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 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

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 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

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

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

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

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

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.

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.

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

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

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

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

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

Here are some interesting findings:

• 68 percent of packaged foods and beverages contain added sugars

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

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

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

Taxation:

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

Outcomes have been positive in Hungary, France and Mexico.

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

Awareness campaigns, restricted availability and marketing: 

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

Labeling: 

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

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

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

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

Dr. Ayala

Better health by cutting sugar for just 10 days

The recent prevailing mood regarding sugar swings between worry that it’s not particularly good for you, to conviction that it’s downright poison. 

There’s no doubt that sugar makes food more appealing – some say even craveable and addictive – and that a sugar-amplified diet has a role in overeating and obesity. But what several researchers are finding is that regardless of weight gain, regardless of caloric intake, sugar – especially fructose – in excess is detrimental to health.

A rigorous new study in Obesity, led by Robert Lustig, shows that reducing overconsumption of fructose is metabolically beneficial in and of itself.

The study involved 43 obese 8-18 year-olds, all of whom were heavy sugar consumers (28 percent of their diet was added sugar!) and also had at least one metabolic risk factor, such as high blood pressure, glucose intolerance or high triglycerides.

For 9 days this group ate an added-sugar restricted diet, while still aiming to maintain the same amount of total carbohydrates and calories. 

Short explainer about sugar, fructose and glucose; I promise it’s short and necessary in order to understand what this experiment teaches. Foods and drinks are usually sweetened with sugars that are a combination of the simple sugars glucose and fructose. Sucrose (table sugar) is a two-sugar molecule with 1 glucose and 1 fructose bound together, and is therefore exactly 50 percent glucose, 50 percent fructose. High Fructose Corn Syrup (HFCS) is about 45 percent glucose, 55 percent fructose. Practically all forms of caloric sweeteners used in food processing are glucose/fructose mixes. So how does one maintain the sugar level while reducing fructose? The answer is starches, which are pure glucose chains.

The study didn’t change the kids’ diet to a kale, hemp seed and quinoa retreat, but rather just replaced foods with lots of added sugars with other processed foods such turkey hot dogs, pizza and baked potato chips, that have little or no added sugar, and instead contain carbs in the form of starches.

Just 10 days later there were significant metabolic improvements: Glucose tolerance, blood lipids and other markers of liver health changed for the better.

As mentioned before, the study aimed to keep caloric intake steady, and for the kids' weight to stay the same. However, despite the effort, and even though the researches even added calories to that effect, the kids lost about 1 kg on average (2.2 pounds) in the 9-day study. Could this mild weight loss explain these metabolic improvements? The researchers performed regression analysis and claim it’s unlikely -- I won’t go into that complicated explanation. 

So, is sugar toxic?

This study is further proof that reducing added sugar to more reasonable amounts benefits kids at risk of metabolic syndrome and diabetes.

Dr. Lustig often warns about the dangers of fructose, emphasizing that glucose isn’t the problem. In practicality, since added sugars are almost always at least 50 percent fructose, the sensible advice it to cut all added sugar.

Sugar in large amounts is definitely associated with weight gain, and likely also independently with diabetes and metabolic and heart disease. Reducing it (even without intentional caloric restriction) usually leads to weight reduction, and to improved health outcomes.

So cutting on added sugar and aiming for the World Health Organization's and the American Heart association’s target of no more than 6 teaspoons a day for women, 9 teaspoons a day for men, is very sound advice. The first step towards that not-easy-to-achieve goal is to know how much sugar is added to our food, which is what’s proposed by the FDA, and fought mightily by the food industry.

Dr. Ayala

Tricking parents into bad choices

Parents usually have their kids’ best interest in mind. They want them to grow healthy, acquire eating habits that promote wellness, and have beautiful, strong teeth. 

So how come kids are drinking so much sugar, an ingredient on the top of the list of foods to consume-less-of? Are kids buying it themselves? Are parents unable to resist kids’ appeals for the sweet stuff? Or are parents unaware that sugary drinks are unhealthy?   

A group of researchers from the Rudd Center for Food Policy and Obesity, led by Jennifer Harris set out to understand what parents think about sugary drinks for their kids. The findings appear in Public Health Nutrition.

The researchers collected data from almost 1000 parents. And while it would be expected that parents would provide some sugary drinks as an occasional treat – to be enjoyed yet not promoted as a building block of good nutrition – the study found parents actually thought many of the sugary drinks did promote health. The majority of parents (56 percent) perceived Vitamin Water as somewhat or very healthy.  Sunny D (a fruit drink), Gatorade (a sports drink) and Capri Sun were considered healthy by about 40 percent of parents.

While most of the parents in this study (94 percent) thought soda was unhealthy, many believed that vitamin, fruit and sports drinks were healthy, and while ingredients like artificial sweeteners, high fructose corn syrup and caffeine raised red flags, claims for naturalness, antioxidants and vitamin C made parents believe a drink was a good addition to their kids’ diet. A third of the parents said they actually looked for such claims on the label and that it influenced purchasing behavior. 

Marketing liquid candy as health

Parents’ confusion isn’t accidental. The study reports that $784 million were spent in 2010 on sugary drinks ads and that adults saw on average 364 TV ads that year, about one a day. Many of these ads are directed at parents, and emphasize nutrition, planting the misperception that vitamins or electrolytes in a drink make it a good choice.

Which is the better choice?

So which should kids have, soda or vitamin drinks? The correct reply is neither. Both offer pretty much nothing kids need and sweeteners that they don’t. They are special occasion indulgences at best. As to sports drinks, they have specific limited usefulness – they are for athletes involved in prolonged, vigorous physical activity – and are not for everyday hydration even when exercising. Fruit drinks, as opposed to 100 percent fruit juice (which has its own issues), may contain some fruit juice, but are mostly sugar or HFCS, color and flavor (natural or artificial), with the occasional added vitamins to suggest health. They, too, should be viewed as soda.

It’s a pity that it’s perfectly legal and so easy to misinform parents with bogus health claims and misleading marketing messages.

Dr. Ayala

Simple measures that convince kids to drink less sugar

Everyone besides the soda industry is trying to get us to drink less soda. The World Health Organization recently revised its guidelines and recommends that added sugars should account for no more than 5 percent of daily calories – one can of soda exceeds that quota, and it’s hard to see how sugary drinks fit in a healthy diet. Health experts have been warning about the consequences of sugary drinks – obesity, metabolic disease and diabetes – for many years. The message is slowly sinking in and soda sales are in continuous decline that's intensifying despite ever increasing advertising and marketing propping up the category.

Teens probably pay the least attention to health warnings, so how can we get the group that drinks the most soda to notice?

A bunch of new studies experiment with simple, practical approaches to get the message across.

5 miles for a bottle of soda

Sara Bliech and her colleagues experimented with converting the calories-per-bottle into the more actual miles-of-walking and report the results in the American Journal of Public Health. They posted 4 types of signs in 6 corner stores in low-income neighborhoods in Baltimore: absolute calories, number of teaspoons of sugar, and number of minutes of running or miles of walking it takes to burn off a beverage. The miles-of-walking message, for instance, read: “Did you know that working off a bottle of soda or fruit juice takes about 5 miles of walking?” and performed best. After the signs were put up sugary drinks purchases were significantly reduced, a reduction that persisted even after the signs were removed. Kids bought fewer soda and sports drink bottles, smaller ones and more water.

According to this, signage, and putting calories in context helps change kids’ behavior.

Mountains of sugar 

Another recent study in Appetite translates the sugar content in sugary drinks – it currently appears in grams in the nutrition label – into something more tangible. 

Bakers and cooks perhaps know that there are 4 grams in each teaspoon of sugar, but I doubt it’s common knowledge -- a 20 oz. bottle of soda has about 65 grams of sugar, but what does that mean?

The researchers, led by John Milton Adams, found that when sugar content was translated into concrete representations of sugar cube pyramids the attractiveness and selection of sugary drinks went down, compared to when people read the sugar content in grams. There was no need to talk about the health issues related to overconsumption of sugar, people just found mountains of sugar unappealing. But furthermore, in a neat experiment in Adams' series, undergrads learned how to convert miles to kilometers, dollars to Euros or sugar in grams to sugar in cubes. They were then offered a drink as a reward, and the students that learned the sugar cube conversion chose the sugary drink less often.

65 grams of sugar are meaningless, but 16 teaspoons or 26 cubes don’t look like something you should consume mindlessly. Take a look at Sugarstacks and see if you feel the same way. And here it is if you want empower yourself with an imaginary sugar cube pyramid: each cube (the usual type sold in supermarkets) is 2.5 grams of sugar (Sugarstacks uses a larger cube that’s equivalent to 1 teaspoon).

When soda disappears 

A practical way to lower consumption is to make these drinks less available. Parents have been doing it at home, and schools are increasingly adopting new rules that practically ban sugary drinks. The new Smart Snacks in School nutrition standards are part of the Healthy Hunger-Free Kids Act of 2010, are planned for implementation this year, and will do away with soda sold at school.

The Nationwide Children’s Hospital in Columbus, Ohio implemented such a ban in 2011 in all food service, and an article in the American Journal of Public Health describes what happened following this sweeping step.

In the 2 years prior to the ban, the hospital had an extensive communications campaign that included posters, fliers, education tables and the recruitment of key people to champion the change. Cafeterias reduced sugary drink orders, almost ran out by January 2011, when whatever was left was removed – from cafeterias, coffee shop, gift shops, food service venues and vending machines. The hospital still allowed diet drinks, a few sports drinks, 100% fruit juices and chocolate milk.

And here’s what happened: the purchases just shifted. Families bought more milk, water, fruit juice and coffee and revenues didn’t suffer -- revenues from beverages increased in 2011 by about 3 percent compared to the previous year. I’m sure that the hospital also gained from the positive image such a step brings with it. One of the common comments I hear is: how come there’s soda vended in every hospital corner – and especially next to the Healthy Weight Program and the diabetes clinic?

Indeed, how come?

Dr. Ayala