NUTRITIION CONTROVERSIES:Tackling tough topics with facts,

not emotion

Keith-Thomas Ayoob, EdD, RD, FADA, CDNAssociate Clinical Professor of Pediatrics

Albert Einstein College of MedicineNew 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”

A R T I F I C I A LC O L O R S

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 Composition

N = 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

• 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

SUGARSUGARSUGAR

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

Boys Girls0

50

100

150

200

250

300

350

400

450

500

Total2-5 yr6-11 yr12-19 yr

CDC/NCHS -- March 2012

Percent of total calories by sex and age

Boys Girls0

2

4

6

8

10

12

14

16

18

20

Total2-5 yr6-11 yr12-19 yr

CDC/NCHS March 2012

Percent of calories from added sugars by type of food & location

Bev-er-

ages

Food0

10

20

30

40

50

60

70

HomeAway

CDC/NCHC March 2012

NHANES 2001-02

Sources of All Simple Sugars Present in Children’s’ Diets

Fruits, 13.3%

Vegetables, 2.1%

(15.4%)

Milk, milk products,22.2%

Meat, poultry, fish andmixtures, 1.4%

All other grain products,5.5%

(29.1%)

Cakes, cookies, piesand pastries, 8.2%

Sugars and sweetsincluding candy, 11.9%%

Carbonated softdrinks, 16.8%

Fruitades and other beverages,12.6%

(49.5%)

RTE cereals, 5.1%

Misc. = 0.9

Source:Bell Institute for Health & Nutrition

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

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090.0

0.5

1.0

1.5

2.0

2.5

3.0

1.741.85

2.07

1.42

Kids 2 to 5Kids 6 to 12Teens 13 to 17Adults 18+

36

Pyramid Servings of Dairy (Milk, Cheese, Yogurt) in Average Day

Source: NPD Nutrient Intake Database (Self-reported consumption); Years ending

February

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

Series1

-40%

-35%

-30%

-25%

-20%

-15%

-10%

-5%

0%

-23%-35%

Cartonschosen

Actual consumption

2010, Milk PEP

“They’ll just adapt” --NOT!

Se-ries1

-38%-37%-36%-35%-34%-33%-32%-31%-30%-29%-28%

Year 1Year 2

• They adapt to NOT having milk

• They ALSO miss on: 8 gm protein 1/3 daily calcium 8-oz. fluid

2010, Milk PEP

Change in consumption

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

2-5 yr 6-11 yr 12-19 yr 20-39 yr 40-59 yr0

50

100

150

200

250

300

MaleFemale

NCHS Data Brief #71 August 31, 2011

Where are kids getting their sugary drinks?

43

35.5

1.4

20.3

Away from home (48% of all sugar drinks)

StoreRest/Fast fdSchool/Day careOther

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 PediatricsAlbert Einstein College of Medicine

Bronx, NY718-430-3970 x6412ktayoob@msn.com

http://www.usnews.com/debate-club/should-sugar-be-regulated/consumers-need-to-be-empowered-not-made-into-victims