system destroys the pancreatic islet cells that produce insulin, and therefore causes a state in which the body doesn’t produce the critical hormone. The Swedish study, found that 2 drinks of sweetened beverages doubled the risk of latent autoimmune diabetes in adults (LADA) – which is an adult onset autoimmune mediated diabetes, with features similar to type 1 diabetes -- and this was regardless of whether the drinks had caloric or non-caloric sweeteners. And in this study, there was a dose-response relationship: the more sugary drinks, the greater the risk of diabetes.

Industry sponsored confusion

In the face of growing evidence warning us about the harms of sugary drinks the beverage industry fights back by spreading confusion.

A new study in the Annals of Internal Medicine finds that of 60 studies looking at the relationship between soft drinks and obesity, type 2 diabetes, and metabolic syndrome, the majority, and all those that were led by independent researchers found a link. When the study didn’t find a link that study was always conducted by researchers with financial ties to the soft drink industry.

The researchers, from University of California San Francisco, led by Dean Schillinger, warn:

“This industry seems to be manipulating contemporary scientific processes to create controversy and advance their business interests at the expense of the public's health.”

Industry-sponsored studies create the feeling that soda’s harmful effects are controversial, when in fact, pretty much all experts in the field and independent researchers claim otherwise.

Nevertheless, soft drinks are in continuous decline, that, despite ever increasing spending on marketing and soda tax opposition.

Dr. Ayala

Full disclosure: I co-founded Herbal Water, which makes organic herb-infused waters that have zero calories and no sugar or artificial ingredients. I’m also a pediatrician and have been promoting good nutrition and healthy lifestyle for many years.

Drink like a music celebrity?

What do the fit, beautiful music celebrities whom our teens admire eat and drink? According to the ads they help make it’s junk food and sugary drinks that got them into the great shape they’re in.

Which I seriously doubt. I’d bet that they actually treat their health as a great asset, and protect that asset by being very, very careful with what they eat.

A new study, led by Marie Bragg, in the journal Pediatrics, compiled a list of top music celebrities associated with the Billboard Hot 100 Chart, and then looked at foods and drinks these musicians endorsed and helped advertise.

Sixty-five of the 163 music celebrities in the study endorsed foods and drinks. Fifty-one of them endorsed beverages, mostly full-calorie sugary drinks. Most of the foods endorsed (80 percent) were energy dense and nutrient poor, i.e. junk food. Baauer, will.i.am, Britney Spears, Justin Timberlake, Maroon 5, Pitbull, and Jessie J were the most prominent food and drink endorsers. And the food and beverage companies are certainly getting their money’s worth: There were 312 million You-Tube views of the 94 celebrity food and soft-drink ads in the researchers’ sample – and that’s just one media channel.

Does Justin Timberlake really drink soda? Here’s what he told Bon Appetit about how he eats:

“I’m such a Type A personality–when it comes to a road trip, I plan my food so far in advance. I roll hard with a cooler. I don’t mess around. I want to avoid ending up eating fast food. I try to stay away from that.”

Britney Spears recently stunned the world with her amazing abs, and she, too, didn’t get there by drinking soda, but rather, as her trainers report, by eating clean, unprocessed food and good carbs. This is how Spears describes the way to her beach body:

“I’m really into raw food — sushi, basically…any kind of fruit.”

The authors admonish the practice revealed by this study:

“Obesity has become such a pressing public health issue that society must acknowledge the human suffering and costs associated with diabetes, obesity, and associated comorbidities. Musicians, actors, and other celebrities can be tremendously influential, particularly for the young fan base that may be swayed by their endorsements. Celebrities should leverage their influence to promote more healthful messages, and more effort should be made to reduce the exposure of children and adolescents to marketing, particularly for unhealthy food and nonalcoholic beverages."

The same author headed another study in Pediatrics several years ago that similarly showed the extent and reach of star athlete endorsed junk food. That study found that 24 percent of all the top athlete endorsement deals were for foods and beverages, almost all for junk food and sugary drinks. 

Associating junk food and sugary drinks with fitness, strength, vigor, success, health and beauty is pretty ironic. But I guess that as long as we’re buying into it, these endorsements will continue.

Dr. Ayala

Full disclosure: I co-founded Herbal Water, which makes organic herb-infused waters that have zero calories and no sugar or artificial ingredients. I’m also a pediatrician and have been promoting good nutrition and healthy lifestyle for many years.

Does candy make you fat?

Nutrition and public health experts specifically target sugary beverages as a key diet ingredient to cut if we want to improve health and avoid obesity. I devoted a recent post to the rationale behind that advice.

There are, of course, many sugar-rich treats, and when kids think of sweet delights the image is of candy and chocolate, rather than of sugary drinks. Are these sweet foods as much to blame for overweight and obesity as soda?

A group of Australian researchers, led by Constantine Gasser, assumed that would be the case. Candy is a major source of added sugar in the American diet (although it’s dwarfed by the amounts consumed through drinks – on average kids take in 5 times more calories from drinks than they do from candy) and although chocolate has some health benefits, they assumed that chocolate and candy would be associated with obesity and its related diseases. In a new analysis in the American Journal of Clinical Nutrition they collected all studies that looked at the relationship between candy consumption and overweight and obesity, and found 11 such studies, which together included almost 180,000 kids and teens.

To their surprise, the meta-analysis found that the more chocolate and candy kids ate, the slimmer they tended to be. The odds of being overweight or obese were 18 percent lower among the most avid consumers of chocolate and candy.

Do thin people eat chocolate?

The authors discuss the counterintuitive results and say that: “Just like expected findings, unexpected findings can reflect the truth, bias, residual confounding, and/or chance.“

They don’t think their findings are just by chance due to the large number of people in the studies and the consistency they saw in the association between chocolate and candy and weight.

If the results are true, it might be that these sweets are quite satiating, and that people tend to eat reasonable amounts of them.

Another option is reverse causality: Kids who are overweight cut chocolate from their diet, while thin kids allow themselves some candy.

And yet another possibility is that overweight kids underreport their chocolate intake.

Overall, though, it seems like although sugary drinks and chocolate both contain high levels of sugar, the former is consistently associated with obesity and overweight and the later is not. It might be that liquids are not ‘sensed’ the same way chewable food, or that the amounts of sugar one typically gets from soda are much larger, compared to what a typical serving of chocolate would provide, or maybe it’s something else.

This isn’t permission to binge on chocolate, but every reasonable guideline allows some discretionary calories for fun and pleasure – the Dietary Guidelines for Americans suggest limiting sugar to less than 10 percent of calories per day.

To me, chocolate -- one of life’s great joys -- remains a good little thing to splurge on.

Dr. Ayala

Why are sugars in drinks singled out?

Soda taxes are in the news. The UK government announced a new tax that will be proportional to the amount of sugars in drinks and that it hopes will help curb childhood obesity. Philadelphia's new mayor, Jim Kenney, is trying to pass a sugary drink tax, but is presenting it in the more palatable way of increasing revenue for education, libraries and parks in poverty stricken neighborhoods. Mexico enacted a soda tax in 2014, and it seems to work: Sales of sugary drinks dropped by as much as 12 percent. Berkeley, California approved a sugary drink tax in 2014, and San Francisco and Oakland are considering putting one on the ballots this fall election.

While added sugar is on the things-to-eat-less-of list, the added sugar in drinks is a specific target for health experts and governments. Anti-soda is a growing movement. Liquid or solid, sugar has 4 calories per gram, but most weight loss and healthy lifestyle programs target the liquid form of sugar first.

The Western diet contains lots of sugar, and while sugar is added to many foods, most of the added sugar hides in drinks – soda, sports drinks, energy drinks, flavored milk and fruit juices – and that might be enough to explain why sugary drinks are linked so tightly with obesity.

But studies have shown that there is something distinctive about getting calories in liquid form. Solid sugars affect satiety, while studies have demonstrated that liquid sugar doesn’t suppress appetite -- sugary drinks’ calories are just added, and the meals eaten with the them will be just as large, if not larger. When it comes to type 2 diabetes, obesity is a well known major risk factor, but several studies have suggested that sugary drinks are an independent risk factor for the widespread disease.

So is it just that liquid sugar lends itself to overconsumption, or does sugar in liquid form pose an especially tough burden on our body’s metabolism?

Sugary drinks, glucose intolerance and diabetes

A study in the Journal of Nutrition followed 564 Canadian kids aged 10-12 years for 2 years, assessed their liquid and solid added sugar intake, and looked at their fasting sugar, fasting insulin, insulin resistance and weight. The kids were healthy but at risk for obesity because at least one of their parents was obese, and about 40 percent of the kids were already overweight or obese when the study began.

The results show that sugar in liquid rather than in solid form was associated with higher levels of fasting glucose and fasting insulin, and also with greater insulin resistance. Insulin sensitivity, which was assessed with an index that used the kids’ oral glucose tolerance tests, was reduced with higher dietary intakes of sugary drinks. Insulin resistance grew with higher intakes of liquid sugar.

The way our body deals with sugar is a good predictor of type 2 diabetes risk. High levels of fasting glucose and fasting insulin show that the cells are not responding properly to insulin (insulin, secreted in reaction to food, normally pushes sugar into cells, and its levels during fasting are supposed to be low.) Impaired glucose tolerance is a pre-diabetic state, and untreated, may develop into full-blown type 2 diabetes. So the results of this study suggest that liquid -- rather than solid -- added sugar predisposes to diabetes, independent of obesity rates, which in this study’s 2-year follow up were no different between the groups.

So while too much sugar is a problem, this study adds to the body of evidence that demonstrates that sugary drinks are especially harmful; their high availability, low price and effective marketing make them an important contributor not only to obesity, but also to pre-diabetes in kids. Mind you, type 2 diabetes used to be called adult onset diabetes, and was unheard of in pediatric practice several decades ago. Nowadays, it is estimated that 1 in 4 teens has pre-diabetes or diabetes.

Dr. Ayala

Full disclosure: I co-founded Herbal Water, which makes organic herb-infused waters that have zero calories and no sugar or artificial ingredients. I’m also a pediatrician and have been promoting good nutrition and healthy lifestyle for many years.