Friday, February 28, 2014

Would you like sugar with that label?

Since nutrition labels - on packaged foods and restaurant menus- are my passion, if I did not address today's FDA announcement in my blog post I imagine my readers would worry that something dreadful had happened to me.  I am here, busy, but not too busy to stop to make note of today's announcement.

So YES, I saw the announcement and I think it is a step in the right direction, but I have two big concerns.

1) You still have to pick up the package (and those you want to compare it with) and turn it around to see the info.
2) A proposal is NOT a law, and heck, even if it was, I wouldn't feel that much more encouraged.  Psst... FDA we are still waiting for those restaurant menu label rules.

There are also several things that are good in the proposal.
I love that it includes an Added Sugar amount, and this recent blog post explains why you should be glad, too.  It is also good that the label is going to emphasize, with bold lettering, the calorie amount and make serving sizes more reasonable (hmm, this sounds like the IOM recommendations for a Front of Pack label that never happened).  But wait, I should clarify - reasonable was the wrong word - very wrong word.  I meant realistic.  The new serving sizes will reflect what a person is likely to consume in one sitting, not what is calorically appropriate for them to consume.  Lastly I think it is good that the label will highlight the amount of vitamin D in a serving. Americans don't lack for much in their diets, but most do not get enough vitamin D.

I either agree with or am ambivalent about some of the other changes.  For example, I agree that we don't need to know the percent of calories that come from fat, but do need to know the amount of fat, especially by type i.e., TFA which is harmful and  saturated fat, which might be harmful.  I understand why the FDA suggests keeping the percent daily value, but I hope that in the end they will change what the 'recommended' average daily calorie amount is and emphasize that the average daily calorie amount may or may not be YOUR recommended amount.

Some food manufacturers are upset about the proposal and will fight to keep the changes from happening - they say its too costly, and I say, use some of the marketing money you spend so freely.  Otherwise or nonetheless, expect many of your products to start having less grams of sugar and less calories - YES!

Here is the sample label from the FDA and a link to the press release where this picture was originally posted.


Sunday, February 23, 2014

Get Your Fiber - from food

This quick post regarding dietary fiber is my reaction to a commercial for a supplement called Benefiber.  
It is true that most Americans need more fiber in their diets, and it is true that a diet high in fiber is associated with improved health.  
The Dietary Guidelines for Americans list fiber as a nutrient to increase and on page 88, the Guidelines  present a table of foods that are good sources of fiber. The best way to obtain fiber is from food, in fact, there is little, if any, evidence to suggest any benefit from a fiber supplement. Just like any other nutrient, the best place to get it is from your plate.  Choose foods that are naturally high in fiber instead of fiber pills - no matter what the commercial tells you.  The Guidelines do not recommend pills except under the rarest of circumstances, for example, if food is not available.
Notice the many fiber rich foods on the cover - these are the foods we should eat, within our own caloric limits.  The body needs food.

Friday, February 14, 2014

Ah, Sugar, Sugar -

Earlier this month, a research team representing the CDC and 2 schools of Public Health (Emory and Harvard) published results from a study that examined the association between consumption of added sugar and the risk of dying from heart disease.  You can read the entire study here.

Briefly, this study consisted of a secondary data analysis.  A large sample of Americans participated in a continuous survey (NHANES III) that assessed behavior, including dietary intake, from 1988 to 1994. The researchers matched the participant IDs to an existing mortality data file that tracked deaths to the year 2006.  Researchers followed the survey participants until they died or until the study period ended (2006).  The researchers used statistical methods to set aside (control for) other factors that can cause heart disease death (e.g., smoking, weight) and focused on how sugar intake influenced death from heart disease.  They found that as sugar intake increased so did death from heart disease – regardless of what someone weighed.   

Because I trust that the association between sugar intake and heart disease death is real, it’s important to talk about 1) what ‘excess’ means – i.e., at what level does sugar intake become harmful, 2) how you (and I) can determine sugar intake, and 3) ways to reduce sugar intake. 

Dietary guidance on sugar intake varies.  The World Health Organization suggests that people consume less than 10% of their total DAYS worth of calories from sugar; the USDA/DHHS Dietary Guidelines for Americans combines solid fat and added sugar into one category and recommends that we consume less than 25% of total DAILY calories from solid fats and added sugar; and the American Heart Association (whose mission is preventing heart disease and heart disease deaths) suggest the lowest intake.  The AHA recommends that women (who generally need less overall calories and macronutrients than men) consume no more than 100 calories a day from added sugar and men no more than 150 calories from added sugar. 

In the research study, the people who consumed less than 10% of their daily calories from added sugar had the least number of heart attack deaths.  (I eat ~ 1800 cals a day so that translates to 180 sugar calories a day for me, at the 10% level.  I want to keep my max level between 100 and 180 cals a day, which is the American Heart Association and World Health Organization recs combined. 

Before I present some package labels, I want to clarify a few terms: added sugar, calories per gram, and sugar grams.  The research linking sugar to heart disease death is specific to added sugar, not the kind you find naturally in fruit and vegetables (fructose) or in milk products (lactose); however, products made from fruits, vegetables and milk often do have added sugar. (By the way, there is no natural sugar in almond milk, so any sugar grams you see listed on the label is added.  My almond milk has 0 grams of sugar).

Sorting out added versus natural sugar in some products can be tricky and might require some label sleuthing.  One thing to keep in mind is that very few juices are 100%  juice.  IF you have a 100% fruit product – i.e., no other ingredients listed, then you are safe to disregard the sugar grams on the label (but not the calories!).  IF you eat a fresh (unpackaged) apple, a cup of broccoli, a tomato, etc.. you are good to go.  Usually canned vegetables are also free of added sugar, but you should double check. A can of tomato sauce with no added sugar will have ~ 2 grams of sugar per serving, but a can of spaghetti sauce will often have added sugar that you won’t detect unless you read and understand the ingredient list. The nutrition facts panel doesn’t currently separate the added sugar from the naturally occurring sugar. 

The ‘back of pack’ nutrition facts panel lists sugar, in grams, under the category carbohydrate.  A gram of sugar contains 4 calories.  IF you are trying to stay at 150 calories from sugar (a day) that is 37 grams (or 9 teaspoons) – quite a lot!   Until front of pack labeling becomes standardized and mandatory on all products, you will have to read your labels carefully to choose the product with the lowest amount of sugar in any particular category of food.  Take cereal for example.  To make the best choice, read the labels and the serving sizes across boxes (use the nutrition facts panel) and choose the one that is lowest. It is easier to watch your grams throughout the day.  For me that means I need to keep mine at 48 or below, and below is better - to meet my goal of no more than 180 sugar calories per day.

One way to lighten up on sugar is to avoid drinking it – forgo fruit juices and sports drinks – they almost always have added sugar. Another place to make a lighter choice – peanut butter.  Some brands/types, like Smucker’s All Natural, have no added sugar.  I know this because the label says one gram of sugar and the ingredients list does not name anything that could be code for sugar. 

Here let me show you:

There is 1 gram of sugar and the ingredients are peanuts and salt.


There are 8 grams of sugar in a half a cup of no sugar added applesauce, and as you can see from the ingredients list, the product only contains apples, water and a preservative.  Hence, none of these 8 grams of sugar or 32 calories of sugar (8g x 4) counts towards your daily limit.

Now here are examples where all of the sugar grams and the associated calories would count towards your added sugar total.

First is the dreaded sports drink.  There is nothing in the ingredient list that leads me to believe this drink contains ANY fruit juice.  Note also that ingredients are listed in order of amount.  The first ingredient is water and the second is high fructose corn syrup – aka – added sugar.  A 12-ounce serving of this beverage has a whopping 21 grams of sugar or 21g x 4 = 84 sugar calories.  Ah, this is a great example of fuzzy math because the label claims only 80 calories per serving.  They have rounded DOWN.  I find this ghastly.  Anyways, one glass of this and you’re about done with added sugar for the day.  

Here is another example of excess sugar.  This is a box of Cracklin Oat Bran.  One serving has as much added sugar as a serving of Oreo cookies: 14 grams or 56 sugar calories.

The next examples are from my Mom’s snack jar.  Some surprises.

My favorite packaged cookies in the world, Marinela Suavicremas have less sugar grams per serving than Nature Valley crunchy OatsnHoney and a Fiber One 90 calorie lemon bar – which by the way is the smallest of the three snacks, in weight.  My cookies, 4 cookies per serving have 6 grams or 24 sugar calories, the 2 bar OatsnHoney serving has 12 grams or 48 sugar calories and the (tiny) Fiber One bar has 8 grams or 32 calories from sugar. 

In the examples I provided, cereal had the most sugar.  Other things to watch for include dairy desserts – in the research study any sugar in a dairy dessert was considered added sugar; and soda, which is the leading source of added sugar in the American diet. A single serve bottle of soda has about 39 grams of sugar or 156 sugar calories per serving.

So there you go.  Regardless of weight or any other physical or health characteristic, sugar intake at or above 10% of daily calorie intake increases the risk of death from heart disease.  The researchers provide numbers for the absolute risk differences in their article.  It is also important to know that the risk increases according to the ‘dose’ of sugar.  By this I mean, a person who eats around 200 calories of sugar a day (50 grams) has a higher risk than someone who eats 100 calories of sugar a day (25 grams), but less than someone who consumes 300 calories of sugar a day (75 grams).

Just FYI, this is a front of pack label that can be helpful for same product comparison because it includes the serving size.

Sunday, February 2, 2014

Is Obesity Always Associated with Poor Health Outcomes?

I will be the first to admit that my headline question seems anathema to me.  I believe that being over fat, if nothing else, puts undo stress on ones joints and can lead to ambulatory problems.  Moreover, I believe in and promote the science suggesting that excess adipose tissue (i.e., being over fat) increases the risk of developing diabetes, heart disease and some cancers.  So why would I question the adverse effects of obesity in a headline?  My pause, if you will, has to do with a provocative and interesting narrative written by Victor Etuk and published in the Hektoen International (A Journal of the Medical Humanities).  In his article, Mr. Etuk describes "fattening rooms," which are a part of Efik culture in the Nigerian state of Calabar. You can read his article here, and another by Enang Oe here.  

As part of a ritual of passage into adult hood, young women between the ages of 15 and 18 , according to Oe, spend up to a year or more in 'fattening rooms.' In these rooms, the young women eat a lot of food (calorically dense food) and engage in very little physical activity.  They also take part in other traditional rituals that signal a rite of passage.  In the Efik culture, plumpness is positive; it signals well being and prosperity, not personal failure and unhealthiness as it does in the US.

Both Etuk and Oe write about the tradition, which has been declining, in an effort to end it. Mr. Etuk focuses on the high level of obesity - in itself a reason for discontinuing the 'fattening rooms' and Mr. Oe focuses on the risk of diabetes associated with obesity - which is associated with (and the purpose of) the tradition.

I exchanged several emails with Mr. Etuk in an attempt to learn one thing:  Is obesity in these specific women associated with adverse health outcomes? Mr. Etuk never directly answered my question, instead he said, "well, the obesity rates are very high in these women."  I expect that we had some communication challenges, but what I specifically wanted to know, and did ask, was whether the obesity in Efik women led to diabetes, heart disease, arthritis, etc.  I think the answer is, 'we don't know."  Mr. Oe's article referenced the diabetes rate for Nigerian woman, a low 2%, and only speculated that, due to the high level of obesity in Efik women, they would have high rates of diabetes.

Of course, it is a plausible theory, even quite likely.  In the US and similar countries, the link between obesity and the adverse health consequences I mentioned are established.  I was pushing Mr. Etuk because his article was calling for a substantial, other imposed, cultural change - a breaking of centuries old tradition.

The end to 'fattening rooms' may absolutely be merited, but I wouldn't dare 'assume' it so.  There could be genetic factors in this tribe of women which protect them from otherwise obesity related outcomes, or other parts of their culture may somehow protect them.  I shared my thoughts with Mr. Etuk - that there might be something protective about the culture, he noted that positives included "homekeeping, good mannerism, femininity and beauty etiquettes" and asked if I thought those would be protective against obesity.  That wasn't exactly where I was headed, but I appreciate that Mr. Etuk spoke with me. I think his article is interesting and obviously thought provoking.  I, however, crave evidence. 

I expect the reason health outcomes are not given is because they are not known.  It is possible that the Efik culture does not wish to share this information, or perhaps its members do not practice traditional medicine or even classify disease the way that Western cultures do.  The bottom line of my post is that while I promote obesity prevention based on the evidence I see, it is specific to men and women in the US and similar countries.  I am conscious of the many complexities of how obesity leads to disease and don't think that what applies to Western nations necessarily applies to a tribe of Nigerian women - it very likely could, but before anyone attempts to topple a meaningful, cultural tradition, they ought to check.