How Can We Improve Nutrition and Public Health?

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I recently read a couple of articles, one from a newspaper and another from a journal, that talked about South American countries and how their governments should deal with the obesity epidemic and how some are approaching this issue. There may be lessons we can use here for us in the U.S. and other parts of the world.

Some historical perspective: the last public health initiative that actually worked well in the U.S. was during WWII. To direct more meat to the people fighting the war, the government enlisted any and all means to convince the public that organ meats were actually delicacies. Instead of a simple call to support the war movement, the pitch was to help consumers understand how organ meats such as brains, intestines, liver, and kidneys were nutritious. Along with that, they provided recipes for how to prepare these special parts of cows and pigs. It worked and those cuts were really considered delicacies. After the war ended, the special nature of these parts gradually drifted away.

In my opinion, that was the most successful public health education program ever done. When you consider all that’s been done related to educating the public about cholesterol, fat, trans fat, and sugar, nothing has ever gotten people to change their habits; the nutrition facts label is often more confusing that helpful. It’s obvious we need help, but what and how? We’ll take a look at what these countries in South America have tried on Thursday.

What are you prepared to do today?

        Dr. Chet

The Bottom Line on Sugary Drinks and Cancer

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The question is simple: do we avoid all sugary drinks, including fruit juices? The best I can come up with is to withhold judgment and don’t get excited about it for now. Let’s take a look at what the concerns of the researchers were and then my concerns.

Researchers’ Concerns

The first is that the NutriNet-Santé study was not a randomized sample. That means that only those people who were interested in participating for whatever reason did so. The sample was predominantly women at 78.7% of the cohort with a mean age of 42 years. The researchers accounted for age and gender in the statistical analyses, but that doesn’t account for the lack of randomization.

Researchers also stated that the rate of cancer was much lower: 620 of the 100,000 people in the study compared with 972 per 100,000 people in all of France. They adjusted the numbers to reflect the age and gender distribution in France, but I used the numbers actually given in the study. They also said the diagnosis of cancer was self-reported. I can’t believe anyone would say they have cancer if they don’t, but it would have been better if it were verified.

Related to that, some cancers were limited, thus affecting the statistics. If you don’t have enough of any type of cancer, it’s difficult and scientifically shaky to calculate a relationship.

Younger subjects consumed higher amounts of sugary drinks than older subjects. There were other factors as well, but these also were taken care of statistically. Further, they acknowledge what I alluded to: when people self-report, they can over- and under-estimate their intake. They also chose only the subjects that had at least two diet records completed in the first two years; the potential was 10 if all records were completed by all subjects. That seems low to me—there’s too much missing data.

Finally, this was an observational study and thus cause and effect can’t be attributed to the results. But it does raise questions.

My Questions

I think they could have gone a long way to answering the question about sugar intake if they had compared the fruit intake with the juice intake: take the fruit intake, calculate the sugar content, then match it with juice intake with the same sugar content. What was the rate of cancer in each group? Doing the direct comparison could go a long way to suggest whether it’s the sugar alone or if the effects were ameliorated with the fiber and phytonutrients of whole fruit with the same amount of sugar. That’s an obvious question; this is an ongoing study so maybe they’ll do that in the future.

I also think that running a comparison of total carbohydrate intake could also give us insight. If someone had a high carbohydrate intake, especially if it were high in refined carbohydrates, that might be meaningful as well.

The Bottom Line

The question I was left with was this: how could less than a half-cup per day of any type of added sugary drink that contained fewer than 50 sugar calories cause an increase in cancer? It just doesn’t make any kind of sense when you consider the total mean average calorie intake of the subjects was 1,850 calories. If the total sugar intake from solid foods of the individuals was high, or it was highly refined carbohydrates, that could make a difference. That analysis wasn’t done.

At this point, I wouldn’t stop drinking a glass of fruit juice or adding some juice to a smoothie. Don’t go out of your way to drink more fruit juice, but don’t avoid it either; certainly you should choose fruit juice from whole fruit over soda with sugar. If you have an artificial sweetener you like, use that instead of sugar. As for other drinks that contain sugar, they’re highly refined carbohydrates so you should be keeping those under control anyway. While this was an interesting and controversial report, nutrition is still about balance. Keep that in mind as you choose what you eat and drink every day.

What are you prepared to do today?

        Dr. Chet

Reference: BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2408.

Finding the Cancer Risk in Sugary Drinks

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In Tuesday’s Memo, I reviewed the methodology of the NutriNet-Santé study in France. As I suggested, it was solid. The sugary drink choices included fruit juices, sodas, sugar-sweetened hot and milk beverages, sports drinks, and energy drinks. In terms of the data collection, I can’t think of anything they could have done better.

Turning to the statistical analysis, it was complicated to say the least. The use of high-speed computers allows for many statistical analyses to be done in short order, even with over 100,000 subjects. My only concern is that, as they did the trend for hazard ratios, they adjusted for many variables including age, gender, energy intake, and family history. How many variables? About 24 in all by my count. That’s not necessarily wrong, but there are some that would seem obvious such as total carbohydrate intake from all foods, and percentage of calories from carbohydrates other than vegetables and fruit.

Another way of analyzing the data was something I’ve done before, and that’s compare the rate of cancer to the national cancer statistics in France. In this case, the rate of cancer in France is 0.95% while it was 0.87% in the unadjusted data from the study. That’s very close and a bit lower than the national average.

Must we avoid even a half-cup of fruit juice per day? Is the sugar in your coffee or sweet tea causing a significant increase in your risk of getting cancer? I’ll let you know on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2408.

Is There a Link Between Sugar and Cancer?

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Sugar has been in the news with the publishing of the latest results from the NutriNet-Santé study from France. The headlines of press releases suggest that drinking as little as four ounces of a sugary drink, including fruit juice, per day was related to an increased risk of getting cancer. Sugary drinks of all types except fruit juice were associated with an increased risk of getting breast cancer. These were all hazard ratio trend analyses; as the consumption increased, so did the risk of cancer.

If you read the Memos regularly, you know my approach is to always check how the data were collected. In this study, they used three 24-hour dietary records that included two weekdays and one weekend day. The diet records were done every six months throughout the duration of the follow-up, about five years. They subjects entered their data online; with over 100,000 subjects, that’s the only way this study could be done.

Of all the types of diet assessments, this is as close to the gold standard as I’ve seen. They had 97 different sugary drinks and 12 artificially sweetened drinks that were possible choices with very detailed descriptions and photos of drinks to help assess portion size. The only step they didn’t take was to have the records checked by a dietician before the subjects entered their data online. The methods in this study were solid compared to just about every other study I’ve talked about.

Should we avoid all sugary drinks at this point? More on Thursday. Tomorrow is the July Insider Conference call; this is your chance to learn more about nutrition and get your questions answers. You can still be included, so check out memberships right now.

What are you prepared to do today?

        Dr. Chet

Reference: BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2408.

MSG Is Safe, But Be Wary

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The controversy regarding MSG certainly won’t end with this Memo, but I want you to know what the research says so you can make an informed decision. There’s no question that some people have sensitivities to certain food additives, and I’m not diminishing that response in any way. My point in doing this series of Memos was to dispel myths that have grown around some food additives such as MSG.

Why was the early research wrong? The Chinese Restaurant Syndrome grew from a single physician who described how he felt after eating Chinese food. More case studies were published, then small trials that seemed to support the observation. As time went on, trials with better controls over subjects and their reactions were done to test those responses attributed to MSG.

Regarding the excitotoxic brain damage, for the most part, that research injected glutamate (and not MSG) directly under the skin or directly into the digestive system. Because of its importance in so many chemical reactions, glutamate is tightly regulated and does not cross the blood-brain barrier. In other words, the research could have been done better. When it was, the results of those studies could not be duplicated.

Where does that leave you? Reading labels, I hope. I just checked the label of smoked ham: no MSG but there were at least three different sources of sodium. Same was true for beef jerky. That contributes to the high sodium intake we all have if we eat those foods.

You can’t really get away from MSG anyway; it’s naturally found in so many foods such as meats, cheeses, and even in tomatoes. There could be a benefit to using MSG: it may lower your overall sodium intake because it takes a lot less MSG to give the umami flavor than salt does.

But be wary. Umami flavor can become addictive. You know those chips I like so much? Some have MSG added, and they’re tough to eat in reasonable amounts. It may be best to avoid them altogether unless you can control the quantity you eat. That was why MSG was thought to cause weight gain; by itself, it doesn’t but it can cause a person to overeat, and that for sure will increase body weight.

Like anything else, unless you’re allergic, MSG can be a part of a reasonable diet to add flavor to food. If it helps make people want to eat broccoli and cabbage, I’m all for that because the benefits of the vegetables far outweigh any harm from the sodium.

Don’t forget to let me know if you’ve ever had a negative reaction to MSG. I’ll give the results next week.

What are you prepared to do today?

        Dr. Chet

References:
1. Questions and Answers about MSGhttp://bit.ly/32tvELS.
2. N Engl J Med 1968; 278:796.
3. Science. 1969 May 9;164(3880):719-21.

Early Research on MSG

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People have been ranting against MSG for decades, but I never paid attention until I read a study on a group of subjects who said they had a negative response to eating Asian foods. The subjects were tested under four scenarios consecutively, dependent on their response to the prior test results. The study demonstrated that when exposed to massive amounts of MSG versus a placebo, there were no consistent responses from this sensitive group of subjects. That’s meaningful because it challenged common knowledge.

That common knowledge began with a letter to the New England Journal of Medicine by a physician after reporting symptoms he felt after eating a meal of Asian foods; it wasn’t research, just a personal anecdote. At the same time, a researcher from Washington University in St. Louis began a series of studies on glutamate and other protein precursors that demonstrated the excitotoxicity affects on brain tissue; excitotoxicity (ex-SIGHT-o-tox-ISS-i-ty) refers to nerve cells being damaged or killed by excessive stimulation by the neurotransmitter glutamate. That was when the bulk of the negative research on MSG drew attention. However, over a period of years, other researchers attempted to duplicate those studies with unsuccessful results.

Where does that leave us? Other than a variety of conspiracy theories, MSG doesn’t seem to have the negative impact that has been attributed to it. I’ll finish this up on Saturday but my original question still stands: if you feel you respond negatively to MSG, reply to this email and I’ll let you know the results next week.

What are you prepared to do today?

        Dr. Chet

References:
1. N Engl J Med 1968; 278:796.
2. Science. 1969 May 9;164(3880):719-21.

A Closer Look at Monosodium Glutamate

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People these days love salty, and as I’ve said before many times, I especially love salty: nuts, chips of any kind, cured meats such as ham. I believe if bacon weren’t salty, it wouldn’t be as popular as it is. Mix salt with amino acids, especially glutamine, and it creates a taste called umami. It’s an almost irresistible flavor that some people, if not most, can’t stop eating.

Now what if I told you that monosodium glutamate (MSG) had been added to those specific foods to give it that umami taste? (It hasn’t, so don’t throw out the bacon or jerky just yet.) What would you think then? You might not be so enamored with those foods because MSG has been linked to headaches and brain dysfunctions. Some people attribute symptoms of allergic reactions to MSG that include breathing issues, the aforementioned headaches, and many other neurological-type issues.

Would you believe that MSG probably doesn’t cause those symptoms in most people? That the “research” showing that MSG is bad was poorly done, and to some degree, wasn’t even really research? For sure, you don’t want to miss Thursday’s Memo. Until then, let me know if you’ve responded negatively to MSG by replying to this Memo.

What are you prepared to do today?

        Dr. Chet

Reference: Questions and Answers about MSG http://bit.ly/32tvELS.

That Sugar Film: A Fantasy

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Let me clear up a few things right away. I’m not a fan of overeating sugar, whether pure cane sugar or high fructose corn syrup. But glucose is the perfect fuel because it burns completely with only carbon dioxide and water as the by-products. I think what everyone should do is respect glucose for what it can do and what overconsumption can do: make us fat—but no more than the other carbohydrates we over consume. With that in mind, let’s take a look at the filmmaker’s weight gain.

He claims to have eaten the equivalent of 40 teaspoons of sugar a day, keeping his calories the same as his regular diet, and gaining almost 20 pounds. My simple opinion is: bull. People in the movie spent some time suggesting that a calorie is not just a calorie, that somehow you can get more from sugar. I’ll address that in a moment. The real problem is that while he thinks he didn’t over eat, he absolutely must have to gain close to 20 pounds in two months. Period. I’m not suggesting he intentionally lied, but I watched him eat and he was not measuring much of anything. Unless you weigh or measure, you can’t say that you ate what you claimed you ate.

But let’s say that he was correct, that he ate 2,300 calories per day with 800 calories coming from sugar. What that would require was somehow more calories are extracted from sugar. My question is how? To go molecular for a second, the energy we get from food is the energy stored in the chemical bonds of the food; if we take in more fuel than we need, the body stores the extra energy as fat. If sugar has only so much energy stored in the chemical bonds, how can it release more? Glucose or fructose, doesn’t matter. That would require some form of unknown chemical reaction that could create energy. That doesn’t happen in any biochemistry of food I’ve ever studied. If it could, it would come at a cost, an energy cost somewhere.

The idea that a calorie is not a calorie has always been a foolish argument because there’s no chemistry to support it. We cannot make more energy than we begin with. The only way he gains 20 pounds is he overate. A lot.

He spends a lot of the movie talking about sugar spikes and falls that made him “addicted” to sugar. I’ve never seen anyone drink that much fruit juice, to the extent that it wasn’t reasonable. I asked on Facebook how sugar affects people who drink juice or any other form of sugar, but not sodas. The results were 1:3 against a sugar rush of any kind. I also included physicians and other healthcare professionals. Was it a formal study? No. And neither was what the author did to himself in this film.

To me, his film was a real work of fiction. Add it to your collection of fantasy films.

If you reduce the amount of sugar in your diet after watching this film, that’s great. You really can’t go wrong getting your calories from better nutritional choices. But don’t base your decision on this pretend research.

What are you prepared to do today?

        Dr. Chet

That Sugar Film: The Results

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I hope that this sunk in on Tuesday: Damon Gambeau, the filmmaker, was going to eat 40 teaspoons of sugar per day. The rest of the story was that he was not going to eat cakes and cookies or drink full-sugar soda. He was going to eat what might be considered health foods: low-fat yogurt, fruit juices, whole grain cereals with sugar added, and other things with Australian names I don’t recognize. By the end of each day, it had to equate to 40 teaspoons of sugar or about 168 grams, not counting all the other carbohydrates.

What happened after 60 days? One of his liver enzymes was off, up 20 points over the safety level, which was never really explained. His triglycerides were up significantly, from about 60 mg/dl to 132 mg/dl. While that’s up, it’s not really abnormal for a fasting triglyceride level.

The real change was in his weight. Based on weigh-ins, he gained 19.8 pounds in 60 days. He also gained 10 cm around his waist—that’s close to four inches. And here is the kicker: his estimated caloric intake before the self-study was around 2,300 calories per day. He claims that his caloric intake remained at 2,300 calories per day throughout the experiment. All the experts went nuts. Taubes said it’s got to be the sugar. Another said sugar has to be the problem.

Oh, really? I’ve got some comments on that on Saturday—and you won’t want to miss them.

What are you prepared to do today?

        Dr. Chet

Review: That Sugar Film

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Summer gives us a chance catch to up on reading or binge watch a television series, so I thought I’d watch some of the nutrition documentaries that I’ve been asked about. I’ve done some in the past such as Forks Over Knives. It gives me a chance to check the facts on what’s said and how true or relevant it is. That’s the case with the film titled That Sugar Film. It was written, directed, and starred in by an Australian filmmaker Damon Gambeau. Hugh Jackson even performed the opening scene.

The premise of the movie is that all sugar is bad. There was at least one anti-sugar and ketogenic diet proponent in Gary Taubes author of Good Calories, Bad Calories. The filmmaker also assembled a team of experts who were going to provide information and medical supervision during an experiment he wanted to conduct on himself. The experiment was to see how a high-sugar diet, one typical of the average Australian, would impact him. Based on what he claimed to eat, he was somewhere between the paleo diet and the ketogenic diet before that.

There was the requisite discussion of the cholesterol hypothesis and how fat was chosen as the demon to avoid instead of sugar as they relate to heart disease. The sugar industry conspiracy was also talked about in the same vein as the tobacco industry. But it’s what he did to himself that was by far the most interesting: switching to a diet that contained 40 teaspoons of sugar a day for 60 days. What happened to him? That’s coming on Thursday.

What are you prepared to do today?

        Dr. Chet