Category Archives: Diet, Habits, & Other Behaviors

Eating Habits That Improve Health and Reduce Cancer Risks While Helping with Weight Loss

The latest research shows that measuring your waistline and keeping your BMI (body mass index) at a reasonable number will help keep you alive and healthy, while reducing your chances of developing cancer or cancer returning after treatment.[1] Research also shows that certain foods improve your health even if they don’t help you lose weight. This article will focus on eating habits that help you lose weight, but will also include information about the kinds of foods that are good for your health even if they don’t affect your weight.

Let’s start with the obvious: Sticking to a healthy diet in order to lose weight is hard for almost everyone. Keeping track of calories and fat can be confusing, and the nutrition labels on the foods we buy aren’t always that helpful. How are consumers supposed to figure out which diet advice is just hype – that ultimately doesn’t contribute to better health – and which advice offers good, medically sound information?

Here are some basic guidelines to keep in mind:

  • Calories matter
  • Serving size matters
  • Fats and cholesterol matter
  • Fruits, vegetables and whole grains matter
  • Exercise matters
  • Sticking to it matters

The Key to Losing Weight is to Eat Fewer Calories than You Burn in a Day- But There is More to it than That

Simply increasing your activity level might be enough if you only need to lose a few pounds to get your BMI into a healthy range. Most of the time, however, eating fewer calories is also going to be needed. Scientists have found that, in order to lose weight, a person must burn more calories than they consume.[2] Unfortunately, calories add up quickly!  For example, have you eaten at a fast food chain recently?  To work off the calories from a double cheeseburger, extra large fries and a 24 ounce soft drink – about 1500 calories – you would have to run for two and half hours at a ten minute mile pace! (For more information, see Fast Food Facts: Calories and Fats).  And some chain restaurants offer meals that have much more calories for lunch or dinner than an average person should eat in an entire day!

What happens if you exercise without lowering the calories you’re eating? A 2009 study found mixed results: some lost a significant amount of weight while others gained weight.[3] Although some weight loss strategies are effective for some people but not others, eating fewer calories and increasing exercise is most likely to help most people shed pounds.

Eating Fewer Calories Doesn’t Necessarily Mean Eating Less

The trick to dieting without being hungry is to choose foods that contain fewer calories and also fill you up. An example would be having a piece of fruit instead of fries with lunch.  It helps to remember that not all foods are created equal!  Some foods, such as nuts, are high in nutrients and essential vitamins, while others lack nutritional substance, such as products containing added sugars. “Nutrient-dense food” provides substantial amounts of vitamins and minerals and relatively few calories, but leaves you feeling fuller while also supplying valuable fuel for your body.  A person is more likely to stick to a diet if calories are nutrition-dense and offer variety.[4]

Empty calories from foods with processed and refined sugars, such as candy, pasta and bread made from white flour, and many energy drinks and soft drinks, leave you hungry again soon after, craving more food.  In contrast, the “complex carbohydrates” in vegetables, whole-grain breads and cereals, and low-fat yogurt and milk, provide long-lasting nutrients, improve digestion, help stabilize blood sugar, and keep your energy at an even level.  Although fruits are also considered simple carbohydrates, they contain vitamins and nutrients that occur naturally, unlike those found in processed and refined foods.

A 2011 study in the respected New England Journal of Medicine found that certain foods were linked to weight change more than others.[5] After following participants for an average of 17 years, researchers found that gaining weight was most strongly linked to foods such as potato chips, sugar-sweetened beverages, and red meat.  People who ate more vegetables, whole grains, nuts, fruits, and yogurts were less likely to gain weight over the years, even though some of those foods are quite high in calories.

What about low-carb diets versus low-fat diets? A 2014 study compared the effects of both diets on body weight and cardiovascular health. They found that the low-carb diet was much more effective than the low-fat diet for losing weight and reducing cardiovascular risks.[6] So hold back on the white bread, but don’t feel bad about eating some olive oil.  But if you want to maintain that weight loss, remember that variety in your diet as well as exercise are also important.

Don’t Assume that Foods Marketed as “Healthy” Really Are or Will Help You Lose Weight

Don’t fall for the “health halo” effect: assuming that all foods at restaurants marketed as “healthy” or all foods of a category labeled “healthy” (e.g., salads) are actually better for you.  Research shows that customers at fast food restaurants underestimate the calories in their meals [7] and most consumers underestimate the calorie content of foods that are labeled “low-fat.”[8] For example, if you look at a bag of potato chips, you will probably see that the “low fat” ones almost have the same number of calories as the regular chips made by the same company.

The choices that will keep your calories down are not always obvious.  For example, a 2013 study found that adolescents ordered about the same number of calories at Subway as they did at McDonald’s.[9] Try to check the nutritional contents of your meal options and make an informed decision. If nutritional information is not posted in the restaurant, it is probably available on the restaurant’s website.

Eating 5 Small Meals Is Not Better than Eating 3 Larger Ones

For several years, some experts have claimed that eating 5 or 6 times a day can be a better way to lose weight than eating only 3 times a day.  However, the latest research indicates that is not true.[10]

Studies have found that eating off of smaller plates or bowls helps people eat less, because most of us tend to fill our plate and then finish what is on it.[11],[12] Unfortunately, portion sizes for restaurant meals, baked goods, other prepared foods, and even homemade meals – everything from breakfast muffins to a plate of spaghetti – have grown to very unhealthy proportions in the last few decades. This is contributing to the obesity epidemic.

In addition to adjusting your portion size, limiting the hours when you eat can also help you maintain a healthy weight. In a study published in British Journal of Nutrition in 2013, researchers followed a group of healthy men for four weeks. They ate their normal diets during all four weeks, but for 2 of those weeks, they fasted for 11 hours at night (from 7 pm to 6 am). The study found that under the time-restricted conditions, the men consumed approximately 200 fewer calories per day and lost weight during the two weeks of nightly fasting compared to the two weeks when they did not fast at night. The researchers believe that it was the combination of few calories and night-time fasting that resulted in the weight loss.[13]

What About Fats?

Recent research has shown that eating foods high in cholesterol don’t necessarily contribute to a person’s cholesterol levels.  The past focus on fats is also being questioned, especially in light of an investigation indicating that the original reports that blamed fats were written by researchers paid by the sugar industry.[14]

Fats are high in calories, but some fats are more dangerous for you than others.  The least healthy ones include saturated fats and of trans fats. These tend to be the kinds of fat that are solid at room temperature – like the fat in meat products, butter, margarine, shortening and lard – and the fats that come from baked goods and fried foods.  The fats that are good (in moderation) are “unsaturated” or “polyunsaturated” fats. These tend to be liquid at room temperature, like canola oil, olive oil and some of the other vegetable oils. There are exceptions, however, such as coconut oil, which is high in saturated fats. Diets such as the Mediterranean diet, which includes more unsaturated fats and plant-based foods, can lower the chances of cardiovascular diseases. So, for people who find it difficult to stick with a low-fat diet, such as a vegan or vegetarian diet, there are other healthy alternatives.[15Check the nutrition label before you buy, to be sure that you’re choosing the product with the lowest possible saturated fat content.

Eat More Fruits, Vegetables, Whole Grains, and Low- or No-Fat Dairy Products Every Day

There are many good resources to help you learn about healthy eating, such as the US Department of Agriculture website at My Plate. Nutritionists at the Harvard School of Public Health have similar (but not identical) healthy food guidelines. What these diets have in common includes recommendations to:

  • Aim for at least five servings of fruits and vegetables a day. Usually, the more colorful the fruit or vegetable, the more nutritious. For example, dark green spinach has more nutrients than light green iceberg lettuce. In 2023, an analysis of studies of 2372 adults with mean ages 20 to 67 reported that a vegan or vegetarian diet can help people reduce their risk of developing cardiovascular diseases.[15However, research has also shown that any diet that replaces at least some fats, carbohydrates, and foods high in added sugar with fresh fruits and vegetables is likely to improve your health.[16]
  • Try and choose whole grain cereal, pasta, rice, and bread. Many foods that claim “whole wheat” or “whole grain” on the front of the package actually contain very little, but breads that are truly high in whole grains now give the exact amount in a very obvious place on the label.  Be sure to see if the amount listed is for one slice or two – in many cases, a “portion” is listed as 2 slices for the amount of grains but only one slice when listing calories per portion!  And don’t be fooled by bread color: dark brown breads are often colored with coffee or other dyes, not whole grains.
  • Avoid food that is high in sugar, such as pastries, sweetened cereal, and soda or fruit-flavored drinks.
  • Reduced-fat or no-fat (skim) milk, reduced-fat cheese, and low-fat or no-fat yogurt are good sources of the protein and calcium we need. Try to eat 2-4 servings of low-fat or no-fat dairy products each day.
  • Fruits and vegetables often cost less than unhealthy foods.[17],[18] By buying healthy food options, you’re doing both your body and your wallet a favor!

Exercise Does Burn More than Calories

Increasing the amount of exercise you do each day means you burn more calories to help you lose weight.  And it doesn’t take much; just 30 minutes of moderately strenuous daily exercise helps prevent heart disease, which is the #1 killer of women and men in the U.S..[17] The exercise you choose doesn’t need to be elaborate either, or even take place in a gym.  Walking, biking, swimming, or gardening can do the trick, and getting a friend or family member to exercise with you can turn this into a valued part of your daily routine.  Learn more about the health benefits of physical activity and how to get started from the CDC.

Staying Healthy is a Life-Long Proposition

Don’t think about dieting as a short-term weight loss goal.  Instead, ask yourself the question: How long do I want to live and how sick do I want to be?  Scientists have found that one of the keys to success is to think about these goals every day.[18] For example, people who get on a scale and check their weight daily are more successful at keeping their weight under control than people who don’t.[18]

Don’t Waste Your Time and Energy and Money on “Quick Fix” Solutions

For some people, there may be faster ways to lose weight than following the diet suggestions listed here.  But those quick solutions tend to be temporary; even bariatric surgeries don’t necessarily provide long-term solutions.  Learning to eat in a healthier way allows you to sometimes indulge in foods that aren’t so healthy, while still being healthier than you ever were before, and living longer.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

  1. For more information about BMI and how it is calculated, see Obesity in America: Are You Part of the Problem?
  2. Thomas, D.M., Bouchard, C., Church, T. et al. Why do individuals not lose more weight from an exercise intervention at a defined dose? An energy balance analysis. Obes Rev. 2012; 13: 835–847
  3. Church, TS, Martin, CK, Thompson, AM et al. Changes in weight, waist circumference and compensatory responses with different doses of exercise among sedentary, overweight postmenopausal women. PLoS ONE. 2009; 4
  4. Vadiveloo M, Sacks, FM, Champagne, CM, et al. Greater Healthful Dietary Variety Is Associated with Greater 2-Year Changes in Weight and Adiposity in the Preventing Overweight Using Novel Dietary Strategies (POUNDS Lost) Trial. J Nutri. 2016, doi: 10.3945/jn.115.224683
  5. Mozaffarian D, Hao T, Rimm, EB, et al. Changes in Diet and Lifestyle and Long-Term Weight Gain in Women and Men. The New England Journal of Medicine. 2011;364:2392-404.
  6. Bazzano LA, Hu, T, Reynolds, K et al. Effects of Low-Carbohydrate and Low-Fat Diets: A Randomized Trial. Annals of Internal Medicine. 2014;161(5):309-310
  7. Block, JP, Condon, SK, Kleinman, K, et al. Consumers’ estimation of calorie content at fast food restaurants: cross sectional observational study. BMJ 2013; 346
  8. Ebneter, DS, Latner, JD, Nigg, CR. Is less always more? The effects of low-fat labeling and caloric information on food intake, calorie estimates, taste preference, and health attributions. Appetite 2013. 68(1): 92-97)
  9. Lesser LI, Kayekjian K, Velasquez P, et al. Adolescent purchasing behavior at McDonald’s and Subway. J Adolesc Health. 2013 Oct; 53(4):441-5.
  10. Varady KA. Meal frequency and timing: impact on metabolic disease risk. Curr Opin Endocrinol Obes. 2016 Jul 21.
  11. Hanks, A, Kaipainen, K, Wansink, B. The Syracuse Plate: Reducing BMI by Introducing Smaller Plates in Households. J of Nutrition Education and Behavior. 2013, 45 (4), Supplement, S41
  12. Wansink, B, Painter, JE, North, J. Bottomless Bowls: Why Visual Cues of Portion Size May Influence Intake. Obesity Research. 2005,13 (1)
  13. LeCheminant, JD, Christenson, E, Bailey, BW, Tucker, LA. Restricting night-time eating reduces daily energy intake in healthy young men: a short-term cross-over study. British Journal of Nutrition. 2013, 110 (11)
  14. Connor, Anahad. How the Sugar Industry Shifted Blame to Fat. The New York Times. 2016.
  15. Koch, C., Kjeldsen, E., Friikkle-Schmidt, R. Vegetarian or Vegan Diets and Blood Lipids: a Meta-Analysis of Randomized Trials. European Heart Journal. 2023, ehad211.
  16. National Institute of Diabetes and Digestive and Kidney Diseases. Take Charge of Your Health: A Guide for Teenagers. U.S. Department of Health and Human Services. Available
  17. Bishop, K., Wootan, MG. Healthy bargains: Fruits and vegetables are nutritious and economical. A Center for Science in the Public Interest study. Available
  18. Carlson A, Frazao E. Are Healthy Foods Really More Expensive? It Depends on How You Measure the Price. Washington, D.C.: United States Department of Agriculture. May, 2012. Report No. EIB-96.
  19. Pandey, A, Garg, S, Khunger, M, et al. Dose Response Relationship Between Physical Activity and Risk of Heart Failure: A Meta-Analysis. Circulation. 2015;
  20. Bertz, F, Pacanowski, CR, Levitsky, DA. Frequent Self-Weighing with Electronic Graphic Feedback to Prevent Age-Related Weight Gain in Young Adults. Obesity. 2015; 23(10): 2009-2014

Everything You Need To Know About The New Weight Loss Drugs

Jenny Niwa

You have probably heard about several very popular new weight loss drugs, such as Wegovy, Ozempic, Mounjaro, and Zepbound.  Although Ozempic and Mounjaro are specifically approved by FDA for treating diabetes and not for weight loss, all four are being used by people who want to lose weight. Before you decide whether to take these drugs, here are some things you should know.

What are these drugs and how do they work?

The FDA approved Ozempic in 2017 for the treatment of type 2 diabetes and Wegovy in 2021 for weight loss for adults with obesity or who are overweight and have at least one weight-related health condition.  Although these drugs have been on the market for several years, their popularity really exploded in 2023. Mounjaro was approved in the spring of 2022 for Type 2 diabetes and Zepbound was approved in late 2023 for those with obesity or who are overweight with an additional chronic condition such as hypertension. While Ozempic and Mounjaro are not approved specifically for weight loss, doctors may prescribe them anyway – that’s called prescribing it off-label. All four curb hunger and reduce the intake of food. The medications are currently administered by injection once a week, but they may soon be available in pill form.

Both Wegovy and Ozempic  are made of semaglutide. Mounjaro and Zepbound are made of tirzepatide.  Both mimic the GLP-1 hormone, which is made naturally by the body. GLP-1  does 2 things: 1) It One is to slow the passage of food through the stomach, which helps people feel fuller longer; and 2) it promotes insulin release and helping reduce blood sugar.

What do research studies say? 

In August 2023, Wegovy’s maker, Novo Nordisk, claimed in a press release that the drug reduced the risk of serious heart problems. The company described a randomized trial of 17,500 patients with obesity and heart disease, although patients with diabetes were excluded.[2] Half of the participants received regular injections of Wegovy and the other half received a placebo. Rather than publish the results in a peer-reviewed journal, Novo Nordisk publicized their research in a press release that claimed that Wegovy reduced heart attacks, strokes, and deaths by 20% compared to placebo, and this was widely reported in the media. However, this statistic is misleading because it is a relative risk. When the study was finally published in the New England Journal of Medicine on November 11, 2023, the results did not sound as impressive:  8% of the people in the placebo group had had a nonfatal stroke or heart attack or died due to cardiovascular causes, compared to 6.5 percent in the Wegovy group[3] That decrease from 8% to 6.5% is a 20% decrease, but the difference is only 1.5% for patients considering whether it is a meaningful difference for them.

In August 2023, a study published in the New England Journal of Medicine found that the medication reduced the risk of heart problems for diabetes patients who were at high risk for cardiovascular complications. [4] This study included more than 3,000 patients with type 2 diabetes, who were randomly assigned to receive once-weekly Ozempic or a placebo for 2 years. Results showed that 108 of 1648 patients (6.6%) taking Ozempic either died, had a nonfatal heart attack, or nonfatal stroke, compared to 146 of 1649 patients (8.9%) who took the placebo.  This was statistically significant (which means it did not occur by chance), but is a difference of only 2.3%.

Mounjaro has been found to reduce blood pressure, which could improve health, but no published studies have provided evidence that it reduces heart disease.

What are the side effects?

The most common side effects of these GLP-1 medications include stomach issues such as nausea and diarrhea. Some patients experienced persistent vomiting or cyclic vomiting syndrome and severe gastroparesis. Gastroparesis is stomach paralysis and occurs when there is a delay or stopping in food movement from the stomach to the small intestine.

Warnings about other possible serious side effects that are listed on the companies’ websites include inflammation of the pancreas, gallbladder problems, increased risk of low blood sugar, kidney problems, serious allergic reactions, change in vision for people with type 2 diabetes, increased heart rate, and depression and thoughts of suicide.[5]

In January 2024, a new FDA report listed potential links between the medications and extensive hair loss (called alopecia), a swallowing problem that can occur during surgery called aspiration, and thoughts of suicide.[14]  A few days later, the FDA announced that their preliminary review did not support an increase in thoughts of suicides among patients taking these drugs, but the FDA also said they had drawn no conclusions based on their preliminary findings and would continue to review new data.

An even more serious side effect is the risk of thyroid cancer. According to a study conducted by the European Medicines Agency (EMA, which is the European version of the FDA), researchers found that using GLP-1 medications for 1-3 years may increase the risk for all types of thyroid cancers.[6]

Concerns about aspiration and suicidal thoughts are not new. For example, in 2023 there were media reports about potential complications from anesthesia for people taking these drugs. The American Society of Anesthesiologists advises that people taking these drugs should make sure to stop taking the medication a week before surgery. People who know they are going to have surgery are advised not to eat for 24 hours before surgery, but since these drugs affect how long food stays in the stomach, a 24-hour fast is not enough to prevent regurgitating food during the operation. This is dangerous because vomiting under anesthesia can cause pneumonia and other fatal problems due to the food and stomach acid getting into the lungs.[7]  This risk may be impossible to prevent if someone taking the drug requires emergency surgery.

What Happens if You Lose Weight and Want to Stop Taking the Drug?

Most weight loss strategies work for a limited time; when people stop dieting or exercising, they gain the weight back. Is the same true for the new weight loss drugs such as semaglutide and tirzepatide? Unfortunately, most patients take these drugs for less than 3 months and the number still taking the drug after 1 year is even lower. A study of more than 1,900 patients by researchers at the Cleveland Clinic found that patients’ use of semaglutide and several other weight loss medications dropped from 44% at 3 months to 33% at 6 months and just 19% at 12 months.[8]  Regardless of whether they stopped taking the drugs due to side effects, cost, or other reasons, the long-term benefits of these drugs are limited because when they stop taking the drugs, their stomach no longer feels full. A study conducted with almost 2,000 adults without diabetes found that one year after no longer taking Wegovy, participants regained two-thirds of their prior weight loss.[9]  

There is still much that is unknown about these drugs. It is unclear how these drugs affect patients after years of use, whether the drugs are effective at maintaining a certain weight after long-term use, and whether most patients will benefit from taking the drugs for a limited period of time or if they need to stay on for the rest of their lives. Current literature suggests that such medications may need to be taken life-long to experience long-term benefits and prevent any negative consequences that come from discontinuing use. [8]

Other Questions to Consider

In 2022, Novo Nordisk spent a total of $11 million to promote their Ozempic and other weight-loss drugs, including $9 million on meals and $2 million on travel for thousands of doctors to promote their weight-loss drugs.[10] That included more than 457,000 meals; nearly 12,000 prescribers had food paid for by the company more than a dozen times in that one year. Buying meals for doctors is not illegal, but this extreme level of “generosity” raises concerns. If these drugs are so effective, why did the company think it necessary to provide all these free meals?  And since the drugs became much more popular after the company spent all that money providing free meals to doctors, do you wonder if doctors are prescribing these drugs because they have they been unduly influenced to prescribe them?

Is taking these weight loss drugs right for you?

Ozempic is FDA approved for patients with type 2 diabetes and is not approved for weight loss. Due to the risk of thyroid cancer, if you or any family member has ever had a type of thyroid cancer, taking any of these 4 drugs may be dangerous. Similarly, if you have sensitivity to gastrointestinal problems, these drugs may not be right for you.

In January 2024, Eli Lilly, the maker of Mounjaro and Zepbound, warned against their use for cosmetic reasons. The company reminded physicians and patients that GLP-1 drugs are meant for serious diseases (obesity or Type 2 diabetes) and not for cosmetic weight loss. [15]

Another thing to consider is the cost, which is much higher in the U.S. compared to other countries.[11] If insurance does not cover the cost, one monthly dose of Ozempic costs about $900, and the cost for Wegovy is about $1,350 per month.[12],[13] The cost of Mounjaro is similar to Ozempic and Zepbound costs somewhat less than Wegovy. Since they are relatively new, there are no generic versions. You may be able to lower the costs of these drugs through savings programs or through coverage on your health insurance plan. Many private insurance providers cover these drugs to treat Type 2 diabetes. When used for weight-loss purposes, it is much less likely to be covered. Medicare does not cover these drugs, although patients, doctors, and Congress are pressuring Medicare to do so.

The media attention to these 4 drugs makes it seem that they are the only FDA-approved weight loss drugs. They are not. However, all weight loss drugs have unpleasant and potentially serious side effects, and these 4 seem to be more effective.

If you are eligible and interested in taking these drugs, you should first and foremost make sure to talk to your physician and discuss what to expect, the possible side effects, and your medical history. If you are not eligible for these drugs or are not interested in using them, there are other methods available that can help you lose weight and improve your health if you stick with them. These include exercising daily or regularly, developing healthier eating habits, and knowing when to eat.

[1] Hoffman, S. (2023) The Differences between Saxenda and Wegovy. Very Well Health.

[2] Chen, E., and Joseph, A. (2023). Novo’s obesity drug Wegovy lowers cardiovascular risk by 20%, landmark trial finds. STAT+.

[3] Lincoff, A. M., Brown-Frandsen, K., Colhoun, H. M., Deanfield, J., Emerson, S. S., Esbjerg, S., Hardt-Lindberg, S., Hovingh, G. K., Kahn, S. E., Kushner, R. F., Lingvay, I., Oral, T. K., Michelsen, M. M., Plutzky, J., Tornøe, C. W., & Ryan, D. H. (2023). Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. New England Journal of Medicine.

[4] Marso, S., Bain, S., Consoli, A., & Eliaschewitz, F. (2016). Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. The New England Journal of Medicine.

[5] Novo Nordisk. (n.d.). Tips for managing common side effects.,The%20most%20common%20side%20effects%20of%20Wegovy%C2%AE%20may%20include,runny%20nose%20or%20sore%20throat.

[6] Bezin, J., Gouverneur, A., Penichon, M., Mathieu, C., Garrel, R., Hillaire-Buys, D., Pariente, A., & Faillie, J.L. (2022). GLP-1 Receptor Agonists and the Risk of Thyroid Cancer. Diabetes Care.

[7] Goodman, B. (2023). They took blockbuster drugs for weight loss and diabetes. Now their stomachs are paralyzed. CNN.

[8] Most Stop Taking Weight Loss Drugs Within 1 Year. (n.d.). Medscape. Retrieved December 12, 2023, from

[9] Wilding, J. P., Batterham, R. L., Davies, M., Van Gaal, L. F., Kandler, K., Konakli, K., Lingvay, I., McGowan, B. M., Oral, T. K., Rosenstock, J., Wadden, T. A., Wharton, S., Yokote, K., &  Kushner, R. F. (2022). Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes, Obesity and Metabolism, 24(8), 1553–1564.

[10] Florko, N. (2023). Novo Nordisk bought prescribers over 450,000 meals and snacks to promote drugs like Ozempic. STAT+.,to%20promote%20drugs%20like%20Ozempic&text=WASHINGTON%20%E2%80%93%20Novo%20Nordisk%20spent,weight%20loss%2Dinducing%20diabetes%20drugs

[11] Amin, K., Telesford. I., Singh, R., & Cox, C. (2023). How do prices of drugs for weight loss in the US compare to peer nations’ prices? Health System Tracker.

[12] Wilson, A. (2023). How much does Ozempic cost without insurance?. RO.

[13] Wilson, A. (2023). How much does Wegovy cost? RO.

[14]  FDA Looking Into New Risks With Popular Weight-Loss Drugs. (n.d.). Retrieved January 9, 2024, from

[15]  Open Letter Regarding the Use of Mounjaro® (tirzepatide) and ZepboundTM (tirzepatide) | Eli Lilly and Company. (n.d.). Retrieved January 12, 2024, from

Artificial Sweeteners: Do They Help You Lose Weight or Gain it? Are they Safe?

Danielle Pavliv, Laura Gottschalk, PhD, and Amanda Chu

When people want to treat themselves to something sweet without having to treat themselves to a larger pants size too, they often reach for low-calorie, artificial sweeteners. But do artificial sweeteners actually help you lose weight? The answer is not necessarily. As for their safety, the answer becomes more complex.

What are Artificial Sweeteners?

The most popular types of sugar substitutes in the US and many other countries are artificial sweeteners. Artificial sweeteners are typically made in a laboratory and don’t contain calories or supply your body with energy, vitamins, or anything else nutritious. These sweeteners are many times sweeter than sugar, so less is needed to reach the same level of sweetness as something containing sugar. Sweeteners can be used in the home for baking and cooking, and they can also be found in soft drinks, candy, and canned foods that are not necessarily sweet. These artificial sweeteners are considered to be “ultra-processed” and in addition to being used as sweeteners in foods that are marketed as “low-sugar” or “sugar-free” are also used to mask the taste of preservatives or other ingredients in foods that are not sweet.[10]

There are six types of artificial sweeteners currently approved by the FDA.

TTwo “natural” sugar substitutes have also been approved by the FDA. Brand names such as Truvia, PureVia, Enliten (Steviol glycosides), Nectresse, Monk Fruit in the Raw, PureLo (monk fruit extract) are all made from plants. But before being sold in the store, they must first be highly processed in a laboratory. So don’t be fooled into thinking that the word “natural” means that it comes straight from nature to your table.

Do Artificial Sweeteners Help You Lose Weight?

It makes sense that eating and drinking fewer calories by switching to sugar substitutes should lead to weight loss. However, there are several studies that found that people who drink diet drinks weigh more than those who don’t.[1] However, that does not mean that the sugar substitutes cause weight gain, since people who are overweight may choose diet drinks in an effort to lose weight.

Researchers are questioning whether these products may actually make it more difficult to lose weight, perhaps because sweet drinks and foods make people crave more sweets.  For example, research published in 2021 found that drinking beverages sweetened with the artificial sweetener sucralose, led women and people with obesity to eat larger amounts of food at their next meal.[11] That would definitely stand in the way of people trying to lose weight.

The best way to study if artificial sweeteners help people lose weight is known as a randomized controlled trial. People in the trial would be randomly put into groups—one group uses artificial sweeteners while the other group uses sugar. Then, the two groups can be compared to see if using artificial sweeteners had a different impact than sugar. However, randomized clinical trials would be very difficult to conduct on artificial sweeteners because they are in so many different types of food, not just diet drinks.

In 2023, the World Health Organization (WHO) scrutinized scientific reviews of the effect of artificial sweeteners on weight control and concluded that artificial sweeteners do not help people lose weight.[2]

Are Artificial Sweeteners Safe?

A 2020 study published in the journal Cell Metabolism by a group of Yale researchers found that the consumption of the common artificial sweetener sucralose (found in Splenda, Zerocal, Sukrana, SucraPlus) in combination with carbohydrates can turn a healthy person into one with high blood sugar.[3]

You may have heard claims that artificial sweeteners could change hormone levels [4], increase the risk of heart problems [5], and cause higher rates of type II diabetes.[6] An important 2022 French study of more than 100,000 adults followed for a median of 9 years found that consuming artificial sweeteners was associated with a very slight increased likelihood of experiencing newly diagnosed cardiovascular conditions such as heart attacks and stroke. The study identified three artificial sweeteners that seem to cause the greatest increases. People taking aspartame (NutraSweet, Equal) were more likely to have a stroke, while people taking acesulfame potassium (Sunnett, Sweet One) or sucralose (Splenda) were more likely to develop coronary artery disease.[7]

The reasons why artificial sweeteners might harm cardiovascular health are unclear. However, experts suggest that these sweeteners could increase inflammation, metabolic disruptions, and alterations in the gut microbiome and blood vessels. That may increase the chances of developing conditions such as type 2 diabetes, unhealthy cholesterol levels, and high blood pressure.

Artificial sweeteners also increase the chances of being depressed, according to a study published in 2023 on 31,712 women aged 40-62. After statistically controlling for other traits such as age, smoking, and BMI, women who consumed larger quantities of artificial sweeteners and artificially sweetened beverages were more likely to be depressed. While the reasons are not fully understood, the use of these artificial sweeteners can lead to changes in the brain that could contribute to the development of depression.[8]

For many years, there were concerns about whether artificial sweeteners cause cancer. A recent study by the WHO’s International Agency for Research on Cancer (IARC) has found a possible link between aspartame and liver cancer. While the risk of cancer from aspartame is considered low for most consumers, those who consume large quantities could be harmed. In addition, children may reach the daily recommended limit more easily due to their lower body weight. In fact, a 44-pound child would only need to drink approximately four cans of Diet Coke per day to exceed the maximum recommended limit. That is why it is so important to be very careful to consume as little aspartame as possible, especially for children, to reduce the chances of developing cancer.[9]

Should You Use Artificial Sweeteners?

Does the increased risks of obesity, diabetes, and heart disease from consuming large amounts of sugary drinks may outweigh the risks posed by artificial sweeteners?  That is still now clear, but based on the research so far, it makes sense to avoid the largest drink sizes, whether sugary or artificially sweetened. There is growing evidence that consuming even small amounts of artificially sweetened beverages may result in similar health risks to sugary drinks, and they apparently do not help with weight loss. Finding healthier alternatives, such as making your own coffee or tea, or flavoring water with slices of lemon, lime, watermelon, or apple, is a good strategy for your health. And, keep in mind that you should never consume more calories in other food because you “saved” some by drinking a non-caloric drink![7]

All NCHR articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff. 

The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.


  1. Anderson GH, Foreyt J. Sigman-Grant M, Allison DB, The use of low-calorie sweeteners by adults: impact on weight management. J Nutr. 2012 Jun;142(6):1163S-9S.
  2. The World Health Organization. WHO advises not to use non-sugar sweeteners for weight control in newly released guideline. May 2023. Retrieved from
  3. Dalenberg JR, Patel BP, Denis R, Vinke PC, Luquet S, Small DM. Short-Term Consumption of Sucralose with, but Not without, Carbohydrate Impairs Neural and Metabolic Sensitivity to Sugar in Humans. Cell Metabolism. Clinical and Translational Report, Volume 31, Issue 3, P493-502E7. March 03, 2020.
  4. Brown RJ, Walter M, Rother KI. Effects of diet soda on gut hormones in youths with diabetes. Diabetes Care. 2012 Mat;35(5):959-64.
  5. Vyas A, Rubenstein L, Robinson J. et al. Diet drink consumption and the risk of cardiovascular events: a report from the Women’s Health Initiative. J Gen Intern Med. 2015 apr;30(4):462-8.
  6. Suez J, Korem T, Zeevi D, et al. Artificial sweeteners induce glucose intolerance by altering the gut microbiota. Nature. 2014 Oct 9;514(75210:181-6.
  7. Corliss, Julie. Sugar substitutes: New cardiovascular concerns? Harvard Medical School. January 1, 2023.
  8. Florko, Nicholas. WHO says aspartame might cause cancer–but that most adult consumers don’t need to worry. STAT. July 13, 2023.
  9. Florko, Nicholas. WHO says aspartame might cause cancer–but that most adult consumers don’t need to worry. STAT. July 13, 2023.
  10. Look for these 9 red flags to identify food that is ultra-processed. (2024, January 2). Washington Post.
  11. O’Connor, A., Steckelberg, A., & Reiley, L. (n.d.). How fake sugars sneak into foods and disrupt metabolic health. Washington Post. Retrieved January 11, 2024, from

Fast Food Calorie Count Cheat Sheet

Andrea Sun, Avery Nork, Jenny Niwa

Fast Food Facts (download pdf)

Let’s face it:  With so much to do, it’s hard to eat right. And even though you know that fast food tends to be more fattening and less healthy, fast food chains are convenient and avoiding them may not be the most realistic. However, obesity is linked to a wide range of health problems, including breast cancer, endometrial cancer, colon cancer, and liver cancer, and knowing your healthiest options can go a long way for your overall health.

There is good news. The FDA implemented the new menu labeling rule in 2018 after facing delays and challenges since it was finalized in December 2014.[1]

As a result, chain restaurants with 2 or more locations under the same name have to provide accurate information about calories and other nutritional information. Many changed their ingredients or made portions smaller to reduce calories. Customers can now consume fewer calories without dramatically changing their eating habits.[2] Consumers now are empowered to make more informed choices about their food and it is easier to choose healthier eating habits.

How Many Calories Should I be Consuming a Day?

The United States Department of Agriculture (USDA) has recommended dietary guidelines that include the number of calories you should consume a day, depending on your age, level of activity, and whether you are a man or woman.[3] The chart below will help you find out how many calories you should be getting.[3] If you regularly consume more than the recommended amount, you will probably gain weight.

Recommended Daily Calorie Intake by Gender and Age Based on Activity Level

Activity Level
Gender Age (years) Sedentary Moderately Active Active
Female Child





Male Child 2-3 1,000 1,000-1,400 1,000-1,400

Females 4-8




























Males 4-8
















































Source: HHS/USDA Dietary Guidelines for Americans, 2005 [3]

Sedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life. Moderately active means physical activity equal to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity typical of day-to-day life. Active means physical activity equal to walking more than 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity typical of day-to-day life. The calorie ranges are different for different age groups. For children and adolescents, more calories are needed at older ages. For adults, fewer calories are needed at older ages. [3] The National Center for Health Research wants to give you examples of menu choices offered by some of the most popular fast food chains. Take a look — you may be surprised!

Fast Foods by Category:

Pizza per slice: Calories
California Pizza Kitchen Original BBQ Chicken 190
Domino’s Medium Ultimate Deep Dish EXtravaganZZa Feast 350
Domino’s Medium Cheese 190
Domino’s Medium Cheese and Pepperoni 220
Papa John’s Medium Garden Fresh on Original Crust 200
Papa John’s Medium Spinach & Tomato Alfredo on Original Crust 200
Pizza Hut’s Medium Thin n’ Crispy, Pepperoni 200
Pizza Hut’s Medium Original Pan Meat Lover’s Pizza 310
Pizza Hut’s Medium Original Pan Hawaiin Chicken Pizza 240

Cheeseburges and Hamburgers Calories
Burger King Whopper (with cheese) 790
Five Guys (with cheese) 980
McDonald’s Quarter Pounder (with cheese) 520
Wendy’s ¼ Pound Single burger (with Cheese) 610
Hamburgers without cheese are ~100-150 calories less

Chicken: Calories
Burger King 8 Piece Chicken Nuggets 390
Burger King Original Chicken Sandwich 680
McDonalds McNuggets (10 piece) 410
McDonald’s McChicken 400
Wendy’s 10 Piece Chicken Nuggets 491
Wendy’s Spicy Chicken Sandwich 500
Popeyes Chicken Sandwich 700
Kentucky Fried Chicken Original Recipe Chicken Breast 390

French Fries: Calories
Burger King Medium Fries 387
Five Guys, Regular 953
McDonald’s Medium Fries 320
Wendy’s Medium Fries 427

Burritos: Calories
Baja Burrito with Chicken 988
Chipotle Chicken Burrito (with rice, black beans, pico, sour cream, and cheese) 1115
Taco Bell Beefy 5-layer Burrito 490
Taco Bell Grilled Cheese Burrito, Ground Beef 720

Sandwiches: Calories
Panera Smoky Buffalo Chicken Melt – Toasted Baguette 830
Panera Roasted Turkey & Avocado BLT (whole) 860
Quiznos Honey Mustard Chicken Sub, 8” 830
Quiznos Tuna Melt, 8” 660
Subway Turkey, 6 inch (no mayo no cheese) 280
Subway Sweet Onion Chicken Teriyaki, 6 inch (no mayo no cheese) 330

Salads (no dressing): Calories
McDonald’s Bacon Ranch Grilled Chicken Salad 440
Panera Greek Salad 400
Panera Strawberry and Poppyseed Chicken Salad 350
Quiznos Honey Mustard Chicken, Full 550
Subway Oven Roasted Chicken salad with MVP parmesan vinaigrette dressing 200
Wendy’s Apple Pecan Salad 450

Muffins: Calories Sugar
Au Bon Pain Cranberry Walnut 520 29 g
Dunkin Donuts Blueberry 460 44 g
Dunkin Donuts Honey Bran Raisin 440 39 g
Starbuck’s Blueberry 424 36 g
Starbuck’s Skinny Blueberry 264 29 g

Donuts: Calories Sugar
Dunkin Donuts Glazed Donut 260 12 g
Krispy Kreme Original Glazed Donut 190 10 g
Starbuck’s Old-fashioned Glazed Donut 480 30 g

Bagels: Calories
Dunkin Donuts Everything 350
Einstein’s Asiago Cheese Bagel 300
Einstein Everything 280
Starbuck’s Plain 280

Other Breakfast options: Calories
Burger King Sausage, Egg, and Cheese Biscuit 526
Dunkin Donuts Egg and Cheese Bagel 460
McDonald’s Sausage McMuffin with Egg 480
Taco Bell’s Breakfast Crunchwrap with Sausage 730
Starbuck’s Cheese Danish 290
Starbuck’s Banana Walnut & Pecan Loaf 410

Coffee: Calories Sugar
Dunkin Donuts Mocha Swirl Latte (10 oz) 220 32 g
Dunkin Donuts Coolatta with Skim Milk (16 oz) 140 29 g
Dunkin Donuts Latte (10oz) 120 9 g
Dunkin Donuts Coffee (14oz), (no milk or sugar) 10 0 g
Starbuck’s Caramel Frappuccino, Grande Nonfat with Whip 390 66 g
Starbuck’s Caffè Mocha, Grande Nonfat Milk, no Whip 250 34 g
Starbuck’s Caffè Latte, Grande 2% Milk 190 17 g
Starbuck’s Coffee Frappuccino Light 110 23 g
Starbuck’s Caramel Macchiato, Grande 250 33 g

Where to Find This Information?

Don’t fall for the “health halo” effect by assuming that all foods at restaurants marketed as “healthy” or salads and other foods you assume are healthy are actually better for you. Several fast food chains and restaurants have their nutrition information on their websites. If your favorite foods are not listed above, go to the chain’s website and look for the calorie information. You may be shocked…or pleasantly surprised! Remember: knowledge is power. Knowing how many calories are in your favorite snack or meal-on-the-go can help you watch your weight and stay healthy.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.


1. Federal Register. Food Labeling; Nutrition Labeling of Standard Menu Items in Restaurants and Similar Retail Food Establishments. National Archives. 2014. Access from

2. Evich, Helena. Obama’s calorie rule kicks in thanks to Trump. Politico. 2018. Access from

3. U.S. Department of Agriculture. Dietary Guidelines for Americans 2020-2025. Access from

Dietary Supplements Before and During Chemotherapy

Meg Seymour, PhD, National Center for Health Research

Many Americans, including those with cancer, take dietary supplements. People take supplements because they believe it will help them stay healthy and give them vitamins and minerals they may not get from their diet. Chemotherapy patients often take supplements because their nausea makes it difficult to eat, and they want to be sure to get enough nutrients. 

People think of dietary supplements as a no-risk insurance policy to improve nutrition, but a study published in 2020 shows that supplements can have risks if you are undergoing chemotherapy. More than 1,000 breast cancer patients were asked whether or not they took any supplements either before or during their chemotherapy.[1] The researchers then continued to evaluate any subsequent cancer or death for up to 15 years (almost all of the women were followed for at least 5 years).

  Results showed that patients who took vitamin B12 before and during their chemotherapy were more likely to die or have their cancer return. They were also more likely to die from any cause, not just from cancer. This increase in cancer recurrence or death was only for people who took the B12 supplements both before and during their chemotherapy. Patients who only took the B12 supplements before chemotherapy or only took supplements during chemotherapy were not more likely to have a recurrence of their cancer or die. Patients who took Iron supplements both before and during chemotherapy were also more likely to have their cancer return or to die of any cause. However, the same was also true for people who only took iron supplements during their chemotherapy.

The researchers also looked at antioxidant supplements, which include vitamins A, C, and E. They found that most patients did not take these supplements both before and during chemotherapy, but those who did were more likely to have cancer return after treatment. However, this finding was not “statistically significant,” which means that more research is needed to determine whether these worse outcomes occurred by chance.  In addition, the 44% of the patients in the study who were taking multivitamins did not have better or worse outcomes than people who were not taking them.

This is what scientists call an observational study rather than a clinical trial. In a clinical trial, some patients would be randomly assigned to take supplements and others would be assigned to take a placebo (with no active ingredients). In an observational study, people make their own decisions about what treatment (in this case supplements) to take. Those who chose to take supplements might have different health issues or health habits than those who did not. For example, it is possible that the people who were more likely to take supplements both before and during their chemotherapy were less healthy to begin with. For example, they could have been taking B12 or Iron supplements because they had anemia, and anemia may have increased the possibility of cancer recurrence or death. Also, because patients were asked whether or not they took supplements (instead of being given the supplements by researchers), it is impossible to know whether what patients said about supplements was completely accurate. For example, some patients could have said that they were regularly taking a supplement, but really they only took it occasionally.   

Dr. Christine Ambrosone, the lead researcher of the study, said in an interview that this is only one observational study, and doctors should not necessarily base their recommendations on this single study. Doctors need to consider the specific needs of each patient. For example, someone with anemia might need a dietary supplement, and the benefits of those supplements might outweigh the potential risks. 

If you are considering taking a dietary supplement, it is important to keep in mind that the Food and Drug Administration does not regulate dietary supplements for purity and quality. There is no guarantee that a supplement will work or even that it contains exactly what the bottle says it contains.[2] It is always important to talk with your doctor to help you decide if the benefits of any dietary supplement you are considering outweigh the potential risks. 


  1. Ambrosone, C. B., Zirpoli, G. R., Hutson, A. D., McCann, W. E., McCann, S. E., Barlow, W. E., … & Unger, J. M. (2019). Dietary Supplement Use During Chemotherapy and Survival Outcomes of Patients With Breast Cancer Enrolled in a Cooperative Group Clinical Trial (SWOG S0221). Journal of Clinical Oncology, JCO-19.
  2. Brooks, J, Mitchell, J., Nagelin-Anderson, E. , & Zuckerman, D. National Center for Health Research. How Safe are Natural Supplements? 2019.

Do Vitamin D Supplements Prevent Cancer and Heart Disease? What the Research Says

Meg Seymour, PhD

Approximately 40% of Americans are low in vitamin D.[1] Low vitamin D has been linked to a number of health problems, including cancer, heart disease, and heart attack.[2, 3] 

Sunshine on your skin (without sunscreen) is a great way to get vitamin D (15 minutes between 10 a.m. and 3 p.m is key)[4], but many Americans don’t get that much sun, especially during colder months. Popular foods that provide vitamin D include fish and fortified milks or cereals.[5]  Scientists have studied whether taking vitamin D supplements could decrease the risk of developing health problems for people who do not get enough vitamin D from these natural sources. 

Do Vitamin D Supplements Help Prevent Cancer?

Researchers have conducted several long-term clinical trials to determine whether vitamin D supplements can decrease the risk of developing cancer. Randomized, controlled clinical trials are the “gold standard” of research. In these trials, some participants were assigned to take vitamin D supplements, and others were assigned to take a placebo (sugar pill). Then, the researchers measured whether or not the people given the supplements were less likely to develop cancer over time. 

A 2018 study found that vitamin D supplements did not prevent cancer. Researchers assigned 5,000 people, ages 50-84, to either take 100,000 IU of vitamin D or placebo once a month for 3 years. After 3 years, they found that monthly supplements of high doses of vitamin D did not decrease the percentage of people developing cancer.[6] An even larger study from 2019, of almost 26,000 patients over the age of 50, also found no benefit. The researchers assigned participants to take either 2000 IU of vitamin D or a placebo every day for over 5 years. People taking vitamin D every day were just as likely to develop cancer as the people taking the placebo.[7] 

A meta-analysis published in 2019 also looked at the impact of vitamin D supplements on cancer. A meta-analysis is a type of combination study that combines the results of many smaller studies. The study found that although vitamin D supplements did not prevent cancer, people who took daily vitamin D supplements were less likely to die from cancer.[8] The researchers suggested that even though vitamin D supplements do not prevent cancer, perhaps they affect the way that tumors grow. However, a bigger meta-analysis (combining more than 30 studies totaling 18,000 participants) found no difference in deaths from cancer for those who did or did not take the supplements.[9] The two meta-analyses had different methods and looked at different studies, so further research is needed in order to determine whether or not vitamin D supplements actually can prevent deaths from cancer. 

Most people taking vitamin D are taking it combined with calcium. For that reason, it is important to look at research that examines the effect of taking them both. A 2017 study looked at more than 2,300 women ages 55 and up. Half were assigned to take 2,000 IU of vitamin D and 1,500 mg of calcium per day, and the other half were assigned to take a placebo every day. The researchers followed them for 4 years and found no difference between the two groups in the chances of getting cancer.[10]

Why is it that people with low vitamin D are more likely to develop cancer, but vitamin D supplements do not prevent cancer? One possibility is that people low on vitamin D might be different from people with enough vitamin D in ways that are related to an increased risk of cancer. For example, people might be low in vitamin D because they do not go outside and exercise regularly, and people who exercise regularly are less likely to develop cancer [11]. Obese people are more likely to develop cancer, and obese people tend to have lower levels of vitamin D.[12]

Are Vitamin D Supplements Good for Your Heart?

People who do not have enough vitamin D are more likely to develop heart disease and have heart attacks.[13,14] Researchers have conducted clinical trials to find out if vitamin D supplements can help prevent heart disease. The same large study from 2019 that measured vitamin D supplements and cancer also looked at whether or not people taking the supplements had fewer heart attacks. The study found no benefit: there was no difference in the number of heart attacks between those taking vitamin D and those taking placebos.[7] 

Since people taking vitamin D supplements often take calcium supplements as well, researchers want to understand if taking both of these supplements affects heart health. The results of these studies are not consistent, with some showing an increase in strokes,[15] and others finding no impact on heart health.[13] More clinical trials on the combination of vitamin D and calcium are needed to draw any conclusions about whether these supplements are helpful or harmful to heart health. 

Vitamin D and COVID-19

Research has shown that Vitamin D supplements can help protect against acute respiratory infections like the flu[16]. That is why in 2020, research is underway to determine if vitamin D supplements can help protect against COVID-19. Thus far, the research has found that people low in vitamin D are more likely to have tested positive for the coronavirus than people who are not low in vitamin D.[17] This research is based on studies of people who tested positive at a time when testing in the U.S. was relatively rare and many of the people who were tested did so because they had respiratory symptoms such as coughs or flu-like symptoms. Since these were not clinical trials, it is not clear whether being low in vitamin D makes someone more susceptible to COVID-19 symptoms, or whether old age or other traits increases the chances of having low vitamin D levels and also increases the chances of developing COVID-19. Research is being conducted to determine if vitamin D can help prevent serious symptoms or help patients recover.

Potential Risks of Supplements 

Some older research found that taking a combination of vitamin D and calcium increased the risk of kidney stones.[18] However, more recent research has found that there is no increased risk of kidney stones in people taking the combination of vitamin D and calcium.[10] A large clinical study conducted in 2019 found that taking vitamin D supplements alone did not increase the chances of developing kidney stones, upset stomach, or hypercalcemia (too much calcium in the blood).[7] 

The Bottom Line

There is not enough evidence to conclude whether taking vitamin D prevents cancer or heart problems. The United States Preventive Services Task Force, a federally funded group that analyzes scientific research, has concluded that there is not enough evidence to say that the benefits of taking supplements, including vitamin D and calcium, to try to prevent heart disease and cancer outweigh the risks.[19]

If you are worried that you are not getting enough vitamin D, talk with your doctor about getting your vitamin D levels tested. If you choose to take a supplement, be sure to talk with your doctor about the amount of vitamin D you are taking. Unless you have a medical need and your doctor recommends it, it is not recommended to take more than 4,000 IU of vitamin D per day. It is better to try to get your vitamins from food or the sun.[20] The Food and Drug Administration requires that food packaging in the United States say what percentage of your daily vitamin D needs are included in a serving of packaged food. Read the labels on your food if you are concerned about getting enough vitamin D in your diet. For more information about vitamin D, what it does for the body, and getting vitamin D from food and the sun, click here. 

  1. Forrest, K. Y., & Stuhldreher, W. L. (2011). Prevalence and correlates of vitamin D deficiency in US adults. Nutrition Research, 31(1), 48-54.
  2. Hossain, S., Beydoun, M. A., Beydoun, H. A., Chen, X., Zonderman, A. B., & Wood, R. J. (2019). Vitamin D and breast cancer: A systematic review and meta-analysis of observational studies. Clinical Nutrition ESPEN, 30, 170-184.
  3. Garland, C. F., Garland, F. C., Gorham, E. D., Lipkin, M., Newmark, H., Mohr, S. B., & Holick, M. F. (2006). The role of vitamin D in cancer prevention. American Journal of Public Health, 96(2), 252-261. 
  4. U.S. News and World Report. How Much Time in the Sun Do You Need for Vitamin D? Updated July 2018.
  5. Dietary Guidelines 2015-2020. Vitamin D: Food Sources Ranked by Amounts of Vitamin D and Energy per Standard Food Portions and per 100 Grams of Foods.
  6. Scragg, R., Khaw, K. T., Toop, L., Sluyter, J., Lawes, C. M., Waayer, D., … & Camargo, C. A. (2018). Monthly high-dose vitamin D supplementation and cancer risk: a post hoc analysis of the vitamin D assessment randomized clinical trial. JAMA Oncology, 4(11), e182178-e182178.
  7. Manson, J. E., Cook, N. R., Lee, I. M., Christen, W., Bassuk, S. S., Mora, S., … & Friedenberg, G. (2019). Vitamin D supplements and prevention of cancer and cardiovascular disease. New England Journal of Medicine, 380(1), 33-44.
  8. Keum, N., Lee, D. H., Greenwood, D. C., Manson, J. E., & Giovannucci, E. (2019). Vitamin D supplementation and total cancer incidence and mortality: a meta-analysis of randomized controlled trials. Annals of Oncology, 30(5), 733-743.
  9. Goulão, B., Stewart, F., Ford, J. A., MacLennan, G., & Avenell, A. (2018). Cancer and vitamin D supplementation: a systematic review and meta-analysis. The American Journal of Clinical Nutrition, 107(4), 652-663.
  10. Lappe, J., Watson, P., Travers-Gustafson, D., Recker, R., Garland, C., Gorham, E., … & McDonnell, S. L. (2017). Effect of vitamin D and calcium supplementation on cancer incidence in older women: a randomized clinical trial. JAMA, 317(12), 1234-1243.
  11. Willer, A. (2005). Cancer risk reduction by physical exercise. World Review of Nutrition and Dietetics, 94(R), 176.
  12. Nair, R., & Maseeh, A. (2012). Vitamin D: The “sunshine” vitamin. Journal of Pharmacology & Pharmacotherapeutics, 3(2), 118.
  13. Chin, K., Appel, L. J., & Michos, E. D. (2017). Vitamin D, calcium, and cardiovascular disease: a “D” vantageous or “D” etrimental? An era of uncertainty. Current Atherosclerosis Reports, 19(1), 5.
  14. Vanga, S. R., Good, M., Howard, P. A., & Vacek, J. L. (2010). Role of vitamin D in cardiovascular health. The American Journal of Cardiology, 106(6), 798-805.
  15. Khan, S. U., Khan, M. U., Riaz, H., Valavoor, S., Zhao, D., Vaughan, L., … & Murad, M. H. (2019). Effects of nutritional supplements and dietary interventions on cardiovascular outcomes: an umbrella review and evidence map. Annals of Internal Medicine, 171(3), 190-198.
  16. Martineau AR, Jolliffe DA, Hooper RL, Greenberg L, Aloia JF, Bergman P, Dubnov-Raz G, Esposito S, Ganmaa D, Ginde AA, Goodall EC. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ. 2017; 356.
  17. The Scientist. Trials Seek to Answer if Vitamin D Could Help in COVID-19. August 2020. 
  18. Jackson, R. D., LaCroix, A. Z., Gass, M., Wallace, R. B., Robbins, J., Lewis, C. E., … & Bonds, D. E. (2006). Calcium plus vitamin D supplementation and the risk of fractures. New England Journal of Medicine, 354(7), 669-683.
  19. Moyer, V. A. (2014). Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 160(8), 558-564.
  20. Harvard Health Publishing. Harvard Medical School. Taking too much vitamin D can cloud its benefits and create health risks. Published November 2017. Updated December 2019. 

Is Vaping Safer than Smoking Cigarettes?

Laura Gottschalk, PhD, John-Anthony Fraga, Jared Hirschfield, Diana Zuckerman, PhD, National Center for Health Research

Electronic cigarettes, or e-cigarettes, are being marketed as the “safe” new alternative to conventional cigarettes. By February 2020, reports of 68 deaths and more than 2,800 vaping-related hospitalizations due to lung illnesses have made it clear that vaping can be even more dangerous than smoking.1,2

The CDC has reported that Vitamin E acetate is a potential cause for the outbreak, but it might not be the only one.2 Many of the patients report vaping marijuana products or marijuana and nicotine products, but others only vaped nicotine products. Until these reports of hospitalized teens and adults are scrutinized in greater depth, we won’t know what types of vaping are most dangerous and under what circumstances.

E-cigarettes come in a variety of forms and include vape mods, Juuls, and vape pens. There are brand name products (Juul is the most widely used) and “home-made” versions.  Some contain high levels of nicotine, while others contain marijuana or just contain flavoring.  The focus of this article is on e-cigarettes because most of the research that exists has been done on them, but much of the information below is relevant to these other products as well.

The big questions are: Are they safe?  Will they reverse the decline in smoking—giving new life to an old habit—or can they help people quit smoking?  Here is what you need to know.

What are E-cigarettes?

E-cigarettes are battery-operated devices that were initially shaped like cigarettes, but now include vape mods, Juuls, and vape pens. Some look like flash drives or highlighter pens, making it easy for teens to hide them in plain sight.  The brand-name products contain nicotine, an addictive drug that is naturally found in tobacco and that stimulates, causes stress during withdrawal, and then feels relaxing as continued exposure follows withdrawal. It is the nicotine in cigarettes that makes smoking so addictive, and the same is true for most vaping and juuling. These electronic products allow nicotine to be inhaled, and they work by heating a liquid cartridge containing nicotine, flavors, and other chemicals into a vapor. Because e-cigarettes heat a liquid instead of tobacco, what is released is considered smokeless.3

Is Vaping Safer than Smoking Traditional Cigarettes?

The key difference between traditional cigarettes and e-cigarettes and related products is that the latter don’t contain tobacco. But, it isn’t just the tobacco in cigarettes that causes cancer and other serious diseases. Traditional cigarettes contain a laundry list of chemicals that are proven harmful, and e-cigarettes have some of these same chemicals.

While smoking can cause lung cancer, breast cancer, emphysema, heart disease, and other serious diseases, those diseases usually develop after decades of smoking. In contrast, in 2019 it became clear that vaping could cause seizures and serious lung damage after just a year, possibly less, based on CDC reports of patients hospitalized for lung damage caused by vaping.2,3 While there have been warnings about the possible risk of e-cigarettes for a decade, it was not expected that they could cause such severe damage in such a short period of time.

The COVID-19 pandemic has raised even more concerns about the safety of vaping. Youths aged 13-24 years old who have used e-cigarettes are more likely to be diagnosed with COVID-19, be tested for the virus, and to experience Covid-19 symptoms.4

Since 2009, FDA has pointed out that e-cigarettes contain “detectable levels of known carcinogens and toxic chemicals to which users could be exposed.” For example, in e-cigarette cartridges marketed as “tobacco-free,” the FDA detected a toxic compound found in antifreeze, tobacco-specific compounds that have been shown to cause cancer in humans, and other toxic tobacco-specific impurities.5 Another study looked at 42 of these liquid cartridges and determined that they contained formaldehyde, a chemical known to cause cancer in humans.6 Formaldehyde was found in several of the cartridges at levels much higher than the maximum EPA recommends for humans. In 2017, a study published in the Public Library of Science Journal showed that significant levels of benzene, a well-known carcinogen, were found in the vapor produced by several popular brands of e-cigarettes.7

The body’s reaction to many of the chemicals in traditional cigarette smoke causes long-lasting inflammation, which in turn leads to chronic diseases like bronchitis, emphysema, and heart disease.8 Since e-cigarettes also contain many of the same toxic chemicals, there is no reason to believe that they will significantly reduce the risks for these diseases.

In fact, a preliminary study presented at the 2018 annual meeting of the American Chemical Society found that vaping could damage DNA.9 The study examined the saliva of 5 adults before and after a 15-minute vaping session. The saliva had an increase in potentially dangerous chemicals, such as formaldehyde and acrolein. Acrolein has been proven to be associated with DNA damage, for example, and DNA damage can eventually cause cancer.10

A study of mice funded by the National Institutes of Health found that e-cigarette smoke could cause mutations in DNA that could increase the risk of cancer. These specific mutations have been shown to potentially contribute to the development of lung and bladder cancer in mice exposed to electronic cigarette smoke. The researchers claim that these chemicals could also induce mutations leading to cancer in humans. It has not been reported how many of those harmed had used juul devices. While many of those harmed had vaped marijuana, many also used nicotine e-cigarettes,11 so the risks of “juuling” need to be carefully and immediately studied.

Because they are smokeless, many incorrectly assume that e-cigarettes are safer for non-smokers and the environment than traditional cigarettes. However, a study published in the International Journal of Hygiene and Environmental Health found that the use of e-cigarettes results in increased concentrations of volatile organic compounds (VOCs) and airborne particles, both of which are potentially harmful when inhaled.12 Although e-cigarette vapor may not result in the obvious smell and visible smoke of traditional cigarettes, it still has a negative impact on air quality, especially when vaping indoors.

There are no long-term studies to back up claims that the vapor from e-cigarettes is less harmful than conventional smoke. Cancer takes years to develop, and e-cigarettes were only very recently introduced to the United States. It is almost impossible to determine if a product increases a person’s risk of cancer or not until the product has been around for at least 15-20 years. Despite positive reviews from e-cigarette users who enjoy being able to smoke them where regular cigarettes are prohibited, very little is known about their safety and long-term health effects.

There is also danger from e-cigarettes exploding in the user’s mouth or face.  Last year, the British Medical Journal used data from several agencies to estimate that there were roughly 2,035 e-cigarette explosions and burn injuries in the U.S. just in a three-year period from 2015 to 2017. One of the authors of the study stated that the number was likely higher as such incidents were not well tracked. The report also said that e-cigarettes, commonly powered by a lithium-ion battery, could overheat to the point of catching fire or exploding, a phenomenon known as “thermal runway.”13

Can Vaping Help to Cut Down or Quit Smoking Regular Cigarettes?

If a company makes a claim that its product can be used to treat a disease or addiction, like nicotine addiction, it must provide studies to the FDA showing that its product is safe and effective for that use. On the basis of those studies, the FDA approves or doesn’t approve the product. So far, there are no large, high-quality studies looking at whether e-cigarettes can be used to cut down or quit smoking long-term. Most of the studies have been either very short term (6 months or less) or the participants were not randomly assigned to different methods to quit smoking, including e-cigarettes. Many of the studies are based on self-reported use of e-cigarettes. For example, a study done in four countries found that e-cigarette users were no more likely to quit than regular smokers even though 85% of them said they were using them to quit.14 Other year-long studies, conducted in the U.S., had similar findings.  A study published in a prestigious medical journal in 2014 found that although smokers may believe they are vaping e-cigarettes to help them quit,  6-12 months after being first interviewed, nearly all of them are still smoking regular cigarettes.15 Similarly, a year-long study published in 2018 compared smokers who used e-cigarettes to traditional cigarette smokers, and concluded that e-cigarette users were more likely to say they were trying to quit but no more likely to successfully kick the smoking habit, with 90% of e-cigarette users still smoking regular cigarettes at the end of the study.  Until there are results from well-conducted studies, the FDA has not approved e-cigarettes for use in quitting smoking.16

Teenagers, Children, and Vaping

According to survey data collected between 2014 and 2017, 9% of middle and high schoolers reported that they were current vaping users. Vaping was most common among Native Hawaiian and Pacific Islanders (18%), as well as American Indian and Alaskan Native teens (13%). About 10% of White and Hispanic teens vaped, and vaping was least common among Black (5%) and Asian teens (4%).17 The percentage of teens who reported vaping doubled between 2017 and 2019.18 In 2019, about 28% of highschoolers and 11% of middle schoolers reported e-cigarette use. Most teens who vaped reported that they used flavored products.19 Two 2020 surveys found that the percentage of students vaping decreased early in the year. A CDC study analyzing data from the National Youth Tobacco Survey, a study of over 14,000 students, found that about 20% of 9th-12th grade students and 5% of 6th-8th grade students reported that they used e-cigarettes in the last 30 days.20 A different survey conducted by researchers from the University of Michigan, funded by the National Institute on Drug Abuse, studied over 8,000 students in only the 10th and 12th grades, and found that 22% reported vaping in the last 30 days.21 Although these numbers are still high, and comparable to the statistics in 2018,17 they are notably lower than 2019. E-cigarette use may have dropped due to growing awareness of the dangers of these products, including media coverage of young men hospitalized with serious lung damage.21,22 The drop may also be due to raising the legal age for the purchase of tobacco products and the ban on flavored products.21,23

It is important to note that these surveys conducted about e-cigarette use in 2020 were collected between January and March of 2020, and the surveys were stopped due to the COVID-19 pandemic.  

An online survey conducted in May 2020 measured how e-cigarette use changed during the pandemic, during a time where many people are staying at home.24 The survey included almost 1,500 participants under 21 (the legal age to purchase tobacco products) who reported e-cigarette use. Over half of the underage e-cigarette users who responded to the survey reported that they had changed their e-cigarette use during the pandemic. About 20% of the sample had quit using e-cigarettes altogether, about 17% reduced their use slightly or by half, and another 9% actually increased their nicotine use. 

The researchers followed up by asking those participants who reduced their e-cigarette use for the reasons why they lowered it. About 14% reported that the primary reason for reducing was because they were at home and their parents would know, 18% said the primary reason was because they can no longer get the tobacco products, 23% said it was because they know e-cigarette use harms the lungs, and another 37% said that their reasons were a combination of those 3 reasons. Of those who increased their use during the pandemic, about 25% reported that it was due to boredom, 15% because they were stressed, 7% because they needed a distraction, and about 50% said that their reasons were a combination of those 3 reasons. 

Future research is needed to measure whether e-cigarette use has changed even more as the pandemic has continued, as well as to measure the overall percent of youth still using e-cigarettes. 

E-cigarette and juul use by young people is worrisome for several reasons:

  1.     The younger people are when they begin smoking, the more likely it is they will develop the habit: nearly 9 out of 10 smokers started before they were 18.25
  2.     Nicotine and other chemicals found in e-cigarettes, juuls, etc. might harm brain development in younger people.26
  3.     Vaping may introduce many more young people to smoking who might otherwise never have tried it, and once they are addicted to nicotine, some may decide to get their “fix” from regular cigarettes. Whether vaping or juuling is a “gateway” to regular cigarettes or not, young people who use them risk becoming addicted to nicotine and exposing their lungs to harmful chemicals.
  4.   While smoking can cause permanent lung damage over the years, vaping can cause inflammation resulting in hospitalization and permanent damage after just a few weeks or months.27,28

The sharp rise in vaping among youth highlights the need to stop manufacturers from targeting teenagers with candy-like flavors and advertising campaigns. Although the FDA banned flavors for reusable vape devices, flavored disposable e-cigarettes are still being sold.20 However, in July 2020, FDA issued warnings to 10 companies selling flavored disposable e-cigarettes, notifying them to remove their products from the market because they do not have the authorizations required to sell them.29 

Even children who are too young to smoke have been harmed by e-cigarettes and related products. The liquid is highly concentrated, so absorbing it through the skin or swallowing it is far more likely to require an emergency room visit than eating or swallowing regular cigarettes. In 2012, less than 50 kids under the age of six were reported to poison control hotlines per month because of e-cigarettes. In 2015, that number had skyrocketed to about 200 children a month, almost half of which were under the age of two!30

Many e-cigarettes look like USB devices, and some are made to look like other products, in order to disguise their use. The Director of Communications at the FDA’s Center for Tobacco Products has written this guide to help parents identify these hidden e-cigarettes. The FDA has also helped create this pamphlet for parents and teens to discuss the risks of vaping, and it provides resources for saying “no” and for quitting.

For more information about juuls, check out our article here.

How are these products regulated?

The FDA was given the power to regulate the manufacturing, labeling, distribution and marketing of all tobacco products in 2009 when President Obama signed into law the Family Smoking Prevention and Tobacco Control Act and in 2010 a court ruled that the FDA could regulate e-cigarettes as tobacco products.31

E-Cigarette Ad

It wasn’t until 2016 that the FDA finalized a rule to regulate e-cigarettes, which would ban the sale of e-cigarettes to anyone under the age of 18 and would require all e-cigarettes that hit shelves after February 15, 2007 to go through a “premarket review,” the process that the FDA uses to determine whether potentially risky products are safe.25 Companies were to be given from 18 months to two years to comply with this rule and prepare their applications. However, in 2017, the Trump administration appointed a new FDA Commissioner, Dr. Scott Gottlieb, who defended the safety of e-cigarettes and delayed implementing the rules until 2022.9 Nevertheless, as the epidemic of e-cigarette use among youth became obvious, in 2018, Commissioner Gottlieb threatened to crack down on the advertising of e-cigarettes to children under 18.32 Critics have questioned whether sales and ads can be effectively restricted. Moreover, Commissioner Gottlieb resigned in 2019, and it is unclear how the agency will respond to the growing evidence that vaping can cause serious harm. However, in 2019, a federal court ruled that the FDA must implement regulations in May 2020 instead of waiting until 2022.

In September, President Trump responded to the health crisis by proposing a ban on flavored e-cigarettes. Two months later, the administration has not taken any action as Trump states that he is worried children will seek out unsafe alternatives if flavors are banned. In the meantime, individual states have always had the power to pass laws restricting the sale and use of e-cigarettes. Current laws pertaining to e-cigarettes are available on the Public Health Law Center website.

The Bottom Line

E-cigarettes, juuls, and other similar products have not been around long enough to determine the harm they cause in the long run. Unfortunately, many people, including teenagers, are under the impression that e-cigarettes are safe or that they are effective in helping people quit smoking regular cigarettes. Studies by the FDA show that e-cigarettes contain some of the same toxic chemicals as regular cigarettes, even though they don’t have tobacco. There is evidence that some of these toxic chemicals can cause DNA damage that can cause cancer. More important, the reports of teens and adults who died or were hospitalized due to vaping are proof that vaping can be extremely dangerous even after just a few weeks, months, or years.

The big three tobacco companies—Lorillard, Reynolds American, and Altria Group—all have their own e-cigarette brands, so it’s not surprising that e-cigarettes are being marketed and advertised much the way regular cigarettes used to be. Here are the 7 Ways E-Cigarette Companies Are Copying Big Tobacco’s Playbook.

Although there are clearly serious dangers from vaping, more research is needed to confirm the impact of vaping on DNA damage, especially in children. Meanwhile, claims that e-cigarettes are an effective strategy to quit smoking are not supported by the evidence thus far. In addition, more toxicological studies and epidemiological studies are needed to understand the hundreds of reports of permanent lung damage and deaths from vaping.  It is essential to find out whether some types of vaping are more dangerous than others in the short-term and the long-term.  To understand the risks for everyone who vapes, research is needed to compare the risks of specific brands of e-cigarettes with tobacco products, as well as to neither smoking nor vaping.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.

  1. Robert Langreth. More Evidence Links Vaping Lung Injuries to Vitamin E Acetate. December 20, 2019. 
  2. Centers for Disease Control and Prevention. Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Updated 2020.
  3. O’Connor RJ. Non-cigarette tobacco products: What have we learned and where are we headed? Tobacco Control. 2012;21(2): 181–190.
  4. Gaiha SM, Cheng J, Halpern-Felsher B. Association between youth smoking, electronic cigarette use, and COVID-19. Journal of Adolescent Health. 2020;67(4):519-523. doi:10.1016/j.jadohealth.2020.07.002
  5. Food and Drug Administration. Summary of Results: Laboratory analysis of electronic cigarettes conducted By FDA. FDA News & Events. July 22 2009.
  6. Varlet V,  Farsalinos K, Augsburger M, et al. Toxicity of refill liquids for electronic cigarettes. International Journal for Environmental Research and Public Health. 2015;12:4796-4815.
  7. Pankow JF, Kim K, McWhirter KJ, et al. Benzene formation in electronic cigarettes. PLOS ONE. 2017;12(3),e0173055.
  8. Centers for Disease Control and Prevention. Overviews of Diseases/Conditions. February 2019.
  9. McGinley, L. FDA sued for delaying e-cigarette, cigar regulations. Washington Post. March 27 2018.
  10. Lee HW, Park SH, Weng MW, et al. E-cigarette smoke damages DNA and reduces repair activity in mouse lung, heart, and bladder as well as in human lung and bladder cells. Proceedings of the National Academy of Sciences of the United States of America. 2018;115(7), E1569.
  11. Kaisar MA, Prasad S, Liles T, et al. A decade of e-cigarettes: Limited research & unresolved safety concerns. Toxicology. 2016;365: 67–75.
  12. Robert Langreth. More Evidence Links Vaping Lung Injuries to Vitamin E Acetate. December 20, 2019.  
  13. Kaplan S. E-Cigarette exploded in a teenager’s mouth, damaging his jaw.  The New York Times. June 19 2019.
  14. Adkison SE, O’Connor RJ, Bansal-Travers M, et al. Electronic nicotine delivery systems: International tobacco control four-country survey. American Journal of Preventive Medicine. 2013;44(3):207-215.
  15. Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarette use and smoking cessation. JAMA Internal Medicine. 2014;174(5):812–813.
  16. Food and Drug Administration. Electronic Cigarettes. FDA News & Events. 25 July 2013.
  17. Odani S, Armour BS, Agaku IT. Racial/ethnic disparities in tobacco product use among middle and high school students—United States, 2014–2017. Morbidity and Mortality Weekly Report. 2018 Aug 31;67(34):952.
  18. Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME. Trends in adolescent vaping, 2017–2019. New England Journal of Medicine. 2019 Oct 10;381(15):1490-1.
  19. Cullen KA, Gentzke AS, Sawdey MD, Chang JT, Anic GM, Wang TW, Creamer MR, Jamal A, Ambrose BK, King BA. E-cigarette use among youth in the United States, 2019. JAMA. 2019 Dec 3;322(21):2095-103.
  20. Gentzke AS, Wang TW, Jamal A, et al. Tobacco Product Use Among Middle and High School Students — United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1881–1888. DOI: icon.
  21. Miech R, Leventhal A, Johnston L, O’Malley PM, Patrick ME, Barrington-Trimis J. Trends in Use and Perceptions of Nicotine Vaping Among US Youth From 2017 to 2020. JAMA Pediatrics. Published online December 15, 2020. doi:10.1001/jamapediatrics.2020.5667
  22. Grady D. A Young Man Nearly Lost His Life to Vaping. The New York Times. October 15, 2019.  
  23. Stobbe S, Perrone M. Big drop reported in vaping by US teenagers. Associated Press. September 9, 2020. 
  24. Gaiha SM, Lempert LK, Halpern-Felsher B. Underage Youth and Young Adult e-Cigarette Use and Access Before and During the Coronavirus Disease 2019 Pandemic. JAMA Network Open. 2020 Dec 1;3(12):e2027572-.
  25. Centers for Disease Control and Prevention. Fact sheets: Youth and tobacco use. Updated 2019.
  26. Centers for Disease Control and Prevention. Preventing tobacco use among youth and young adults. 2012.
  27. Scutti S. Teen develops ‘wet lung’ after vaping for just 3 weeks. CNN. May 18, 2018.
  28. Song MA, Reisinger SA, Freudenheim JL, Brasky TM, Mathé EA, McElroy JP, Nickerson QA, Weng DY, Wewers MD, Shields PG. Effects of electronic cigarette constituents on the human lung: A pilot clinical trial. Cancer Prevention Research. 2020 Feb 1;13(2):145-52.
  29. U.S. Food and Drug Administration. FDA Notifies Companies, Including Puff Bar, to Remove Flavored Disposable E-Cigarettes and Youth-Appealing E-Liquids from Market for Not Having Required Authorization. Updated July 2020. 
  30. Kamboj A, Spiller HA, Casavant MJ, et al. Pediatric exposure to e-cigarettes, nicotine, and tobacco products in the United States. Pediatrics. 2016;137(6). pii: e20160041.
  31. Food and Drug Administration. Regulation of E-Cigarettes and Other Tobacco Products. FDA News & Events. April 25, 2011.
  32. Saltzman J, Freyer F. The FDA issues a warning: Teen vaping is ‘an epidemic.’ Boston Globe. September 13 2018.

Can Belly Fat Cause Cancer?

Ammu Dinesh and Claire Viscione, National Center for Health Research

Belly fat is common among men and women. However, when a person’s body shape looks more like an apple than a pear, that could increase their likelihood of developing cancer. 

More than two-thirds of adult Americans are overweight or obese.1 Most people know that obesity increases the risk of diabetes, heart disease, and high blood pressure. But did you know that being overweight increases your chances of developing cancer, and that having an “apple” body shape due to belly fat can increase your chances of developing cancer even if you are not overweight?

Why is belly fat dangerous?

Whether your body fat is located at your waist (giving you an apple shape) or hips (giving you a pear shape) makes a difference to your health. Women tend to gain more belly fat as they get older. Regardless of their weight, white, black, and Latina women with a waistline measurement of 35 inches or more have higher health risks. This is also true for Asian women with a waistline of 31 inches or more. Although it is important to get rid of excess fat in general, belly fat is the most threatening to your health.

Physicians use often use body mass index (BMI) to estimate whether you are overweight or obese. However, determining your waist circumference is just as important. Even if you are not overweight or obese, if you have a lot of belly fat, you are more likely to develop cancer.

Unlike the fat that sits just beneath the skin, the fat that sits around internal organs is called visceral fat.2 This fat is the most dangerous, and it is typically what shows up as belly fat. If you measure your waistline, you can get a good idea of whether you have a dangerous amount of belly fat. 

Women Men
Low health risk 31.5 inches or less 37 inches or less
Intermediate health risk 31.6 – 34.9 inches 37.1 – 39.9 inches
High health risk 35 inches or more 40 inches or more

Table 1. What does your waistline measurement mean? 2

Several studies have looked at the relationship between belly fat and cancer. One study followed over 150,000 post-menopausal women ages 50-79 for about 20 years.3 This study found that women who have extra belly fat are at higher risk of death regardless of their weight. Causes of death in the study included cardiovascular disease and cancer. The women of normal weight who had extra belly fat tended to be older, nonwhite, and with less education and income. They were also less likely to use menopausal hormones and to exercise. 

To figure out your BMI for the chart below, enter your height and weight into this calculator.

Apple Shape (Extra Belly Fat) Not “Apple Shape”
Not Overweight (BMI below 25) 20% more likely to die from cancer within 20 years
Overweight (BMI of 25-29.9) 19% more likely to die from cancer within 20 years 4% less likely to die from cancer within 20 years
Obese (BMI of 30 or higher) 26% more likely to die from cancer within 20 years 4% less likely to die from cancer within 20 years

Table 2. Likelihood of death due to cancer in women based on BMI.3

Women who were not overweight or obese but had extra belly fat were just as likely to die from cancer as overweight women with extra belly fat.

A different study followed over 3,000 men and women for 7 years.4 They used CT scans and physical exams to look at the fat throughout the body. Over the course of the study, the men and women developed 141 cases of cancer, 90 heart-related incidents, and 71 deaths from various causes. The study found that people with more belly fat, specifically visceral fat, were about 44% more likely to develop cancer and heart disease, even when adjusting for waist circumference. 

What can you do?

As you can see, belly fat can be very dangerous, especially for women, even if they are not overweight. Losing weight or preventing weight gain can lower health risks. By exercising regularly, you can get rid of unhealthy belly fat. It is also important to change your diet to eat foods that are high in nutrients and essential vitamins. You can do this by eating more fresh vegetables, nuts, and whole-grain breads instead of processed meat, red meat, candy, pasta, and white bread. These few changes can help you lose belly fat and improve the quality and length of your life.

Local bans on unhealthy food and drinks may also be effective in reducing belly fat. A 2019 study shows that a ban on the sale of sugar-sweetened beverages at a large college campus substantially decreased consumption and led to significantly less belly fat.5 Students who stopped drinking the beverages had improved insulin resistance and lower cholesterol. The combination of the ban and a brief motivational talk was even more effective than the ban by itself.

Learn more about how extra body fat can increase your risk for developing cancer, and how you can make a commitment to your health and reduce risky belly fat:


All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff.



  1. Center for Disease Control and Prevention. FastStats- Overweight Prevalence. Updated June 13, 2016.
  2. Harvard Health Publishing. Abdominal obesity and your health. September 2005. Updated January 20, 2017.
  3. Sun Y, Liu B, Snetselaar LG, Wallace RB, Caan BJ, Rohan TE, et al. Association of Normal-Weight Central Obesity With All-Cause and Cause-Specific Mortality Among Postmenopausal Women. JAMA Network Open. 2019;2(7):e197337.
  4. Britton KA, Massaro JM, Murabito JM, Kreger BE, Hoffmann U, Fox CS. Body Fat Distribution, Incident Cardiovascular Disease, Cancer, and All-Cause Mortality. Journal of the American College of Cardiology. 2013; 62(10): 921-925.
  5. Epel ES, Hartman A, Jacobs LM, Leung C, Cohn MA, Jensen L, et al. Association of a Workplace Sales Ban on Sugar-Sweetened Beverages With Employee Consumption of Sugar-Sweetened Beverages and Health. JAMA Network Open. 2019. doi:

Does Infrared Light Therapy Work for Weight Reduction?

Danielle Pavliv, Sandy Wang and Varuna Srinivasan, National Center for Health Research

Wouldn’t it be great if we could each shed a couple of inches off our waist without having to diet or exercise?  For years, millions of Americans have tried pills, injections, “natural” herbs, and even berries that are supposed to help us shed pounds.  Unfortunately, these usually don’t work.

The latest magical way to lose weight is infrared light, also known as “red light therapy” or “low light therapy”

Infrared therapy is also suggested for pain management, jaundice, eczema, wrinkles, scars, improved blood circulation, and to help wound and burns heal faster. That doesn’t mean it actually works for any of those things. But in this article, we’re focusing on whether it works to help you look thinner. 1

Light therapy uses near infrared light, usually from lasers, lamps, or tanning bed-like devices. The patient is told to either lie down or sit in front of the light for a specific amount of time on a regular basis (usually once a day). One popular device is the infrared body wrap, consisting of large silicone bandages or pads that emit infrared light around the legs, torso and arms. In addition, patients are told that red light therapy is supposed to improve the appearance of cellulite and help shape the body.

If it sounds too good to be true, it probably is. There is little scientific evidence supporting the claims that infrared light, whether administered by lamp, laser or while in a body wrap, can help people lose weight or shape their body. Nevertheless, in 2010, the FDA cleared a laser called Zerona, manufactured by Erchonia Medical Inc., which uses red light therapy to remove “unwanted” fat without surgical procedures. This device is not approved by the FDA – it is “cleared for market”, which is a different cleaning service process that does not require that a device be proven safe or effective.  Since 2010, several devices using the same technology have been cleared for marketing in the U.S. for body contouring and fat reduction. 2

Light therapy has been tested in clinical trials of patients, but these studies were not as scientific as they would need to be to prove safety or effectiveness. Most studies have few patients who have very similar demographics. Since the patients and clinicians know that the patient is being treated, and in most studies the patients getting treatment weren’t compared to patients getting a different treatment, this could result in a type of “placebo effect.” The placebo effect is when patients believe in a treatment and for that reason it seems to help even if the treatment isn’t actually effective. Also, the companies that make the light therapy devices provided funding to conduct the studies, which can result in overly optimistic results.

Despite all these substantial shortcomings, the studies showed only a small benefit from the light therapy.  So, even if the treatment has some benefit, which is doubtful, the benefit may not be substantial enough to be worth the time and money for the treatment.

In addition, all of the studies were short – none were more than 4 months long, and none followed up with the patients for more than a few weeks after treatment. So, we cannot know how long even small changes might last or what might happen if patients continued the treatment for years.

And what about the risks? Almost all of the studies did not provide any information about potential side effects of the therapy. However, one study done in Poland looked at the effects of LLLT used in close contact with the skin.  They found that patients developed skin ulcers as a result of certain types of lasers. 3

What exactly do the studies show?

A study funded by Erchonia (the company that makes Zerona) included 54 overweight or obese patients.4 Most of the patients were Caucasian men which is odd, since most weight loss patients are women. The patients were treated weekly for 6 weeks. The study found a significant reduction in the combined circumference of hips, waist, thighs, and upper abdomen by 13 cm (about 5 inches) after 6 weeks. Two weeks after the final treatment, patients lost another 2 cm (about 0.8 inches). However, patients knew that they were getting this treatment and may have changed their diet or exercise in an effort to succeed. These patients were not compared to a control group, so we can’t tell how much patients would have changed without the treatment. Also, patients were only studied for two weeks after their last treatment, so we do know how long this reduction lasted.

Whether or not infrared therapy is effective on its own, some scientists are studying whether it can potentially boost the benefits of exercise. To do this, they study obese patients all of whom are in an exercise program. Half the patients also get light therapy and the other half don’t. Results in these studies show us that it is possible that infrared therapy boosts the effect of exercise on weight loss. However, the studies were not well designed so it is impossible to know.

 A study in Brazil tested whether LLLT and aerobic exercise could reduce the chances of obese women developing heart disease.5 It was a well-designed study: 62 women were given an exercise regimen and randomly assigned to either be exposed to LLLT or a placebo for 4 months. LLLT increased the effectiveness of aerobic exercise to improve the women’s heart health. The scientists reported that LLLT reduced the abdominal fat and the women’s total body fat as measured by waist circumference and other measures. However, the study did not follow the women after their 4 months of treatment, so we don’t know how long the effect lasted.

Another device using Water Filtered Infrared Radiation (known as wIRA) is currently being studied to see if it helps patients lose weight.6 In this study, all 40 patients engaged in aerobic exercise 3 times a week for 4 weeks, with some patients also treated with wIRA while exercising. Although they were able to show a statistical difference in weight loss between the two groups (p<0.001), there were so few people in the study to be certain, and not enough information about any benefits lasting more than 4 weeks.

The uses of wIRA are currently being studied for a variety of medical conditions.7,8 However, there are currently not enough studies to conclude how effective it is for weight loss.

Bottom Line

Light therapy may possibly reduce fat in the short term, but studies are small and only follow patients for a few weeks or months. We don’t know if any likely benefit is large enough to be meaningful or how long it might last.  So, if you want to lose weight, sustain weight loss, and get fit, we suggest exercise and dieting in a healthy manner. These tried and tested methods are also shown to decrease the overall risk for heart disease and some cancers in the long term.

All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff.


  1. LED light therapy accelerated healing pain reduction red near infrared. (2015). Retrieved from
  2. (2018). 510(k) Premarket Notification. [online] Available at:
  3. Jankowski M, Gawrych M, Adamska U, Ciescinski J, Serafin Z, Czajkowski R. Low-level laser therapy (LLLT) does not reduce subcutaneous adipose tissue by local adipocyte injury but rather by modulation of systemic lipid metabolism. Lasers in Medical Science. 2017;32(2):475-479. doi:10.1007/s10103-016-2021-9.
  4. Thornfeldt CR, Thaxton PM, Hornfeldt CS. A Six-week Low-level Laser Therapy Protocol is Effective for Reducing Waist, Hip, Thigh, and Upper Abdomen Circumference. The Journal of Clinical and Aesthetic Dermatology. 2016;9(6):31-35.
  5. Duarte FO, Sene-Fiorese M, de Aquino Junior AE et al (2015) Can low-level laser therapy (LLLT) associated with an aerobic plus resistance training change the cardiometabolic risk in obese women? A placebo-controlled clinical trial. J Photochem Photobiol B 153:103–110.
  6. Möckel F, Hoffmann G, Obermüller R, Drobnik W, Schmitz G. Influence of water-filtered infrared-A (wIRA) on reduction of local fat and body weight by physical exercise. GMS German Medical Science. 2006;4:Doc05.
  7. Hoffmann G. Principles and working mechanisms of water-filtered infrared-A (wIRA) in relation to wound healing. GMS Krankenhaushygiene Interdisziplinar. 2007;2(2):Doc54.
  8. Al-Ahmad A, Bucher M, Anderson AC, et al. Antimicrobial Photoinactivation Using Visible Light Plus Water-Filtered Infrared-A (VIS + wIRA) Alters In Situ Oral Biofilms. Hamblin M, ed. PLoS ONE. 2015;10(7):e0132107. doi:10.1371/journal.pone.0132107.

The Dangers of Juuling

John-Anthony Fraga, National Center for Health Research

What is Juuling? Is it safer than smoking?

A new type of e-cigarette called “juul” has become so popular that it is now about 68% of the $2 billion e-cigarette market. The “juul” is especially popular among children and young adults due to its sleek and discreet design, its ability to be recharged on a laptop or wall charger within one hour, and its liquid-filled cartridges that come in popular flavors like cool mint, creme brulee, and fruit medley.

As of February of 2018, 68 deaths and more than 2,800 cases of serious lung illness related to e-cigarettes have been reported to the CDC. [9] It was not initially known whether those harmed had used juul devices. However, various 2019 reports state that all types of e-cigarettes were used by the teens and adults who were harmed by vaping, so the risks of “juuling” need to be carefully and immediately studied. [10]

Juuling has become very common at teenage hangouts and even at school. Medical professionals are very concerned because juul delivers higher concentrations of nicotine than other e-cigarettes. Not only is nicotine highly addictive, but it is also toxic to fetuses and is known to impair brain and lung development if used during adolescence.[1] It is not replacing cigarette smoking but rather encouraging it: A 2017 study found that non-smoking adults were four times more likely to start smoking traditional cigarettes after only 18 months of vaping, which includes “juuling.”[7] For more information about e-cigarettes in general, check out our article here.

How does the Juul Work?

According to Juul Labs, the company that owns and sells the juul e-cigarette, the device uses an internal, regulated heating mechanism that creates an easily inhaled aerosol. This mechanism prevents the batteries in the juul from overheating and exploding, which has been a problem for other brands of e-cigarettes. Juul is easy to use because there are no settings to adjust or control. All that is required is a non-refillable juul pod cartridge that clicks into the top of the juul and contains a nicotine e-liquid formula. This e-liquid is heated and converted into vapors that are inhaled by the user. One of the reasons it is so popular among youth is that it is so easy to use – no prior experience or knowledge required. All they have to do to intake nicotine is to put a juul to their mouth and inhale.

What makes Juuls different from other e-cigarettes?

The increased harm of juuls compared to other e-cigarettes is due to the concentration and contents of its juul pods. The e-liquid is 5% nicotine by volume, which is more than twice the concentration of nicotine in similar devices like the Blu e-cig cartridge (2.4% nicotine). This increases the risk of addiction; in fact, a study done by the UK’s Royal College of Psychiatrists showed that nicotine is about as addictive as cocaine and even more addictive than alcohol and barbiturates (anti-anxiety drugs).[2]

The impact on the developing brain is also of great concern. Brain imaging studies of adolescents who began smoking at a young age had markedly reduced activity in the prefrontal cortex of the brain, an area critical for a person’s cognitive behavior and decision making, leading to increased sensitivity to other drugs and greater impulsivity.[3] The amount of nicotine in one juul pod is equivalent to a pack of cigarettes. Since teens often use multiple pods in one sitting, they can unknowingly become exposed to unsafe levels of nicotine that can have immediate and long-term health consequences. In 2016, the Food and Drug Administration (FDA) was given the authority to regulate e-cigarettes such as juul but has allowed e-cigarette manufacturers to postpone their applications for FDA approval until August 2022. Meanwhile, these harmful devices can remain on the market and continue influencing adolescents to become addicted to nicotine.[8]

Another reason why the juul is a unique threat to teens is its patented formula of nicotine. While other brands use a chemically modified form called “freebase nicotine,” juuls use “nicotine salts” that more closely resemble the natural structure of nicotine found in tobacco leaves. This makes the nicotine more readily absorbed into the bloodstream and makes the vapor less harsh so that it is easier to inhale more nicotine for longer periods of time.

In addition to this patented formula, juul pods contain a greater amount of benzoic acid, 44.8 mg/mL, compared to other e-cigarette brands, which are in the range of 0.2 to 2 mg/mL. According to the Center for Disease Control and Prevention (CDC), benzoic acid is known to cause coughs, sore throat, abdominal pain, nausea, and vomiting if exposure is constant, which is the case when using a juul.[4] This is due to how juuls utilize the properties of benzoic acid to increase the potency of the nicotine salts in its e-liquid.

What makes Juuls popular among children and teens?

Since juuls are small, discreet, and closely resemble a USB drive, they can be easily hidden and used in a wide variety of settings, such as the classroom. Teachers and school administrators across the nation are finding students juuling when their backs are turned: Students can take a hit, blow the small, odorless puff of smoke into their jacket or backpack, and continue their school work in a matter of seconds. Compared to other forms of teenage rebellion, juuling is especially dangerous as middle and high school students are unknowingly becoming addicted to nicotine at an alarming rate.

Because a person must be at least 21 to purchase a juul or juul pod, a juul black market is the source for many teens, through eBay or Craigslist. In response, the FDA contacted eBay to raise concerns about listings of juul products on its website, resulting in the removal of the listings and the creation of measures to prevent new listings from being posted.[5]

In April 2018, FDA Commissioner Scott Gottlieb announced that he was creating a Youth Tobacco Prevention Plan aimed at stopping the dramatic rise in the use of e-cigarette and tobacco products among youth. The FDA specifically asked Juul Labs for documents related to product marketing and research on the health, toxicological, behavioral, or physiological effects of their products in order to understand why youth are so attracted to them.[6] Additionally, Juul Labs is currently facing lawsuits in several states claiming that its products were deceptively marketed to youth under the legal smoking age. The FDA now plans to create enforcement policies for e-cigarette manufacturers, including juul, that are marketing their products to children and teenagers.

The Bottom Line:

The popularity of juuls among adolescents exposes them to large amounts of nicotine that can have adverse health risks for their physical and emotional development. While juuls are called e-cigarettes, they look nothing like them, making it easy for children and teens to secretly use them without a parent, guardian, or teacher noticing. This may be just a temporary trend, but if the FDA does not quickly do more to restrict flavors that appeal to adolescents and to educate the public about the risks, it is likely to create an enormous increase in young people addicted to nicotine.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.


  1. England, L., Bunnell, R., F. Pechacek, T., Tong, V., & A. McAfee, T. (2015). Nicotine and the Developing Human (Vol. 49).
  2. Nutt, D., King, L. A., Saulsbury, W., & Blakemore, C. (2007). Development of a rational scale to assess the harm of drugs of potential misuse. The Lancet, 369(9566), 1047-1053. doi:
  3. Musso, F., Bettermann, F., Vucurevic, G., Stoeter, P., Konrad, A., & Winterer, G. (2007). Smoking impacts on prefrontal attentional network function in young adult brains. Psychopharmacology, 191(1), 159-169. doi:10.1007/s00213-006-0499-8
  4. Centers for Disease Control and Prevention. Safety Material Data Sheet: Benzoic Acid. Accessed July 30, 2018. Available at:
  5. “Statement from FDA Commissioner Scott Gottlieb, M.D., on new enforcement actions and a Youth Tobacco Prevention Plan to stop the youth use of, and access to, JUUL and other e-cigarettes. ” FDA News & Event. FDA, April 24, 2018. Accessed: July 30, 2018.
  6. “Official Request of Information for JUUL Labs.” FDA Rules and Regulations, FDA. April 24, 2018. Accessed: July 30, 2018.
  7. Primack, B. A., Shensa, A., Sidani, J. E., Hoffman, B. L., Soneji, S., Sargent, J. D., . . . Fine, M. J. (2018). Initiation of Traditional Cigarette Smoking after Electronic Cigarette Use Among Tobacco-Na&#xef;ve US Young Adults. The American Journal of Medicine, 131(4), 443.e441-443.e449. doi:10.1016/j.amjmed.2017.11.005
  8. “FDA’s Comprehensive Plan for Tobacco and Nicotine Regulation” FDA Newsroom, FDA. August 6, 2018. Accessed: August 8, 2018.
  9. Centers for Disease Control and Prevention. Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Updated 2020.
  10. Johnson CK.  What we know so far about the US vaping illness outbreak.  AP: The Washington Post.  September 10, 2019.