Added Sugars--Finding Balance

When I was a kid, one of my favorite breakfasts on a cold morning was cinnamon toast.  My mom would butter slices of bread, sprinkle them with cinnamon and sugar, and then do a quick broil in the oven.  A little slice of heaven.  And on mornings like today, when my youngest announced that she was "feeling un-awesome", warm cinnamon toast and a glass of skim milk helped get her day off to a better start. 

But the larger food environment we live in today is very different from my childhood.  Cinnamon toast was a true treat, as other than some homemade cookies and a very small glass of breakfast OJ, we didn't have a lot of added sugars in our environment.  How do I balance my family's eating in our current sugar-prone environment so I can give them these treats without feeling like I am dooming their health? 

Cinnamon toast

What is Sugar?

Sugars are simple carbohydrates known as mono- or disaccharides.  While a great source of energy and essential for brain function, sugar by itself offers no other nutritional advantages.  However, in fruits, the sugar fructose is packaged with the fruit's fiber, vitamins, minerals, and phytochemicals.  A glass of milk delivers the sugar  lactose along with protein, minerals, and vitamins.

The trouble begins when we move from whole foods like fruits and milk to processed foods.  Even minimally processed foods often have added sugars.  Unfortunately, the current Nutrition Facts panel only gives a total sugar amount.  As a result, a food like chocolate milk is going to have a total sugar amount that includes the naturally-occurring lactose and the added sugars. 

What are Added Sugars?

The list of added sugars can be long, but essentially added sugars are any and all sugars added by a cook or manufacturer to a food. I have complied the list below from USDA MyPlate and the American Heart Association.

agave syrup
anhydrous dextrose
brown rice syrup
brown sugar
confectioner's powdered sugar
corn sweetener
corn syrup
corn syrup solids
dextrose
fructose
fruit juice concentrate
high-fructose corn syrup (HFCS)
honey
invert sugar
lactose
malt sugar
maltose
maple syrup
molasses
nectars (e.g., peach nectar, pear nectar)
pancake syrup
raw sugar
sucrose
sugar
white granulated sugar

A recent Canadian Heart and Stroke Association document also argues that Canadians need to watch their consumption of "free sugars".  By this they mean fruit juices, sugar that has been freed of its fruit form.

Why limited Added Sugar?

The Yale's Rudd Center for Food Policy and Obesity has put together a great summary of studies regarding added sugar and health.  The increased consumption of added sugar has been linked to cardiovascular disease, type 2 diabetes, non-alcoholic fatty liver disease, obesity, and other negative health effects. 

How much Added Sugar?

The current Canadian Heart and Stroke Association recommendation is less than 10% of your daily calories from added sugar.  For a 2,000 calorie diet, this would be about 200 calories from added sugars or about 12 teaspoons.  The American Heart Association general recommendation is 5 teaspoons per day for women (100 calories) and 9 teaspoons for men (150 calories).

Whether you follow the 10% rule or a blanket amount based on gender, both amounts are much lower than current US consumption.  The Canadians are at 13% of daily calories (not including fruit juice).  The 2005–10 National Health and Nutrition Examination Survey puts Americans at 20 teaspoons per day, with teens having the highest consumption at 34 teaspoons per day.

Calculate your Added Sugar Limit.

• Estimate your daily calorie needs.  MyPlate has a great table to get you started.  For this example, I will use 1800 calories, the general estimate for a woman age 31 to 50.
• Calculate 10%.  Ten percent of 1800 calories is 180 calories.
• Calculate grams of sugar.  Sugar, like all carbohydrates is 4 calories per gram.  180 calories divided by 4 calories equals 45 grams.  For this example, the daily limit is 45 grams of added sugar.
• Convert to teaspoons.  Sometimes it is easier to know the upper limit in teaspoons.  Sugar is about 4 grams per teaspoon.  45 grams divided by 4 grams equals just over 11 teaspoons.

What about my kids?

For my girls, they need around 1600 calories per day.  Ten percent is 160 calories.  Their maximum of added sugars should be 40 grams (carbohydrates are 4 calories per gram) or 10 teaspoons of sugar a day.

I raided my pantry to get a better sense of what added sugar is in our lives. 

Juice--Last year, I stopped buying juice with any regularity.  As I explained to my girls, let's save our sugar for something really fun.  But, we had some leftover OJ from a celebration, so each girl had a 6 oz glass this morning.  Almost 17 grams.  We don't drink soda or sports drinks, but a typical 12 ounce soda has 8 teaspoons of sugar so I probably should have given them a Coke!

Yogurt--One girl is a big fan of Stonyfield's fat free organic lemon.  The container has 27 grams of sugar, but that sugar is a combination of the naturally-occurring lactose and the added sugar.  Using the power of Google, I found the plain version clocks in at 12 grams of sugar, meaning 15 grams of added sugar. 

Pop-Tarts--Yes, we have frosted Strawberry Pop-Tarts and skim milk for some of those dark mornings when we need to be at school at 7:15 am (I often imagine the grass-fed milk screaming in protest in the girls' stomachs).  Pop-Tart ingredients  # 2, 3, and 4 are various forms of sugar, leading to 16 grams of sugar per pastry (yeah, the wheat contributes some, but who are we kidding?).

Yet, these are the easy foods.  Pop-Tarts are never going to be confused with a health food!  And it is easy to balance this morning's OJ with a lunch that is largely added sugar-free.

To me, it is the snack crackers with cane sugar or the pretzels with malt that make life more complicated.  Not to mention, the chicken stock, pasta sauce, and other pantry staples.  While the pretzel and crackers offer a gram or less of sugar on their Nutrition Fact labels, it all adds up. 

Beyond doing calculations like that of the Stonyfield yogurt, some websites do offer short lists of added sugars in common foods like this one from the American Heart Association or this empty calorie chart from MyPlate.

What Did I Learn?

• ALWAYS read the label.  I almost fell over in Whole Foods when I saw sugar listed on the box of chicken stock.
• The label is more important than the image.  A health halo around juice, yogurt and other processed foods don't mean their labels match their hype.
• Cook.  A little less sugar in the cookie (or left out of the stock!) is possible when you control the recipe.
• Balance your (and your kids) day.  Don't count calories, but keep a mental tally of your added sugar intake.  Maybe skip the extra syrup on your morning pancakes in favor of a cookie at lunch.
• Cinnamon toast is yummy.  And since I probably put 1/2 teaspoon of sugar on each slice, at three slices per girl, it is WAY better than some of my other options, even with the sugar in the bread itself.

Cinnamon Toast 

Ready for the oven

• Take white bread (I usually use leftover hot dog buns).
• Spread with softened butter. 
• Sprinkle with a mixture of cinnamon and granulated white sugar.
• Broil for one to two minutes.
• Eat!

Breakfast time

Fruits and Vegetables--What Should You Buy?

To me, one of the great things about early fall is the arrival of fresh local apples.  The kind that taste like you just picked them off the tree.  At our farmers market over the weekend, I tasted an apple sample that put a smile on my face--crisp, tart, so yummy!  As I was filling my bag with these lovelies, I overheard another customer ask the farmer if the apples were organic.  He replied, "No, we used integrated pest management."  Without so much as a 'thank you', the woman turned on her heel and strode off.  All I could think was " You don't know what you are missing!"  But the farmer did himself no favors as he missed an excellent opportunity to educate a customer. 

Local peaches, tomatoes, and pears

Faced with a myriad of choices at the grocery store and farmers markets, how do you chose the best fruits and vegetables for your family?  How does organic compare to conventional?  What is integrated pest management?  Fresh vs. frozen or canned?  Does washing fruits and vegetables matter and how do you do it?  Let's get started with some answers!

Organic versus Conventional

While 'natural' is an unregulated term, there are very specific requirements for food to carry the USDA Organic label.  By USDA definition, organic means:

• Produced without excluded methods (e.g., genetic engineering), ionizing radiation, or sewage sludge.
• Produced per the National List of Allowed and Prohibited Substances.
• Overseen by a USDA National Organic Program- authorized certifying agent, following all USDA organic regulations. 

 Food can be labeled with the USDA certified organic label if they are '100% organic' or 'organic' (meaning basically 95% of the ingredients are organic).  'Made with organic' can be used if 70% of the food is made with organic ingredients, but cannot carry the USDA certified organic label.

In many grocery stores, the certified organic produce is more expensive than conventionally grown fruits and vegetables.  Is the premium worth it?  To decide what is best, it is helpful to examine the question in two ways: nutrient quality and pesticides.

Nutrient Quality

Conventional farmers argue that there is no significant difference in the vitamins, minerals and phytochemicals found in conventional vs organic produce.  But organic advocates beg to differ.  Unfortunately, the science is unclear.  While a 2009 American Journal of Clinical Nutrition review of 55 studies found no difference, organic proponents took issue with the methodology.  A 2014 study did find a difference in phytochemicals, with organics having more.  But, again, critics took issue with the study, particularly that any health benefit of the observed increase in phytochemicals.  Sadly, the ongoing debate doesn't help the average consumer. 

However, as I researched this topic, I was struck by the number of articles that outlined or mentioned how other factors, in addition to organic vs conventional, influenced mineral, vitamin, and phytochemical content.  For example, different species and even different cultivars have different profiles of phytochemicals.  Post-harvest handling--transportation time, storage, freezing, canning--also influences the nutrient profile.  And surprising to me is that sometimes phytochemicals increase with the post-harvest handling! 

My take-home on nutrient quality is that there may be a difference between organics and conventional produce, but not enough to influence buying decisions.  However, when selecting fruits and vegetables it is perhaps helpful to expand beyond your usual rainbow, integrating a new varieties of fruits and vegetables into your diet.

Pesticides

In my mind, this is where the rubber meets the road on organics.  Simply put, conventionally grown fruits and vegetables use synthetic pesticides.  Organic certification restricts the kind and type of pesticides and, as a result, organic produce has a lower level of pesticides.  In 2012, the American Academy of Pediatricsurged pediatricians to educate parents about pesticides in their children's food, noting that "Children encounter pesticides daily and have unique susceptibilities to their potential toxicity." 

The Environmental Working Group (EWG), using data from the USDA and FDA, have complied lists of those conventional fruits and vegetables with the most and least amounts of pesticides, otherwise known as the Dirty Dozen and the Clean 15.  For the Dirty Dozen, the EWG suggests buying organic when possible to limit pesticide exposure.  The Clean 15's lower levels of pesticides makes conventional produce a good choice. 

• Dirty Dozen--apples, strawberries, grapes, celery, peaches, spinach, sweet bell peppers, imported nectarines, cucumbers, cherry tomatoes, imported snap peas and potatoes
• Clean 15--avocados, sweet corn, pineapples, cabbage, frozen sweet peas, onions, asparagus, mangoes, papayas, kiwis, eggplant, grapefruit, cantaloupe, cauliflower and sweet potatoes
• Dirty Dozen Plus--This category is for leafy greens (kale and collard greens) and hot peppers.  The pesticides on these vegetables are at low levels, but are contaminated with pesticides that are toxic to the nervous system.

Frankly, the Dirty Dozen list is enough to make you run screaming from the produce section of your grocery store!  But keep a few key facts to keep in mind:

• Wash your produce.  When the USDA processed the samples, they were washed or peeled to mimic consumer behavior.  As a result, the pesticide load may be higher on unwashed produce (more on washing below).
• Cook your produce.  Cooking reduces the levels of pesticides.
• Still eat your fruits and vegetables.  Even the EWG, a group with a clear opinion on pesticide matters, urges consumers to eat fruits and vegetables, even if conventional is your only choice.  Far better to eat the conventional apple than the donut!
• Data may not be current.  EWG relies on USDA sampling data to compile their lists.  Some items like strawberries, celery, and kale, have not been testing since 2008.  We can hope that future sample testing leads to a reshuffle of the Dirty Dozen.
• GMO-fruit and vegetables are limited.  If you are concerned about GMO in the produce aisle, know that the produce does not have to be labeled (and probably won't be).  That said, there is not a lot of it.  According to EWG, some zucchini and yellow squash are genetically engineered, along with some sweet corn.  Non-organic papayas grown in Hawaii are pretty much all GMO.  If you want to avoid GMO produce, buy organic.

Eating Local

The EWG lists focus on conventional fruits and vegetables, offering organic as an alternative.  But talk to your local farmers at the weekly farmers market and you will find there is a third option.  I spoke with several farmers selling at my market.  Both, and many others, use integrated pest management (IPM).  What is IPM?  As I listened to the farmers and read this great description from one orchard, I realized IPM is a middle ground.  These farmers still use pesticides when necessary, but try other things first like mating disruption for moths and planting more hardy fruit. 

One pesticide highlighted by the EWG in their Executive Summary was diphenylamine (DPA).  DPA has been banned in the European Union, but is applied to most conventionally grown apples and some pears in the US to prevent fruit skin discoloration.  In my conversation with two local apple farmers, neither applied anything to their apples post-harvest.

In her book What to Eat, Marion Nestle notes her personal priority list is "(1) organic and locally grown, (2) organic, (3) conventional and locally grown, (4) conventional" (page 66).  For me, I would move 'conventional and locally grown' to the number 2 spot.  The produce is likely tastier, leading my family to eat more.  And, if I can talk to my local farmer, I can come away with a better understanding of their version of conventional.

Fresh, Frozen, or Canned?

One article I reviewed looked at vitamin C content as a marker to compare fresh and frozen fruits and vegetables.  Examining peas and broccoli, the vitamin C levels were similar between fresh-from-the-store and commercially frozen.  Interestingly, peas stored in-home for several days were not as good as frozen!  This study and others have demonstrated that frozen and canned vegetables and fruits, processed at their peak, offer nutritionally sound (and sometimes less expensive) alternatives to fresh produce. 

In selecting canned and frozen items, be sure to read the label.  Some frozen vegetables, for example, contain added salt.

Washing

My biggest at-home change this week from my research will be washing produce.  As noted above, the USDA samples used by EWG were washed and peeled as done at home.  So with no washing, the levels are sure to be more.  But how to wash? 

Just washed tomatoes, ready to be dried

From Foodsafety.gov:

• Cut away any damaged or bruised areas.
• Rinse produce under running water. Don’t use soap, detergent, bleach, or commercial produce washes.
• Scrub firm produce—like melons or cucumbers—with a clean produce brush.
• Dry produce with a paper towel or clean cloth towel… and you’re done. 
• The good news? Bagged produce marked “pre-washed” is safe to use without further washing.

And from the University of Maine Cooperative Extension, a few more tips:

• Produce with a lot of nooks and crannies like cauliflower, broccoli or lettuce should be soaked for 1 to 2 minutes in cold clean water.
• Some produce such as raspberries should not be soaked in water. Put fragile produce in a colander and spray it with distilled water.
• Drying clean paper towel can remove more bacteria.

Foodsafety.gov and other sites made a point to emphasize that it is important to wash all fruits and vegetables, even those you are going to peel.

After reading Foodsafety.gov, I still wondered about the various commercial washes.  Thankfully, the University of Maine Cooperative Extension article cover this issue.  They compared rinsing with distilled water to a Proctor and Gamble product and two other treatments.  Their finding?  Distilled water was as good or better than the alternatives!  While distilled or bottled water is great because it is filtered and purified, they also note very clean cold water works as well.

 Local Tomato Sauce--washed and cooked!

First step?  Washing and drying the local Roma tomatoes, of course!

With generous pour of olive oil, I cooked one white onion and two cloves of garlic, roughly cut, over low heat.  When the onion was getting clear, I started adding the tomatoes.  I cut the Roma tomatoes into rough quarters and dropped them into the pot as I went.  Once the tomatoes were in, I added about a teaspoon of Italian seasoning and 1/2 teaspoon of Kosher salt. 

Then on went the lid and they simmered at low heat (with occasional stirring) for about 30 minutes.  Next, the lid came off (to try to get some liquid to evaporate) and I dialed the heat down to a true simmer. 

After another 20 to 30 minutes, it was time for the blender!  A quick spin around the blender on the puree setting made for a simple tomato sauce to top our evening's linguine!  The extra was frozen for another day.

Fruits and Vegetables--Focus and Variety

My girl is not a big fan of salad, even when drowning in Ranch dressing.  But she does eat some veggies like broccoli with a sprinkling Parmesan cheese or peas.  And she likes a long, long list of fruits.  I try to take a long view, hoping that repeated exposure to new foods means someday she will dive into coleslaw or sauté zucchini.  But should I worry about her veggie-lite lifestyle?  And how much should she (and me) be ideally eating?

A good place to start with fruits and vegetables is MyPlate's recommendation.  Their graphic depicts half of your plate filled with fruits and vegetables.  This recommendation stems from data that diets rich in fruits and vegetables lower the risk of some cancers and decrease the likelihood of developing diabetes, heart disease, and hypertension.  Additionally, fruits and vegetables are nutrient-rich low-caloric density foods which helps you maintain an appropriate weight.  While fruits & vegetables provide needed energy in the form of carbohydrates, they also are good sources of a variety of vitamins, minerals, fiber, and numerous phytochemicals. 

But the recommendation only tells part of the story and sparks many questions:

--My Plate suggests to "focus on fruits. vary your veggies".  Why are these recommendations important?

--What does "half a plate" look like for practical, daily eating?

--Both the My Plate graphic and Harvard's Healthy Eating Plate suggest more veggies than fruit.  But what is a mom to do with a kid who hasn't yet developed a fondness for salad?

"focus on fruits.  vary your veggies."

I appreciate the desire for alliteration, but the recommendation should really be "vary your veggies AND your fruit."  Whether fruit or vegetable, each kind of produce offers a different profile of vitamins, minerals, and phytochemicals.  So while a red bell pepper is a great source for vitamin C  (anti-oxidant and important for collagen formation), you want to consider some dark leafy greens, like spinach, as they are amazing sources per weight of vitamins like K, E, & A. 



A Rainbow of Farmer's Market Peppers. 
Our family tried them all (the girls with
hummus).  We decided they pretty much
all tasted the same, except the yellow
pepper which has a hint of tomato.



When considering variety, I think is important to keep in mind that nutritional science is still in its infancy.  The complex interplay between nutrition and the human body is still being elucidated.  For example, the first vitamin wasn't discovered until 1913 (vitamin A).  Beyond vitamins and minerals, consider our understanding of phytochemicals.  Not considered nutrients, phytochemicals are compounds found in plant-derived foods that have biologic activity.  For example, resveratrol acts as an anti-oxidant and is found in grapes.  Another example are the indoles which may prevent damage by carcinogens and are found in broccoli, watercress, and other cruciferous vegetables.  The list of phytochemicals is long and growing, yet their impacts are just now being understood. 

Lastly, to my mind, one of the most fascinating new area of research is the elucidation of gut bacteria complexity (for example, the American Gut Project).  We are just scratching the surface in understanding how gut biodiversity can be impacted by the veggies, fruits, and other foods we eat and how, in turn, that diversity can impact our health.  In the absence of a complete list of all of the "right" fruits and vegetables based on nutritional science, eating a variety serves as a way to ensure you consume all the nutrients needed for a healthy life.

What does "half a plate" look like?

Key to making "half a plate" work is to focus less on specific meals and more on the overall daily intake.  For me, each time I see the My Plate graphic, my mind thinks "dinner", yet to achieve the goal of 2 to 3 cups of veggies per day for adults (printable of age and sex specific recommendations) and 1.5 to 2 cups of fruit for adults (printable of specific recommendations), fruits and vegetables need to be a part of every meal or snack. 

A great photo essay on thekitchn shows 10 options for a daily intake of 2 cups of fruit and 2.5 cups of veggies.  Looking at the photos, of course, option # 1 of a big salad, apple, and raisins, seems easily achievable, but many of us don't hit the daily totals.  For myself, I know I had my daily veggie intake earlier this week when I made sesame coleslaw (so yummy!  see recipe at the end of this post), but yesterday, my homemade tomato sauce wasn't quite enough and I should have added a salad.

My Plate has a couple of great pages detailing what constitutes a cup of veggies and a cup of fruit.  It is important to note that the USDA's My Plate include potatoes, including french fries, as a vegetable.  Harvard's Healthy Eating Plate does not count this starchy vegetable as part of their "half a plate" suggestion.

Veggies vs. Fruit

The USDA My Plate recommendations for children are as follows:

		Daily Veggie	Daily Fruit
Children	2-3 years old	1 cup	1 cup
	4-8 years old	1.5 cups	1 to 1.5 cups
Girls	9-13 years old	2 cups	1.5 cups
	14-18 years old	2.5 cups	1.5 cups
Boys	9-13 years old	2.5 cups	1.5 cups
	14-18 years old	3 cups	2 cups

 

 In our house, I would say we often hit the fruit target, but the veggie recommendation?  More rarely.  What is the solution?  Some parents, concerned about their children's well-being and fruit and veggie intake, hide vegetables and fruits in other foods (or buy products that offer this subterfuge).  This approach doesn't teach children to like the taste of vegetables or fruits.  Others require children to finish X in order to have Y (usually dessert).  In the case of dessert as a reward for finishing other foods, it overvalues these treats in children's minds.  I would like to offer that there are other options.

While variety is clearly important, Ellen Satter argues that "Fruits and vegetables carry the same nutrients, so a child can be well-nourished on either". Perhaps just as importantly, Satter recommends leaving virtue and pressure off the menu.  Pressure, even positive "great job!" or "take one bite", can backfire.  Kids start to see certain foods as undesirable (as Satter says ''if they have to do all that to get me to eat it, it can't be good'').  Highlighted on the Fruits and Veggies More Matters website is a 2014 study that demonstrated the preschool aged kids ate fewer carrots and crackers when told these foods would make them healthier or help them learn to read or count. 


Early fall apple

Along with pressure, virtue doesn't help.  In her steps to Mastering Family Meals, Satter suggests a little Ranch dressing or butter might help make vegetables more palatable for children (and adults!). 

One of the hallmarks of Satter's approach to eating is to remember that food is pleasurable.  In the next post, I will delve into issues of local, organic, and conventional, but a strong argument for local and fresh may simply be those fruits and veggies taste better and are more pleasurable to eat! 

As Satter's approach takes the long view of eating, creating lifetime habits.  Dina Rose in her book, It's Not About the Broccoli, offers a similar view.  She argues parents need to focus less on nutrition and more on habits, specifically proportion, variety, and moderation.  She suggests taking the pressure off dinner to be the big veggie serving time, by serving fruits or vegetables at every meal or snack.  One suggestion is to take advantage of hunger by offering vegetables as appetizer.  And if your family needs dessert, Rose suggests that on some evenings, your dessert is fruit.

Translating Focus and Variety in my kitchen

My conclusion is that we are on the right track.  My girl eats a variety of fruit from grapes to fresh pineapple to expensive berries to all kinds of pears and apples and more.  She doesn't get all the variety she needs from the fruit, but it is a solid start.  On the vegetable side, I need to keep serving the regulars that are happily eaten, but be on the lookout for new recipes that may entice her (and the rest of my family) to eat veggies we would normally reject.  And my research reinforced my philosophy of not forcing eating or tasting, but trusting that someday she will gobble down a big salad.

Easy 2 cups--Coleslaw

At some point, I stopped eating coleslaw.  Somehow, I didn't see it as "good for me" in the way I saw salad.  I think it was something about mayonnaise not being a great choice or some other malarkey.  Fast forward to a few years ago when I bought Alice Water's The Art of Simple Food.  From her recipe, I began to understand all of the variety you can bring to coleslaw.  The recipe is simple.  A little salt and pepper.  Then the dressing--one tablespoon cider or wine vinegar to 4 tablespoons olive oil.  Of course, red wine or apple cider vinegar will create a different coleslaw and I found myself experimenting.  And subbing mayonnaise for olive oil is sometimes the way to go.  The key, in my mind, to good slaw is let it marinate in the fridge at least an hour before serving.

However, my new favorite slaw is from Real Simple.  Skipping the cilantro because to me it tastes like soap, my dressing is:

1/4 cup of fresh squeezed lime juice
2 teaspoons toasted sesame oil
1 tablespoon of canola oil
1/4 teaspoon each of pepper and Kosher salt

Using a mix of green and purple cabbage with some carrots, the coleslaw veggies offer a great variety and a pleasurable addition to dinner.

References
All quotes and sources are linked in the above text.  General nutrition information came from Whitney and Rolfes' Understanding Nutrition, 13th ed.