What's in Store?
By Daniel DeNoon
June 11, 2001 -- Six feet tall and bright purple and orange, the attractive display of gummy bears welcomed us to the health food store.
This clearly was not the granola-and-brown-rice health store of my college days. But I was prepared -- at my side was dietitian Nancy Anderson, RD, MPH, an expert on heart-healthy food and coordinator of the nutrition program for The Emory University Heart Center in Atlanta.
Other members of our health-food safari included Anderson's two young children, who immediately clamored for the sticky, animal-shaped treats. But what manner of beast were they -- and what were they doing in a health food store?
"It says 'Supplement for Kids,' and on the back you can see it gives the nutritional information, the ingredients being corn sugar, cane sugar, citric acid, lactic acid, and then flavors," Anderson says as we study the candy-wrapper-like package. "So it is a gummy-bear type thing that is fortified with vitamin C, vitamin A, and vitamin E. It is a candy disguised in part as a vitamin supplement."
We let the youngest child open one of the packages. We'd only just entered the store, and already we'd made a mistake.
Herbs and Supplements on Parade
Our trip to this typical health-food grocery was inspired by a recent talk by Isadore Rosenfeld, MD, Rossi Distinguished Professor of Clinical Medicine at Weill Cornell Medical College, in New York City. Rosenfeld, author of several books on nutrition and alternative medicine, spoke at a recent meeting of the American College of Physicians-American Society of Internal Medicine.
"Many of my patients were buying up a store of herbs and adding them with abandon to whatever I had prescribed," Rosenfeld says. "My patients thought there was nothing wrong with taking herbs because they are a natural product and can do no harm. At first I said, 'It's garbage, but if you want to waste your time and money go ahead -- it won't do any harm.' But then I began to think this was intellectually dishonest. So I reviewed the world literature in some detail."
Rosenfeld found that some of these supplements worked quite well -- and that others could be quite dangerous, especially for patients taking several kinds of prescription drugs. And he found that he was not the only doctor whose patients wanted to know more about alternative medicine.
"I believe there are about 60 medical schools that have started [classes] on alternative medicines," he says. "You never see 'alternative' used any more: now it is 'integrative' and 'complementary' medicines." And there is now a greater tendency to use these herbs together with tried-and-true scientific methods. Much of what was folklore is being looked into by doctors. Interest in herbal medicine will expand. As the population ages there is now a greater incidence of degenerative diseases -- and there is not much we as doctors can do for these. And these herbs cost infinitely less than many drugs."
A Bewildering Display
Once past the gummy bears, Anderson and I were faced with a long aisle stacked with thousands of bottles of vitamins and herbal supplements. The labels promised everything from simple dietary supplementation to remedies for migraine and prostate problems.
"Here are all of your supplements, vitamins, minerals, and different types of 'nutraceuticals' -- or food medicine, if you want to call it that," Anderson says. "There is everything from multivitamins to interesting things like charcoal capsules, amino acids, and different compounds that some people believe to have health benefits."
I ask my guide which ones I should take, worried that I might be spending the rest of my mornings -- and my paychecks -- swallowing pill after pill.
"Most experts believe that a general multivitamin is sufficient for most healthy people or for those with a tendency toward chronic diseases," Anderson says. "The idea is to fill in the gaps your diet might miss, sort of as an insurance policy. However, some people spend an enormous amount of money on various types of supplements, everything from green tea to amino acids to choline cocktails. And whether or not they help -- well, in a lot of cases, this isn't proven. It is a highly unregulated industry. Many of the things you see on the shelves of the health food store are going to make claims that cannot necessarily be substantiated by science."
Anderson stresses the importance of consulting one's doctor before embarking on a supplement-taking odyssey. This is important because a person's needs change over time.
"As we age our needs change, our absorption rates for different vitamins change, and so a multivitamin that has 100% of the daily allowance of most vitamins really can help," she says. "Some people might also benefit from things like a calcium supplement, especially as you get older and have problems processing vitamin D. Calcium and vitamin D work in tandem, and so those are some supplements that benefit people. People were always told they need to get a lot of iron, and one thing we now know is that too much iron can be a bad thing, especially in terms of heart disease. Postmenopausal women or older men don't need iron supplements. So when you are choosing a multivitamin, try to choose one with low or no iron."
But what about the safe old standards like vitamin C?
"Vitamin E and vitamin C and the other antioxidants: The more we are learning, the more we are thinking maybe not to supplement," is Anderson's surprising reply. Early research suggested that antioxidants could be helpful in preventing heart disease, but newer research has called that theory into question. "Five years ago cardiologists typically recommended supplementing with C and E, and now they are backing off because high doses or high levels of those antioxidants have the opposite effect. They become pro-oxidative and cause coronary damage. Talk to your doctor, talk to a dietitian, and make sure you are not just buying stuff that hurts you when you are trying to do yourself some good."
But Anderson doesn't think that you have to buy the most expensive brands to make sure you are getting a quality product.
"As far as most supplements are concerned, experts say generics are just as good as name brands -- and cheaper," she says. "You can't always tell whether a name brand is going to be better absorbed or not. "There is one agency that that looks into this, she says -- into the rate of disintegration, dissolution, potency, purity, and expiration of supplements -- U.S. Pharmacopoeia or USP.
Both Anderson and Rosenfeld recommend looking on the label for evidence that the supplement has been measured out in standard doses. This is indicated by the "USP" or "NF" designation on the label, which means that the supplement meets standards set by the not-for-profit USP in its National Formulary. However, this designation simply means that the supplement contains what it is supposed to contain -- not that it is effective or even safe.
"The other thing is to be careful for children," Anderson warns. "It is one thing to start feeding ourselves vitamins and supplements, but you really need to use special care with children before giving them any kind of supplement."
As we move farther down the aisle, an array of exotic herbal remedies seem to wave to me from the shelf like dancers on a tropical island.
"This is an interesting section because you see all these things like saw palmetto, ginseng, and kava kava," Anderson says. "These are usually blends of different roots or herbs that have some value. These are becoming very, very popular, and we, as a science industry, need to keep up with these things and study them, because some of them do have merit. If you look at the medicines we now use, many of them come from plant sources. So just because it is natural, don't assume it can't be effective for good or bad -- just like chemical medicines."
The herbs start to look different to me now as they take on the appearance of the serious medicines peeking out from behind the counter of a pharmacy.
"There are some things to be aware of," Anderson warns. "Certain blood-thinning medications can react adversely with these different herbs and supplements. For example, ginseng, kava kava, even things like St. John's wort or ginger, can affect the ability of the blood to clot. And some things might affect blood pressure. So when you go to visit your doctor be sure you mention not only what medications you are taking and the doses, but also what herbal supplements you are using. Just because they are natural, don't assume they aren't medicines. It doesn't mean you have to stop taking it, just that your doctor has to be aware of it.
"You want to be careful of are things like amino acids, because they can prove dangerous in some cases -- they can mess with your metabolism and don't really live up to their claims of adding muscle or bulk to people," Anderson continues. "Cod liver oil -- most of the things like this won't do any harm, but they won't do any good, either. You may just be buying something that becomes expensive urine. But there is the potential to over-supplement, so you really have to talk with a doctor or a dietitian about what your needs are and what exactly you need."
Some of these remedies seem to come from common foods. Are the pills more effective?
"It is very difficult to say whether a capsule is going to do the same thing as if that compound was found in a food," Anderson says. "This is because most compounds in foods work act in combination with one another, so you can't just isolate one compound from a food and expect it to have the same benefit it would have if you got it by eating a grapefruit or a tangerine or a cabbage. There are a lot of other compounds that we haven't discovered in those foods that work together. So it's hard to say."
Soy Milk and Juice
As we turn the corner, we are faced with dozens of different cartons filled with stuff that looks like milk, but isn't.
"Here is a neat area with the soy- or rice-based alternatives to milk," Anderson says. "People who have lactose intolerance or an aversion to dairy products for vegetarian or health reasons rely on these. They are a fair source of calcium -- usually they are fortified with calcium and vitamin D -- but they also have the benefit of the soy bean."
Soy products, I learn, are full of isoflavones -- sort of a powerhouse for disease-fighting and health-inducing effects. The non-milk products we look at are either low fat or completely fat free.
"Different soy products will have different levels of isoflavone," Anderson says. "So when you are looking for a soy milk, look for one that is fairly low fat, low calories, and with a good kind of fat, unsaturated fat. Some are more fortified with calcium than others, so especially if you are relying on this as a source of calcium, check the calcium content."
We pass by a display of different types of tofu, a fermented soybean extract. The softer forms, Anderson says, can be used in salad dressings or smoothies. Firmer tofu can replace meat or fish in many recipes.
A few more steps take us to a long row of juices extracted from nearly every conceivable fruit.
"The main thing you want to look out for in juices is that you are getting a lot of true juice and not a lot of sugar -- some things disguised as juice can have quite a lot of sugar," Anderson warns. "People interested in chemical-free products need to look for the organic label."
We turn another corner and see row after row of neatly bagged brown stuff in various shades and shapes, eventually giving way to a shelf of heavy breads and muffins. The kids go off to swordfight with huge organic carrots. Anderson's eyes brighten.
"One thing that is great about a health-food store is you can get wonderful selections of grains that you can't always get in a grocery store," she says. "Whole grain cereal, whole grain bread, just the whole grains themselves like oats or wheat, and it is nice to have that, especially if you do a lot of cooking.
"On the other hand, granola is not always the best health food if it is made with a lot of oils and fats. I think today a lot of manufacturers of granola have gotten savvy and use things like canola oil, but before that they used a lot of coconut oil, which we know is highly saturated. So before buying granola, look to see what kinds of fats they are using. Preferably choose a low-fat granola or one using canola oil."
Health Junk Food
On the next aisle I am surprised to see a display of what look like bags of potato chips.
"We don't really think of chips as health food, but they can be less damaging if they are made out of better ingredients like corn chips that aren't fried or have no salt added," Anderson explains. "But some of the things you find here are fried, and are made out of high saturated fats. We'll just pick one at random and look at the label: These are some sort of organic yellow corn chips with pinto beans and brown rice. Six grams of fat per serving, not too bad compared to blue chips here with 7 grams of fat. This is comparable to whatever fried chips are, but you see that these have only 1 gram of saturated fat."
Anderson notes that the National Cholesterol Education Program recently changed its guideline from saying that no more than 30% of your diet should come from fat to a maximum 35% of the diet.
"This is to allow people more mono- and unsaturated fats in their diets," she says. "What we have learned from the Mediterranean diet is that it is not just how much fat you eat but the type of fat that is equally -- if not more -- important."
The kids reappear just as we approach a shelf full of different nut butters.
"Peanut butter is a natural food, which contains nuts that we know to have a lot of fat -- but it is a monounsaturated fat, a heart-healthy fat so it is actually OK, a great source of protein," Anderson says, removing from our cart several jars added by her young son. "You find other kinds of butter in a health food store, things like almond butter and cashew butter, and tahini made from sesame seeds. All have high protein and are a good source of monounsaturated fats and also a good source of fiber. The main thing when choosing a peanut butter -- and you won't have this problem in a natural foods store -- is to look for the natural peanut butters, the ones that are ground nuts and maybe have a little salt but nothing else added. What you want to avoid are the things like the Jiffs or the Skippys that have hydrogenated oil added to it to make them smooth and creamy. That is not a healthy kind of fat to have, even though it makes it easier to spread."
Vegetables -- the Ultimate Health Food
We now come to a corner of the store unlike any other, where bins overflow with a rainbow of colorful vegetables.
"You can evaluate your diet based on how colorful it is," Anderson says. "Fruits and vegetables should be the basis of a healthy diet, because that is what provides you with so many of the vitamins and antioxidants and the compounds we know to be beneficial for good health. So the colorful things like purple eggplant, green kale or broccoli, orange carrots, red apples, and yellow citrus fruits -- the more deeply colored a vegetable, the more antioxidants are in them. Getting them from a natural source like food it is hard to overdose, and you also get them in the context of other compounds in foods that enhance their ability to work. Compounds we have yet to discover, even, probably help the ones we do know of to work. So these are the basis of the modern food pyramid, a little different than the traditional one based on grains and breads."
It all looks good to me. I ask Anderson whether one must become a vegetarian to be healthy.
"It is not necessary, but it is a good choice, and the benefit to being vegetarian, if you do it right, is to get an abundance of vegetables -- the foundation of a healthy diet," she says. "Being vegetarian is not necessary, but if you choose that lifestyle you can get a lot of benefits."
How much meat should one eat?
"Meat is OK in moderation -- 3 to 6 ounces of lean meat a day," Anderson says, as the hamburger I'd hoped to have for lunch vanishes from my diet. "This is not what we are accustomed to seeing in America -- when we say meat is OK, it should certainly not be the focal point of your meal or your diet. It is a good source of protein and a good source of iron. But you just want to choose carefully: you want your meat to be as lean as possible. Fish is always good to eat, especially the fattier kinds with omega-3 fatty acids."
At the end of the store is a shelf of organic baby food. I ask Anderson whether babies really need organic food.
"Baby food is one of the most strictly regulated foods," she admits. "But infants, being small, you think of the levels of toxicity in them vs. a grownup and it takes much less of something to affect them. It certainly couldn't hurt -- I fed my children organic baby food for the most part. It tends to be less sweet. As babies they will have a tendency to sweets before they are introduced to that, but it is pretty widely accepted to start with vegetables before you move to fruits just so they don't become accustomed to sweet things."
The Bottom Line
"In general, you have to look carefully -- just because it is in a health food store doesn't mean you don't have to read the labels," Anderson says. "Check the fat profile and the fat content, see what kinds of fats they are using. And just because it is vegetarian don't assume it is low fat because that is usually not the case. And watch your serving size, because calories still matter even if they are healthy.
"And watch out for the sugar content of foods. Health food stores are notorious for disguising sugar with many fancy-sounding names like cane juice and cane syrup and honey -- these are all sweeteners and are no better than sugar. It may be less processed, but it is still sugar."
A Brush With Disaster
We wheeled over to the checkout counter. Suddenly the clerk held up the half-eaten bag of the gummy candies.
"Did your little girl eat all of these?" she asked in an urgent voice. "You know they are vitamins, don't you?"
We didn't, even though we'd read the label carefully. Anderson's next stop was at her pediatrician's office, where a call to the poison-control center found that her daughter had only eaten enough vitamins to cause mild intestinal upset.
"Fortunately, the vitamin supplements did not contain iron -- she may not be alive otherwise," Anderson tells me later. "I am calling the manufacturer to discuss the liabilities of their packaging."
The message seems clear. While health foods clearly offer an abundance of beneficial foods and supplements, dangers lurk even in the most innocent-seeming packages. Know what you are getting -- and getting into -- before you buy.
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