Tagged Nutrition

Obesity Stigma And Yo-Yo Dieting, Not BMI, Are Behind Chronic Health Conditions, Dietitian Claims

In a recent New York Times opinion column, dietitian Christy Harrison, an “intuitive eating coach” and author, responded to a fellow clinician who had questioned some of her thoughts on the link between being overweight and developing other medical conditions.

Harrison noted that although most health professionals have been taught that higher body mass index (BMI) causes poor health outcomes, she wrote, “unfortunately, that just isn’t true.”

She added: “We have a host of issues associated with high B.M.I.s. But correlation doesn’t prove causation, and there’s a significant body of research showing that weight stigma and weight cycling can explain most if not all of the associations we see between higher weights and poor health outcomes.”

We decided to investigate the point she was making, which is at the center of a larger, often-heated debate about whether it is possible to be overweight and healthy at the same time — a perspective advocated by the “Health at Every Size” movement, of which Harrison is a part. With nearly 72% of U.S. adults considered overweight or obese, this is a pressing issue.

When we reached out to Harrison to find out the basis of her statement, she responded quickly, citing two papers as her main sources.

The first, a 2011 piece published in the Nutrition Journal, argues it might be better to shift away from weight-loss efforts to improving health in other ways that are weight-neutral.

Its lead author, Linda Bacon, a professor at the University of California-Davis, wrote “Health at Every Size: The Surprising Truth About Your Weight,” a 2010 book embraced by “fat acceptance” advocates.

It addresses Harrison’s first point with this: “While it is well established that obesity is associated with increased risk for many diseases, causation is less well-established.”

The other paper, a 2014 piece in the Journal of Obesity, makes similar arguments.

Causation, Correlation, Association: Let’s Unpack That

There is an old saw used by most statisticians: Correlation does not equal causation.

But what does that mean? Let’s use a fake example: Some people have trouble seeing at night. Turns out all those people ate carrots. Ergo, there could be a correlation between eating carrots and night vision problems.

That doesn’t prove anything else, though, such as causation. Correlation is necessary when trying to determine causation, but doesn’t prove it.

“Epidemiological studies never show causation, only association,” said Dr. Samuel Klein, director of the Center for Human Nutrition at Washington University School of Medicine in St. Louis.

To establish cause, epidemiologists need more evidence.

The best way, considered the “gold standard,” is to randomly assign people to one group or another ― feeding one group carrots and withholding carrots from the other. Researchers would then monitor any difference in how many people develop night vision problems.

That’s nifty, but not always possible or ethical. One could not, for example, randomly assign some people to a group and then cause them to become overweight.

Instead, researchers use different types of studies, such as those that compare groups of people who already have the characteristic — say, carrot eating or being overweight — with those who don’t to see if patterns emerge.

They use methods to control for things that might affect the results, such as age, gender, income level, whether a person smokes and other factors. Then they can estimate how strong of an association or correlation they see.

With smoking and lung cancer, very strong associations were seen, leading to the conclusion that, yes, smoking causes lung cancer. But does excess weight cause other health conditions, such as diabetes, heart disease, cancer, sleep apnea or joint problems?

“With the case of weight, the associations are much weaker,” said Kendrin Sonneville, assistant professor of nutritional sciences at the University of Michigan School of Public Health.

So on this point, Henderson’s statement holds up. Current scientific research supports a correlation between being overweight and suffering poor health outcomes, but it does not definitively establish causation.

But others, especially clinicians, say there is little doubt that being overweight strongly raises the risk of developing such health problems.

“This isn’t up for debate,” said Dr. Harold Bays, chief science officer for the Obesity Medicine Association, which represents practitioners who treat overweight patients.

“The overwhelming amount of clinical and scientific data supports obesity as a disease, both as a direct and indirect contributor to a large number of adverse metabolic and other health consequences,” he said.

A 2018 Endocrine Society scientific statement, for example, looked across many studies of overweight and obesity, concluding that the two contribute to “type 2 diabetes mellitus, cardiovascular disease, some cancers, kidney disease, obstructive sleep apnea, gout, osteoarthritis, and hepatobiliary disease, among others.”

Then things get murky.

Bays and the other experts agreed that some people who are overweight might not develop other conditions.

“It is absolutely true that not all cases of diabetes, hypertension, cancer and fatty liver are due to obesity,” said Bays.

They acknowledged that people who fall into the category of being obese or overweight may even appear healthy metabolically — at least for a while.

But there’s also a caution.

“If you say, ‘Wait a minute, is their blood sugar where we want it … aren’t their triglycerides a little high and what about their blood pressure?’ And that’s not even to mention pain to the joints or sleep apnea,” Bays said. “When you drill down, very few people would truly meet the criteria of being metabolically healthy but obese, and if you follow them for five or 10 years, now the majority are going to have something.”

What About The Stigma?

There’s been less research around Harrison’s second point: that most, if not all, of the diseases associated with being obese or overweight are caused instead by the stigma heavy people face, or the yo-yo effect of dieting, losing weight and then gaining it back again, in regular cycles.

She pointed to research included in the paper by Bacon reporting that weight cycling could lead to hypertension, or high blood pressure. The research, however, found associations though not specific causation.

Similarly, in another study Harrison provided, people who reported weight discrimination ― 6% of the sample studied — had twice the risk of physiological stress over nearly 10 years. Such stress can be associated with Type 2 diabetes, hypertension and cardiovascular disease, the study said.

But most of those we spoke with strongly disputed the sweeping statement that so many chronic conditions can be caused by stigma and weight cycling.

While those two things can factor into health problems, they are not responsible for most of the health outcomes seen by her patients, said Dr. Fatima Cody Stanford, an obesity medicine physician and an assistant professor of medicine and pediatrics at Harvard Medical School.

Stanford also takes issue with advocates who promote the idea that being overweight isn’t a big health risk factor.

“The Health at Every Size movement goes against what we know about obesity as a disease,” Stanford said. “Their aim in that movement is to not learn the science.”

Our Ruling

Harrison said the notion that a higher BMI causes poor health outcomes “just isn’t true” ― adding that “we have a host of issues associated with high BMIs. But correlation doesn’t prove causation, and there’s a significant body of research showing that weight stigma and weight cycling can explain most if not all of the associations we see between higher weights and poor health outcomes.”

On a strict reading of the science, she has a point. It is very difficult to prove definitively what causes disease, and showing “correlation” is a different finding than causation. However, she appears to apply this standard selectively, using it both to undermine the relationship between high BMI and poor health outcomes, and as evidence of how weight cycling and stigma are linked to certain chronic health conditions.

But in the case of obesity, researchers in multiple studies nationally and worldwide have shown definite links between being overweight and developing diseases, such as diabetes, and conditions, such as painful joints. There is far less evidence for the role that weight stigma and yo-yo dieting has in the development of those medical problems, although the experts urge continuing research into those questions.

We rate Harrison’s statement as Mostly False.

Millions Of Diabetes Patients Are Missing Out On Medicare’s Nutrition Help

Louis Rocco has lived with diabetes for decades but, until he met with a registered dietitian in August, he didn’t know eating too much bread was dangerous for him.

“I’m Italian, and I always eat a lot of bread,” he said. After two hour-long visits with a dietitian — including a session at his local grocery store in Philadelphia — Rocco, 90, has noticed a difference in his health.

“It’s helped bring down my sugar readings,” he said of changes in his diet including eating less bread. “I wish I knew I could have had this help years ago.”

After getting a referral this summer from his doctor, Rocco learned that Medicare covers personal nutritional counseling for people with diabetes or kidney disease.

The estimated 15 million Medicare enrollees with diabetes or chronic kidney disease are eligible for the benefit, but the federal health insurance program for people 65 and older and some people with disabilities paid for only about 100,000 recipients to get the counseling in 2017, the latest year billing data is available. The data does not include the 20 million enrollees in private Medicare Advantage plans.

Health experts say the little-used benefit represents a lost opportunity for beneficiaries to improve their health — and for the program to save money by preventing costly complications from the diseases.

An estimated 1 in 4 people 65 and older have diabetes and 1 in 3 have chronic kidney disease. Kidney disease is often a complication of diabetes.

The prevalence of diabetes has risen markedly in the past 20 years and the condition is more common as people age.

Nationwide, there are 100,000 registered dietitians — more than enough to meet demand, said Krista Yoder Latortue, executive director of Family Food in Philadelphia, which employs about 50 dietitians including the one who visited Rocco. Medicare data showed about 3,500 dietitians billed the program for nutritional counseling in 2017.

The problem may be that not enough physicians know about the Medicare benefit. Doctors have to refer patients to a dietitian.

Congress approved the benefit, which began in 2002, after studies found medical nutrition counseling leads to improved health outcomes and fewer complications for older patients. Under the preventive health provisions of the Affordable Care Act, the counseling has been available without out-of-pocket costs to Medicare beneficiaries since 2011.

Medicare pays for three hours of dietary counseling during the first year the benefit is used and two hours in subsequent years. A doctor can appeal to Medicare for additional nutritional therapy if the physician believes it is medically necessary.

Larry Lipman, 70, of Falls Church, Va., said he was shocked to learn he had diabetes earlier this year because he’s relatively thin and is an avid cyclist.

When his doctor recommended meeting with a dietitian, he not only said yes but also brought along his wife, who does most of the cooking.

“It was great because I could ask specific questions and get into the nitty-gritty about how I eat, what I eat and when I eat,” said Lipman, a retired journalist.

“I’ve learned I needed to cut down on portion sizes of rice and other things to keep my carbohydrates down,” he said. “I’m thinking more about what I eat every time and staying away from Doritos and ice cream.”

Doctors shoulder some of the blame for patients not getting dietary counseling by failing to refer them to dietitians.

“It’s a lot easier to prescribe a medication than it is to discuss the importance of nutrition and get patients to meet with a registered dietitian,” said Dr. Holly Kramer, a Chicago nephrologist and president of the National Kidney Foundation.

“I don’t understand how we have this burgeoning obesity and diabetes epidemic and we are not using dietitians in our clinics for all these patients, yet we are paying for all these things that mediate from the disease process such as arthritis, dialysis and amputations,” she said.

Jennifer Weis, a registered dietitian in Philadelphia, said the limited hours Medicare covers is frustrating given how difficult it is to change behaviors in older adults.

“It’s better than nothing, but in my mind is not sufficient,” she said.

Doctors might not be aware of the Medicare option since “it’s a challenge to keep up with what is a covered benefit and what is not,” said Dr. Michael Munger, chairman of the American Academy of Family Physicians who practices in Overland Park, Kan. He said that many doctors who don’t practice with a large health system may not be familiar with dietitians in their community.

For convenience, Munger said, he refers his diabetes patients to a nurse practitioner in his office for nutritional counseling. But only registered dietitians are covered under the Medicare benefit, so his Medicare patients face a copayment for that service.

Nutritional counseling is not the only underused Medicare benefit that can prevent health complications.

Fewer than 5% of Medicare beneficiaries use their 10 to 12 hours of diabetes self-management training benefit, which can cover individual and group sessions providing tips for eating healthily, being active, monitoring blood sugar, taking drugs and reducing risks.

Part of the problem, said Yoder Latortue in Philadelphia, is there is a lot of misinformation about whom the public can trust on nutrition advice.

“Everyone eats and everyone has an opinion,” Yoder Latortue said.

Lauri Wright, a Jacksonville, Fla., registered dietitian and spokeswoman for the Academy of Nutrition and Dietetics, said the federal Centers for Medicare & Medicaid Services sends out notices to health providers once a year but more information is needed.

About 10,600 registered dietitians have enrolled to treat Medicare patients, a CMS spokeswoman said. She said the agency has been advising health providers about the benefit and promoting it to enrollees on its website and its annual handbook that it sends to beneficiaries.

Still, “I think because only two diseases are covered by Medicare and the rest aren’t, it falls off everybody’s radar,” Wright said.

Watch: Five Things To Know About Hunger Among America’s Aging

One out of every 13 seniors in America struggles to get enough food to eat while the federal program intended to help hasn’t kept pace with the graying population.

Kaiser Health News Midwest editor/correspondent Laura Ungar explains what you need to know about this largely hidden problem.

How the Government Supports Your Junk Food Habit

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Credit Fred R. Conrad for The New York Times

At a time when almost three-quarters of the country is overweight or obese, it comes as no surprise that junk foods are the largest source of calories in the American diet. Topping the list are grain-based desserts like cookies, doughnuts and granola bars. (Yes, granola bars are dessert.)

That’s according to data from the federal government, which says that breads, sugary drinks, pizza, pasta dishes and “dairy desserts” like ice cream are also among Americans’ top 10 sources of calories.

What do these foods have in common? They are largely the products of seven crops and farm foods — corn, soybeans, wheat, rice, sorghum, milk and meat — that are heavily subsidized by the federal government, ensuring that junk foods are cheap and plentiful, experts say.

Between 1995 and 2010, the government doled out $170 billion in agricultural subsidies to finance the production of these foods, the latter two in part through subsidies on feed grains. While many of these foods are not inherently unhealthy, only a small percentage of them are eaten as is. Most are used as feed for livestock, turned into biofuels or converted to cheap products and additives like corn sweeteners, industrial oils, processed meats and refined carbohydrates.

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Health advocates have long pointed out this seeming contradiction. While the federal government recommends that people fill half their plates with fruits and vegetables to help prevent obesity, only a small fraction of its subsidies actually support the production of fresh produce. The vast majority of agricultural subsidies go instead to commodity crops that are processed into many of the foods that are linked to the obesity crisis.

“The subsidies damage our country’s health and increase the medical costs that will ultimately need to be paid to treat the effects of the obesity epidemic,” a 2012 report from the U.S. Public Interest Research Group, a nonprofit consumer advocacy organization, concluded. “Taxpayers are paying for the privilege of making our country sick.”

Now federal health researchers have examined the relationship between metabolic disease and the consumption of federally subsidized foods.

The study, led by a team at the Centers for Disease Control and Prevention and published this month in JAMA Internal Medicine, looked at over 10,000 adults and the foods they reported eating in a typical day. Then the researchers split the subjects into groups according to the proportion of foods they ate that were derived from the seven major subsidized commodities.

After adjusting for age, sex, socioeconomic factors and other variables, the researchers found that those who had the highest consumption of federally subsidized foods had a 37 percent greater risk of being obese. They were also significantly more likely to have belly fat, abnormal cholesterol, and high levels of blood sugar and CRP, a marker of inflammation.

While the study does not prove cause and effect, its authors say that this strong association is consistent with other research showing that diets that are higher in subsidized foods tend to be poorer quality and more harmful to health.

“This tells us that the factors that influence the prices of our foods are an additional factor,” said Ed Gregg, chief of the epidemiology and statistics branch in the C.D.C.’s Division of Diabetes Translation. “We’re hoping that this information reaches policy makers and the people who influence how subsidies work.”

The subsidies program was started decades ago in part to support struggling farmers and to secure America’s food supply. Since 1995, the government has provided farmers with close to $300 billion in agricultural subsidies overall, which are included in the federal farm bill, along with money for nutrition initiatives like the federal food stamps program, known as SNAP. The farm bill is renewed by Congress every five years and is projected to cost $956 billion between 2014 and 2023.

But critics say the subsidies program no longer serves its original purpose. Instead of supporting small farmers who grow fruits, nuts and vegetables – which the government calls “specialty crops” — the program now primarily subsidizes large producers that churn out a handful of “commodity” crops that include grains, corn, sorghum and oilseeds like soybeans.

According to the Government Accountability Office, small “specialty” farms represent three-quarters of the country’s cropland but receive just 14 percent of government subsidies. Large agribusinesses that specialize in growing the major commodity crops represent 7 percent of the cropland and receive about half of all subsidies.

Previous versions of the farm bill even stipulated that farmers who took subsidies for commodity crops could not grow fruits and vegetables. If they did, they were penalized, said Caroline Franck, the co-author of a 2012 report in the Archives of Internal Medicine that explored the role of agricultural subsidies in obesity.

Ms. Franck, a research assistant at the Lady Davis Institute for Medical Research of the Jewish General Hospital, McGill University, said many factors influence what people choose to eat. While it’s difficult to argue that subsidies are a direct cause of obesity, they clearly play a role.

“I think it’s safe to say that what happens at the top of the food chain has an impact on what happens at the bottom,” she said. “Agricultural policies are just not aligned with public health goals.”

In part because of public pressure, the last farm bill, which was passed in 2014, allowed farmers who grow commodity crops to use 15 percent of their acreage to grow fruits, vegetables and other specialty crops. It provided support to organic farmers, including $100 million for research to improve organic production. And it funded a “healthy incentives” program that encourages food stamp recipients to consume more fruits and vegetables by increasing the value of food stamps that are used to buy fresh produce at retail stores or farmers’ markets.

Ms. Franck said that early results suggest that the program is increasing the amount of fresh produce people consume. But others are not so sanguine. Raj Patel, a research professor at the Lyndon B. Johnson School of Public Affairs at the University of Texas at Austin, said that the funding for fruits and vegetables in the most recent farm bill was “crumbs” compared to the billions in subsidies for commodity crops.

Dr. Patel said it was time for the federal government to adopt a “national food policy” like one that has been proposed by the Union of Concerned Scientists, a nonprofit advocacy group. Among other things, a national food policy would ensure that farm workers receive fair wages, that all Americans have access to healthy foods, and that the government’s nutrition recommendations and agricultural policies are aligned, he said.

“It would transition us away from the unhealthy consequences of the current industrial food policy,” he said. “I think there’s something very broken about the subsidy system.”

An App to Deconstruct Your Food

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A screenshot of the Sage app.

A screenshot of the Sage app.Credit

Ever wondered how long you’d have to swim to burn off the calories in an organic peanut butter cup? Or how far the strawberries or burger on your plate traveled to get there?

For answers, ask the Sage Project, one of the latest of the food technology companies helping consumers navigate nutrition. While a number of food apps count calories and track eating habits, Sage goes beyond the food label to give customers additional information about additives and preservatives, how much sugar has been adding during processing or how far a food has traveled.

“Food labels are a data visualization that we see every day, but we don’t get a lot from them,” said Sam Slover, the co-founder and chief executive of Sage. “There are a lot of things about those labels that make assumptions about what you know and what you want to know.”

Do we really need another food app? Apple’s app store already lists more than three dozen apps offering users information and advice about calories, nutrition data and weight loss, but research shows that many consumers have a failed relationship with their food apps. For instance, in January, about 16 percent of the people who downloaded the Lose It app were using it once a day. By June, only 10 percent were using it that often, according to research firm 7Park Data.

“These apps have trouble keeping customers loyal — if you use them successfully, you don’t need them any more, and if you don’t use them successfully, you may not think it’s worth it to try more,” said Byrne Hobart, the lead analyst at 7Park Data. “They’re kind of like the dating apps that way.”

The Sage app hopes to inspire more loyalty by providing a trove of useful and quirky information about the food you eat. It contains data on about 20,000 products, though you still may not find your favorite junk foods. Most of the products in the database are described as “natural” and “organic.” But if you shop at Whole Foods, you’re in luck. Sage has partnered with Whole Foods Market, deconstructing all of the roughly 7,000 items sold in the grocer’s new “365” store chains in Los Angeles and Lake Oswego, Ore.

To begin using Sage, which is available online or as a web-based app, a user signs up and enters any food restrictions and personal preferences. Only want to see products without additives and preservatives? No problem. Interested in digestive health? Sage will comb through its database and show you products with probiotics, high fiber and whole grains.

The app displays a wide variety of information using colorful graphics and animated food characters, and it’s surprisingly fun and entertaining to use. The app told me that Surf Sweet gummy bears, for instance, do have a fair amount of added sugar but also have “good nutrient density,” meaning that, among other things, they supply a high amount of vitamin C (much to my delight). A jump-roping chocolate bar informs me that I’d need to jump rope for 19 minutes — or a snorkeling olive recommends 23 minutes of swimming — to burn off a serving of Justin’s Organic milk chocolate peanut butter cups.

“Customers want a better understanding of how a product is sourced, the quality standards behind it, whether the labor that made it was paid a fair wage, its impact on the environment,” said Jason Buechel, the chief information officer at Whole Foods. “This is a way to give them all that information that isn’t captured on the nutrition label.”

Take the Beast Burger, for instance, a meatless burger sold at Whole Foods. Type the name of the burger into Sage or flip through a list, and you’ll find its basic nutritional profile and calorie content, with highlights of its nutritional strengths.

Using animated food characters — a pear doing yoga, a watermelon riding a bike — the app shows how much exercise would be required to work off the burger. In my case, it’s 20 minutes of running, 22 minutes of jumping rope, 28 minutes of swimming or biking, 44 minutes of dance or 89 minutes of yoga.

Sage also identifies any allergens — corn and seeds in the case of the Beast Burger — and offers detailed explanations of all the burger’s ingredients, and why they’re used should you be interested. For instance: “Calcium chloride, a salt, is used in canned goods to improve stability and quality and as a firming agent in tofu production.”

The system awards “badges” to the burger for things like an abundance of healthy fats and protein and having recyclable packaging, and it explains what diets — dairy free, gluten free, vegan, vegetarian and ketogenic — it does not violate. To make nutrition recommendations like “fiber friendly” or “heart healthy,” Sage uses nutritional standards set by the Food and Drug Administration and the American Heart Association. An in-house team of dietitians and nutritionists have created standards for badges like “healthy fats” or “contains probiotics” — areas where the F.D.A. doesn’t set guidelines.

Finally, the app tells you where the product is made or sourced. The Beast Burger is American made. If you decided to check out Driscoll strawberries, you might learn your batch came from Mexico.

It also can tailor daily nutritional requirements to a user’s specific weight, height and lifestyle. For instance, Sage came up with a recommended daily caloric intake of about 3,300 calories that is rich in protein for Mr. Slover, given his height, weight and exercise routine — he’s a triathlete. It recommended a 1,600-calorie diet with a lower portion of protein for his mother.

“All those things on a label telling you that a product gives you, say, 10 percent of the daily requirement of protein is based on a default, 2,000-calorie-day diet, a kind of one-size-fits-all approach that doesn’t work,” Mr. Slover said.

One thing the Sage app won’t tell you is what you should or shouldn’t eat. You will have to figure that out for yourself. “I’m not a big fan of red, yellow and green scoring mechanisms for food,” Mr. Slover said. “I don’t think they’re well received by consumers or used very much.”

No Health Benefit to Replacing Fat With Carbs

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Low-fat diets that are high in carbohydrates are unlikely to improve your health, a new study shows.

Researchers came to the conclusion after studying the eating habits and health behaviors of 126,233 men and women who completed health questionnaires every two to four years for up to 32 years. Then they calculated the effect of replacing just 5 percent of saturated fat calories with another type of fat or carbohydrates.

The study, in JAMA Internal Medicine, found that replacing 5 percent of daily calories from saturated fats (mainly animal fat) with foods high in monounsaturated fat, such as olive oil and avocados, was associated with a 27 percent reduction in total mortality and reduced death from cardiovascular disease, cancer and neurodegenerative disease.

A similar switch from saturated fat to polyunsaturated fats, such as the omega-3 and omega-6 fatty acids in fish and walnuts, was associated with a 13 percent reduction in total mortality and a 29 percent reduction in death from neurodegenerative diseases.

But replacing saturated fats with carbohydrates, such as sugars and refined grains, did not confer any health benefits.

“Not all fats are created equal,” said the senior author, Dr. Frank B. Hu, a professor of nutrition at the Harvard T.H. Chan School of Public Health. “We should eat more good ones from fish and avocados, instead of animal fats. And second, the low-fat, high-carbohydrate diet is not beneficial for improving health and longevity.”

Ask Well: Is Watermelon Good for You?

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Credit Karsten Moran for The New York Times

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Eat Whole Grains, Live Longer?

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Credit Karsten Moran for The New York Times

Two large review studies have reached the same conclusion: Eating whole grains is associated with significant reductions in the risk for premature death.

One report, in BMJ, found that whole grain consumption was associated with a reduction in the risk for death from cancer, coronary heart disease, respiratory disease, infectious disease and diabetes. Using data from 45 studies, researchers calculated that compared with eating none, eating 90 grams of whole grains a day reduced the risk for all-cause mortality by 17 percent.

The other analysis, in Circulation, used data from 14 prospective studies with 786,076 participants and found that compared with those who ate the least whole grain foods, those who ate the most had a 16 percent reduced risk for all-cause mortality and an 18 percent reduced risk for cardiovascular mortality. Each 16-gram increase in whole grain intake reduced mortality risk by 7 percent.

A slice of 100 percent whole grain bread contains about 16 grams of whole grains, and current dietary guidelines recommend 48 grams or more of whole grains daily.

The senior author of the Circulation study, Dr. Qi Sun, an assistant professor of nutrition at Harvard, cautions that eating whole grains is not a panacea.

“You shouldn’t hope that you will cure diseases with whole grain foods,” he said. “You still have to pay attention to other good dietary and behavioral practices.”

Is Sugar Really Bad for You? It Depends

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Credit iStock

The federal government’s decision to update food labels last month marked a sea change for consumers: For the first time, beginning in 2018, nutrition labels will be required to list a breakdown of both the total sugars and the added sugars in packaged foods. But is sugar really that bad for you? And is the sugar added to foods really more harmful than the sugars found naturally in foods?

We spoke with some top scientists who study sugar and its effects on metabolic health to help answer some common questions about sugar. Here’s what they had to say.

Why are food labels being revised?

The shift came after years of urging by many nutrition experts, who say that excess sugar is a primary cause of obesity and heart disease, the leading killer of Americans. Many in the food industry opposed the emphasis on added sugars, arguing that the focus should be on calories rather than sugar. They say that highlighting added sugar on labels is unscientific, and that the sugar that occurs naturally in foods like fruits and vegetables is essentially no different than the sugar commonly added to packaged foods. But scientists say it is not that simple.

So, is added sugar different from the naturally occurring sugar in food?

It depends. Most sugars are essentially combinations of two molecules, glucose and fructose, in different ratios. The sugar in a fresh apple, for instance, is generally the same as the table sugar that might be added to homemade apple pie. Both are known technically as sucrose, and they are broken down in the intestine into glucose and fructose. Glucose can be metabolized by any cell in the body. But fructose is handled almost exclusively by the liver.

“Once you get to that point, the liver doesn’t know whether it came from fruit or not,” said Kimber Stanhope, a researcher at the University of California, Davis, who studies the effects of sugar on health.

The type of sugar that is often added to processed foods is high-fructose corn syrup, which is the food industry’s favored sweetener for everything from soft drinks to breads, sauces, snacks and salad dressings. Made commercially from cornstarch, high-fructose corn syrup is generally much cheaper than regular sugar. It contains the same components as table sugar – glucose and fructose – but in slightly different proportions.

What about “natural” sweeteners?

Food companies like to market agave nectar, beet sugar, evaporated cane juice and many other “natural” sweeteners as healthier alternatives to high-fructose corn syrup. But whatever their source, they are all very similar. To suggest one is healthier than another is a stretch, experts say. In fact, last month, the F.D.A. urged food companies to stop using the term evaporated cane juice because it is “false or misleading” and “does not reveal that the ingredient’s basic nature and characterizing properties are those of a sugar.”

Is high-fructose corn syrup worse than regular sugar? How is it different?

High-fructose corn syrup and regular sugar are so similar that most experts say their effects on the body are essentially the same.

The main difference is that the variety of high-fructose corn syrup used in soft drinks tends to have more fructose. In one 2014 study, researchers analyzed more than a dozen popular soft drinks and found that many sweetened with high-fructose corn syrup – including Pepsi, Sprite, Mountain Dew, Coca-Cola and Arizona Iced Tea – contained roughly 40 percent glucose and 60 percent fructose. Regular sugar contains equal parts glucose and fructose.

Why doesn’t the F.D.A. require that added sugars be listed in teaspoons rather than grams?

When the new food labels go into effect, the daily recommended limit for added sugars will be 50 grams, or roughly 12 teaspoons, daily. (One teaspoon of sugar is 4.2 grams.) But the new food labels will list the amount of added sugars solely in grams.

Many nutrition advocates have urged the F.D.A. to require that food labels list added sugars in both teaspoons and grams on food labels, arguing that Americans often underestimate the actual amount of sugar in a product when it’s expressed in grams alone.

But the F.D.A. ultimately sided with the food industry, which opposed the teaspoon proposal.

“It would be difficult, if not impossible, for a manufacturer to determine the volume contribution that each ingredient provides toward the added sugars declaration,” the agency said. “For example, a cookie made with white chocolate chips and dried fruit would have added sugars in the form of sugar in the batter as well as in the white chocolate chips and the dried fruit.” The F.D.A. also said that requiring both grams and teaspoons would “cause clutter and make the labels more difficult to read.”

But Michael Jacobson, the president of the Center for Science in the Public Interest, an advocacy group that had petitioned the F.D.A. to require the teaspoon measurement, said the agency was under enormous pressure from the food industry, “which knows that consumers would be far more concerned about a product labeled 10 teaspoons than 42 grams.”

So what’s the issue with added sugars?

It mainly comes down to the way they’re packaged.

Naturally occurring sugar is almost always found in foods that contain fiber, which slows the rate at which the sugar is digested and absorbed. (One exception to that rule is honey, which has no fiber.) Fiber also limits the amount of sugar you can consume in one sitting.

A medium apple contains about 19 grams of sugar and four grams of fiber, or roughly 20 percent of a day’s worth of fiber. Not many people would eat three apples at one time. But plenty of children and adults can drink a 16-ounce bottle of Pepsi, which has 55 grams of added sugar – roughly the amount in three medium apples – and no fiber. Fiber not only limits how much you can eat, but how quickly sugar leaves the intestine and reaches the liver, Dr. Stanhope said.

“You can’t easily eat that much sugar from fruit,” she said. “But nobody has any problem consuming a very high level of sugar from a beverage or from brownies and cookies.”

Why is it a problem to have too much sugar?

Many nutrition experts say that sugar in moderation is fine for most people. But in excess it can lead to metabolic problems beyond its effects on weight gain. The reason, studies suggest, is fructose. Any fructose you eat is sent straight to your liver, which specializes in turning it into droplets of fat called triglycerides.

“When you ingest fructose, almost all of it is metabolized by the liver, and the liver is very good at taking that fructose and converting it to fat,” said Dr. Mark Herman, an assistant professor of medicine at Harvard. Studies show a predictable response when people are asked to drink a sugary beverage: A rapid spike in the amount of triglycerides circulating in their bloodstreams. This also leads to a reduction in HDL cholesterol, the so-called good kind.

Over time, this combination – higher triglycerides and lower HDL – is one major reason sugar promotes heart disease, said Dr. Aseem Malhotra, a cardiologist and adviser to the United Kingdom’s national obesity forum. This sequence of events may even overshadow the effects of LDL cholesterol, the so-called bad kind.

“What many people don’t realize is that it’s triglycerides and HDL that are more predictive of cardiovascular disease than LDL cholesterol,” Dr. Malhotra said. “I’m not saying LDL isn’t important. But if there is a hierarchy, triglycerides and HDL are more important than LDL.”

Dr. Malhotra said that when people reduce their sugar intake, “their overall cholesterol profile improves.”

“I see this in so many of my patients,” he added. “The effects are rapid.”

How much sugar is too much?

One of the largest studies of added sugar consumption, which was led by the Centers for Disease Control and Prevention, found that adults who got more than 15 percent of their daily calories from added sugar had a higher risk of cardiovascular disease. For the average adult, that translates to about 300 calories, or 18 teaspoons of added sugar, daily. That may not sound like a lot. But considering that a single 12-ounce can of Coca-Cola has almost 10 teaspoons of sugar, it can add up quickly

The study found that most adults got more than 10 percent of their daily calories from added sugar, and that for 10 percent of people, more than 25 percent of their calories came from added sugar. The biggest sources for adults were soft drinks, fruit juices, desserts and candy.

While those might seem like obvious junk foods, Dr. Malhotra said, about half of the sugar Americans consume is “hidden” in less obvious places like salad dressings, bread, low-fat yogurt and ketchup. In fact, of the 600,000 food items for sale in America, about 80 percent contain added sugar.

Everyone’s tolerance for sugar is different. Studies show, for example, that people who are already obese may be more susceptible to metabolic harm from sugar than others. But Dr. Malhotra said that he generally advises people to follow the World Health Organization’s guidelines, which recommend that adults and children consume no more than about six teaspoons daily of added sugar.

“Could I tell you the exact limit where sugar starts to definitely impact cardiovascular health?” he said. “That’s difficult. But I think if people stick within the W.H.O. limits, then their risk is reduced.”

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Should You Take a Vitamin? Do You Know What a Vitamin Is?

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Credit

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Credit Catherine Price

Many people can rattle off the names of the most popular vitamins and the foods that contain them in abundance. But understanding exactly what vitamins are and what roles they play in the body is far more complicated. In fact, though scientists recognize that there are 13 vitamins that are essential for good health, there is no real consensus on what they actually do and exactly how much of them we truly need.

Catherine Price, a science journalist, explores these questions and more in a book that was recently released in paperback, called “Vitamania: Our Obsessive Quest for Nutritional Perfection.” Ms. Price traces the history of vitamins from their discovery as lifesaving organic compounds that prevented strange diseases to their ubiquity today in foods, beverages and dietary supplements. Ms. Price sheds surprising light on the mythology surrounding vitamins and explains why even basic advice promoted by experts – like the nutrient requirements for healthy adults known as the recommended dietary allowance, or RDA – may be misguided.

Recently, we sat down with Ms. Price to discuss some of the most common misconceptions about vitamins, the reasons vitamin D testing can be misleading, and which questions you should ask yourself before deciding whether to take a multivitamin. Here are edited excerpts from our conversation.

Q.

Why did you write this book?

A.

I have Type 1 diabetes, which forces me to think about how food interacts with our bodies every time I eat. And yet when my husband turned to me out of the blue one day and asked, “What is a vitamin?” I realized I didn’t know the answer. Vitamins turned out to be a perfect subject for me. I love investigating things that seem so familiar to us that we never think to ask questions about them. They were a mystery hiding in plain sight, and I was intrigued.

Q.

How have vitamins changed the way we think about food?

A.

Vitamins were the first “superfoods”— they introduced the idea that there are particular foods, ingredients and dietary chemicals that have health benefits that go beyond mere nutrition. It turns out that there’s a direct line between the discovery and early marketing of vitamins and our current beliefs in the magical powers of kale. Learning about the history of vitamins made me much better at recognizing nutritional hype, which helps me make much better — and calmer — decisions about what to eat.

Q.

What are some of the most common misperceptions about vitamins?

A.

My biggest pet peeve is that when we hear the word “vitamin,” we automatically think of pills instead of food — and then use “vitamin” to refer to all dietary supplements. This is incorrect. There are only 13 vitamins, which are essential for health, compared to over 85,000 dietary supplements for sale in America. Also, we assume that scientists know exactly what vitamins do in our bodies and how much of each we need, but they don’t. We assume that all vitamins and dietary supplements are required to be tested for safety and effectiveness before they’re sold. But they’re not.

Q.

Should the average person take a multivitamin?

A.

Ask yourself what you eat. Does your plate look like the cover of a Michael Pollan book? Then you’re already getting plenty of vitamins and other nutrients from your food. Do you eat a lot of fortified foods like breakfast cereal and sports drinks? Then you probably don’t need to take a multivitamin either, because you’re essentially eating one. The people who benefit the most from multivitamins are those with restricted diets or health issues that make it hard to absorb nutrients from food, or who get most of their calories from foods that are so junky that they haven’t even been enriched with synthetic vitamins. Man cannot live on potato chips alone.

Q.

In your book you say it’s a bad idea to get tested for blood levels of vitamin D and other nutrients. Why?

A.

I wouldn’t say it’s necessarily bad — it’s more that it’s not particularly helpful. We know that vitamin D is essential for healthy bones, but the jury’s still out on what else it might do. This makes it impossible to determine what our requirements actually are, which in turn makes it impossible to figure out what an optimal level should be. And despite an ongoing standardization effort, results for the same blood sample can differ depending on which lab they’re sent to. It’s like taking an exam that doesn’t have an answer key — and that’s scored differently depending on who grades it.

Q.

Why is taking large doses of some vitamins a bad idea?

A.

It’s a bad idea to assume that just because something is essential in small doses, bigger doses must be better. Some vitamins are known to be toxic in high doses. Vitamin A is the most notorious. In some cases, high doses of vitamins that we thought would be helpful have been shown to cause more harm than good. In the 1990s, high doses of beta-carotene, which is a precursor to vitamin A, were tested as a possible prevention for cancer, but were eventually linked to an increased risk for lung cancer, especially among smokers. Remember: Even water can kill you if you drink too much of it.

Q.

In your book you argue that the “Percent Daily Value” figures on food and supplement labels are close to meaningless. Why?

A.

First of all, we each have different vitamin requirements, which means that 100 percent for me is not 100 percent for you. Second, the recommended dietary allowances aren’t meant as personalized recommendations to begin with. And third, most of the percentages in the “percent daily value” column on current food and supplement labels are calculated off of the RDAs from 1968. Yes, 1968. The FDA plans to use more updated recommendations in the next version of the nutrition and supplement facts panels, but for now, most of those numbers are still based on recommendations that are nearly a half a century old.

Q.

What are some of the most peculiar things you learned about vitamins while writing this book?

A.

That synthetic vitamin D is made by irradiating grease from sheep’s wool. That American politicians became convinced that thiamin deficiencies would make us lose World War II. That the guy who discovered vitamin B12 did so by eating raw meat, regurgitating it, and then tube-feeding it to his unknowing patients. And that before being affiliated with vitamins, Fred Flintstone and Barney Rubble used to advertise Winston cigarettes. It turns out that the story of vitamins is much bigger, weirder, more interesting and more useful than I ever could have anticipated.

Diet High in Saturated Fats May Be Linked to Dense Breasts

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Teenage girls who eat a diet high in saturated fat are at increased risk of developing dense breasts, a study concludes. Dense breasts contain more fibrous and connective tissue than normal and are a risk factor for breast cancer.

Researchers studied 177 girls, ages 10 to 18 at the start of the study, who periodically filled out dietary recall questionnaires. The scientists measured breast density by M.R.I. when the members of the group were 25 to 29 years old. The study is in Cancer Epidemiology, Biomarkers & Prevention.

Average dense breast volume in those in the lowest quarter for saturated fat intake was 16.4 percent, compared with 21.5 percent for those in the highest quarter.

Consumption of unsaturated fats had the opposite associations — the higher the consumption of unsaturated fats, the lower the average dense breast volume.

“We looked only at the associations of breast density with fat intake,” said the senior author, Joanne F. Dorgan, an epidemiologist at the University of Maryland School of Medicine. “Whether this will then be related to an increase in breast cancer later in life, we don’t know. But breast density itself is associated with increased risk.”

The authors controlled for many health factors, but they acknowledge that unknown variables could have affected their results.

“This is all observational data,” Dr. Dorgan said, “and needs to be confirmed before we can make health recommendations.”

Potatoes Tied to High Blood Pressure Risk

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Credit Karsten Moran for The New York Times

Eating potatoes four or more times a week may increase the risk for high blood pressure, a large new study has found.

Researchers pooled results from three observational studies involving 187,453 men and women followed for more than 25 years. The participants returned health and diet questionnaires every two years, including whether a doctor had diagnosed hypertension. The study is in BMJ.

After controlling for body mass index, physical activity, smoking and other factors, they found that compared to eating potatoes only once a month, having one potato — baked, boiled or mashed — four to six times a week increased the risk for hypertension by 11 percent. Eating four or more four-ounce servings of French fries a week increased the risk by 17 percent. Adjusting for salt and saturated fat intake did not change the results, but the authors acknowledge that they could not control for all possible variables.

The researchers suggest that potatoes cause a rapid rise in blood glucose levels, which is associated with blood vessel problems and inflammation. This may increase the risk for hypertension.

“We don’t completely know what a healthy diet is,” said the lead author, Dr. Lea Borgi, an associate physician at Brigham and Women’s Hospital in Boston, “and I have no opinions about what people should eat. It’s important that studies like this continue the discussion.”

The New Performance Enhancer in High School Sports? Nutrition

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Jordan Burg, 18, learned to make smart food choices for sports through a nutrition program at his school.

Jordan Burg, 18, learned to make smart food choices for sports through a nutrition program at his school.Credit Jenna Schoenefeld for The New York Times

Jordan Burg, 18, who plays varsity football and baseball and runs track, never used to think about what he was eating. But after he learned at school that nutrition was as important to his athletic performance as attending practice, he changed his diet.

Before, “I figured that I worked out so hard, it didn’t matter,” he said. “I ate ice cream whenever I pleased, cheese on everything and soda every day.” Now, he said, “I find myself at the salad bar having grilled chicken salads,” and on game days “I eat chicken breast and fish, and I make sure I drink as much water as possible.” He also avoids processed foods and red meat.

Jordan, a senior at the Windward School in Los Angeles, a private co-ed school for grades 7-12, said, “I am experiencing far fewer muscle cramps as well as less muscle fatigue.”

He credits this change to Windward’s heavy focus on nutrition as part of its athletic program, something that appears to be a new trend in high schools, said Molly Wong Vega, a dietitian who provides her services to three public school districts in the greater Houston area. Long a standard part of professional and college programs, the emphasis on diet is shifting to the high school level.

“Schools are starting to bring in dietitians to discuss the importance of nutrition with young athletes to complete the circle,” Ms. Wong Vega said. “Suggesting a snack of bell peppers with hummus may be a way to help increase vitamin A and C intake and give a little zinc as well,” which she says can help with muscle and tissue repair.

Ms. Wong Vega said public school districts often have tighter budgets than private schools, making it harder to hire specialists in sports nutrition. She is not employed directly by the schools but works with their athletic trainers through the Houston Methodist System, a network of hospitals. She said it took her and another dietitian a full semester to talk to all the coaching staff members and 900 athletes at just one high school.

The Chandler Unified School District in Arizona, a public district in the suburbs of Phoenix, has three dietitians on staff. One is Wesley Delbridge, also a spokesman for the Academy of Nutrition and Dietetics, a trade group representing some 75,000 registered dietitians and other nutrition professionals.

“By hiring a dietitian, districts receive that extra skill set that can improve their meals and increase health,” said Mr. Delbridge, a registered dietitian who directs the district’s food and nutrition department. “I have been advocating for school nutrition departments and food service departments to hire dietitians for some time, and I’m happy to see more and more schools incorporate nutrition not only into their athletic programs but into its core programs.”

Mr. Delbridge and his team developed “peak performance packs,” boxes of food that students in the district’s high schools can buy in the cafeteria for $5. There are three choices: endurance, muscle building and rapid recovery packs, each aimed at giving student athletes solid nutritional choices for their sport.

The endurance pack, for example — for sports like soccer, cross country, track and wrestling – contains whole-grain pasta salad, fresh fruit, string cheese, vegetables, hummus and a beverage high in electrolytes, intended to help prevent cramping and muscle fatigue. The muscle-building pack contains foods that are high in lean protein, both plant- and animal-based, to encourage muscles to repair and build up again.

Sports nutritionists concede that getting kids to eat healthfully remains a struggle.

“We don’t say ‘don’t eat this, don’t eat that,’” said Kermit Cannon, who heads the Windward School’s program to incorporate healthy eating into its curriculum. “We emphasize that good nutrition, along with sleep and exercise, will not only benefit you as a student athlete, but those habits will benefit you for a lifetime.”

Tackling eating disorders is also often part of the nutrition programs, with some dietitians providing one-on-one sessions with students. Mr. Delbridge is sometimes asked by a coach or a counselor to talk with student athletes who have eating disorders, and their parents.

“We would discuss their current weight, exercise activity and intensity, and I would show them what the final amount of calories they need in a day to maintain that activity level,” Mr. Delbridge said. “This can sometimes shock the student, because it seems like a lot of calories. Then we discuss how to meet these needs with healthy choices.”

Roberta Anding, a sports dietitian at the Kinkaid School, a private school in Houston for pre-kindergarten to 12th grade, said both boys and girls can struggle with body image. “How we provide these young men and women the life skills to navigate food choices, a college cafeteria, see how alcohol plays a negative role in your performance, how to recover properly — that’s truly focusing in on wellness for life.”

Robert Bach, the principal of Stillwater Area High School in Minnesota, said for several years now, students have had access to individual sessions with a nutritionist to help them make smart food choices. “It’s about lifelong health so that our students can lead a healthy lifestyle they carry beyond their classes,” he said.

Sela Kay, a sophomore at the Windward School, said that learning about nutrition at school has made it easier for her to make healthier food choices.

“Even after I am done with organized sports someday, I want to continue leading this healthy lifestyle,” said Sela, 16, who plays varsity basketball and runs track. “I know now that will start with my food choices.”

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Fruits and Vegetables to Fight Cataracts

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Credit Andrew Scrivani for The New York Times

Here’s another reason to eat your fruits and veggies: You may reduce your risk of vision loss from cataracts.

Cataracts that cloud the lenses of the eye develop naturally with age, but a new study is one of the first to suggest that diet may play a greater role than genetics in their progression.

Researchers had about 1,000 pairs of female twins in Britain fill out detailed food questionnaires that tracked their nutrient intake. Their mean age was just over 60.

The study participants underwent digital imaging of the eye to measure the progression of cataracts. The researchers found that women who consumed diets rich in vitamin C and who ate about two servings of fruit and two servings of vegetables a day had a 20 percent lower risk of cataracts than those who ate a less nutrient-rich diet.

Ten years later, the scientists followed up with 324 of the twin pairs, and found that those who had reported consuming more vitamin C in their diet — at least twice the recommended dietary allowance of 75 milligrams a day for women (the R.D.A. for adult men is 90 milligrams) — had a 33 percent lower risk of their cataracts progressing than those who get less vitamin C.

The researchers concluded that genetic factors account for about 35 percent of the difference in cataract progression, while environmental factors like diet account for 65 percent.

“We found no beneficial effect from supplements, only from the vitamin C in the diet,” said Dr. Christopher Hammond, a professor of ophthalmology at King’s College London and an author of the study,published in Ophthalmology. Foods high in vitamin C include oranges, cantaloupe, kiwi, broccoli and dark leafy greens.

”This probably means that it is not just vitamin C but everything about a healthy diet that is good for us and good for aging,” he added.