Friday, March 28, 2014

Resources for Information on Artificial Sweeteners

The purpose of this post is to share a few resources.  On several occasions, I have written about the apparent safe use of artificial sweeteners as a substitute for sugar(s).  I do use artificial sweeteners on a daily basis myself.  I have made my decision based on my understanding of the research on artificial sweetener safety  and the knowledge that the sweeteners, a food additive, are regulated by the FDA.  You have to make your own decisions on whether or not to use them.  The links I offer today may help you to do so in an informed manner.

First, the reason that I went digging into this again is because I watched a video lecture from NIH Grand Rounds titled, Artificial Sweeteners and Obesity: More than an Association?  The speaker was Kristina Rother, MD.  You can see the presentation here.

In her presentation, Dr. Rother made mention of a "number"; the amount of aspartame or sucralose a person could consume every day for the rest of their life (based on body weight) and stay below the threshold for any negative side effect.  I subsequently searched for this 'threshold' information, and then emailed the Food and Nutrition Information Center with the USDA to find it.  I am going to share some links, but the main one - of which I have just been speaking - came with these instructions:
The Food and Agriculture Organization of the United Nations has an online, searchable database that lets you search for detailed information on Food Additives.  If you search for a particular additive and then click on the PDF symbol in the “Specification” row, you will see the ADI value at the top of the PDF on that additive.

To get your answer about how much sweetener you can safely (according to available science) consume, you have to click on the PDF symbol.  ADI stands for Acceptable Daily Intake.

I want to note, and you'll see it in the aspartame pamphlet, that some people have a genetic condition which prevents their body from adequately breaking down an amino acid in aspartame called phenylalanine.  People with this condition cannot use aspartame (often sold in blue packets), but its the amino acid that is the problem not the aspartame.  If you have this condition, you already know it; its quite serious.

Another concern that people have expressed with regard to aspartame is a story/myth about military personal serving in the middle east who drank diet soda and became ill.  This was likely due, if even true, to the fact that aspartame is not a heat stable substance.  You might have noticed that I use sucralose (yellow package) when I bake, and that is why.

If you have heard aspartame stories that sound terrifying, read this Snopes response written by an evaluator at the FDA.

 The third most common artificial sweetener, is saccharin. I don't use saccharin (pink packets) because it is super, super sweet, not because I think I will get bladder cancer. I also don't use the more expensive sweeteners, stevia and truvia - I get plenty of fiber from whole grains and buying a sweetener because it has fiber seems silly to me.

The American Cancer Society and the National Cancer Institute both have webpages dedicated to artificial sweeteners and I find these organizations credible.

So here are the links that I found either on the USDA Food and Nutrition Information Center webpage or that were provided by email correspondence with nutrition information assistant Valerie Stoner.

To look up the Acceptable Daily Intake of food additives, such as aspartame, click here.  You will have to search for the additive you are interested in and click on the pdf symbol.

To see the National Cancer Institute's fact sheet on artificial sweeteners and cancer, click here.

To see the American Cancer Society's aspartame information, click here.

The International Food Information Council also provides information on aspartame and sucralose.  

I hope you find the information in these documents helpful. The decision to use artificial sweeteners is a personal one.  Some people use them to avoid consuming excess amounts of sugar (in any form); and as discussed in a previous post, the amount considered  'in excess' is under review.

Friday, March 21, 2014

Does Fast Food in the Neighborhood Make You Fat?

There is evidence that 1) quick service restaurant meals,1 and sit down restaurant meals,2 provide excess calories and 2) that consuming excess calories leads to adverse health outcomes in most people.3,4  In non-experimental studies, people who consume the most fast food meals have also been the ones with health problems and these studies led the way for studies related to ‘obesogenic’ environments.5

I first heard the term ‘obesogenic environment’ when reading the research and policy recommendations of Professor Boyd Swinburn (University of Auckland).  Obesogenic environments push behavior that may lead to obesity.  One of these pushes might be the availability of cheap, high calorie foods.

Researchers have investigated the association between living, learning or working near quick service restaurants and certain outcomes. [Quick service (aka fast food) restaurants are defined as places where you purchase your food at a counter, receive it within minutes of ordering it and the food is often fried.  Pizza restaurants are included). Three questions researchers ask are 1) whether being near to quick service restaurants – convenience/marketing – leads people to purchase or consume more fast foods than not being near to them, 2) what exactly is near? (e.g., .1 mi, .5 mi, 1 mi), and 3) does the number or density of them influence the amount of consumption (i.e., is it worse to have 4 quick service restaurants within a .5 mile than it is to have 2 within a .5 mile)?

Researchers have also investigated whether there is an association between exposure to quick service restaurants and other health outcomes, like obesity and increased body fat.  Most of the studies6 that investigate exposure to restaurants and frequency of fast food consumption, weight differences and markers of obesity, use cross sectional (observational) data.  This means that they measure the ‘risk’ (exposure to restaurants) and ‘outcome’ (consumption/patronage, weight, BMI, obesity) at the same time.   

There are a few studies that follow people over time to see if increasing fast food consumption increases weight or BMI,7 but they too suffer the limitations of an observational study.  

Observational studies on fast food exposure and outcomes measure the number of quick service restaurants a person is exposed to, usually within .5, 1 and 5 miles of their home or school and then compare something they think should be different (weight, obesity rate, body fat, weight gain) between people with varying levels of exposure.  Good research will include measures of other things that could ‘cause’ the outcome of interest, so that the only difference between the groups is their level of exposure to that causal factor.  True equivalence between groups is only possible in randomized experiments and even then, equivalence is often approached more than actualized. 

In the ideal, a researcher would conduct an experimental study instead of an observational study.  He or she would randomly assign some people to live near a bunch of quick service restaurants (e.g., McDonalds, Burger King, Church’s, Taco Bell, Pizza Hut, Long John Silvers) and other people not to live near them. These two groups would be alike in the outcomes that the researcher planned to measure – e.g., the average meals of fast food per week or the average BMI at the start of the study. 

Such a study is not possible, and observational cross sectional studies lack the sine qua non of causality – temporality.  Before we can say that X caused Y, e.g., that exposure to restaurants leads to obesity, we have to show that the ‘exposure’ came before the outcome.  Since the researchers in fast food studies have not created the environments (they did not pay McDonalds to open stores within 5 miles of your house ) nor randomly assign normal weight people to live in environments with varying levels of quick service restaurants, they cannot make the ‘living near a quick service restaurant leads to obesity’ conclusion.  Without being able to randomize to environments or introduce the risk (create temporality), researchers cannot rule out other possibilities for their findings, but even with other possible causes, the hypothesis that being near to quick service restaurants at home, work or school leads to more frequent quick service restaurant visits, over consumption of calories and the adverse health events that follow, makes sense. 

In the most recent fast food study, Burgoine and colleagues8 used data from a national UK study to examine several outcomes related to exposure to quick service restaurants.  Over 5000 persons (N = 5442) answered questions (and completed a dietary recall) as part of a UK Health study; the people were also measured by study staff such that their BMIs could be calculated from objective data.  The participants provided their home and work addresses so that the researchers, using GIS, could map the quick service restaurants and supermarkets that were within about a mile of their homes, their jobs and even along their routes to work!  The researchers created 4 levels of exposure and each participant was placed into the relevant group for analysis (there were 4 exposure settings: home, work, on the commute and all combined).  NOTE: In the UK, quick service restaurants are called take away food outlets and the food sold there is take away food – but the definition is the same as the quick service restaurant definition I gave above.

The number of take away outlets per level was different for each of the 4 exposure settings, but level 1 usually had 3 or less outlets and level 4 had 15 or more. 

The researchers compared groups (based on their level of exposure: level 1 thru level 4) on dietary intake, BMI and the odds of being overweight or obese.  The researchers compared each group of exposure level 2, 3 and 4 to the group of people with level 1 exposure (the least exposed group) in all of the settings (home, work, commute, combined).  With regard to the amount of take away food consumed (by self-report in the dietary recall), the most exposed group (level 4) did consume more take away food than the least exposed group (level1) but no differences that could be attributed to exposure were found in the other groups.  In regards to consumption and exposure in the work environment, groups in level 3 and 4 ate more take away foods than those in level 1 and the amount of extra consumption was greater in the level 4 group than the level 3 group.  Groups in level 2 and 1 were not found to be different from each other in the amount of take away foods consumed.

With regard to the risk of increased consumption of take away foods related to the amount of exposure on the commute, there was only one difference and it was between the least exposed and the next to least exposed (i.e., level 2).  In this case, the least exposed group had 1 or fewer take away outlets on their route and the level 2 group had 1 to 5.  The more exposed group ate LESS take away meals than the 0 -1 outlet group.  No other differences in consumption were related to exposure on the commute.   The last category, the combination home, work, and commute, was similar in finding to the work results.  Both groups with level 3 exposure and level 4 exposure ate more take away food than those in the level 1 group and the amount consumed by level 4 group members was higher than that consumed by the level 3 group members. 

Similar differences were seen with the BMI and the odds of being obese, but exposure to take away outlets did not influence the odds of being overweight.  More exposure (level 3 and 4) was associated with higher BMI and odds of being obese. The most substantial difference in the odds of being obese was for the home environment.  Here the most exposed group (level 4 with 15-47 outlets near their home) was more than twice as likely to be obese than those in the no exposure group.

The Burgoine study is a cross sectional study so one cannot conclude that the increased exposure to take away food outlets led to the higher BMIs or obesity or even the greater amount of fast food eaten, but it supports the hypothesis.  I agree with the authors of the study that policy to limit exposure (perhaps through zoning laws) is a good idea.

(By the way, one of the factors that the researchers controlled for in their statistical model was the number of supermarkets in each of the food environments.  This allows them to make the assertion that regardless of access to fresh foods in a grocery store, the presence of take away outlets is still negative.)

References Cited

Thursday, March 13, 2014


No matter how much you exercise, sitting for extended periods of time and for cumulative amounts of time (i.e., sitting for long periods many times a day), may be harmful to your health.  Several studies have found an association between sitting time and things we’d rather avoid.  They include 1) metabolic syndrome1 (defined as changes in 3 of the 5 following biomarkers which themselves increase the risk of heart disease, diabetes and stroke: being overfat by waist size, having high blood fat levels (triglycerides), high blood sugar, high blood pressure (or being on medicine to treat either of those), and/or low HDL cholesterol levels); 2) an increase in death from any cause2; and 3) difficulty completing self-care activities3, e.g., dressing, eating.

Most studies, including those whose outcomes I just mentioned, adjusted for physical activity and found that independent of how often a person engages in exercise, sitting for multiple 1-hour periods each day is bad for health. Sedentary behavior - sitting around doing stuff - is a risk factor by itself - independent of physical activity/exercise. A person who eats a plant-based diet, does not smoke, exercises everyday... still needs to ‘not sit’ for long periods of time.  What I mean to emphasize is that even if you go to the gym, play golf, run, etc., an hour or more every day, the more you sit, the greater your risk for poor health.  When I suggest you sit less and you say, “but I golfed 18 holes this morning” that is like my suggesting you don’t smoke and you saying, “but I golfed 18 holes this morning.”  Golfing does not protect you from the consequences of sitting 6 hours a day any more than it protects you from the consequences of smoking.  Spending more than a few hours a day in sedentary behavior puts you at risk for poor health. (I am not sure that any scientist has quantified what amount of sedentary behavior is actually safe, so we just have to go with ‘less is better.’)

In addition, one of the studies showed that the association between sitting and poor health was influenced by total sitting time, AND whether or not that total time was split up.  In other words, if two people sit for 8 hours a day, but one of them takes short physical activity breaks every hour, the one taking the breaks will have less disease or markers of disease (e.g., inflammation, abnormal blood sugar) than the constant sitter.4  This is assuming that they both exercise the same amount and are alike in other ways. 

The latest study on sedentary behavior and poor health investigated the association between sitting time and the ability to complete Activities of Daily Living. I would like to share a few details about that self-care study today.  First the citation and link:

In this study, Dunlop and colleagues found an association between time spent in sedentary activity, defined as (sitting while) watching TV, working or playing games on the computer, reading, playing cards, etc., and difficulty completing Activities of Daily Living (ADLs). 

Dunlop et al evaluated responses from a nationally representative sample of US adults over the age of 60 who were randomly selected to participate in one year of the National Health and Nutrition Examination Survey, NHANES.  Their study sample included more than 2000 adults who were all over age 60.  Each of the participants wore an activity monitor for 7 days.  From the information generated by the monitors, the researchers could tell when the people were being still - as opposed to the people reporting when they were still. (To be clear, the accelerometers were not perfect.  For example, the monitors did not detect if a person was riding a bicycle and I think the ones used in this study could not be worn in water.)  The outcome that these researchers evaluated was ADLs.  This is an important outcome because older adults who do not have trouble with their ADLs are more likely to be able to live independently.  ADLs for this study included getting dressed, getting in and out of bed, walking and eating.

The take home message from this study, the one that you can apply to your life right now (even if you, like me, are under age 60) is that in this sample of older adults, for every additional hour of sedentary activity (sitting at the TV, computer, playing cards, reading) there was a 46% greater chance of having difficulty with one or more of the ADLs I listed in the above paragraph. 

The researchers also studied the percent of total time in sedentary activity per day as a predictor of ADL problems.  In this case, for every 10% increase in time spent sedentary, there was about a 70% increase in the chance of ADL problems.  I didn’t see (in the article) what the comparison was or the absolute value, which bothers me a little.  But for simplicity, if you and I are just alike, every hour more that I sit than you sit, my risk of having ADL trouble increases by almost 50%. 

The authors of the study hope that physicians will start asking their patients how much time they spend in sit-down activities and encourage them to take activity breaks.  One idea the authors/researchers had is for someone to lead a physical ‘activity’ before and after a book club or bingo meeting.  I LOVE it.

Saturday, March 8, 2014

Nutrition Labels: Chaos, Confusion and Coercion

As it turns out, the FDA didn't publish those final rules for menu labeling last month and the IOM didn't persuade the government to mandate new front of pack labels for packaged foods. Instead, there is a mix match of existing individual state and city menu labeling laws and states continue to send more bills on labeling to their legislatures.  Even the US Congress has a new restaurant menu labeling bill, which is attempting to rewrite the current law (the one not yet implemented or enforced).  In the new bill, lobbyists for convenience stores, entertainment venues and grocery retailers are trying to get their constituents or companies excluded from mandatory labeling.  I disagree with the entertainment venue exclusion, or any exclusion for an establishment selling foods without a label, e.g., a steam table at a grocery store or 7-Eleven.

With regard to packaged foods, I expected that the recommended update to the nutrition facts label would see years of delay, but I did not expect that a group would form to scare us into believing that being told the amount of calories and sugar in our food was a threat to our independence!  Seriously.  The group is called Keep Food Legal, because apparently full disclosure on the ingredients in the products we purchase is somehow paternalistic and threatens our individual liberties.

BTW, in more sugar news, the World Health Organization has updated its stance on limiting sugar intake (to reduce obesity and oral disease); they recommend no more than 5% of total daily calories from added sugar.  This is a little less than is recommended by the American Heart Association.  If you missed the blogpost where I introduced the sugar concerns generated from recent research, you can read it here.

Lastly, the Grocery Manufacturers Association is going full steam ahead with its Facts Up Front labels (and spending lots of money to do it).  The problem with industry front of pack labels and the individual city and state menu laws is that they are not standardized across products or states and do not necessarily have the information that is most important to us (e.g., some list total carbohydrates instead of grams of added sugar).  

That being said, I am starting to warm up to the industry sponsored front of pack food labels because I think they are the best we're going to get for a while. And the Facts Up Front labels list sugar grams and calories, which matter.  

That's my update on labels. The next blog will be about sedentary activity and why you and I should avoid it.

If you want more info on the food industry and labeling, I recommend a ConscienHealth blog post - access it here.