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PHOENIX (Newsweek) January 10, 2006 —

Harrison, PA.: Next to wa­ter, what is the healthiest liquid to drink? Can I get the water I need from something else?
DR. MEIR STAMPFER.: You don’t need to monitor water as if it were medicine. Your needs will vary de­pending on the temperature, hu­midity, physical exertion and other factors. The widely quoted recom­mendation for eight glasses a day doesn’t have a strong scientific basis. Other fluids can help keep you hydrated. Tea and coffee can provide fluid without extra calories. Though juices can provide nutrients, they also pack a lot of excess calories. Artificially sweet­ened beverages also provide the fluid without calories, but I recom­mend against them. Although data are very sparse, some experts be­lieve they may distort our natural taste sensations, leading to a ten­dency to seek more sweets.

BALTIMORE, MD.: Are there any harmful herbal supplements on the market?
Many Americans assume that the government requires any supple­ment be tested for safety before it is sold. But that is not the case. As long as no specific health claims are made (which would require approval by the FDA), the market­place is wide open. For this reason, I strongly recommend that people avoid herbal supplements unless there is reasonable evidence for efficacy and safety. This recom­mendation would particularly hold true for pregnant women or women who may become pregnant. It is very likely that some supplements on the market are harmful. Chaparral, for example, has been asso­ciated with liver damage. Just be­cause a product is “natural” or “organic” does not mean that it cannot be harmful.

ARVADA, COLO. I had estrogen-positive breast cancer in 2000. I would like to eat more healthy foods, but is there a risk of get­ting too much estrogen from products like soy milk?
Some studies suggest that higher intake of soy might reduce breast cancer, but others have found that soy-derived estrogens can stimu­late cancer-cell growth. Until the research becomes clearer, I’d sug­gest that you stay away from soy milk and other products containing artificially high levels of soy estro­gens (it’s fine to eat soybeans and tofu). Interestingly cow’s milk, whether organic or not, can also contain sub­stantial concentrations of estrogen because much of it comes from pregnant animals. So I would recommend against drinking too much milk. You can get the calcium you need from the rest of your diet, from a moderate amount of dairy products and, if neces­sary, from calcium supplements.

CHRISTIANA, TENN. Why are the majority of medical people so resistant to the connections be­tween diet and disease, and so eager to prescribe drugs?
Because their training tends to fo­cus on disease and its treatment, prevention gets relatively short shrift. When I was in medical school, the students organized their own course in nutrition be­cause so little was offered in the regular curriculum. Nutrition training has improved since then, but more is still needed. The phar­maceutical industry is a second factor. It spends a lot of money de­veloping and promoting drugs, while the commercial interests re­lated to prevention are small and unfocused. A third element is that health plans are more likely to pay for treatment than to cover pre­ventive care. Finally, there are the patients themselves. Most of us go to the doctor when we’re sick and need treatment. Few of us would be satisfied if, instead of writing prescriptions, our doctors advised us to lose weight, change our diets and start exercising.

MAUI, HAWAII: Are genetically modified foods contributing to the obesity problem? Are our bodies able to digest and absorb nutrients from these foods?
There’s no evidence linking genet­ically modified foods to obesity. We absorb and digest nutrients from these foods just as we would from any other. The major causes of the obesity problem in the United States are no mystery. It’s simply a consequence of people eating more calories than they burn and gaining weight. The leading source of calories in the U.S. is sugared beverages, which accounts for about seven percent of all calories consumed. This is a big part of our problem since it is so easy to consume calo­ries in liquid form. The No. 2 source is cake and sweet rolls, fol­lowed by hamburgers and cheeseburgers, then pizza, and No. 5 is potato chips and corn chips. Those food items account for about one-fifth of all the calo­ries consumed in our country. The other side of the equation is at least equally important. In popula­tion surveys, it turns out that the No. 1 activity in our country for burning calories is not jogging or walking but driving a car! The next form of activity for total caloric ex­penditure is office work. No. 3 is watching TV or movies, then taking care of children. No. 5 is an activi­ty performed while sitting quietly, and number six is eating! The problem has nothing to do with ge­netically modified foods.

SPOKANE, WASH.: Both my fa­ther and my great-grandfather died from prostate diseases. Are there specific foods I should be eating to reduce my risk?
Men with a family history of prostate cancer are moderately more likely to develop prostate cancer. Diet very likely influences prostate cancer risk, and this is an area of intense study. Although no foods or supplements are proven to decrease the risk, there are a number of intriguing clues. As the data accumulate, it seems prudent to take these into account. One potentially preventive nutrient is selenium, a trace element. In one study to see if selenium would re­duce the recurrence of skin can­cer, researchers unexpectedly found that prostate cancer mortal­ity decreased in the selenium group as compared to placebo. A large nationwide study called the SELECT Trial is currently under way to test this hypothesis, but the results will not be available for several years. There is a narrow range of safe intake levels for se­lenium, which is toxic in high dos­es. Intake of more than 400 mi­crograms per day should be avoided. Another promising sup­plement is vitamin E, which was also unex­pectedly found to re­duce prostate cancer in a trial of smokers. In­terestingly, it may have more effect among smokers than among nonsmokers. This is also being tested in the SELECT trial. Lycopene, which gives tomatoes their red color, has also been linked with lower risk for prostate cancer. Another nutrient to con­sider is vitamin D. Many Ameri­cans-especially African-Ameri­cans-have inadequate levels. One nutrient that may do more harm than good in large quantities is calcium. Several studies suggest that too much calcium intake can actually increase men’s risk of prostate cancer.

MADISON, ALA. How do I use the glycemic load table?
Consideration of glycemic load can be an important aspect of healthy eating. Foods can be ranked ac­cording to how much their carbo­hydrate content can raise blood sugar levels, and this constitutes the glycemic index. The glycemic load also takes into account the amount of carbohydrate. For ex­ample, carrots have a high glycemic index, telling us that the carbohydrate in carrots can rapidly raise blood sugar. However, they don’t have a whole lot of carbohy­drate, so they have a modest glycemic load. Carrots are still a healthy food and should not be avoided (to the contrary!). Gener­ally, it is preferable to choose foods that have a low glycemic load. This means choosing mini­mally processed whole-grain foods instead of highly refined carbohydrates, limiting consump­tion of potatoes and avoiding added sugars. When the levels of blood sugar rise rapidly, this caus­es a rapid rise in insulin, followed by a rapid decline in blood sugar. This cycle can stimulate appetite and promote overeating, and also increases the risk for diabetes and heart disease.

MIDLOTHIAN, VA.: I’m 48 and in good health for my age, but I have a beer belly. I there a sensible diet or exercise I can perform to reduce the size of my belly?
The best exercise for a big belly was propounded by my father-in-law, Alvin Blum: pushing yourself away from the table. Seriously, there is no exercise that can target ab­dominal weight loss. Crunches can strengthen the ab­dominal muscles, but you can’t see the ef­fects until you lose the extra fat. This can on­ly be done by going on a long-term diet in which you consume fewer calories than you burn.

Though you may be in good health now, the big belly will likely sap your vitality as well as years from your life, so don’t wait for the diagnosis of a health condition to provide you with motivation. Losing weight is more important for those with a big belly (as opposed to those whose excess weight is distributed in the hips).Waist circumference is a strong predictor of increased risk for heart disease. By the way, though it’s often called a “beer belly,” beer does not promote weight or waist gain any more than any other source of calories.

LOUISA, VA.: Is there a dietary safeguard against Alzheimer’s?
Dietary factors for Alzheimer’s disease are being intensively studied, but so far none have been proven. Proof is difficult, since it is not feasible to conduct long-term dietary experiments in humans. Alzheimer’s disease develops gradually, and dietary factors are likely to have their im­pact many years be­fore symptoms be­come evident. Once symptoms appear, it may be difficult to al­ter the course of the disease through diet. So far, several dietary factors seem promising, and these are the same factors that may re­late to lower risk of heart disease. This is no coincidence, since vas­cular disease plays an important role in cognitive decline. Physical activity is consistently associated with a lower risk of cognitive de­cline. Studies suggest that intake of antioxidants-especially beta carotene-may reduce this risk, as well as adequate intake of folate. Many studies find that moderate alcohol intake (defined as up to one drink a day for women, and up to two drinks a day for men) is also linked to lower risk of cognitive decline, though of course higher levels of intake increase risk of cognitive decline. In one study, in­dividuals who had two or more episodes of passing out from alco­hol intoxication had a far higher risk of cognitive decline in later life. This critical area of diet and Alzheimer’s needs far more study.

CARY, N.C.: What can I do to lower my risk of dying from a heart attack as my father did? I try to eat right, but I am about 20 pounds overweight.
We know many ways to lower risk of heart disease. In one analysis in the Nurses’ Health Study, we found that following five simple behavioral guidelines would reduce risk of heart disease by more than 80 percent in women, even before considering medical remedies. The bad news is that only about 3 percent of the participants were following all five guidelines. The first three are simple: don’t smoke, get adequate physical activity (at least one half hour per day of vigorous or moderately vigorous activity), maintain a body mass index (BMI) of between 18.5 and 25. The fourth guideline is to moderate alcohol consumption. Obviously, some people should avoid alcohol altogether, such as those with alcohol problems. Excess alcohol should always be avoided-it’s much better not to drink at all then to drink too much, even occasionally. The fifth guideline is a healthy diet. In the analysis we did in the Nurses’ study, we identified six dietary elements: avoiding trans fats (from hydrogenated vegetable oils), replacing saturated fats with polyunsaturated fats, eating an adequate amount of fish, getting adequate fiber and folate, and sticking to a diet relatively low in glycemic load. A healthy diet includes nuts, fruits and vegetables, and legumes, with a lower intake of red meat and refined carbohydrates. Besides these behavioral factors, other risk factors are extremely important. These include high cholesterol, which can be treated with statins, and high blood pressure, which can be treated with many medications. Diabetes can also be treated with medications that can lower risk. Between the many behavioral factors, and the many medications that can treat cardiovascular risk factors, you can dramatically reduce your risk.

SAN DIEGO, CALIF.: My thyroid gland was removed 30 years ago. Since then, I have been unable to lose weight. Do you have any suggestions?
Thyroid hormone can influence body weight, and one of the symptoms of thyroid insufficiency is weight gain. So the first step is to be sure that your levels of thyroid hormone are where they should be. Your doctor can have this checked. Most likely, the levels are fine, and the weight gain is unrelated to the removal of the thyroid gland. If so, you should increase your physical activity and adopt a diet that will lead to gradual weight loss. Since any source of calories can lead to weight gain if they exceed the calories burned, the key elements of a weight-loss diet are first, to choose a healthy diet, and second, to choose a diet that will enable you to feel reasonably satiated so you can stick with it long term. Diets with a reasonable amount of healthy fats and protein typically are more satiating than those with very high levels of carbohydrates, especially refined carbohydrates. Different diets work for different people. Extreme diets of all sorts seem to work in the short term, but not for the long haul. A diet leading to gradual weight loss—say, two pounds a month—is more likely to be successful long term than a fad diet.

WATERTOWN, WIS.: Does my husband need to take a calcium supplement? He generally drinks an 8-ounce glass of skim milk daily and has a yogurt. I know it’s important for women, but how much calcium do men need?
Calcium is essential for men and women, but the optimal dietary intake is controversial. Although calcium is needed for healthy bones, beyond a modest level of intake (about 1,000 milligrams daily for adults), there is no compelling evidence that more is better. Countries with the highest intake of dairy products do not have lower fracture rates than low intake countries. The high levels of dietary calcium that are currently recommended are based largely on short term studies of bone metabolism, and do not take into account long term effects (which are much harder to study). Women experience rapid bone loss after menopause, so there is no reason not to consume the recommended levels of calcium. But for men, it is a different story. Although men also lose bone with age, it is much less rapid. More important, a number of studies suggest that too much calcium intake by men can increase the risk of prostate cancer. In one study, men who took calcium supplements had more than twice the risk of prostate cancer than nonusers of supplements. Too little calcium is related to elevated risks of colon cancer, so one must strike a balance. For these reasons, I recommend that men avoid separate calcium supplements (the small amounts in a typical multivitamin preparation are fine), and avoid excessive intake of dairy products. As in many aspects of diet, moderation is key.

BIRMINGHAM, ALA. I’m diabetic and have had breast cancer. Up until two years ago, I sprang out of bed and walked two miles everyday and ate healthy. But my weight has jumped. Now at 46, I drag myself to work and creep around like an old woman. Any suggestions?
About two-thirds of U.S. adults are overweight, representing an enormous public health problem. For most adults overweight is best defined as having a body mass index, a measure of weight and height, of 25 or more. Getting to and maintaining a healthy weight are critical goals for everyone, but especially for those with diabetes and breast cancer. In the majority of cases, Type 2 diabetes is a direct consequence of being overweight. Also, being overweight increases the risk of breast cancer after menopause, and also may lead to a poorer long-term prognosis. The good news is that it is never too late to make a change for the better. Many studies show that even moderate weight loss can substantially improve diabetes. In some instances, patients are even able to avoid diabetes medication after substantial weight loss and increased physical activity. There is a vicious cycle: with weight gain, there is a loss of feeling of energy that reduces physical activity. This in turn promotes further weight gain. The challenge is to turn this around to a virtuous cycle. By increasing physical activity, it is much easier to lose weight, which encourages a sense of well-being and motivates regular physical activity. Weight loss essentially entails expending more calories than one consumes. It is not true that eating fat makes you fat, any more than any other caloric source. The challenge is to identify a long-term healthy diet that is tasty and satisfying, but will still promote weight loss. This can be achieved through a diet rich in fruits and vegetables, substituting whole grain for refined grain products, with adequate healthy fats. Few people successfully lose weight without increasing physical activity, which is also important for health. It will improve diabetes and may further reduce your risk of a recurrence of breast cancer.

Stampfer is chairman of the department of epidemiology and professor of epidemiology and nutrition at the Harvard School of Public Health. He is also professor of medicine at Harvard Medical School and the author of more than 700 scientific publications. Readers should consult a medical professional for an accurate diagnosis.