It is happening!

It has been eight years, but the National Restaurant Menu Labeling Law (part of the Patient Protection and Affordable Care Act) will be in effect on Monday. Restaurant chains with over 20 locations will be required to post the calorie content of their standard offering on menu boards and print menus. The goal is to raise awareness of the amount of calories in the items we choose - and to do so before we make that choice. This law has the potential to change our behavior as consumers as well as the behavior of those providing us with food and beverages. Will the calories available to purchase decline? Will we purchase AND consumer fewer calories? If the answers are yes, will the country's obesity rate plateau or decline? I sure hope so - but that's a lot of ifs. 

Meanwhile, the recommended changes to the Nutrition Facts Panel have been delayed to 2020 - here we go again. The main change on those labels is an emphasis on total calories and added sugar and a de-emphasis on total fat. 

On a personal note, sorry I don't post much anymore, but my students require a substantial amount of my time!

It's what you eat, not what you call the diet.

David Katz and Stephanie Meller co-authored a systematic (careful, organized, detailed) review of research related to 7 popular dietary patterns (e.g., low carbohydrate, low fat, Mediterranean, paleolithic, vegan).  You can access their work, including a table that lists the diet categories and the features of that diet here.  For example, the paleolithic diet is based on - or tries to emulate - what we believe our Stone Age ancestors ate, therefore people consuming a paleolithic diet avoid processed foods and eat a lot of vegetables and fruits. The rationale for why each diet pattern is included in the review, or why we should care, is also listed in the table.  For example the low glycemic diet is included because a lot of research is devoted to studying how the body handles foods of different glycemic values (I have blogged about this) and glycemic index and glycemic load could matter for diabetes control.

The actual research article is about 13 pages long.  It is thorough.  It is NOT hard to read - if you have ever asked yourself (or me!), "which is the better diet?" - take the time to read the article for yourself.  Heck, start with the discussion section at the end if you like and if intrigued, go back and read the information about the diets themselves. The authors do not throw statistics at you.  They tell you why they chose to include certain studies, for example, because they were experiments that included a representative sample.  We, the readers, take it on faith that the study authors' (Katz and Meller) interpretation is correct and that they have done due diligence.  I want you to know that I feel confident in the conclusions made by these two authors. 

Here is the take away.  With regard to weight, it is still about calories and some diet patterns make it easier for a person to consume the right amount of calories for themselves.  That is not universal; the pattern that is right for me might be a disaster for you.  If you're curious, I am a blend between Mediterranean and vegetarian as these diet patterns are described in the article.  [That is an important point.  Any of these diet patterns can be trouble if the substitution one makes is to a food containing a high amount of a nutrient of concern, e.g., stop eating cheeseburgers start eating cake.]

But Drs. Katz and Meller were writing about diet patterns and health not weight loss.  Is it healthier to avoid meat altogether or to eat a low carbohydrate diet, for example?  At the conclusion of their study of the studies, Katz and Meller emphasize that we already know the answer and no matter how we actively or passively distract ourselves with the 'diet of the day,' the truth is the same.  A plant based diet, which is minimally processed and contains select carbohydrates (my new favorite way of distinguishing them), and meats that when eaten come from animals who themselves had a natural, plant based diet is health promoting.  The review also debunks the myth that grains make you fat and instead supports a dietary pattern that includes whole grains which are high in fiber because they are associated with lower rates of disease and better weight control.  My Mediterranean diet is high in whole grains and fiber.

Just an FYI, another way that Katz and Meller address the oft misunderstood carbohydrate is to suggest limiting "the objectionable carbohydrate sources—namely, starches and added sugars."
Amen to that.

Here is the proper citation and a link to the article.

Katz, D. L., & Meller, S. (2014). Can We Say What Diet Is Best for Health?. Annual Review of Public Health, 35(1).

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.