Transcript Nutrition Communications in the New Millenium

NUTRITIION
CONTROVERSIES:
Tackling tough topics with facts,
not emotion
Keith-Thomas Ayoob, EdD, RD, FADA, CDN
Associate Clinical Professor of Pediatrics
Albert Einstein College of Medicine
New Jersey School Nutrition Association
August 16, 2012
3 examples of
“risky” topics
• Artificial colors
• Sugar
• Flavored milk
Common thoughts…
• Sugar is making kids
 Hyperactive/diabetic/high
• “Artificial colors make them
hyperactive”
ARTIFICIAL
COLORS
What ARE they?
• Regulated by FDA
• 2 kinds of colors in food:
 Certified color additives
 Colors exempt from certification
9 Certified colors
• Blue #1
• Blue #2
• Green #3
•
•
•
•
•
•
Red #2
Red #3
Red #40
Orange B
Yellow #5
Yellow #6
Exempt colors
• Naturally derived but are still color
additives, must comply with regulations
• More expensive
• May impart flavors
What are they doing in our food?
• Compensate for color losses
• Maintain uniformity when colors
naturally vary
• Enhance naturally occurring colors
THE BIG QUESTION:
DO COLORS IN FOOD
CAUSE HYPERACTIVITY?
HISTORY
• Started with Feingold in the 1970s
• Hyperactivity caused by:
 Salicylates
 Artificial flavors
 Artificial colors
Feingold, BF Delaware Med J 1977
McCann et al (2007)
3 yo
8/9 yo
153
144
Mix A
20 mg AC
25 mg AC
4 AC + Na
benzoate
Mix B
30 mg AC
62 mg AC
4 AC + Na
benzoate
N=
Composition
General population
• Double-blind, placebo-controlled
•Global hyperactivity aggregate scores
•
McCann et al (2007)
• Comparing Mix A against placebo, Mix B
against placebo:
 3 y.o.: in both cases, Mix showed significantly
greater hyperactivity scores
 8/9 y.o.: in both cases, Mix showed
significantly greater hyperactivity scores
…but….
McCann et al (2007)
• When adjusted for:






Week during trial
Sex
Maternal education
SES
GHA in baseline week
Pretrial diet………
McCann et al (2007)
• Effect in 8/9 y.o., was significant only at
highest dose (Mix B)
• Effect in 3 y.o. was significant only at the
lower dose (Mix A).
McCann et al (2007)
Among authors’ conclusions:
“…substantial individual differences in
the response of children to the
additives.”
Conclusions of EFSA panel
• “…the study provides limited evidence
that the two mixtures had a small and
statistically significant effect on activity
and attention.”
• They also concluded that the McCann
study did not provide an acceptable
basis for altering the ADI for colors.
EFSA Journal, 2008
Guidance
• Perceived or real, some subset of
children may be especially sensitive or
high-responders to ACs
• Look at quantity/frequency
 4 oz. of candy for a 3-year-old and
 8 oz. of candy for an 8-y.o. is EXCESSIVE
 Smaller amounts may matter little or none
• Assess context, setting, situation
SUGAR
SUGAR
SUGAR
The buzz
• Sugar gets kids hyperactive
• Sugar makes kids overweight
• HFCS: The new trans fat. It gives you
diabetes, metabolic syndrome, etc.
• Fructose causes high blood pressure.
How much sugar do we eat?
• Total added sugars eaten, per capita1:
 1999: 107.7 lb.
 2007: 97.0 lb. (=120 gm/day)
1 - ers.usda.gov, accessed 9/21/09
Mean calories from added
sugars by age and sex
500
450
400
350
300
250
200
150
100
50
0
Total
2-5 yr
6-11 yr
12-19 yr
Boys
Girls
CDC/NCHS -- March 2012
Percent of total calories
by sex and age
20
18
16
14
12
10
8
6
4
2
0
Total
2-5 yr
6-11 yr
12-19 yr
Boys
Girls
CDC/NCHS March 2012
Percent of calories from added
sugars by type of food & location
70
60
50
40
Home
30
Away
20
10
0
Beverages
Food
CDC/NCHC March 2012
Sources of All Simple Sugars
Present in Children’s’ Diets
RTE cereals, 5.1%
Fruits, 13.3%
Sugars and sweets
including candy, 11.9%%
(15.4%)
Vegetables, 2.1%
Carbonated soft
drinks, 16.8%
Milk, milk products,
22.2%
(49.5%)
(29.1%)
Fruitades and other beverages,
12.6%
Source:
Bell Institute for Health & Nutrition
Meat, poultry, fish and
mixtures, 1.4%
Cakes, cookies, pies
and pastries, 8.2%
All other grain products,
5.5%
Misc. = 0.9
NHANES 2001-02
HFCS: the evil of the
moment
• 2 basic kinds:
 HFCS 42: 42% fructose
 HFCS 55: 55% fructose
• Cane sugar (sucrose):
 50% fructose
• Take-away message: HFCS is really not
high in fructose
What IS high in fructose:
• Apple juice:
 65% fructose, 35% glucose
• Pear juice:
 74% fructose, 26% glucose
Sugar, HFCS, and obesity?
• Evidence suggests
otherwise
• IOM report (2002):
 Higher intakes of sugar are
associated with lower rates
of obesity
 “No clear and consistent
association between
increased intake of added
sugars and BMI.”
Sugar & HFCS and obesity -- NOT
• Inverse relationship found between sugar
intake and bodyweight or BMI:
 Saris (2003)
 Hill & Prentice (1995)
• Inverse relationship between total sugar
intake and total fat intake:
 Gibson (1996)
Sucrose and weight loss, satiety
• 42 women – two groups
 All on low-fat, low calorie diets
 1 group consumed 43% of energy as sugar
• Result:
 No differences in weight loss, mood, hunger,
stress level
 Equal decreases in BP, %BF, plasma lipids
Surwit, AJCN 1997
Sugar & hyperactivity:
How the rumors started
• Case study of 1 child by Crook (1974)
 Sugar was removed, behavior improved
• Controlled studies unable to replicate
results
Sugar and behavior
• Negative associations generally dismissed
by the scientific community1
• Perception of sugar by parents and
consumers continues to defy years of
sound science and logic.
• Some evidence that behavior is positively
affected by sugar.
1 – IOM, Dietary carb, 2002
Meta-analysis by
Wolraich, et al (1995)
• 23 studies
 Double blinded, placebo-controlled
 Known quantity of sugar
 Reported statistics useful for computing
dependent measures
Meta-analysis by
Wolraich, et al (1995)
• Conclusion:
 “Sugar does not affect the behavior or
cognitive performance of children. The
strong belief of parents may be due to
expectancy and common association.”
In fact…….
Sugar can even IMPROVE
behavior and performance
• Decrease in activity after sucrose1 or
glucose2
• Sugar-containing snack can enhance
ability to stay on task3
• Glucose enhances long-term verbal and
spatial memory4
1 – Behar et al (1994); 2- Saravis et al (1990)
3 – Busch et al (2002); 4- Sunram-Lea et al (2001)
But….
THE DUMBEST
FIGHT IN SCHOOL:
CHOCOLATE MILK
Based on Consumer Self-report Data,
Americans Under-consume Dairy
Pyramid Servings of Dairy (Milk, Cheese, Yogurt) in Average Day
3.0
2.5
2.07
2.0
1.85
1.74
1.42
1.5
1.0
0.5
0.0
36
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Source: NPD Nutrient Intake Database
(Self-reported consumption); Years ending
February
Kids 2 to 5
Kids 6 to 12
Teens 13 to 17
Adults 18+
Suburban Connecticut
• Sept/Oct/Nov: 2007 vs. 2008
 2007: FF and LF milk, white & chocolate
 2008: FF and LF milk, white only
• RESULT:
 Declines in milk consumption, 35-62%
JADA, 2009
WHEN FLAVORED MILK
“DROPS-OUT”…
•
•
•
•
58 elementary & middle schools
7 school districts across the country
Flavored milk was eliminated
Also studied:
 # of cartons chosen
 Amount of milk consumed
2010, Milk PEP
…KIDS SPEAK
WITH THEIR HANDS
Cartons
chosen
Actual
consumption
0%
-5%
-10%
-15%
-20%
-23%
-25%
-30%
-35%
-40%
2010, Milk PEP
-35%
“They’ll just adapt”
-28%
-30%
-32%
Year 1
Year 2
-34%
-36%
--NOT!
• They adapt to NOT
having milk
• They ALSO miss on:
 8 gm protein
 1/3 daily calcium
 8-oz. fluid
-38%
Change in
consumption
2010, Milk PEP
Wansink & Just
• Two cafeteria lines:
 Typical meals
 “healthy express”
• Add low-fat chocolate milk to
healthy express line:
 18% increase in better-for-you foods
 28% decrease in low-nutrient foods
Harvard:
“Kids’ll drink what’s there”
• 4 schools, suburban Boston
• 2 schools: regular menu, white & flavored
milk
• 2 schools, “chef assisted”, white milk, with
flavored milk 2 days/week
• Measures: milk intake during two days,
after 2 years
Devil’s details
• Intake measured over 2 days
• Chef-assisted schools offered flavored
milk on ONE of the two days
• Intake not broken down by day, so no
info on consumption difference on
flavored milk vs. white milk days.
Emotion:
“40 cal/day of sugar = 11 lb/yr”
• Are the 35% of kids who skip milk losing
weight?
• So…..
80 FEWER cals/day = 22 lb LOSS/year?
Flavored milk: FACT
• 2763 children 6-11 years
1125 teens, 12-17 years
• 3 groups:
 Non-consumers of flavored milk
 0-240 g
 >240 g
Johnson, R et al, 2002, JADA
Flavored milk drinkers had:
• More calcium ~100-150 mg/day
• No additional intake in added sugars
• Lower intake of soft drinks/fruit drinks
Johnson, R et al, 2002, JADA
Sugary drinks
How much are they getting?
Where’s it coming from?
Daily calories from sugar drinks
300
250
200
Male
150
Female
100
50
0
2-5 yr
6-11 yr
12-19 yr
20-39 yr
40-59 yr
NCHS Data Brief #71 August 31, 2011
Where are kids getting their
sugary drinks?
Away from home (48% of all sugar drinks)
20.3
1.4
43
Store
Rest/Fast fd
School/Day care
Other
35.5
NCHS Data Brief #71, August 31, 2011
Discretionary calories:
How much is too much?
1400 cal/d 2000 cal/d 2400 cal/d
Total DC
171 cal
267 cal
362 cal
From fat
14 g
18 g
22 g
From sugar
16 g
32 g
48 g
Ref: 2005 US Dietary Guidelines for Americans
Discretionary calories
“…small amounts of sugars added to nutrient-dense
foods, such as breakfast cereals and reduced-fat milk
products, may increase a person’s intake of such foods…
thus improving nutrient intake without contributing
excessive calories.”
e.g. to drive the consumption
of nutrient-rich foods
2005 US Dietary Guidelines for Americans
The sugar shake-down
• Sugar’s not “angel food” but it’s not
“devil’s food” either
• It does NOT get kids “hyper”
 More likely to be situational
• Not a matter of “good” or “bad” but “how
much” and “how often”
REMEMBER THE GOAL
HEALTHIER CHILDREN
Keith-Thomas Ayoob, EdD, RD, FADA
Associate Clinical Professor of Pediatrics
Albert Einstein College of Medicine
Bronx, NY
718-430-3970 x6412
[email protected]
http://www.usnews.com/debate-club/should-sugar-beregulated/consumers-need-to-be-empowered-not-made-intovictims