HOW TO PREVENT CANCERS

Our expert: Dr Therese O'Sullivan

You've probably heard it all of your life – breakfast is the most important meal of the day.

And research shows eating something before you bolt out the door in the morning – be it porridge, poached eggs or peanut butter on toast – can help to boost your concentration, energy levels and set you up for better eating throughout the day.

You've probably also been told eating breakfast will help kickstart your metabolism – helping you burn energy efficiently and avoid weight gain.

But is eating breakfast really necessary to get your metabolism going? (And what does this mean anyway?)

There is no clear evidence breakfast can significantly affect your metabolism, says Dr Therese O'Sullivan, senior lecturer in nutrition and dietetics at Edith Cowan University.

But what is clear is breakfast has other benefits.

"From observational studies what we see is people who eat breakfast also tend to eat a healthier overall diet, one that is more nutritious and higher in fibre. People who skip breakfast are more likely to miss out on important nutrients," O'Sullivan says.

Your metabolism involves all the chemical processes going on inside your body that keep you alive and functioning. These processes include breaking down the food you eat into nutrients as well as those necessary for the building and repairing your body.

The food you eat provides your metabolism with the energey it requires to carry out these processes, take in more than you need and your body stores it. But your metabolism also affects the amount of energy your body needs at any given point.

Your metabolism can be divided into three components:

basal metabolic rate (BMR), which is the amount of kilojoules your body burns to maintain functioning at rest. This accounts for 50 to 80 per cent of your overall energy requirements.the energy you use when physically active, this accounts for 20 per cent of your daily energy use, and contributes to your metabolism in terms of the amount of energy the body needs to burn.thermic effect of food, which is the energy you need in order to eat, digest and metabolise your food.

One possible explanation for why so many of us believe breakfast affects our metabolism is due to the way our metabolism responds when we go long periods without food.

O'Sullivan says randomised controlled trials have shown the metabolisms of people on starvation or crash diets slow down to conserve energy, which means their BMR can drop by up to about 15 per cent.

As well, when people lose weight quickly during long periods without food they also lose lean muscle tissue or muscle mass, which can also contribute to a reduced metabolism. Most of your basal metabolic rate is determined by the amount of muscle you have, so the more muscle you have the faster your metabolism is.

However, O'Sullivan says, studies looking at the effects of reduced food consumption on your metabolism were conducted over a period of 10 days to a month. So while it is possible a shorter fast – such as that we do every night when we sleep – may have a similar impact, there is no solid evidence at the moment to support this, she says.

As well as the amount of muscle mass you have, there are a range of other factors that will affect your metabolism.

Age – As you get older your metabolism generally slows, this is thought to be because of a loss of muscle tissue, and also hormonal and neurological changes. When babies and children go through periods of growth, their metabolism speeds up.

Gender – As men are usually larger than women, they generally have faster metabolisms.

Body size – People with bigger bodies tend to have a larger BMR.

Genetics – This can also play a role in whether you have a slower or faster metabolism, and some genetic metabolic disorders can also affect your metabolism.

Physical activity – Regular exercise increases muscle mass and encourages your body to burn kilojoules at a faster rate, even when at rest.

Hormonal factors – Hormonal imbalances caused by certain conditions, including hypo- and hyperthyroidism, can affect your metabolism.

Environmental factors – The weather can also have an effect on your metabolism – if it is very cold or very hot, your body has to work harder to maintain its normal temperature and that increases the metabolic rate.

Drugs – Caffeine and nicotine can increase your metabolic rate, while medications including some antidepressants and anabolic steroids can contribute to weight-gain regardless of what you eat.

Diet – Certain aspects of your diet can also affect the metabolism, for instance if you don't have enough iodine for optimal thyroid function it can slow down your metabolism.

While none of the factors known to affect your metabolism appear to be strongly linked to breakfast, it doesn't mean you should skip it.

People who don't eat breakfast may miss important nutrients needed for the day, and are less likely to make up for it later on, says O'Sullivan.

"If you don't have any breakfast you may be hungrier than usual around mid-morning, and the hungrier people are, the more likely they are to go for energy dense snacks," she says.

"When you're really hungry you're more likely to make choices that are more energy dense, and that may be foods that are less nutritious," O'Sullivan says. "It's important to keep a range of healthy snack options on hand like nuts, fruit and yoghurt."

Dr Therese O'Sullivan is a senior lecturer in nutrition and dietetics at Edith Cowan University, she spoke to Jenny Pogson.

Published 25/11/2013

In Sunday's New York Times, the editors ask prominent economists to weigh in on how to face the economic challenges ahead of us in 2012.  Richard Thaler, of the University of Chicago, who wrote (with Cass Sunstein) Nudge, the best selling book on behavioral economics argues that employers have the opportunity to tackle one of our biggest challenges, health care spending.  Employers are choice architects - they can make changes in how choices are offered that make one choice easier, or the default.  Thaler argues that by making a few changes, employers can improve workers' health, leading to greater productivity, fewer sick days, and lower insurance costs.


First, Thaler argues, make eating at work easier, by prominently featuring a variety of healthy options and putting in an attractive salad bar before the burger line.  How might this look in real life? Let me use the cafeteria at my office as an example.  

There are at least four cafeterias on our hospital/medical school campus and they aren't all run by the same people, so the situation likely looks different on the other side of campus, but this is what it looks like in the cafeteria that sits right under my office and nearest the cancer center.  The first thing you see when you walk in, is the grill/fry-o-later area.  Serving up burgers, hot dogs, fries and onion rings, it invariably has a long line, which makes it easy to miss that there is a sandwich counter immediately to your left.  The sandwich counter is hidden behind a high wall and camouflaged further by shelves of chips and candy, so unlike in many sandwich shops, you can't see the choices.  You can see two featured sandwiches.  Sometimes one is healthy, but not always.  Just past the sandwiches (and around the candy display) is the hot meal counter, which features one Weight Watchers entree each day.  This may reflect my own food preferences, but I rarely find this entree to look very appetizing or particularly healthy (I realize “healthy” can have lots of different meanings, but something high in cheese and refined grains rarely meets my metric).  To the far right of the sandwich bar is the pizza station, which usually features 3-5 types of pizza (most laden with meat) and another cheesy doughy option, like calzone, daily. Across from the sandwich bar is the featured entree special of the day.  The days I've visited in recent memory this has been: nachos loaded with ground beef and processed cheese of the orange variety ( which I confess to finding appealing on Super Bowl Sunday, but I'm not kidding myself about it fitting in the healthy realm and I accept the health consequences of my choice), and beef stir fry laden with sauce of the kind women's magazines regularly tell readers to avoid choosing when dining out, roast beef covered with gravy and accompanied by mashed potatoes. Just past the featured entree is the salad bar. I think most cafeterias these days have a salad bar, but having a salad bar and having an “attractive” salad bar are not the same thing. To their credit, since I started at my office nearly 5 years ago, the cafeteria has added mixed greens and baby spinach as daily options, offering something other than the white-ish iceberg lettuce of the early days. And there are proteins in the salad bar choices - typically hardboiled eggs, one type of canned bean and diced turkey or tuna. But the salad bar is a long way from what I’ve seen else where and a long way from allowing you to create the kind of salad you might get down the street at one of the neighborhood sandwich shops. Dried fruit? Nope. Other kinds of fruit? It is on the other side and is charged at a different rate. Nuts? No, but there are sunflower seeds. Cheese? Yes, there is usually grated orange cheese. I give the cafeteria credit, I can definitely create a greek salad for myself that rivals that fancy sandwich shop on the corner (with the possible exception of the tomatoes that always look a bit iffy) at a fraction of the cost. But it doesn’t look “attractive” and I’ve got to do all the work, which perhaps explains why there is never a line at the salad bar and I am 10 times more likely to see the people in front of and behind me at the checkout with fried chicken than a salad. This, I think, gets to the fundamental point - if you want people to make the healthy choice you have to make it easy and attractive.

What about Thaler’s other suggestions? His second is making exercise easier. The health benefits of exercise, as we have said many times on CNiC, don’t require marathon duration or rigor. Walking is enough. And many employers subsidize gym memberships or arrange discounts, including mine. But you shouldn’t have to leave work to get a little walk in - making stairwells attractive is one way and the suggestion Thaler focuses on. In our conglomerate of old and new buildings, my workplace has lots of unattractive stairwells that are often hard to find. At a previous job, I had the privilege of sitting on a committee that was thinking about how to design a new hospital building and one of the most compelling ideas I heard was to make the stairwells front and center - highly visible and the easiest choice (instead of pushed off into the corner and behind a heavy metal door). One of our newest buildings on campus, which also serves as the home to our outpatient cancer care, has a lovely open stairwell at one end of the building, easily visible from the entrance. I enjoy seeing staff using the stairs and leaving the elevators to our patients, many of whom aren’t well enough to climb the stairs to the upper floors of the building. As we embark on a series of renovations and construction of new facilities as part of the 10 year plan, I look forward to seeing how our leadership makes stair use an easy option. In addition, our campus has launched a series of paths around the area (affectionately called “Tread the Med”) to allow staff and visitors to take walking breaks or have walking meetings (as Thaler plans to do in 2012). We have often used these exact “paths” around campus for our walking interventions during inclement weather and they are a great resource. I applaud the leaders who thought to leverage the bridges and hallways that link our conglomerate of old buildings as a means to promoting activity! Combined with easily located, accessible and attractive stairways, our step counts on campus should continue to rise.

Since most Americans spend more waking hours at work than at home, the role of our employers and workplaces at making healthy choices easy (or at least easier) can’t be underestimated. As part of our new TREC @ WUSTL center, our colleagues are examining just this - workplace policies that impact obesity, diet and physical activity.

As anyone who's ever been on a diet knows: taking the pounds off can be hard, but keeping the pounds off can be even harder.  The main reason for this simply seems to be that it's just easier to keep up with a new exercise and diet program over the short term than it is over the long-term.  While we may be willing to sustain ourselves on some wild, restrictive diet for a few months, especially if the pounds start to melt away, over time it gets harder and harder to keep it up, and eventually our old habits, our old ways of doing things, slowly bubble back to the surface, and we find ourselves putting the weight back on.

This is why most experts suggest making a small number of small changes when it comes to weight loss.  Taking baby steps gives us time to get our footing with a new behavior, with a new approach to eating, and helps it to actually become part of our lifestyle rather than a strange restriction that needs to be endured and then eventually discarded after three months because its so unpleasant.

In this vein of small changes breeding long term success is a Danish study in the latest issue of the New England Journal of Medicine that shows that small differences in the make-up of what eat can help maintain real weight loss over time.

In this study, about 800 overweight participants who had recently lost weight were randomly assigned to one of five diet groups - each group had a varied combination of protein level and glycemic load, a measure of how quickly the carbohydrates in the diet are converted to glucose in the blood (study).  Diets with high glycemic loads (such as those with a lot of white bread, potatoes, and white rice) have been shown in some studies to increase the risk of weight gain as well as heart disease and diabetes.  Diets with a low glycemic load (such as those with a lot of whole grains or low amount of carbohydrates) may help keep calorie intake in check and promote feelings of fullness.

The researchers found that the group who ate a high protein, low glycemic load diet had the most success keeping weight off over time.  Those who ate a low protein, high glycemic load diet did the worst.  Worth noting: those who ate the high protein, low glycemic load diet not only had the most weight loss success but also had the highest rate of adherence of any group, meaning more people in this group were more likely to keep up with that way of eating than in any other group.

While the weight benefits were pretty modest, with participants in the high protein, low glycemic group weighing an average of about 4.5 pounds less over six months than those in the low protein, high glycemic group, it is a real difference that if sustained over time could have a big impact on health, both for the person, and on a broader scale, the nation.

Although this is just a single study, what's most heartening from these results is that maintaining the new weight after weight loss, and even continuing to lose weight, seems possible over the long term with a diet that isn't that radical and that's enjoyable enough to continue over the long term.

A healthy high protein diet with a low glycemic load would include foods like skinless chicken, fish, beans, low fat dairy as well as whole grains and brown/wild rice.  Healthy fats, like canola oil and olive oil, also help keep glycemic load down because they slow down digestion.  Red meat, high-fat dairy, and refined grains should always be kept to a minimum.

Related CNiC Posts:
Weight
Diet
Exercise

There is a fascinating little study out this week in the journal Appetite, which was also highlighted in a piece in The Economist.  What the study found was that dieters, when they felt they were given a larger piece of pizza than other people were for lunch (pieces were actually the same),  were more likely to eat more cookies afterward than the others were.  While it's hard to pin a motivation on exactly why this was, one explanation is that the dieters felt the perceived larger piece of pizza pushed them off their dieting program, which then opened the "might as well" flood gates when it came to eating cookies afterward.

There are a number of possible conclusions to draw from this study when it comes to battling the current obesity epidemic -- all of which would be little more than conjecture.  But, it does highlight the very complex problem we're dealing with it comes to weight gain and weight loss and the important role that external influences can have on our internal cues to eat.

With the food industry spending millions to get us to eat more and more food (most of which is unhealthy), it's important to do what we can to listen to our bodies and understand when we're truly hungry and when we've eaten enough to feel satisfied but not bursting.  It seems like a simple thing but this small study and the growing numbers of people who are overweight and obese tell us its not.

Try these simple steps to get in touch with your internal cues and keep your weight in check:

• Exercise, exercise, exercise.  Being active is one of the best ways of controlling weight.
• Go Mediterranean.  A diet rich in fruits, vegetables, whole grains, and healthy oils (like olive oil) can make you feel full,  help regulate your appetite, and actually taste really good
• Choose smaller portions and eat more slowly.  Slow down and give your body a chance to feel full before you move on to seconds.
• Be a mindful eater.  Food is big business, and their main goal is to get you to eat.  Try to listen to what  your body is telling you, not what the food business wants you to hear.  

Today I hopped over to Forbes.com to review their "most stressful cities" list (and was relieved that St Louis wasn't topping another "bad" place to live list -- I think topping the syphilis list is enough). While I was there, a link to a list of "10 foods you should be eating" caught my eye. I'm always wary of such lists, and this one provided a nice reminder of why:

The list starts out with three great foods - cherries, blueberries and kiwi. All three are great choices because they are fruit and eating a lot of fruits and vegetables have been shown to decrease risk of several diseases, including cancer. The problem, to me, is that most Americans don't come anywhere near to eating enough fruit, regardless of the type. Also, the three fruits are in season for a pretty short period of time, making their cost pretty high the rest of the year. Add to that, the fact that berries tend to top lists of fruits that absorb the most pesticides, so other lists are telling you to only buy organic and you've got a major cost issue on your hands. For most people, just starting to eat 2-3 servings of fruit a day, of ANY fruit, is going to be a big step.

The list then moves on to proteins -- grass-fed beef, wild salmon, flax seed and whey protein powder. While I certainly see the merit of choosing grass-fed beef over industrial beef for the reasons listed (omega-3 content being a big one, environmental impact being another), the context is missing here. Grass-fed beef is expensive and most Americans eat too much red meat of all kinds and certainly don't need beef appearing on a list of things they need more of. If you want to up your omega-3 intake, replace your meat intake with other sources of protein rich in omega-3, like fish and flax seed and aim to reduce your meat intake in general.

The list ends with dark chocolate. With overweight and obesity rates topping 60% in the US, I don't think anyone needs encouragement to eat more chocolate. Granted, the fine print suggests looking for chocolate with at least 60% cocoa content (ruling out most candy bars in the checkout aisle), but portion size and frequency of intake are big issues here and neither is mentioned.

Also overlooked in the discussion is that much of the data supporting the "superfood" concept don't come from studies of people eating those foods. The data come from studies of human cell lines or of extracts of a single component/nutrient that the food is high in. The problem with these studies is 1) that flesh and blood humans are very different from a collection of cells in a petri dish and 2) that the volume of intake needed to reach the dose given to the cells or extracted and given to humans is difficult to achieve through consumption of the food itself.

So, the cold reality is that there are no real "superfoods," just like there are no magic bullets.  It's simply a title dreamed up by magazine editors or folks who don't have a good understanding of the science linking diet and human health.

Of course, overall diet can have a large impact on chronic disease, and making simple, largely inexpensive, changes to what we eat can have big benefits.  Eating a diet rich in fruits, vegetables, whole grains, and healthy fats (like poly and monounsaturated fats); and low in red meat and unhealthy fats (like saturated and trans) will trump any collection of "superfoods" when it comes to health benefits, and it'll likely save you a lot of money along the way.

I wonder if by suggesting that people need to go spend $30 on organic blueberries and eat chocolate to be healthy we actually encourage the status quo as so few people have the ability to spend at this level and so few read the fine print of the message? What do you think? Do these lists help you make healthy choices or confirm that you are/aren't healthy already?

In previous posts, we’ve talked about implementing the weekday vegetarian plan or moving from your farm share box to a meal plan. For those who don’t have a big pile of recipes in the kitchen (or who are at work trying to figure out what to make for dinner that night), the internet is a GREAT resource for just this type of meal planning.

Last week I realized I had a bunch of eggplant from my farm share that I needed to use up. I was at the office, so on my lunch break (of course), I went to a few of my favorite websites for recipes using eggplant. On Smitten Kitchen, I found a recipe for an eggplant and barley salad. I looked through the ingredient list to see how it aligned with my recipe goals:

- Whole grains? Yes – the recipe base is barley, a tasty whole grain. I think you could also substitute brown rice if that’s what you have, but we always have barley in the freezer (which helps keep it from going rancid in the sweltering swampy summer heat of St. Louis).

- Vegetables? YES! In addition to eggplant, the recipe calls for zucchini and tomatoes. Both are in season and were looking fantastic at the Washington University School of Medicine Farmer’s Market last Thursday so I grabbed both.

- Color? Lots of it! Nothing makes a healthy dish less appetizing than a sea of drab brown colors. But Deb’s recipe is full of color – green (zucchini and lots of fresh herbs), red (tomato), purple (red onion, eggplant and olives)

And of course, the ultimate test was the taste – which was delicious. I scaled back the oil, salt and sugar by about half and skipped the cheese and thought the result was fantastic.

Knowing that I was going to make this on the weekend and that my husband would appreciate some meat after a week of delicious meatless meals, I headed over to another favorite website, One Hungry Mama, for some ideas. I’ve found that one of the keys to keeping my sanity when cooking family dinners is to focus on one dish and keep everything else simple. Since the barley salad had a good amount of chopping involved, I was looking for a main course dish that involved little to no effort. As usually happens, Stacie had the perfect option – slow cooker ribs. While ribs aren’t appearing on any “healthy living” list anytime soon, they are a fine “occasional” food, particularly if that is your only red meat for the week! I’d never thought to do ribs in the slow cooker before but the ability to drop them in and forget them was hugely appealing. And, as Stacie notes, the slow cooker is a great resource for hot summer days when you don't want to turn on the oven (see above). My family’s favorite barbeque sauce isn’t sold in stores around here (hint hint Dinosaur guys), but thankfully, they have a cookbook that includes the recipe for their Mutha sauce. I like to cook up a batch at the beginning of summer and freeze it in 2 cup portions. Since I still have a bit left, I decided to use that instead of Stacie’s Asian BBQ sauce recipe (that I’m hoping to try another day). I knew I’d want to throw the ribs on the grill at the end as Stacie suggests to get that nice crisp edge so I scaled back the sauce I put in the slow cooker to about one cup (the sugars in barbeque sauce will burn on the grill and you’ll get too much char). When the ribs were done in the slow cooker (perfectly cooked, falling off the bone), I slathered a tad more sauce on them (about ¼ cup) and put them on the grill for about 3 minutes. When I took them off, I slathered on another 1/3 cup of sauce and served the rest on the side.

Last, I took some gorgeous sweet corn I picked up at the farmer’s market and cooked that. It was a great summer meal – full of flavor, whole grains and vegetables.

This week, the Wall Street Journal reported on the launch of a new scoring system in grocery stores developed by the company, NuVal, which worked with a panel of (reputable) nutrition and health experts to create a scoring system that can be used to evaluate the nutritional value of products. While creating a perfect scoring system isn’t going to happen, NuVal does a pretty good job. Here are a few of the reasons why we think so:

1) “Healthy” is a pretty ambiguous word these days and some food items or nutrients may be more or less beneficial depending on your goal. For example, lycopene may reduce risk of prostate cancer, but for the 50% of us (i.e. women) without a prostate, that may not be a real priority when making food choices. Despite the limitations inherent in any scoring or valuation system, NuVal is pretty good at highlighting items that would fall under the “healthy” category for just about any “health” outcome. Unlike, say, the manufacturer produced labels trying to entice me to buy sugar-laden cereals because they threw in a scoop of whole grains. For example, even though Kashi brand cereals all contain whole grains, the Strawberry Fields cereal gets a score of 11 as compared to the 7 Whole Grain Flakes that gets a 29.
2) It provides a sense of magnitude of “healthiness” (I’m starting to feel a bit like I’m diving into Colbert’s “truthiness” here, but stick with me). I think most people would accurately guess that shredded wheat (unfrosted) is “better” than cocoa whatevers, but I think seeing the difference between shredded wheat and a cereal plenty of people I know think of as being “okay” (certainly not the healthiest cereal in the aisle but not a demon either) like Life (91 vs 25) might push folks to reconsider the Life and look for a cereal with a bit more fiber. My guess is that it will also help many parents look a little closer at the items marketed to kids. There are plenty of kids yogurt products in my local grocery store with as much added sugar as a candy bar. For someone rushing through the store with a tired, hungry (and thus, cranky) kid, the single number in front of the shelf might push a healthier choice when full label reading isn’t feasible.
3) That said, I’m still intrigued by the system and curious how iceberg lettuce gets the same score as canned spinach. I think other shoppers will be too and hopefully their curiosity will get them to read the labels (does that canned spinach have added salt perhaps?)

I’m sure the NuVal system will continue to evolve and alternates are surely on the way. I can easily see someone combining the UPC reader app on my iPhone with an eating guide app. What do you think? Anyone have NuVal in their local grocery? Is a system like this helpful or do the “huh?” moments make you wonder about the whole thing? Would you rather have a topic specific rating system? Perhaps that eating guide app would let you pick your goal – cancer prevention, weight management, cardiac rehab or general health?