Flawed Study is Encouraging

   Today I read about a menu labeling intervention that took place in 1990.  It involved 4 restaurants within a small geographical area (adjacent counties in one state).
   It is an older study so we have to give the researchers a break for promoting low fat meals, instead of meals low in saturated fat.
   For the intervention a heart symbol was placed on certain menu items that were lower in fat and thus "healthier."  This was based on the science we had at the time.  The researchers planned to collect sales data at baseline (before the labels) and after the labels.  They would check to see if the proportion of labeled items sold to non labeled items increased.  
   They had a nice research design in mind.  Their plan included NOT labeling menus at one of the restaurants - at least not at first.  They wanted to compare the results to a "control" group.  It is similar to a drug study where two groups are alike but one gets the drug and the other doesn't and then you check some outcome, like blood pressure.  IF the drug group has better BP, you have reason to believe it was the drug that made the difference.  SO, if the percent of low fat menu items sold increased in the restaurant using the labels as compared to the other, then it suggests that the labeling caused the increase.  Got it?
   The second design feature that they planned to use was taking away the labels to see if the sales of those items stayed the same or decreased.  If they decreased, that would add evidence to the importance of the labels.
   Well - these two features just didn't happen.  They didn't happen because the restaurant managers would not cooperate and that is the encouraging part of this flaw!
   The restaurant manager of the store that was not supposed to use labels used them anyway - without checking with the researchers first.  In all restaurants, when it was time to remove the labels, no one wanted to.  This supports the idea that both customers and restaurant owners/managers find value in identifying healthier items.

Of note - I did check back on the FDA website today to see if another report had been filed on the status of implementing sec 4205 of the ACA   - i.e. the menu labeling law.  I found one sentence dated June 13, 2012.

Policy options in response to comments on the proposed rule are under consideration.

Fast Food Customers - Walk Ins vs Drive Throughs

   About a year before the Food, Drug and Cosmetic Act was amended to include menu labeling, researchers associated with Yale and led by Christina Roberto conducted several studies to explore the effects of menu labeling on purchasing behavior. They were able to use NYC for some of these tests because NYC had added mandatory menu labeling in 2008.  Other scientists have also reviewed these policies.
   As the details of the national law were being negotiated, restaurant owners suggested that drive through menu boards be exempt from the calorie disclosures.  Instead they suggested that a notice be placed on the boards that informed customers about nutrient information that was available in side or on line.  There were problems with this idea.  First, studies had already shown that customers rarely noticed information or made use of it if it was not directly at the point of sale.  Because of this, it was likely that some proportion of fast food customers would not benefit from the law if it exempted drive through order boards.
   Roberto, et al observed customer traffic at 8 different fast food establishments during specific time periods for a total of 39 separate observations. (in Connecticut)  They categorized over 3500 customers as either inside or drive through orderers.  The results of their study likely impacted the final menu labeling rule.  In total, across all the restaurants,  57% of the customers used the drive through.  Curiously,  the lowest drive through rate was at Kentucky Fried Chicken (36%) and the highest was at Dairy Queen (70%) followed by Taco Bell (63%).  
   You might think, well, those were CT restaurants.  This is true, but it is likely that similar numbers would be found in other states.  The researchers' conclusion that menu labeling is needed on the drive through boards as well as inside makes good sense to me.  
   At last check, the legislation does include the drive through boards.  I am hoping to find some time this week to review the status of the vending and menu laws.  The FDA (through the secretary of Health and Human Services) is responsible for explaining to restaurant and vending owners exactly what they have to do, when they have to do it, what the penalty will be for not doing it, and when the FDA will begin enforcement.   The last I read, all is delayed, but the final rule may come out this fall.


The study that I referenced is available here.

Roberto CA, Hoffnagle E, Bragg MA, Brownell KD.

Public Health Nutr. 2010 Nov;13(11):1826-8. Epub 2010 Mar 18.

Odds and Ends

HPV and Herd Immunity  I believe I've mentioned herd immunity when discussing seasonal flu.  Basically, it means that if enough people in your group are immune to an illness, your chances of getting sick decrease even if you are not immune.  The disease gets blocked before reaching you.  I mention it today because there is a suggestion that herd immunity may working to protect some people from HPV.  Public health advocates hope that young men and women will NOT depend on herd immunity.  I am sure that Merck and GSK also hope that you don't skip the vaccines.

Pretentious Grocers  I frequent stores such as Whole Foods and Earth Fare as rarely as possible as I cannot afford to shop at them. I only go if I cannot find a product somewhere else.  In the last week or so I have had to visit both stores.  As usual, the visits led me to gasp at the prices.  Prices on items that I buy at other grocers were priced, not a few cents more, but dollars more.  That is nuts.  The items come from the same place!  These stores promote themselves with offerings of all natural, organic, people and environmentally friendly products, but exclude a great number of people with their prices.  It must be noted that none of the healthy eating indexes (HEI, AHEI and the AHA version) or the DGA, explained here in the last month, mention all natural or organic items in terms of reducing the risk of overweight or disease.  This is because science has yet to make such a link.

Physical Activity When I first presented my exercise tracker, I noted that I did not include general physical activity.  Instead, I focused on what would be considered exercise, by definition.  I did not include all the activity breaks that I take in a day.  Many of those are walks around the block which I have had to limit with my calf injury. So I noticed that in the last 7+ days, I've done more physical chores than usual.  I have cleaned my bathroom and kitchen, using an old fashioned sponge mop instead of my 'swifter,' and getting better results.  I went to the local coin car wash and washed my own car.  Again, it was cleaner by my own hand.  I spent extra time at the community garden, watering, harvesting and pruning.  These are activities that people do much less these days - meaning we are sedentary in general and specifically.

Hyatt Menus The company press release included a statement on the increase in overweight and obese children, but the menu description does not mention any SoFAS or calorie moderation.  It does note choosing food suppliers whose agricultural practices involve sustainability which I value as an environmentally focused person.  However, the rest of the focus is on organic foods.  Intuitively, organic foods should be better for us if they contain less contaminants or additives, but there is nothing to suggest that using them leads to less calorically dense meals.  So if the hotel chain wants to address obesity they are going to have to do it by lowering calories.  If they want to cater to the deep pockets that shop at Whole Foods and Earth Fare, well, they have that covered then.

Aerosol I learned today that aerosol cans are recyclable.  I thought that disposing of the 'contents under pressure' cans was problematic and checked my city's recycling website to see what I could do.  Indeed, I can recycle as long as the can is completely empty and the nozzle is removed.  Pretty cool.

Prosperity and Weight Gain

   Researchers often make note of the parallel rise in economic prosperity and weight gain.  The percent of people who are overweight increases with Gross Domestic Product or GDP.
    It is a challenge and a disappointment.  Countries continue to have a majority of citizens with poor diet quality, but now the cause is an abundance of energy dense, nutrient poor foods not a scarcity of nutrient rich ones.  With increases in GDP the type of food available to people and the ways in which those foods are prepared appears to change.
   The Western Diet of meat, dairy and refined grains takes the place of a plant based meal pattern.  This transition has occurred in China, Mexico, India, Brazil, Egypt to name a few.  These countries are considered emerging markets and are the target of the food industry.  
   Most of us see the connection between international companies such as KFC, mcDonalds, Burger King, Taco Bell and a rise in BMI.  However, as pointed out by Professor Barry Popkin (2007), another Western trend - the supermarket - impacts the diet as well.  His research shows a relationship between obesity in developing countries and these stores.  Yes that is right AND it makes sense.  Think of the Western countries - with over 60% of their populations overweight or obese - UK, USA, Australia, etc.  Perhaps you live in one.  You can confirm that the calorically dense, high processed foods are for sale inside supermarkets.
   We talk a lot about the lack of availability of healthier foods (fruits and vegetables, whole foods), but it is not availability as much as it is access.  Remember - access includes, cost, brand and taste preferences, convenience, and competition.  See the pictures below from one store.  This is just a sample of the displays within that store.  
   Increasingly, nearly every environment in which food and people meet is an obesogenic  (obesity causing) one.

Notice that in the middle photo there are about six different (junk food) displays down the aisle.  The photo on the right has two - candy and donuts.  These were taken at the front, middle & rear of the store.

Which Risk Matters Most?(repost with new link)

Due to the level of importance this post is being republished today. The topic includes the importance of waist circumference as a marker of disease risk. Click here to learn more and to see a picture on how to use a tape measure to get your WC number.   

Dr. Michael Miller, a heart doctor and professor, recently answered some questions about heart disease as it relates to metabolic dysfunction.  Metabolism has to do with how the body breaks things down and processes them.  Certain tests can tell us if the body is having difficulty with those activities, because if it is, health problems could follow.   
   The article with Dr. Millers suggestions is published in the Nutrition Action News Letter July/August 2012 issue.  Within that piece, is a reference to a study that showed the increased risk of both heart disease/attack and diabetes incidence with each factor of metabolic dysfunction that a person has.  The figure from the article was originally published in the AHA journal Circulation.  You can access the article here, for free.  I include the figure below, as it is one of the best representations I have seen.
   First let me explain what factors make up the Metabolic Syndrome while noting that the importance of each one is the subject of debate amongst professionals/scientists.  The 5 factors that were the focus of both the AHA and Dr. Miller articles are:

• Blood pressure equal to or higher than 130/85 mmHg
• Fasting blood sugar (glucose) equal to or higher than 100 mg/dL
• Large waist circumference (length around the waist):
  
  • Men - 40 inches or more
  • Women - 35 inches or more
• Low HDL cholesterol:
  
  • Men - under 40 mg/dL
  • Women - under 50 mg/dL
• Triglycerides equal to or higher than 150 mg/dL

   A person is said to have Metabolic Syndrome if they have any 3 of the above 5 conditions.  As I said, not everyone believes that each is a factor in heart disease nor that each has the same level of impact.  Dr. Miller's assessment makes the most sense to me, based on other articles I have read.  The two most important factors that he notes are triglycerides(TG) and waist circumference (WC).
  Dr. Miller has some quote worthy comments for you to consider, they include:

When the gut is the first thing you see when a patient walks in the door, that is not a good sign

....a lot of men have disturbed metabolism before they reach 40 inches (WC).

Even too much of the right foods can be a problem.

People shouldn't douse their salad with olive oil or they might get too many calories. (in response to a question about healthy oils - douse means use a lot!)

    He also spoke to the issue of getting your TG levels from a health fair, which usually does not include a fasting level.  He said that he has heard of people having a TG level of 400 and being told not to worry about it because it was not a fasting level.  He contends that someone should very much be worried about that level because even immediately after an "unhealthy" meal the TG levels do not rise more than 50% - though they may, in rare instances, double.  So if ones non-fasting TG level is 400, then their fasting level could be 200 and that is TOO high.
   The good news is that TG are directly and substantially reduced through exercise and meal patterns.  Exercise causes the body to release an enzyme that breaks down TGs.  Also, limiting sugar and saturated and trans fats is important.  Dr. Miller recommends very little added sugar - 24 g a day.  He enthusiastically recommends fish oil - but in fish not capsules. There is more but you get the idea.
     Below is the chart I mentioned earlier.  Notice how much higher the risk for adverse health outcomes is when a person has 4 or 5 of the risk factors.  The figure is more readable if you go to the article.

 

What does your body tell you about that meal?

   It is quite interesting to read articles about diet and health that were written between the 70s and 90s compared to those written in the last ten years.  Our ability to measure - whether it be the items that people eat or the metabolic processes that certain foods trigger - has gotten much sharper over time.  This better measurement has led to changes in what is recommended for health and left many of us confused about what to eat.
   One thing has remained consistent for the last 30 years... the majority of people in developed countries are eating too much food and gaining weight because of it.  
   Scientists are now challenging the notion that a calorie is a calorie - even for weight gain (since we already knew that some calorie sources were bad for our health).  It is very likely that the body is doing something different with foods that are high in SoFAS - saturated fats and added sugars, especially if these foods are highly processed.  Refined grains tend to be high in both sat fat and sugar and even contain the dreaded trans fat.  
    People frequently go out to eat lunch when they are working or attending conferences. The majority of foods served in chain and fast food restaurants are calorically dense - made so from the SoFAS.  YES? So, what does nearly every one say about work and presentations after lunch?  "I don't want to be the presenter after lunch, everyone will fall asleep."  OR, "I don't feel like doing any work, I just want to take a nap."  
   I used to feel that way after lunch, too.  I don't now because I eat food that is not calorically dense.  My meals are always low in saturated fat and added sugar. They have a low glycemic load (are not starchy).  I never feel lethargic after I eat.  
   Think about how you feel after you next few meals.  Eating too much of any food will make you uncomfortable, but eating certain foods, even reasonable portions, trigger a different kind of discomfort.  I believe that the way you feel after you eat something - after the taste rush has passed - is a clue as to whether or not it was a healthy food. 

Order UP!

....because we do not get enough calories or convenience in our every day lives.

   A researcher in NC compared the average amount of calories per meal (from a pizza joint) between people who ordered in person at the restaurant and those who placed their orders on line.
I have not read his study, but it is on the list.
   The result of his study was that the meals ordered on line had more calories on average than the ones ordered in person.
The researcher, Dr. Ryan McDevitt, collected information on over 150,000 pizza orders from one restaurant during 4 years.  He found that ordering on line led to more expensive meals with more calories.  I do not know how many more calories or how real the difference was, but I do have a counter point to his idea of WHY this might be happening.
   In a WSJ article, he was reported as saying that people ordering on line might be less likely to feel social pressure to curtail their calories.  Instead they would be less restrained or inhibited.
My comment to him - and I did email him - 

"What?!? Pressure to eat LESS - in the SOUTH?" 

I think that the pizza coupons, TV ads, in store promotions and your friends telling you  "everything in moderation" (which is code for go ahead and eat it) pressures us all to eat more - right out in the open.
   My thoughts on his results?  Glad you asked.  People ordering on line have more TIME to find things to add to their pizza.  I do need to read the study because I do not know if there is a difference in side items ordered, or if he even looked at that.  Imagine all the calories in those dessert breads and stuffed bread sticks and dips and such.
   Seriously, I do see his point.  Some of us do not want to over indulge in front of our friends or family.  Which makes me think that to go orders would be higher in calories than orders eaten on site... esp. if you can order on line and have it delivered to you... because hey, why waste calories going to get it! 

Heat, Hydration and Exercise Amounts

Heat, Hydration and Muscles  This goes into the “learned the hard way” category.  Maybe you can learn from my experience.  As you may recall, I had some pain in my calf a few weeks ago.  Both the physical therapist and later the MD asked me if I had been running when it was very hot.  I had.  It was when NC was having the high heat index days and I was blogging about code red air quality.  The PT said that I was probably tired and hot leading my muscles to cramp and stay sort of knotted up.  I kept trying to run – thinking – well surely those knots will let go.  Instead, it got worse and Monday a week ago, the pain was intense enough to send stress fracture alarm bells ringing and I have not run since (sad me).  I saw the sports medicine doctor on Thursday.  He told his assistant, “It’s the heat.  Remember all the runners that have been coming in with pulled muscles?  They get dehydrated and injured.”  So dehydration was the cause.  Dehydration (when you sweat out more than you drink in) impairs muscle functioning.  The muscles have less blood flowing to them, are not as flexible and elastic as usual and are prone to stresses.  This makes the muscles weaker, increases cramping, and injury risk.  As I recall, I may have run over a root on a trail on one of those super hot days. The muscles that stabilize the ankle couldn’t handle the contraction needed to balance me.  I did not feel any sharp pains – I only felt tightness the next day.  My doctor used an ultrasound to evaluate my injury and found some tears in the perineum – one of the many calf muscles. I do not have a stress fracture and all my joints and muscles are strong. I did learn that the muscles most susceptible to injury during dehydration are the hamstrings, quadriceps and calf.  I thought I was prepared for the.  I wore a fuel belt with electrolyte water , but I guess I needed two bottles not one.  BAH.  Well – I am unhappy but as you’ll see in the exercise chart below – I am NOT sedentary. 

Exercise Amounts

I have added totals to the excel sheet that I use to make my chart. When considering my weekly total,  I should not count the 80 minutes of cycling for transportation.  It does not really meet the definition of exercise. That leaves me with a total of 678 minutes for the week.  Within that total is my time spent on resistance or strength (weights) training.  The PAG (physical activity guidelines) specify time for resistance workouts (at least 20 min 2x a week) apart from the recommendations for aerobic activity.  So I should also subtract my 60 minutes of weight training form the 678 total. That leaves me with 618 minutes spent on walking, running, swimming or cycling in seven days.  I averaged almost an hour and a half each day.  Believe it or not, the PAG suggest that the more one exercises the better the benefit.

My change due to injury is somewhat noticable in the chart below and will be more so next week.  I have added more cycling for fitness (including dirt trails) and and extra day of swimming.  For the extra day of swimming (oh my gosh I used to hate one and now its three!) I am doing pool running with a jog belt.  If you are interested in that, Google has some video links.

Remember you can make your own chart by modifying the excel document I made.  It is available here. link to scribd 

 

 Are you still reading?  Great.  Let me add that I understand that the majority of people have trouble meeting the 150 minutes of aerobic activity per week, none the less 300 minutes.  But it is true, the more you do the better off you'll be (for most people).  Below is the statement from the PAG document itself.  You can check out the guidelines in full here.  There are special sections for people who are disabled or over the age of 65.  However, no one gets away with being sedentary!

The benefits continue to increase when a person does more than the equivalent of 300 minutes a week of moderate-intensity aerobic activity. For example, a person who does 420 minutes (7 hours) a week has an even lower risk of premature death than a person who does 150 to 300 minutes a week. Current science does not allow identifying an upper limit of total activity above which there are no additional health benefits.

Odds and Ends

Whooping Cough According to the CDC, the US is having its worst whooping cough outbreak in 50 years.  Whooping cough is the common name for the bacterial infection, pertussis. The"nickname" is related to the symptoms not the cause.  People who have the infection are contagious during certain periods and the illness can spread to others who are not immune.  Vaccines are effective at preventing both the spread and contraction.  In other words, vaccines protect against getting it yourself and giving it to others.  Most of us received the immunization as children in the DPT shot and its booster.  Many colleges require young adults to get a booster before allowing them to attend classes. The CDC is suggesting that adults may need to get a second booster as well – to protect children.  It appears that the outbreak is related to adults getting sick (often because they have lost their immunity) and infecting children who have not yet had their series of shots.  The number of cases for the year so far are 18, 000.

Helmets and Leaders   I rode my bike on some Greenway trails today.  At one point I came upon a small group.  The group consisted of one man, late 20s, and ten or so children who appeared to be middle school aged.  We were riding in opposite directions so we came face to face.    ALL of the children were helmeted.  It is the law in NC to wear one if you are 16 or younger, but many children do not wear them and the law is not enforced.  The adult in the group was the only one not wearing a helmet. One of the children, a boy, rode off the paved trail into the street. As the boy went off the trail, the adult said, “Tommy, you are not being a very good leader right now.”  And – well – you know what happened next right?  As I rode by, I looked at the man and said – with a light tone, “Neither are you and tapped on my helmet.”  He said, “I know!”

Blood Cholesterol and Heart Disease  This segment can be brief or long and complicated.  I am only just beginning to wrap my mind around what I am learning and the little research I did today is not enough.  Briefly then:  The link between blood cholesterol and atherosclerosis (heart disease due to plaque buildup) is being challenged by many scientists.  It has been debated for a while. One of the arguments is that not everyone who has heart disease has high cholesterol.  It may be that a person’s cholesterol becomes high when other risk factors are in play.  For example, not exercising, smoking and being obese are risk factors for heart disease.  These factors may change the way that the body handles excess calories from fats and sugars and thus the cholesterol that the body creates from them.  I am not sure what this means in the end or what you should do with the information.  I have read that cholesterol lowering drugs should be considered only after weight loss and increased activity have begun. Also that when used; only the least amount of drug that is effective should be given.  There is little evidence to support that lower numbers are better because the cholesterol may be a symptom of some other problem.  For example, if being 30 pounds overweight is causing the sterol to form in the arteries, then having an LDL of 100 while still being overweight is not going to help.

 

News from AHG The information presented below is directly from an email I received from the Alliance for a Healthier Generation.  The goal of the organization is to improve the health and wellbeing of children.  Please go to the websiteto learn more.  The tips that are offered below can apply to adults as well.  If you don’t want to use playground equipment or play tug of war, you can get your resistance training with free weights or exercises that use your body as the muscle load. What I liked best from the email is highlighted in yellow below.   I also like the definitions and examples.

Aerobic Activity: Endurance activities that get muscles moving in patterned movements for a sustained period of time.

Try: Bicycling and swimming

Muscle-Strengthening Activity: Resistance training that increases skeletal muscle power by doing more work than in daily physical activities.

Try: Using playground equipment and playing tug-of-war

Bone-Strengthening Activity:

Impact and tension activities that help grow and strengthen skeletal system.

Try: Running and jumping rope

Different Bodies Are Better at Different Things

Did you know that running a mile at the same speed will have a different effect on different bodies? Lifestyle, metabolism and fitness level all play a part in how exercise affects our bodies. This is because we expend energy at different rates. But with some effort, we can influence that rate.

A body trained to sit, will sit well. A body trained to move, will move well. 
How active is your body?

Inactive: No activity beyond baseline activities of daily living   

Low Activity: Activity beyond baseline but fewer than 150 minutes of moderate activity a week  

Medium Activity: 150 to 300m of moderate activity or 75 to 150m of vigorous activity a week

High Activity: More than 300m of moderate activity a week  

Diastolic

   I had a doctors appointment this week and my blood pressure was assessed.  It was a very healthy, normal 105/70 but it got me to thinking.  I wondered how close my bottom number or 'diastolic pressure' was to normal or abnormal and if there was a specific treatment for changing one of the numbers as opposed to the other. 
   I know that my diastolic pressure has been in the 60s before and though I don't know if that is a good place for it to be, I wondered why it went up. 
   Turns out that the bottom number is considered healthy or normal as long as it is under 80 and above 60.  It is not until the bottom number goes over 90 that one has the diagnosis of hypertension or high blood pressure, but doctors will put a watch on you if your number is over 80.  It is likely that a doctor would advise a person who's bottom number was over 80 and under 90 to watch their weight, eat better and to exercise.  Of course, a drug company might want that doctor to just go ahead and give you a pill.
   The top number, or systolic pressure, is considered safe and normal if it is under 120 (but over 90).  
   The NHLBI (National Heart Lung Blood Institute) is the most credible source that I know of for information about diagnosis and treatment of heart and lung conditions.  On their webpage I found a chart that shows when one is hypertensive by either number.
   My goal today was to see if the treatment for diastolic hypertension differed from treatment for systolic hypertension.  I could find no evidence of this.  What I did learn was that if either number is abnormal, a person is said to have hypertension or high blood pressure and if both numbers are abnormal, the highest value is used to determine what stage of hypertension the patient has.  I imagine that the stage is used to inform how invasive and intense the treatment should be.  High blood pressure is a risk factor for stroke.
   The best way for me to explain about the stages is to show you the chart from the NHLBI.  If your number is 120/90 then you have stage one hypertension by the diastolic number.  If your number is 160/95 you have stage two based on your systolic.
 
    It is said that following a healthy lifestyle can reduce the chances of becoming hypertensive.  A healthy lifestyle, as you know by now, includes not smoking, being of a healthy weight (one in which you have normal blood tests and are not stressing your joints), eating a quality diet (plant based with limits on red and processed meats, add fish and alcohol when appropriate ) and exercising - daily.  If you click here, the NHLBI has some helpful information on preventing hypertension in more detail.

 [note:  people with established high blood pressure must be careful about alcohol use]