Healthy Food & Healthy Living by Dr. Ayala

Why cooking helps with weight loss and wellness

There’s a clear link between eating home cooked meals and diet quality. Eating more home-cooked meals is also associated with lower risk of obesity.

Teaching cooking skills is an important method for improving eating habits, and is more effective than just instructing people about nutrition, but what kind of cooking should be emphasized in these lessons? 

The healthfulness of cooking practices depends on both ingredients and techniques. Health promoting cooking methods include using whole grains, adding herbs and spices, using healthy oils such as olive oil, incorporating fruits and vegetables, using onion and garlic, and using lower amounts of fat. On the other hand are health compromising cooking methods such as deep frying, use of processed foods, animal fat, processed meat, and adding sugar and sweeteners in cooking. A method for quantifying healthy cooking has been established – the Healthy Cooking Index applies a point for each health promoting behavior, and deducts a point for health compromising actions. 

A new study in Appetite looks at about 150 overweight or obese people undergoing a weight loss program. The participants were assessed for cooking practices after the weight loss intervention.

And the results: those who had a higher healthy cooking score achieved more weight loss and ate healthier.

Next, the researchers attempted to identify cooking patterns and came up with three types of cooking: Red Meat Simple, Vegetarian Simple, and Health and Taste Enhancing. 

Red Meat Simple cooks used fewer healthful additions, such as whole grains, fruit, and vegetables, or olive oil while using more red meat and animal fat and cooked meat to high temperatures. 

Vegetarian Simple cooks cooked less meat, were more likely to add fruit and vegetables, to cook with herbs and spices, use healthy cooking techniques (baking, boiling, or steaming), moderate salt and oil use, and to avoid deep frying and cooking meats to high temperatures or charring. 

The Health and Taste Enhancing cooking is characterized by higher use of taste enhancers including herbs,  spices and alliums, as well as healthful use of oils such as olive oil, fruits, vegetables, and whole grains. These kind of cooks were more likely to marinade meat prior to cooking, and to use low-fat cooking methods and moderate the salt and oil when cooking. 

The researchers found that The Red Meat Simple cooking pattern was associated with less weight loss compared to the other patterns.

Why would that be? Healthier cooking habits translate diet advice into everyday life, and make guidelines into meals. Eat-more-veggies is an abstract aspiration, while a tasty salad bowl is an adoptable habit.

Other studies have shown that hands-on cooking lessons resulted in weight loss compared to guidance followed by demonstration only.

The cooking patterns analysis hints at what's most important to impart in cooking classes: “complexity is not a necessary aspect of healthy cooking,” the authors write. “Having more advanced technical cooking skills and, in turn, making more complex dishes does not necessarily yield healthier food consumption. Promoting cooking practices that are likely to positively impact the nutritional content of the foods prepared and deterring the use of practices that are likely to negatively impact the nutritional content of foods we prepare may be more important than trying to achieve advanced levels of culinary expertise.”

Cooking plants 

Since what’s missing most from the American diet is plant based foods and whole foods, practicing kitchen skills on these ingredients is the most valuable.

A study looking at the veggie consumption and cooking skills of university students in Brazil found that less than half the students ate vegetables regularly, but knowing how to cook was significantly associated with eating veggies daily. These results are in agreement with another study of more than 1000 freshmen in the US that found that confidence in the ability to cook from basic ingredients and to follow a recipe was associated with eating more fruits and vegetables and better weight status. 

The basic skills we all need as cooks should include salads knowhow, what to make with whole grains, and a few basic cooking techniques that incorporate vegetables with grains and with protein sources, such as making a stir fry, cooking a soup, and oven roasting.

Knowing how to make healthy, tasty, simple and affordable meals is key to health and weight control, it’s a practice that’s central to wellbeing.

Dr. Ayala

Why is the world getting fatter (and what we can do about it)

Barbara Corkey, PhD, has been the editor in chief of the journal Obesity for the past 20 years, so you can trust that she’s immersed in research of the causes, consequences and treatment of obesity. 

In these 20 years obesity rates in the US increased from 30 to 42 percent, and the rates of extreme obesity doubled (rising from 4.7 to 9.2 percent). Diseases for which obesity is a risk factor – such as type 2 diabetes, heart disease, stroke and some cancers – are correlated with the severity and duration of diabetes, therefore the appearance of obesity at younger and younger ages suggest a tsunami of these chronic diseases.

Corkey writes, in a recent editorial, that we humans “have developed a method to feed the billions of people on the planet, by developing processing of food with preservatives and other chemicals that can make food last longer and make it cheaper to increase calorie density in small packages.”

The cause of obesity, according to the editorial, is the foods that we make, and society overfeeding on them. 

The most consumed foods in the US are highly processed foods, topping the list are things like grain-based desserts (cakes, cookies, donuts, granola bars), chicken dishes, soda and other sugary drinks, pizza, alcoholic beverages, pasta, and beef dishes. Notably missing are fruits and vegetables and whole, unprocessed foods.

We’re now fighting for our health in a world that we humans have changed.

Surgery, drugs and the promise of culinary medicine

What does medicine offer to treat obesity? Key developments, according to Corkey, include bariatric surgery, which according to a recent study in the New England Journal of Medicine increases life expectancy by 3 years compared to the control group – but it's still 5.5 years shorter than the general population's. As to medications, there’s hope: “Novel drug combinations are beginning to close the gap with bariatric surgery and they appear to be very powerful new tools to treat obesity as a disease.”

The great hope, however: Culinary medicine. This is a new evidence based field, that combines nutrition and cooking know-how, in order to help people prevent disease and maintain health by promoting good eating habits. Culinary medicine has been added to the curricula of more than 55 medical schools, residency programs and nursing schools. The advantage of these kinds of interventions is that they can – and should – be started early, really early, before obesity sets in, and not just when illness manifests itself, and that there are no negative side effects.

Health meets food

Turning to your doctor to address obesity and diet-related afflictions is of course just one of the options at hand. 

Physicians used to get only rudimentary nutrition education as part of their training, and if they do have culinary skills it’s due to personal interests and pursuits, and not their medical education or the hospital lifestyle. Culinary skills can be gained in any number of ways: from friends and relatives, from videos and TV, from books and websites. The only way to get food that’s inexpensive, and that’s healthy for humans and for the planet is by getting cooking and preparing meals.

Much like in dentistry, where a visit with the clinician includes guidance on how to brush, floss, and strengthen your teeth, the visit with health professionals should include wellness counseling, especially nutrition education.

And cooking can also provide comfort and lots of joy. There are too many barriers to simple home food preparation, but to reverse the trend we're on, we'll have to overcome those.

Dr. Ayala

Does the microbiome affect diabetes risk?

Type 2 diabetes is a global epidemic and one of the most common conditions impacting people's health. The incidence of this chronic disease and its many consequences is rising, as type 2 diabetes now presents at younger and younger ages. It is estimated that as many as 9.3 percent of the world population had diabetes in 2019, and that by 2030 the rates will surpass 10 percent.

The risk of developing type 2 diabetes is clearly related to obesity and to genetic predisposition. Diet is also a major contributor, but not by the simplistic way people may imagine: People with no sweet tooth at all can also be at increased risk of type 2 diabetes due to poor diets; it’s not just about eating sweets and added sugars. Diabetes is an impairment of sugar metabolism, leading to too much sugar in the bloodstream instead of our cells. Diet and exercise habits affect our body’s sugar metabolism in profound ways, and the fiber and fat that you eat, and how much you move, change how your body deals with glucose, the body’s main fuel, regardless of how much candy and soda you ingest.

Partners in sugar metabolism

But it’s not just the cell's metabolic machinery, pancreatic hormones and the liver that take part in metabolizing our sugars.

Each of us is home to a whole universe of microorganisms: trillions of bacteria, fungi and viruses. Microbial life outnumbers our own cells 9 to 1, and its genetic material outweighs our own 150 to 1. Our inhabitants, our microbiome, we’re finding out, play a role in our immune system, our endocrine system, our propensity for weight gain, our risk of several diseases, our energy levels, our mental state and our mood.  

Do the microbes living in our gut affect how our body deals with sugars and our susceptibility to type 2 diabetes?

A new study in the American Journal of Clinical Nutrition looks at the evidence connecting gut microbes to insulin resistance and glucose intolerance. The researchers identified 45 relevant studies tying specific gut bacteria to sugar metabolism. 

The researchers found that several types, 6 especially, were linked with sugar and insulin metabolism. Some of these bacteria are protective and their presence is associated with lower risk, yet the presence of other bacteria is inversely correlated with diabetes risk. These links seem to be independent of weight status and of diabetes drugs.

One of the mechanisms in which gut bacteria affect health outcomes may be their production of short chain fatty acids. Short chain fatty acids are produced by bacteria when they break down and ferment dietary fiber and resistant starch. 

And indeed, the presence of short chain fatty acids and other metabolites produced by gut bacteria seems to correlate with sugar control, suggesting that short chain fatty acids may be mediating the microbiome’s effect.

Our microbiome probably plays a role in the development of diabetes. But we also, in turn, affect our microbiome to a great extent. A study in Nature finds that just 2 percent of our gut microbiome profile is genetically determined, and the rest is affected by the environment and by lifestyle.

Helping your helpers

The gut microbial community is dynamic, and depends on many factors, including age, medications, genes, exercise,  and especially diet.

Boosting a healthy microbiome doesn’t require any probiotics, nor are any lab tests, supplements or special foods needed. To improve the gut population it’s recommended you eat whole plant foods (including many types of fruit, veggies, legumes, beans, grains etc.,) lots of fiber, embrace variety in your diet, and reduce refined and highly processed foods.

Dr. Ayala

Exercise for the diet resistant

Exercise is a fundamental and super important key to wellness. Physical activity helps prevent diseases, it slows aging, and boosts mental function. It makes you look and feel better. 

But despite what junk and fast food manufacturers suggest in their clever marketing, tying sugary drinks to athletes and the olympic games, exercise will not enable you to burn off all that many extra calories, and on its own – without a reduction on caloric intake – exercise yields less than expected weight loss. 

An exercise deficit issue?

We can’t really outrun the fork and out-exercise a poor diet. 

Obesity isn’t an exercise deficit problem, it’s mostly an overeating and poor diet problem, Americans aren’t that much less active than they were a few decades ago, and exercise alone isn’t a weight loss plan, studies have shown. The calories burnt by exercise are at least partly compensated for, through energy conservation during the rest of the day and by a vigorous appetite and post-workout eating.

Most overweight people who try to lose weight don’t respond to exercise alone that much, but that doesn’t mean that exercise doesn’t help you lose weight. Exercise not only helps burn calories and keep muscle mass during weight loss, it also helps with improving your diet, as people who pursue fitness often find it easier to eat better – exercise often starts and perpetuates a virtuous wellness cycle. 

And now, a new study in eBiomedicine, part of the Lancet, finds that exercise may play a pivotal role in weight loss for a subset of people. For these people, exercise isn’t just a few more “calories out” in the energy balance sheet – exercise actually changes their metabolism.

Most people lose weight when they reduce their caloric intake, but a subset of people lose much less than expected despite adhering to diet programs. The researchers looked at the clinical records of 5000 women, and identified the 20 percentile who were most and least sensitive to diet, based on their weight loss on a 6-week 900 calorie/day supervised diet. They then studied 10 diet-resistant and 10 diet-sensitive obese women among them. These 20 women were put on a closely supervised exercise regimen. Exercise included weight lifting and treadmills, and was done 3 times a week for 6 weeks. The women were followed by weight and body composition measurements, as well as blood and muscle function tests, and muscle composition studies, using a muscle biopsy.

Flawed one size fits all 

The exercise training had minimal effect on the diet-sensitive women, but among the diet resistant women it changed body composition and muscle metabolism – it increased the mitochondrial content and metabolism in their muscle – and enhanced fat loss.

Besides offering hope for the people who find weight loss especially challenging, this study emphasizes that a personalized approach to obesity is warranted. “In cases in which diet-adherent individuals fail to achieve successful weight loss through caloric restriction, exercise may preferentially enhance their weight loss capacity by reprogramming skeletal muscle metabolism to enhance oxidative processes, consistent with our findings in biopsied muscle and derived primary muscle cells,” the authors write. 

Exercise is recommended for every human out there, for fitness’ sake, and definitely for people trying to lose weight. It may play an especially crucial role for a subset of us, whose positive and weight-altering reaction to exercise is uniquely greater, and in which physical activity over-performs.

Dr. Ayala

The rise and rise of tempting flavor and calorie bombs

Obesity rates have doubled in the US over the past three decades, and are now at about 42 percent. This rise follows a dramatic change in our food environment and our eating habits. Over the last few decades food technologists and food manufacturers have increased and popularized food products that are abundant, relatively inexpensive, calorically dense, and are what’s called “highly palatable”.

What’s highly palatable? A winning formula is one that combines sugars, fat and salt in a way that pleases our reward systems, giving us pleasure. The food industry has been busy making highly processed products from low-cost raw ingredients, and formulating them into super pleasing things to eat. They’re so pleasing that it’s hard to stop eating them – and we’re encouraged to never forget an opportunity to snack on them by massive and ever present marketing efforts.

A new study in the journal Public Health Nutrition examines just how much reformulation occurred in the past decades. While other studies focused on the rise in sugar in the American diet, the authors say theirs is the first longitudinal study of the spread of hyper palatable foods.

The researchers looked at the prevalence of hyperpalatable foods in a statistically representative US food system between 1988 and 2018 using three USDA and CDC food databases. Hyperpalatable foods were identified by criteria that look at the content and proportion of sugars, fat and salt in processed foods.

And the results: Hyperpalatable foods rose by 20 percent in three decades. Hyperpalatable foods now make up 70 percent of available foods in the US! The same grain food items were 50 times more likely to be hyperpalatable in 2018 compared to 1988. Foods in categories such as dairy and meats also went through reformulation, making them more exciting to the palate.

The authors suggest that this reformulation may be one key factor contributing to the rise in obesity: “Our findings indicate that the practices introduced to the food companies in the 1980s focused on product reformulation and enhancement may have had ongoing deleterious effects on our food system, contributing to the current obesogenic food environment in the US.”

An interesting finding is that the biggest rise in hyperpalatable foods was in ones with extra fat and salt – these are meal items and savory foods, rather than desserts and sweets. This may represent the expansion in frozen and ready to heat meals.

Resisting temptation

The authors call for public health policies limiting the addition of fat, sugar and salt to processed foods to below the threshold of hyper-palatability. 

Since that’s unlikely to happen anytime soon, the personal health solution is to minimize highly processed foods and prepared meals as much as possible. There’s a reason it’s so hard to stop eating highly processed foods – they’re designed to entice and to leave you wanting more, while at the same time giving you little nourishment. 

In this food environment it’s no wonder vegetables and fruit find it so hard to compete for attention.

Dr. Ayala

This is how weight is gained

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

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

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

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

Weight gain over the decades

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

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

This pattern adds up to 47 pounds over four decades.

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

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

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

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

Habits over time

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

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

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

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

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

Dr. Ayala

Are you in denial about overeating and your weight?

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

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

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

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

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

We’re unaware of how much we eat

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

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

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

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

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

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

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

Dietary patterns rather than calorie counts

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

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

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

Dr. Ayala

Artificial intelligence in the service of food brands

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

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

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

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

End caps and eye level placement

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

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

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

None of this is by chance.

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

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

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

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

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

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

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

Realizing the promise of big data?

Is AI in the hands of food companies of concern?

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

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

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

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

Dr. Ayala

Eating together is a wellness tool

The family meal institution is an endangered species. Losing this important practice is worrisome, since family meals are linked with better nutrition, improved social skills, healthier eating habits, improved family connections and with lower obesity rates.

A meta-analysis in Pediatrics including 17 studies found that shared meals are linked with better nutritional health in kids – healthier weight, healthier choices and fewer eating disorders. Another meta-analysis, published in Obesity Reviews, including 57 studies with over 200,000 participants, finds that family meals are associated with lower risk of overweight, a healthier diet, and fewer unhealthy diet habits.

These pooled studies are correlational, but one can intuitively see why family meals could actually cause better habits: Family meals are usually composed of more nutritious foods, eating together enables role modeling of good habits by caregivers, it nurtures spending time and interacting with others, and it encourages slower, more mindful eating.

Frequent family meals, however, are likely more common in more organized homes, in homes with a higher socioeconomic status – homes with better eating habits and less obesity anyway.

The researchers therefore controlled for socioeconomic status in the meta-analysis, and even when controlling for socioeconomic status, more frequent family meals were correlated with better nutrition and weight status.

But whether eating together conclusively causes better nutrition or not, eating in company is a very good idea. The family meal offers a great opportunity to lead by example, communicate good habits and to bond.

Yet only about half of US households with two or more people eat meals together regularly.

Bringing families together – what works?

With busy and demanding schedules and the availability of processed and prepared foods increasing family meal frequency is challenging.

Which interventions support family meals? 

A new study in the journal Appetite looks at which interventions work best to improve the frequency and healthfulness of family meals especially among low-income families. Six different interventions were put to the test in different combinations, with 2 of the 6 intervention components tested together in each experiment, which makes for 64 different combinations. The interventions were:

• Cooking/Serving Resources: All the tools you need for cooking and serving a meal, including pots, pans, utensils, dishes etc.
• Meal Delivery: Prepared meals once a week , ready to warm up and serve.
• Ingredient Delivery: Delivery of ingredients to supply one meal a week.
• Community Kitchen: Participants were invited to a weekly group session in which you prepare one main dish to take home.
• Nutrition Education Classes: Participants were invited to attend a weekly group nutrition class that included food prep and tastings.
• Cooking Demos: Participants were invited to attend weekly group cooking lessons that included tastings.

These were tried with about 400 families recruited through Head Start, the age of children at the start of the trial was 3-4 years, and the interventions were tested for 8 weeks each.

The families were asked: “How many nights a week out of 7 did you and your child eat dinner together in the same place at home (such as around the table) for most of the meal?”. Families were also asked how many evening a week dinner was made mostly from scratch, how many nights a week dinner was cooked mostly or only from ready made foods (such as canned soup or boxed macaroni), how many nights food was from ready made dinners (such as frozen meals), and how many nights the parent/s or kid/s ate fast food (such as KFC, McDonalds) either at home or on premise.

The combination of Cooking/Serving Resources and Meal Delivery performed best and increased family meal frequency, cooking dinner from scratch, and prioritization of family meals; it also decreased the use of ready made and fast foods.

As you might imagine, supplying cooking and serving utensils, and supplying meals or ingredients garnered good participation. But getting busy parents to take part in weekly nutrition and cooking classes and demos was more challenging, and only 13-15 percent attended. Participation was so low that the researchers couldn’t even test the effectiveness of this intervention.

Eat with pleasure

Gathering around the table works even better to foster normal weight and health benefits when the atmosphere is positive. A study published in Pediatrics looks at key risk and protective factors for childhood obesity in the home, and includes 120 low–income kids and families from the Minneapolis/St Paul area, recording family meals at home for 8 days. These were all families that regularly shared meals, and told that the study focuses on “modern day” dinner, and to just eat as they always do. The video recordings were analyzed for interpersonal and food related behaviors. 

The researchers found that the atmosphere around the table matters: Families that enjoyed the meal, had warm, calm and positive conversations around the meal, had a higher frequency of normal weight. These results held true even after they were adjusted for parental weight.

On the other hand, hostility, frequent criticism, yelling, food lecturing (“children in other countries are starving”) and indulgent and inconsistent parenting were associated with heavier kids. Overweight kids also sat at the table for significantly shorter times.

Sharing meals with the people in your life depends on physical preconditions, such as arranging the time, space, utensils and food. These are barriers that may not be trivial, but well worth overcoming.

A virtuous cycle in which family members await this time to connect, talk and enjoy food and company – and reap the benefits – depends on making mealtimes as pleasurable as possible. 

Dr. Ayala

No meat, low meat, and what really matters for health

The calls to cut back on meat are coming from many directions. The meat industry is a major contributor to greenhouse gasses, climate change, and environmental degradation. Billions of animals suffer and die to satisfy our eating choices.

These altruistic reasons to cut down on meat come on top of the self-serving rationale to do so: Eating less meat is good for you.

Studying the outcomes of a lifetime of dietary habits is difficult – the range of what and how much a person eats is extensive and diets change over time – but decades of research show that the risk of cardiovascular disease is overall lower among vegetarians and vegans. Vegetarians and vegans tend to be thinner, have lower total LDL cholesterol, and lower blood pressures. 

A link between meat and cancer is also well studied. The American Cancer Society recommends limiting or avoiding red and processed meats in order to lower the risk of cancers. The World Cancer Research Fund states that if you eat red meat, shoot for no more than 3 portions (12-18 oz cooked weight) a week, and consume very little if any processed meat.

Low meat, fish, and vegetarian diets and cancer risk 

As noted from the above recommendations, it’s not just vegetarians that can lower their disease hazard, as the risk from meat is cumulative and dose dependent.

A new study in BMC Medicine analyzed the nutrition data from almost half a million British adults, aged 40-70 years, and looked at the incidence of cancer over 11 years, also controlling for diabetes, socioeconomic factors, smoking and obesity.

About half (52 percent) of the cohort ate meat more than 5 times a week, 44 percent ate meat less than 5 times a week, 2 percent ate only fish but no meat, and 2 percent were vegetarian or vegan.

The study finds that those who ate meat less than 5 times a week had a 2 percent reduction in cancer incidence, fish eaters had a 10 percent reduction, and vegetarians and vegans had a 14 percent reduced risk. Low meat, fish and vegetarian eaters had lower risks of all-cause cancer, and especially colorectal, prostate and breast cancer.

But although the study controlled for confounders such as weight status and exercise, the authors note that: “Vegetarians and fish-eaters differ from meat-eaters in many non-dietary lifestyle factors such as lower smoking and alcohol consumption, and higher physical activity. Although relevant potential confounders were added to the multivariable models to adjust for these differences, imperfect measurements and/or changes in these confounders over time may result in incomplete adjustment for these variables.”

Not all meat-free diets are created equal

Not all foods of plant origin are healthy though: French fries, chips and soda are utterly vegan, and obviously don't promote health.

Meat avoidance, in and of itself, doesn’t tell us enough about what people actually eat, therefore studies that look at the content of plant-based diets are informative.

The longest living group of Americans are probably The Seventh Day Adventists, whose health habits—promoted by their religion—include vegetarianism, as well as avoiding alcohol and smoking. Adventists as a group aspire to these rules, and are generally health conscious, but individual adherence is variable, and not all adventists avoid meat. Studying and subgrouping this diverse cohort is revealing.

A new study in the American Journal of Clinical Nutrition following about 77,000 members of the Adventist church for about 7.5 years looked at their rates of death from any cause, and correlated it with how much ultra-processed foods and meat they ate. 

And the results: Eating more ultra processed foods was associated with a 14 percent higher incidence of death. Eating more red meat was also linked with an 8 percent increase in all cause mortality.

The quality of any diet is determined by what you eat more of, and also what you eat less of. 

Instead of categorizing a food just as plant-based you should also question its nutritional quality.

A recent study in the American Journal of Clinical Nutrition including almost 130,000 people, followed for 20 years, sought to see if  plant-based diets affect weight gain, which is an important risk factor for many chronic diseases.

The study uses three indexes of plant-based diets. The first is an overall plant-based index, in which plant-based foods receive a positive score, and animal foods receive a negative one. The other two are subcategories of the first one and rate the healthfulness of of the plant based components of the diet, adding points for healthful plant based foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, tea/coffee) and reducing score for less healthy plant foods (sweetened beverages, refined grains, sweets/desserts).

Participants gained on average 2 to 4.5 pounds every 4 years. Diets that were more plant-based mitigated weight gain. But not all plant-foods and meat avoidance regimens fared equally: People who ate a more healthy plant based diet gained 1.5 pounds less. People who ate an unhealthy plant-based diet gained about 1 pound more.

Similar results are seen studying type 2 diabetes: Overall a high plant-based diet and especially healthy plant-based diets are linked with lower the risk of diabetes. Unhealthy plant-based diets, however, are actually associated with higher rates of type 2 diabetes.

And the same goes for cardiovascular disease: although sticking to a more plant-based diet seems to be protective, when examined more carefully the subgroups of plant-based eating patterns diverge – healthier plant-based diets are linked with lower heart disease risk, but an unhealthy plant-based diet confers a higher risk.

Watch out for highly processed food

As plant based meat and milk alternatives expand – clearly a blessing for animal rights and environmental benefits – make sure that you’re not replacing an eat-less-of ingredient with yet another one that we should watch for: highly processed food.

Many in the meat avoiding population are health conscious, and their wellbeing can be attributed to the myriad of healthy routines they practice, in diet, physical activity, mental wellbeing, smoking avoidance etc., all working in conjunction. 

Vegetables and plants are the essence of a healthy vegetarian lifestyle, meat avoidance alone doesn’t do the trick – and meatless burgers are hardly a plant.

Dr. Ayala

How much junk food is too much?

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

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

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

Junk all around

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

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

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

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

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

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

You are what you eat 

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

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

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

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

You know it when you see it

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

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

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

Dr. Ayala

Does playing with fruit get kids excited to eat them?

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

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

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

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

Digitally marketing fruit 

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

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

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

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

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

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

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

Playing with fruit in real life

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

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

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

Dr. Ayala

No, it doesn't just go through

A new study finds that a common food additive, ubiquitous in processed foods, changes the microbiome and the gut of healthy people

The introduction of highly processed food upon a society reliably predicts a decline in people’s health.

Highly processed food is linked to rising obesity rates and high blood pressure. A large study found a 10 percent increase in ultra-processed food was associated with a 10 percent higher risk of overall cancer and breast cancer. A study in Public Health Nutrition following 12,000 Americans with no underlying illness for more than 20 years, found that a highly processed diet is linked to a 30 percent higher chance of dying early.

Why is processed food harmful?

The convenient, flavorful, ready to eat array of processed foods are low in important nutrients: micronutrients, fiber, and the whole array of what’s in whole foods.

On the other hand they contain much of the things we try to eat less of: sugar, fat and salt.

And then, on top of that, they contain ingredients that the human intestine had never ingested until the advent of these technological innovations: Hydrogenated oils, food coloring, chemical preservatives and emulsifiers are just some of them. The nutrition label lists many ingredients foreign to human food, which up until recently came solely from nature. 

A new study in the journal Gastroenterology looks at emulsifiers – these are a hallmark of highly processed foods, added to improve texture and increase shelf life. Besides natural emulsifiers, such as lecithin, which was originally derived from egg yolk and can also be extracted from plants, there are synthetic emulsifiers such as carboxymethylcellulose (CMC) which are commonly used in industrialized foods. CMC was approved for use in the 1960s, despite no extensive testing, and was presumed to be safe because it’s poorly absorbed and is eliminated in our stool.

In the 60 years since the introduction of this emulsifier we’ve learned that even when something passes through our gut without entering our blood stream it still leaves its mark. Our gut bacteria encounter this substance and it may change the composition of the microbiome; the lining of the gut, the mucosa, which comes in contact with whatever’s just passing through, might also be susceptible.

And indeed, CMC has been shown to promote inflammation, metabolic syndrome and obesity in mice, to induce colitis – bowel inflammation – in predisposed mice, and also to change the mice’s microbiome. But that’s mice. Researchers set out to check CMC’s effect in humans.

The randomized controlled feeding study was conducted at the University of Pennsylvania, and included 16 healthy volunteers. After an 80 hour emulsifier-free diet at home, the participants were randomly assigned to an emulsifier free or one with 15 grams per day of CMC, in a residential setting in order to assure all elements of diet and exercise. 

And the results: CMC clearly changed the composition of gut bacteria, reducing select species and overall diversity, and there was a significant depletion of some of the beneficial bacterial metabolites that are known to help maintain a healthy gut.

Besides looking at fecal composition and metabolites, the researchers also performed sigmoidoscopies before and after the trial, and took biopsies of the distal colon in order to study the gut lining microscopically. In two volunteers on the CMC-containing diet, they found that bacteria were encroaching into the lining – a finding reminiscent of what you can see in people with inflammatory bowel syndrome and metabolic syndrome. This may suggest that when the health of the microbiome is compromised, or due to the CMC exposure, the altered gut bacteria start invading the lining – which when healthy is normally close to sterile.

Emulsifiers ubiquitous in processed foods

This is a small study, and just one chemical component is examined here. In real life people consume many food additives and their precise quantities are unknown. But even in this very short study there were stark changes in gut bacteria, reduction in beneficial fecal metabolites and in a few of the participants, even changes in the lining of the gut.

The authors conclude: “our observations argue that a particular food additive might perturb the host-microbiota relationship to promote disease in a subpopulation of individuals.”

So while individual susceptibility to processed foods’ ingredients may play a part, the highly processed diet is not good for anyone, for the other reasons listed above, and it’s probably one of the worst diets one can eat.

Because besides the low nutritional value, and the unnatural non-food stuff in it, it’s also built for overeating, crafted to please us and to manipulate our reward system. Food chemists design these products with a perfect sugar-fat-salt and flavor combinations, great mouthfeel, chuggability and crunch, making them so pleasing and easy to eat that they’re hard to resist or to moderate.

If there’s one small dietary commitment you want to sign on to for the coming year I suggest it’s to look more carefully at over-processed foods, and replace at least some of them with wholesome ones. A recent study in JAMA shows that two thirds of calories American kids eat now come from highly-processed foods, so we really do have our work cut out for us. 

Dr. Ayala

 

The diet that keeps you young

Age’s just a number, goes the saying, years since birth don’t accurately predict ability, health or how much time’s left. 

Lifestyle often does. Eating well and being active are linked with lower incidence and later-in-life occurrence of chronic diseases such as heart disease, cancer, diabetes and stroke, and with greater likelihood of survival into old age.

How does food increase longevity? There are many mechanisms in which your diet can affect disease, as certain foods affect lipid profiles, sugar metabolism and inflammation, for instance, and all these play a role in disease onset and progression. 

Genetic makeup also predicts disease and lifespan.

Can food change our genes? Diet of course doesn’t change our coded DNA sequence, but diet can modify genes’ expression: which genes are more active and which are suppressed. This fascinating field of study is called epigenetics. Gene expression can be controlled through chemical changes such as methylation, the addition of a methyl group to the DNA chain in an area that doesn’t code for the gene itself. Methylation can occur in many places, and thousands of these sites are known to be correlated with aging, acting like “clocks”, which predict biological age, chronic diseases and mortality. People whose epigenetic age is older than their chronological age are thought to be biologically older and at greater risk of disease, while those with young epigenetic ages are at lower risk.

Diet and lifespan

A new study in the American Journal of Clinical Nutrition looks at the diet and at the methylation patterns of almost 2700 women. Diet quality was assessed in reference to four recommended healthy diet indexes, such as the DASH (Dietary Approaches to Stop Hypertension) and the Alternative Mediterranean Diet.

And the results: Higher diet quality was strongly inversely linked with two widely recognized epigenetic clocks that predict mortality – better diets predicting long lives and younger biological age. The authors conclude: “In summary, we found that healthy eating patterns are associated with some methylation-based measures of biological age. The benefits of healthy eating appear to accrue particularly in women reporting lower levels of physical activity. These findings support the hypothesis that a higher diet quality may slow aging and lower disease and mortality risks.”

Another recent study, including 2000 people, also looked at the overall diet quality using a DASH score, and at methylation profiles using 3 different verified epigenetic aging measures. The DASH score evaluates the intake of dietary components giving high scores for consuming more vegetables, fruit, nuts, legumes, whole grains and low-fat dairy, and for consuming less red and processed meat, sugary drinks, sweets and salt. The study demonstrated that higher diet quality was associated with slower aging according to the methylation epigenetic scores. What’s more, during the 10-year follow up in this study 297 participants died, and both a lower DASH score and the three epigenetic age acceleration measures were significantly associated with all-cause mortality. 

Several other studies look at how certain foods change methylation patterns, suggesting that high intake of plant-based foods slows the clock, that high intake of poultry predicts an accelerated aging, as does red meat. A study of 120 people aged 65-79 year showed slower epigenetic aging when people ate a Mediterranean-style diet for a year.

Anti-aging from within

Anti-aging skin care routines promise young looking skin (the most proven anti aging skin treatment however is ultraviolet radiation avoidance and blocking) and longevity supplements promise death defying miracles – without much evidential support.

But we actually know that certain habits are linked with delayed aging, disease and death. Chief among them are eating well, exercising, avoiding smoking and nurturing social ties. It’s not as  easy as taking a pill or a potion, and you need to stick to it long term.

What does eating well mean? There are very many ways to eat healthfully, and all of them center on emphasizing whole plant-based foods (vegetables, fruits, nuts, legumes, whole grains) and minimizing highly processed foods (fast-food, processed meats, sugary drinks). 

Dr. Ayala

Does a healthy diet reduce the risk of severe Covid-19?

I haven’t written about Covid for a while. Frankly, I was hoping to move on to other health topics by now – we’ve been living under this shadow for almost two years. But Covid-19 is still a central health matter, and many of its mysteries remain unsolved.

One of the most puzzling issues is the incredible variability in disease severity, age notwithstanding. Underlying medical conditions, such as hypertension and diabetes predict a higher likelihood of severe disease, as does obesity, but there’s a lot that can’t be explained by that.

Could nutrition inform some of this disparity? Poor diet is linked with the severity of other infectious diseases. Sound nutritional status supports immunity, lowers the chance of severe, out-of-control inflammation, and malnutrition causes immune deficiency.

This question remains relevant for this pandemic. Although vaccination is the most effective way to prevent severe disease and hospitalization, breakthrough infections are possible and ameliorating those is vital – we’re not completely done protecting ourselves, even with two shots. 

This question is also crucial for other infectious diseases known and yet to come.

Diet and the pandemic

A new study in the journal Gut looks at data from almost 600,000 people in the UK and the US, who were followed from March to December of 2020 by the smartphone based Covid-19 Symptom Study. All participants’ diet was assessed before the study began.

During follow-up almost 32,000 people had Covid-19 infections.

Healthy plant-based diets were associated with lower risk of contracting the disease and of severe Covid-19.

Poor diet quality was associated with lower socioeconomic status, as you might imagine. Healthy behaviors tend to cluster and people who eat healthy may sign on to other health-promoting measures. 

But the association remained strong even after accounting for other healthy behaviors, social determinants of health like education disparities, income inequality, housing insecurity, healthcare access, social isolation, food insecurity, unemployment, public safety etc., and the steps taken to prevent virus transmission such as mask wearing as well as the rates of transmission of Covid-19 in the community.  The authors conclude that: “The joint association of diet quality with socioeconomic deprivation was greater than the addition of the risks associated with each individual factor, suggesting that diet quality may play a direct influence in COVID-19 susceptibility and progression. Our findings suggest that public health interventions to improve nutrition and poor metabolic health and address social determinants of health may be important for reducing the burden of the pandemic.”

Another study of about 3000 health workers from France, Germany, Italy, Spain, UK, and the US showed that those on a plant based or pescatarian diet had lower odds of moderate to severe disease after taking into account other health characteristics, with the vegetarians among the group showing a 73 percent lower chance of moderate to severe illness, and the pescatarians with 59 percent lower odds of significant manifestations.

Again, removing every confounder is impossible, but we already have so many reasons to invest in healthy diets – personally with our own decisions and with public health interventions that increase access and education about the importance of eating well. This isn’t just the Covid-19 pandemic: Poor diets are a risk factor for a long list of chronic diseases, from heart disease to diabetes to cancer.

Dr. Ayala