Putting Diets to the Test

As a new year begins, it will be hard to avoid diet propaganda. I call it propaganda because in my review of the weight loss literature, I find very little evidence that diets are effective for the majority of people who try them. [In contrast, adopting a certain diet pattern (e.g., Mediterranean or plant based) as a life style is health promoting.] 

In some ways, diets are like medication and this may explain why diets fail.  First, like hypertension medication, diets work as long as you ‘take’ them and few diets are palatable or tolerable enough to 'take' forever. Second, like medication for serious mental illnesses, the side effects may be so harsh that the people who need the medicine most cannot tolerate it; like a diet which causes an excess amount of flatulence.  Third, the medication regimen may feel more tedious than the immediate or future disease complications seems to warrant; like drinking vinegar after every meal. Lastly, like pain medications, diets may need tweaking in order to remain effective; once weight is lost, a person requires fewer calories to maintain the new weight.  

Diets are not medications however; they are behavioral modifications or interventions. Considering the above analogies, a successful behavioral intervention for weight loss is as much dependent on the person as it is the intervention. To be successful, the intervention/diet needs to be one that a person is able to follow (with occasional adjustment) without mental or physical anguish for their entire life.  A person could not return to unrestrained eating or reduce their level of physical activity and expect the benefit of said diet to continue.  

Another important factor regarding diets is the amount of weight loss necessary for an individual or sponsor (e.g., government, worksite, researcher) to consider the diet ‘successful.’ Scholars Tomiyama, Ahlstrom and Mann recently raised this issue in an article they wrote for the journal Frontiers in Psychology.  In their article, they suggest holding behavioral interventions, including diets, to the same standards of evidential effect as medications (i.e., FDA approval).  Recall that a drug company has to proceed through certain steps when requesting a new drug application.  It has to show a drug:

• is safe, usually done first in animal studies 
• has limited side effects (ones that are outweighed by the benefit of the medicine)
• addresses an issue or disease that significantly impairs health or quality of life
•  is better than an existing drug for this particular disease 

•  the new drug has to be more effective, have less severe side effects or both  
•  or the regimen for the new drug has to be easier to tolerate than the current treatment (e.g., a once a month injection for osteoporosis treatment vs a daily or weekly pill taken on an empty stomach) 

Drug companies usually start a drug application with the intention of treating only one disease, but they must identify the disease.  Testing goes from the lab, to small groups, to large clinical trials, and then to post market evaluation. 

Imagine the same process for a diet intervention and include efficacy and effectiveness markers, as Tomiyama and colleagues suggest.  A diet intervention (or drug) is efficacious when it works in a lab under controlled conditions and effective when it works in the real world under less than ideal situations –where people might not follow every instruction, every time.  This is where diets seem to fail the most.

Tomiyama and colleagues give a thorough commentary on using FDA standards to test behavioral interventions and they use obesity as their example.  I was able to access the full article after clicking this link and then the tab on the right that says ‘provisional pdf.’ If this idea (testing interventions with the same rigor as testing new medications) intrigues you, I strongly recommend you read the original article.  

My last thought regards something the authors did not mention in comparison to drug trials, but which I would add – marketing and labeling.  A drug company can only market a drug to treat the condition tested in clinical trials.  In addition, marketing material and product labels must include information on side effects; instruct people how to take the drug, and state that not everyone will have the same benefit or side effects when using it.  I would be happy to see this sort of disclosure with diet programs, and expect that if such a high standard were required, most diets would fail to reach ‘market.’

Instead of trying a diet program or worse, diet supplement you see advertised in the coming weeks, why not read more about a health promoting pattern of eating from Harvard’s Nutrition Source – here.

Tomiyama A, Ahlstrom B and Mann T (2013). Evaluating eating behavior treatments by FDA standards. Front. Psychol. 4:1009. doi: 10.3389/fpsyg.2013.01009

Using Advertising to Improve Diet

The post for today was written, by me, as an exercise for a class I am taking to improve my writing.  I chose the study for blog relevance and personal interest, but it may seem more formal than my usual, opinion- infused posts.  Now you know why :)

 In the United States, obesity rates have risen over the past 40 years (Ogden & Carroll, 2010), and many health professionals consider the disease to be epidemic.  The suggested causes of obesity are numerous, interconnected and multi-level.  Because individual level prevention programs are expensive and generally ineffective, researchers have begun testing environmental or societal level strategies that can affect whole populations (Swinburn, Egger, & Raza, 1999).  For example, Rusmevichientong, Streletskaya, Amatyakul and Kaiser (2014) recently conducted a laboratory experiment to compare the effect of 4 types of food advertising on lunch purchases.  The researchers expected that limiting unhealthy food advertising, increasing healthy food advertising and airing anti-obesity messages would each lead to the purchase of items with less calories, fat, sugar and sodium.

If advertisement manipulation is effective in reducing over consumption in the short term, public health advocates will have evidence to promote advertising interventions or policies, which may lead to a reduction in obesity rates over the long term.  Rusmevichientong and colleagues offer some evidence in this regard.

 Rusmevichientong and colleagues randomly assigned 182 adult college students into one of 4 treatment conditions.  All participants watched TV for about 16 minutes. In all but one group (the control), the participants viewed four, five or six, 30 to 60 second advertisements in one of the following categories: unhealthy food advertisements (unhealthy foods were defined as items high in sugar, fat and sodium), healthy food advertisements (ones promoting the consumption of fruits and vegetables), anti-obesity messages, and a mixture of all three types. Before and after the TV viewing, each participant chose a lunch meal from a computerized menu.  The researchers provided $10 meal vouchers, but participants had to pay the difference if their order was more than $10.  The researchers compared the food orders before and after the TV viewing (within participants) and the changes between the groups, including the control. The research design (different in difference) allowed the researchers to compare the magnitude of difference between ad types.

In this laboratory experiment; exposure to the healthy food messages, anti-obesity messages and a mixture of unhealthy, healthy, and anti-obesity messages, led to an increase in healthy food purchases and a decrease in number of calories purchased. The healthy food messages produced the greatest decrease in calories purchased (134) compared to anti-obesity messages (93) or mixed messages (90). There was also some reduction in the fat and sodium content in the meals purchased.  In addition, Rusmevichientong and colleagues found a positive association between these 3 advertisement conditions and ‘becoming healthier,’ which they defined as purchasing a greater number of healthy foods at time 2.  The researchers suggest using anti-obesity ads judiciously and thoughtfully (i.e., ones that are not stigmatizing or fear producing) and healthy food advertising to reduce the over consumption of calories in the US adult population.

Rusmevichientong and colleagues results are important because most research suggesting a relationship between both anti-obesity messages and reduced caloric consumption, and healthy food ads and reduced caloric consumption is based on cross sectional surveys.  Experimental studies allow researchers to claim causal inference, e.g., healthy food ads change behavior. However, this particular study was small, took place outside of a natural setting and used a homogenous set of participants.  Policy advocates may present this evidence along with evidence produced from representative, field based, cross-sectional or longitudinal studies to make a case for new advertising polices.

Citations

Ogden, C. L., & Carroll, M. D. (2010). Prevalence of overweight, obesity, and extreme obesity among adults: United States, trends 1960–1962 through 2007–2008. NCHS Health and Stats.

Rusmevichientong, P., Streletskaya, N. A., Amatyakul, W., & Kaiser, H. M. (2014). The impact of food advertisements on changing eating behaviors: An experimental study. Food Policy, 44(0), 59-67. doi: http://dx.doi.org/10.1016/j.foodpol.2013.10.011

Swinburn, B., Egger, G., & Raza, F. (1999). Dissecting obesogenic environments: The development and application of a framework for identifying and prioritizing environmental interventions for obesity. Preventive Medicine, 29(6), 563 - 570. doi: 10.1006/pmed.1999.0585

 

Will you really burn off those extra calories?

In a recent Nutrition Notes Daily, published by the American Society for Nutrition, a professor from UCLA School of Medicine was quoted as saying, "it takes a lot of exercise to make up for a little dietary indiscretion."  
A vast body of research supports his assertion. Even so, many of us believe that an extra 30 minute walk will erase the damage of a 500 calorie donut, piece of cake or holiday cookies.  It is not so.  In this past post, I introduced the MET or metabolic equivalent as one way to determine how many calories you might burn doing a certain activity at a certain intensity for a certain amount of time.  For example, I found that I burned less than 500 calories by running at a ten minute per mile pace for just over an hour.
In a more recent post, I talked about the belief we have in the self control of our future self.  For example, the belief that tomorrow you will walk twice as long as usual in order to burn off the extra calories you ate today.  Often tomorrow comes and well, its today, so there you are... pinning your hopes on the next tomorrow. 
This is especially important from Thanksgiving to New Years.  One or two days of indulgence can be self corrected, four to six weeks of eating more calories than you need, will lead to weight gain and extra weight is hard to lose. 
(And when you start seeing weight loss ads in January remember that the only way to lose weight or to maintain a weight that is healthy for you, is to make a change that you can stick with - forever.  A short term plan will get you a short term fix and whatever trick you try will only work as long as you use it.)

Does Cancer Change the Dialogue?

Scientists have found that certain genes may place people at risk for disease (e.g., cancer, Alzheimers), but that having the gene does not in and of itself always cause the disease. Epigenetics is the study of how a gene gets turned on, or is 'expressed'.  The expression of a gene is due to some interaction between biology and environment.  In other words, a person may have a gene that puts them at risk for a certain type of cancer but the gene stays dormant or asleep until some other "thing" or "series of things" occurs.  There is ongoing research into the epigenetics of diet and cancer.  In other words, does the diet of a person turn on a cancer gene? 

As a researcher, I am interested in how diet (what and how much a person eats) affects health.  Because some research suggests that a diet high in calories, sugar and certain types of fat leads to obesity, heart disease and diabetes, I feel that it is appropriate to use law to help us limit our consumption of certain foods or food ingredients.  This is a very contentious idea.  Americans' believe that food choices are personal (I believe food choices are swayed by industry, the environment, and social norms).  Some people also believe that being overweight or having heart disease is an acceptable outcome for the enjoyment food provides.  Within that person's value system, the risk of heart disease is not considered high or important.

I wonder if this same global mentality will accompany a finding that too many calories or a diet high in sugar turns on a cancer gene.  People still fear cancer.  Cancer (though seemingly as treatable as heart disease) is not usually considered an acceptable outcome for food indulgences in anyone's value system.

I expect that laws limiting fast food restaurants, taxing sugar sweetened beverages and mandating interpretive, nutrient disclosures (i.e., traffic light labels) will get more support if researchers find a link between the over consumption of certain foods and cancer.

My desire is to test the effect of such laws or strategies, regardless of why they are implemented.  To learn more about my 'new' research interests please click here for my professional website.

Labeling Rules ~ The FDA has us all in limbo

Any day now, or more likely, sometime in 2014, the FDA will release the final rule for the national nutrition/menu labeling law officially meant to apply to restaurants (sit down and counter chains), vending companies, and similar retail establishments.

As of today, the consumer (you and I),  health advocates (myself,  CSPI, the RUDD Center,  many others), the National Restaurant Association, the National Grocers Association, the Association for Convenience and Fuel Retailing, pizza restaurants and other food selling/entertainment venues (e.g., bowling alleys, cinemas) remain unawares and unprepared for what will be required.

Of those listed above, the consumer interest groups (and thus a majority of the general public), public health folks and the National Restaurant Association supported the menu labeling law, but the others did not nor did they expect to get caught up in it.  My personal belief is that anyone selling ready to eat, unpackaged food has an obligation to share with the buyer of that food, pertinent nutrition information.  I would include food sold from steam tables in grocery stores, hot dogs and the like sold in convenience stores and items sold from concession stands at bowling alleys, sports arenas and movie theaters.

I do think that pizza joints should get some leeway in how they present the information due to the individual, made to order nature of pizza.

Once the FDA makes its announcement, retailers will have 6 mos to 1 year to comply.  Then the next battle begins.  Updating the nutrition facts panels on packaged foods. In this case, the concern 
(of food companies) is whether the update is going to mandate  labels that imply a foods goodness, e.g., star ratings or multiple traffic lights.

The new trans fat? Acrylamide 11 Years Later.

My blog site search engine is currently broken.  This is unfortunate because several years ago,  I wrote a post about a chemical found in french fries that was linked to cancer or which actually caused cancer in experimental studies involving mice.  Of course the mice were fed foods with much more of the chemical than most of us would be exposed to, but anytime a substance is considered a carcinogen or in the case of acrylamide a "probable cancer causing substance," I tend to steer as clear of it as possible. 
When I wrote about acrylamide years ago, it did not pose much of a threat to me as I don't eat french fries, chips or any white potato foods.  But the latest report regarding acrylamide includes cereal based foods (which includes cookies, crackers, whole grains and cold cereal) and COFFEE!   This is a sad day.  (To be fair, the first report may have said the same thing and I glossed over it).
Acrylamide is not a naturally occurring substance, but one that is created during some cooking processes.  For example, using really high heats in frying, baking and roasting (coffee beans are roasted and that is how coffee becomes tainted with acrylamide).  In this way, acrylamide reminds me of the harmful chemicals that are created when red meat is grilled and for that matter, the cancer causing chemicals in cigarette smoke (which among other things, also has acrylamide) - the chemicals aren't there until you or someone else does something to the product. 
The FDA has issued some guidance to food manufacturers and growers to help them reduce the amount of the chemical that is 'created' when the foods are processed.  With regard to chips and fries, the sugar in the potato seems to interact with the heat causes acrylamide to develop, so farmers are encouraged to grow low sugar potatoes. For coffee lovers, it is good to know that some types of coffee bean have less acrylamide after roasting than others - the FDA report notes that one lower acrylamide coffee bean is the arabica type (my sister had long ago convinced me it was the better tasting roast and I agree).  
The cereal foods category has me a little perplexed and concerned both personally and professionally. Acrylamide is created from an amino acid in the grains, called asparagine.  When the grains are heated at high temperatures, this amino acid is effected. According to a report I read and link below, the major culprit is whole grain, yes ~ the kind we are supposed to eat more often. I wonder if this means my cereal bars, made from All Bran, oat bran and Kashi Go Lean, or my mini cakes, made from whole wheat and soy flour are sources of acrylamide in my diet. Not cool. This will be a challenge for the FDA because they encourage us to follow the dietary recommendations from the USDA/DHHS  which focus on a plant based diet high in whole grains and fiber.  
The FDA is currently studying the impact of acrylamide in levels Americans are likely to consume (i.e., less than the mice did) in order to determine if more serious measures need to be taken.
For now they recommended avoiding french fries and chips and dark or burnt toast. 
Here are some FDA links that offer more information. 
FDA Q and A 
Food sources and cooking 
This next link is the report to industry and it is very telling, e.g., it discusses growing, transporting, storing and prepping potatoes in a way to reduce the amount of acrylamide that will be produced when those specific potatoes are fried.   The report has a section on cereals and coffee as well. When I was reading this I began to feel the general public's frustration with nutrition science and guidance.  
Lastly, a public health statement from the CDCs Agency for Toxic Substances and Disease Registry from 2012.

What does it mean to be metabolically healthy obese?

     Over the past weekend, I read a summary statement for a research study by Camhi and Katzmarzyk, 2013.  I was intrigued because the exercise and health scientists explored the differences in body composition (e.g., % lean mass, fat mass, bone density, central fat tissue) between two groups of obese people. The people in the study were classified as metabolically healthy obese or abnormal obese. The summary statement did not indicate if obesity was determined by BMI, waist to hip ratio, waist circumference or some other measure.  It did say how the determination of healthy vs unhealthy (metabolically speaking) was made, and I thought this a teaching point.  (FYI: Simply put, metabolic refers to under the skin - cellular processes. So the researchers were not looking at whether or not there were mental health issues, or physical conditions like arthritis, in this group of obese persons.)  I also do not know why the researchers chose the criteria listed below to determine metabolic health, but each has been independently associated with poor health outcomes, like heart disease, in other studies.  Of the following measures, an obese person in the study who had 1 or less of them was considered metabolically healthy, and an obese person in the study who had 2 or more was considered metabolically abnormal.  

The measures were:

1. a blood pressure reading higher than 130/85 mm/Hg
2. a fasting glucose level greater than 100 mg/dl
3. a waist circumference greater than 102 cm men, 88 cm women (click here to convert to inches) 
4. triglyceride level (blood fats) higher than 150 mg/dl
5. hdl (good) cholesterol less than 40 mg/dl men, 50 mg/dl women

     I noticed that they did not use total cholesterol levels or LDL levels. 

     The aim of the study was to see if something about body composition was different between the two groups (could this difference explain the accumulating risk factors).  The researchers did find differences, which were specific to gender.  For most of the body composition measures they assessed(not described here), the metabolically healthy obese had lower values.  For example, both metabolically healthy men and women had lower fat mass and less stomach or trunk fat.  Most every measure was related to a type of adipose(fat) tissue, such that the more fat one had on their body, and in specific places, the more likely they were to have more than 2 of the risk factors and thus be metabolically unhealthy.
     Take home point.  Your absolute weight is not as important as your body composition and the 5 measures listed here are numbers you might want to pay attention to at your doctor's visits.
 

Reducing purchases of sugar sweetened beverages

   I am posting about a study that was discussed in the popular press this week (if I remember correctly, it was an on-line article from a Boston newspaper).  I have not reviewed the research though I did contact the lead author/scientist, Dr. Jason Block to see if a publication is pending.  That being acknowledged, I will summarize the news story and add a few thoughts.
   At the very least, this study on sugar sweetened beverages (SSBs), like soda, juice, sports drinks, flavored whole milk and coffee drinks, offers promising results.  Dr. Block and his research associates tested whether raising the price of SSBs that contain 150 or more calories, would lead to a decrease in purchase of said drinks.  There was a 16% decrease in sales after the price change (1 cent per ounce, so $.20 increase in price).  Without seeing the research article, if there is one, I can't tell you the absolute change in number of beverages sold.  I also don't know what, if anything, the people spent their saved 'soda' money on.  They might have spent the money they did not spend on soda on foods that might be high in sugar or calories, on sugar free drinks, or on nothing. That is an important outcome to assess in these types of studies.
    In a second study, the same team labeled the SSBs with their calorie content and organized the display of drinks by amount of calories.  I assume that the first columns were sugar free items, then low calorie, then high calorie.  In this experiment, sales of low calorie drinks increased by about 11%.
   The results of this work support both the use of calorie labeling and taxation (price manipulation) to change behavior and thus, improve health.  However, I do not know the details of the study, so I make that assertion with some caution.  I would like to know more about any unintended consequences (substituting soda for chips, eg) and whether or not the changes that were seen were able to be sustained over time.  Lastly, this study took place at one work site and the results might be different elsewhere.  
    If/when I hear back about the study itself, I will write a follow up post.  I am very interested in this type of population level intervention.  In other words, putting effort toward changing the environment instead of changing people in one on one interventions (like a diet class).

Cholesterol Lowering Drugs

   To my knowledge, there is little evidence to support broad use of statins - or medicines that lower cholesterol.  The goal for treating high cholesterol is to decrease risk of heart attack and early death.  The research I have reviewed only showed this benefit for statin users who have been diagnosed with heart disease or who have had a heart attack.  It is that group that benefits from use. The new recommendations are to give statin medications based on factors (like having diabetes) other than a persons blood cholesterol level.  In a way, this removes the argument of how high the LDL level has to be before medicine is prescribed and at what dose should the statin be started, based on that LDL number.  The cut off number was always arbitrary.  How could there be more risk at 120 and not 119, for example.  But I don't know that this is any better, because it still places an emphasis on pills over lifestyle.
   I share the concerns of CNNs Dr. Sanjay Gupta who equates this shift to medication over changes in diet (and exercise) as a sign of defeat against the prevention of diseases associated with obesity.  Medication is not the solution here and we shouldn't give up on prevention.
    I understand that efforts to nudge people into better lifestyles has not been successful.  I don't think encouraging people to rely on medicine to fix problems is better than changing the environment to provide people better options (i.e.,  options to be physically active and to eat in moderation).  It does seem that nutrition information and nutrition guidelines are consistently and broadly misunderstood by a majority of persons.  This is in large part due to the complicated and ever changing information out there.  It is confusing and most people don't know what to look for when assessing a food's nutritional content and 'healthiness.'
    Just recently, I walked by a man and woman at the grocery store as the man was reading the back of package nutrition label.  (YAY!)  I heard him say, "Oh no, this is loaded with carbohydrates."  I wanted to stop, go back and ask him,"And what exactly does that mean to you?  Why is that a good or bad thing?"   Because if all someone told me was "its loaded in carbohydrates," I could not make an informed decision.  Sugar is a carbohydrate, so are vegetables and grains!  
   Our education and health promotion efforts must be constant, but simplified. Americans consume diets that are high in calories and items that might lead to high cholesterol, diabetes, obesity, heart disease, etc.  The main objective to improve health should be changing the diet (and increasing activity) not medicating the entire country.  Using medication in this way is as foolish as providing more rescue workers to collect the drowning from the river instead of putting a rail on the bridge to keep people from falling in the river.

Will the new trans fat law start a Peanut Butter war?

   I sure hope so! It is no secret - I am a fan of 'truly' all natural peanut butter.  When I say truly, I mean that the ingredients written on the label, if you didn't churn it yourself at a whole foods store, are simply: peanuts, and sometimes salt.  It is also no secret that Smuckers All Natural peanut butter is my favorite.  I have blogged about it numerous times and even made a You Tube video showing the world how to stir it.
    The reason a truly natural peanut butter needs to be stirred is that at room temperature, the oil will separate.  Peanut oil is NOT a solid fat.  In order to make it solid, it has to be hydrogenated, or in some cases, a solid fat is added to the peanut butter  - like palm or coconut oil (called oil only because they are plant based).  Palm, coconut and palm kernel oil is the same type of fat as beef or butter fat - it is almost 100% solid (saturated) fat.
   Trans fats are bad fats - not in excess, but period - in any amount (according to research reviewed by the FDA).  A trace amount of trans fat occurs naturally, but most trans fats are created in the process used to make unsaturated fats stay solid at room temperature and to make them last longer. [an example of when this process has been applied is when peanut butter is on a store shelf and the peanut oil has not separated - it isn't floating on the top.]
   The FDA is now banning all trans fats because they have been found to lower good cholesterol (HDL), raise bad cholesterol(LDL) - both of which are linked to heart disease, and to independently (whether you have high LDL cholesterol, low HDL cholesterol or normal cholesterol) increase the risk of heart disease.
   So begins the peanut butter war - I predict.  Currently, trans fats are allowed in products, except that nice ban in NYC restaurant foods.  And under current law, if a product contains less than .5 grams of trans fat, the label can say 0 trans fat per serving.  WELL.  The FDA says no amount of trans fat is considered safe.  There is no safe dose.  Just like there is no safe dose of lead. (Besides that - those little .4 grams of trans fat we consume unknowingly from multiple products can add up in a day!)  
   Therefore, when the law takes effect (and no I am not holding my breath), food companies will not be able to claim zero trans fat when they are providing nearly half a gram because they can't sell a product that contains ANY synthetic trans fats.  Hence, I bet those "all natural" but surprising solid at room temperature "no need to stir!" brands of peanut butter, are going to disappear.  I say, 'good riddance.'
    And in the meantime, keep reading those ingredients labels.  Your peanut butter does not need added oils, peanuts have their OWN oil and that is what makes all natural peanut butter natural - the peanuts - and just the peanuts.

If you missed those past posts on the different brands of peanut butter and how the labels can be misleading, click here. If you only have time for one of those posts, I recommend this one, which explains why you have to stir the peanut butter and why that is a good thing.
I am not going to share the You Tube link, though you can find it easily enough.  Some people got into a comments free- for- all about my stirring the peanut butter and said some things I wouldn't want my mother to see!  Still, people should be able to say what they feel (even smart asses) - so I left the posts up.

Future Self-Control

    I am 100% in favor of mandatory nutrition information at the point of purchase for ready to eat foods at all places where they can be purchased (e.g., restaurant, vending machine, movie theater, bowling alley).  I believe that an interpretive system, like the multiple traffic light (red for high in a nutrient, amber for moderate and green for low), is crucial, but I understand that nutrition labeling as a means to change behavior will always be less effective than other strategies, like zoning laws and taxes.
    The provision of nutrition information, even with a color code or star rating system, leaves individuals free to make an informed choice.  Unfortunately, choosing food isn't the same as choosing a dishwasher (which also comes with content info and a rating system).  
   There are many things that influence a food choice.  One of my favorite theories or frames which addresses these nuances is behavioral economics.  
READ THIS GREAT ARTICLE, by Liu, Wisdom, Roberto, and Liu (2013).  
  The reason I think the traffic light labels are crucial is two fold.  First, most people do not have awareness of dietary guidelines or the nutrition knowledge that allows them to determine if a food is high or low in items that are best limited (e.g., saturated fat, sugar, salt, calories).  Second, many people are present biased in their (food) decision making. In other words, the desire for the taste or the happy memory associated with a certain food, is first and foremost in a present biased persons mind.  The needs of  'here and now' trump any consequences (weight gain, ill health) that might occur sometime in the future.
   There is another factor (noted in the article I linked earlier) that I wanted to share.  I think you will go "oh my gosh, that is so true!" just like I did.  This is the belief or confidence we have in the self-control of our future selves.  For example, on a certain day of the week, you know that you should skip dessert.  You are full and can't afford the extra calories.  But it is someone's birthday so you just have to have some, and you'll do better next time or the next day.  Then someone brings cookies to the office and you really shouldn't have any, but everyone else is having them, and they really taste good, so you eat the cookies and promise yourself that tomorrow you will have dinner with out bread.  Oh, but tomorrow comes and the waitress served bread so you have to eat it, right? etc.....

Information for Food Decisions

   The Dietary Guidelines for Americans recommend that calories be monitored on a daily basis.  The recommendation is based on the importance of consuming the appropriate amount of calories to prevent 'over fatness' - which appears to increase the risk for several diseases.
   To be fair, clear and honest, many of us do not know our calorie needs - the amount that balances with our energy expenditure.  This lack of knowledge needs to be addressed, but is not the focus of this post (calorie needs are assessed on an individual basis).  For now, lets pretend that everyone does know their personal needs- and agree that for most of us its between 1800 and 2500 calories a day (NOTE: if you need 1800 calories a day and consistently eat 2500 calories a day, you will have excess fat!)
   Presuming you need 1800 calories a day and you know this, and you obtain many of your meals away from home, to stay on target you need access to nutrition information at the point of purchase at those places . 
    I feel it is imperative that nutrition information be available everywhere  food decisions are made, but it is not.  The national menu labeling law (passed within the Affordable Care Act) amends an older law, the Nutrition Labeling and Education Act which excluded ready to eat foods, like those at restaurants- from nutrition labeling.  This oversight was a mistake and it took a new law to fix it.  The fact that the new law does not include all places that sell ready to eat foods, e.g., entertainment venues, is dumbfounding.  The FDA can fix this - they are responsible for the final rules.  It needs to be fixed now, not 20 years from now.  This is a real fight and certain industries and labeling advocates are battling it out - leading in some part to the delay of national labeling.
   The Center for Science in the Public Interest is lobbying for the expansion of nutrition labeling and today they shared the picture below from a New York City cinema.  NYC has a much broader labeling law, however, the federal law will override state and city laws.  That means even the NYC policy will not include movie theaters, (or theme parks, bowling alleys, etc.) if the federal law doesn't include them.  Take a look at the numbers below and see how important this information is to the person trying to stay in their limits.  BTW, we should all try to stay in our limits, at least most days.   
 

To take part in the campaign to expand labeling - click HERE

Just a note, the Nutrition Labeling and Education Act is the one that mandated nutrition information and nutrition facts panels on the foods you find on grocery store shelves.

What foods are healthy and how can you tell from a menu?

To see the summary abstract of the study I refer to in this blog post, please click here.
The lead author is Lillian Sonnenberg.

   The purpose of this particular post is to share the results of another menu labeling study that used the Multiple Traffic Light (MTL) system to help customers identify "healthier" items.  I have a concern and a point to make regarding overall menu labeling, the federal legislation and why my point probably won't make a difference, but first.. a digression.
   Notice that in the above paragraph I put the word healthier in quotation marks.  I did this because in the research publication the authors assessed purchasing of items deemed healthier if they met criteria to be labeled as green. Two of the 5 criteria for a green label were low calorie (e.g., 500 or less for an entree) and low in saturated fat (i.e., < 2 grams).  The researchers also surveyed the customers before and after they introduced the labels.  The foods sold before and after the introduction of the labels were the same and the researchers knew if a person bought a green labeled food even during the time when no labels were posted.  When the researchers asked customers to answer a few questions after their purchase, the researchers also took their receipts.  Therefore, the researchers could match the survey answers with the items purchased.  A funny thing.. even customers who said that they always or almost always choose 'healthy' items were buying foods that were most often red (or unhealthy).  After the labels were placed, the 'healthy' eaters did only slightly better at purchasing green labeled foods.
   The researchers point out that customers do not seem to know what determines a foods healthiness.  I am not at all surprised and to be fair, isn't 'healthy' subjective and likely to change with every news headline?  Instead, I think that the researchers could have defined healthy in their question. They might have asked how often the customer chose foods low in calories or low in saturated fat (but even here a person must possess some nutrition knowledge to know what constitutes low, which is why MTL labels are effective - green = low).  The researchers failed to mention another likelihood for why people who said they chose healthy items did not in fact buy them. It is possible that they said it because it was the socially correct answer, not because it was what they actually do.
   Ok, now my main point.  Since the Affordable Care Act was passed with a National Restaurant Association supported nutrition menu labeling law included, new research has indicated that calorie disclosure alone (as per the law) is not sufficient to change selections.  Instead, menus using the MTL as the Sonnenberg et al study and many others have found, are more effective.  The law should be amended to incorporate these new findings, but it won't be  - nor will it be overturned - even if the ACA is.  I make both assertions for the same reason.  The National Restaurant Association is in large part responsible for the passing of the law - which in many ways is great.  It probably would not have happened without their endorsing it.  They will make sure that the law stays in place because it prevents states and cities from requiring restaurants to do anything different - it mandates a nationally standardized format that a restaurant chain can implement across its regions.  One law - one format.  And the format won't change (even if it isn't effective, or maybe for that very reason)  because if the MTL was used, the menus would be covered in RED and that would be bad for business.  (I think it would force restaurants to revise their recipes - in a good way-, but I just don't see this getting any industry support)
 

Does vegetarian = low calorie?

   If you are considering a meat free diet specifically to reduce the number of calories you consume, this post is for you.
   There are several reasons why national dietary guidelines, the American Cancer Society and the American Heart Association recommend that 

1. red meat be limited(this includes pork no matter what you tell yourself), 
2. processed meat be avoided or extremely restricted (this includes all lunch meats, bacon, sausage) and 
3. a plant based diet be chosen (lots of vegetables, fruits and whole grains).

    Two words in the start of that sentence explain the dietary advice, heart and cancer.  Evidence suggests that saturated fat in red meats may lead to high blood cholesterol and thickening or hardening of the arteries, and that processed meat increases the risk of colon cancer.  Fruits, vegetables and the fiber from whole grains has been shown to reduce the same problems or diseases.
  Meats also have more calories per gram than plant based items and limiting them can make it easier to consume fewer calories. However, this is only true when all things are equal- (and they never are - equal). Look at the table below, which I created using Jimmy John's gourmet sandwiches - this is a list of the seven 8" sub sandwiches on their menu.  I put them in order from least to most calories per sandwich.

JJs 8" sub sandwiches

 As you can see, the vegetarian sandwich has the most saturated fat and nearly the most calories.  All of the sandwiches, with the exception of the Vito, which is made with Italian lunch meats and an oil and vinegar, contain MAYONNAISE.  I can tell you how the vegetarian sandwich ended up to be so high in calories, but first note that all the sandwiches are a significant source of calories because of the bread - a salad would be a better choice (if not loaded with a mayonnaise based dressing).  The vegetarian option is described on the menu as having 'layers of provolone cheese and an avocado spread,' plus the mayonnaise and a few veggies for a grand total of 640 calories! The cheese, avocado and mayonnaise are the main source of calories, followed by the bread - I suspect.  A more reasonable lunch would have 400 calories, and mine usually have 100 or 200 because I eat small meals often.

All food has the potential to be high in calories and nutrients that are harmful in excess (i.e., saturated fat, sugar, sodium). In order to make sure that when you intend to eat a low calorie meal you actually do, read the menu labels, ask the restaurant staff to hold things like mayo, ask if butter is used on the 'steamed' vegetables and consider skipping butters, breading and sauces when preparing food for yourself.

BTW, this post was inspired by a meeting I am going to next week.  We were given these 7 options to choose from for our lunch.  I replied to the host that I would be bringing my own lunch.  
(That's right.  It doesn't matter that the lunch is free - it doesn't matter if everyone else is going to order from that menu - what matters it what I need for my body and my health.  Surely you feel as interested in your health as I do mine.  Be brave and remember not to eat to please others but to fuel your body - while enjoying the choices you make.)

The Power of Oatmeal

No not as a miracle cure for weight loss... surely by now you know that I don't endorse such nonsense.
I mean the power of oatmeal (oat bran for me) to satiate.  To leave you with a feeling of fullness which lasts for hours.  
I knew that my oat bran with almond milk breakfast was very filling, but now there is research to support this personal experience and to explain why it occurs.

The researchers in this study collected information on how the participants were feeling, e.g., if they 'felt full,' 'were hungry' and what was happening to the oatmeal and the comparison food - ready to eat cold cereal - in the body, i.e., how it was being digested.  The participants reported their feelings at several different time points up to four hours after they ate their assigned breakfast.

It is important to note that the participants each ate both meals, but in random order and about a week apart.  The meals were 1) Quaker oatmeal and 2) Honey Nut Cheerios.  The meals were served with the same amounts of skim milk and had the same amount of total calories.  I do not eat Quaker Oatmeal - but I think they used the kind that you cook with hot water.   I use oat bran which I cook with water and eat with low cal almond milk (+aspartame).  I can say with certainty that if I had equal calories of cheerios and oat bran the cheerios would be half the volume of my oat bran.   And I believe that what you see has an effect on your feelings of satisfaction and fullness.

Anyway,  the study was well done.  The lead author/researcher is Candida Rebello - a nutritionist.  You can read the summary abstract here.

Putting the reports from the participants together with the lab results, the researchers could assert that the oatmeal breaks down more slowly, is thicker going through the small intestine, among other things and is more satiating than the cereal.  There are a lot of details in the article that I am not taking the time to explain, and some I could not explain even if I had the time.  But I think I have shared enough to give you the evidenced based take home message.  Choose oatmeal over cold cereal.

As for myself, I never eat cold cereal as a breakfast.  I believe that it offers too many calories per ounce (it is energy dense) and as this research suggests, doesn't stay with you very long.  I do sometimes have a taste of it as part of my discretionary (treat) calories.

Eating to Please... the Slippery Slope

No matter where you live in the world, society has certain norms about food.  In addition, your family or church culture might have traditions or customs about food.
Some things are easy.  If you are going to a function where food is to be served, whether its an official party, or just a visit to your Auntie's house where food is not to be refused! - go hungry (go to the event hungry).  In other words, don't add to the days calories, include what you eat or drink there as part of your day's total intake.

But what about the social norms that you can't prepare for?  What if someone bakes a cake and brings it in to work?  Or you just drop by a friends house and he or she brings out cookies?  Is it right to eat just to please someone else?  Is it right (smart) to eat just because 'everyone else is'?   I say no.  I think we are on a slippery slope when we start eating to give other people pleasure.  Consistently eating for reasons that are far removed from the main purpose which is to fuel our bodies and brains is dangerous.

To be absolutely 100% clear, food is to be enjoyed!  Tasted, savored, shared - I always enjoy eating but I do not eat to feel enjoyment.  Does that make sense?
Eating to feel good is a very dangerous habit to get into and eating just because someone suggests it, or you are bored, or you want to celebrate.. when you are really not hungry.. that is risky.  It can condition the brain to use food as a crutch or as a feel good medicine.. food should not be used as a security blanket.

It is okay to tell someone that you are too full to try their cake, or heck, that you have allergies, or that you are fasting for religious purposes, tell them anything you want..you do not have to eat to please someone else. But if you know a food event is coming, it makes more sense to go there hungry or to bring a low calorie item to share rather than offend your host.

Please give this post some thought.  One of the reasons - and there are many - that a majority of people weigh more than is healthy for them (70% of US adults), is because they consume more calories than they need, and that is sometimes because they eat for the wrong reasons. (sometimes they eat too many calories by accident, but that is related to food labeling)

McDonalds?

Okay, yes.  I am going to come out and say that this is a good thing.
McDonalds is going to allow people to choose a salad or a vegetable in place of french fries in the value meals.
It is also going to stop promoting soda as a drink option in its happy meals (I wonder about other sugar sweetened beverages like juice and if they will only offer low fat milk, but its a start)

Is McDonalds the right place to do this?  Well, heck yeah.... its THE place to do it.  BTW, if McDonalds can let us substitute salad for fries, I hope the more 'upscale' restaurants will join in.  Actually, didn't I talk about this a year ago?

I am excited.  It has to start somewhere - and since the USA has the highest ratio of McDonalds restaurants per 1 million people in the WORLD - and the near highest obesity rate (I think USA is second) - McDonalds it is.  

I find this change more important than the one over at Burger King.  It is good that BK is thinking of ways to reduce calories in their items, but 270 calories is still a lot more than an 80 calorie salad (minus the high cal/high fat dressing of course)  

In my last blog, I wrote about a french fry burger and a bottomless bowl of pasta so I am calling this progress and leaving it at that.

Is the Food Industry Promoting Obesity?

The US population has a high rate of obesity, perhaps the highest in the world (see the WHO and CDC obesity websites for the numbers).  The simplest explanation, the one without nuance, is that people are eating more calories than they need. The nuanced explanation involves all the reasons why we are consuming too many calories.  For example, one reason is that we don't know how many calories we need.  Another is that, even those who know their caloric needs, cannot reasonably (or accurately) estimate the amount of calories in the food and beverages available to them.  Still another, the food and beverages most readily available and heavily promoted are (ridiculously) high in calories.
So is the food industry a culprit?
I give you three reasons why I think the answer is yes, but note, I said a culprit not the culprit.  They are:

1. The french fry burger
2. Endless bowls of pasta
3. And the Bacon Pepperoni pizza burger

 There are many factors that promote an over consumption of calories.  The cause will always involve an interaction between the person and his or her environment.  But really, does the environment have to be this over the top?  Cheap, calorically- dense, nutrient-poor food is much easier to access than it is to avoid.  That's a problem, but its one we CAN address.

A blog post on weight loss worth a share

I read a post today and shared it on Facebook and twitter, but I really like it so I am going to share it here also.  
 I am familiar with the science and the scientists that this blogger refers to, and I trust her interpretation.

I want to add 3 things.

• Exercise, as I say every chance I get, is essential for good health. One cannot live well without it - and just like medicine, it only works when you 'take it' and you should 'take it' every day.
• Pay attention to tip number 5.  They are talking about Volumetrics and my personal style of eating (but they don't call it that or refer to me!!}.   Note that there is evidence that what you eat matters to your overall health, if not your waistline.
• Remember, science is not about facts.  We observe, test, interpret and trust the evidence that we have today.  Someone can observe something different tomorrow.  Science is supposed to be a work in progress, and it is.

Review the post on weight loss tips that are supported by science written by Alice G. Walton HERE.

PS< I am still here!  My dissertation writing is the most insane hardest thing I may have ever done (to be fair, I collected and analyzed my own data  - twice (2 studies) (but can you believe I lack skill in making written arguments!)... anyways, I will be back, sporadically at first and more consistently in the future.

Shorter Messages Greater Impact

I am going to follow through on an idea I contemplated about a year ago - micro blogging. The main reason for this switch is that I need to concentrate on completing my dissertation (both the data analysis and the writing).  In addition, it makes sense to use shorter messages that are direct and useful.  There is such a thing as losing the reader in too many details, or so I am told by my adviser (:)).

Therefore, I am switching my health education to Twitter.  If you are unfamiliar with Twitter, it allows only 140 characters(letters) to be sent at one time.  

Here is an example of a 'tweet' I sent today:

Food Labels: The terms Healthy and All Natural do not mean low calorie. Often they don't mean healthy or natural either! Read your NFPs.

Tweets can also be in the form of pictures.  I sometimes send out pictures of low energy dense meals or baked goods.
In order to get these messages you have to sign up for a Twitter account if you don't already have one.  After you do this, you can choose other people or companies to follow as well.  For instance, I follow Yale's RUDD Center, Harvard Public Health and Boyd Swinburn.  You can choose how to have the tweets delivered to you.  I opt for an email once a week.  It lets me know if the people/groups I am following have posted anything. 
I am providing two step by step instruction guides for you.  One is in print, click here and the other is a You Tube video, click here.  Take your time setting up your account and remember you can change your preferences or cancel your account any time.  Oh, and then don't forget to follow me!

The Best Pledge We Can Make

   I was at the school rec center last week when a few people were registering as guests. I overheard the staff person as he was asking them to sign a liability waiver. He said, 

"This just means that you are taking responsibility for your body."

    I smiled when I heard it and I have thought about it ever since.  What an awesome concept. What if every person, better yet, every middle school child, signed a pledge committing to take care of their body.

   This commitment could be similar to those kids make about not smoking or doing drugs.  DARE to be healthy, if you will.

   Even better, it could be something required of us, before we get health insurance. 

 I hereby agree to take care of my body.  I will eat well, exercise daily and avoid all forms (active and passive) of tobacco smoke.  I will consume alcohol responsibly and protect myself from environmental toxins/radiation (e.g., sun, xrays, pollution, coal emissions). 

(The government needs to help us out with the last few). 

 I do these things in order to prevent disease and to promote my healthy active life.  

   Now if we can find away to 'police' that... ok, enforce .. ok encourage... though my radical, nanny self wants to add, 

and if I willingly break this vow, I will be responsible for my own health care bills and or higher insurance premiums and copays!

   Seriously, I do pledge to do every thing in my power to live a healthy life and if by no fault of my own, I get sick.. I hope someone will take care of me :)  Ok - even if its my 'fault'... I hope someone will take care of me... just saying.

Myths, Assumptions, Nuances and Obesity

I have been writing about health and wellness in one form or another for 13 years. During that time I have gone to graduate school twice.  
My plan for the blog has always been to present information to the public that goes beyond the headlines.
My goal is to educate the reader in the hopes that he or she will take new science and recommendations for better health into consideration.   These recommendations include consuming a quality diet, getting sufficient exercise, limiting sedentary activity and maintaining a weight lean enough to prevent diseases that are associated with adiposity - or over fatness.

My understanding of research has improved over the years, especially the last few, but the science into the causes of obesity (adiposity) has been plagued with flaws.  Scholars far more experienced and critical than I, have begun to point out these flaws.
I tell you this because I am sensitive to the fact that I may have perpetuated false claims in my own blog or given too much credibility and attention to tenuous claims.  This exactly opposite my goal.  

Here I am speaking about diet quality and healthy weight.
It IS still about calories and the sources of those calories, but it is much more nuanced.  By nuanced, I mean that numerous factors are independently and interdependently related to health and weight.  

There are many problems with the methods used in obesity research and that makes it hard to pull together evidence that can suggest a solution.  Science has taught us a lot. We now need to use more precise measurement methods (e.g. with dietary recall, and body fatness), be consistent with our definitions (what is obesity?) and have more open minds about what the causes could be (is it really just too many calories ?).

This was wonderfully explained by Herbert et al (2013) in a commentary published in the journal Mayo Clinic Proceedings.  The summary can be found here.  They give good advice for improving research.  I will apply this advice in my career.

I will continue to talk about calories (food energy availability) and policies, but these are small parts of a very complex, multi -facted system.

Let me quote from the Herbert article.  I assure you that I believe every word in this paragraph.

...obesity arises from the dynamic interplay of the external environment, inclusive of the social milieu, built environment and food energy availability, behavioral and development processes and a variety of genes and epigenetic effects that, in turn, control a myriad of metabolic systems and subsystems that regulate energy intake, energy expenditure and nutritional partitioning.   

Now I will do my best to restate this in simpler terms:

There are many factors both inside and outside of our bodies that work together to create a condition where obesity is likely.  As one factor changes one or more others reacts and these changes and interactions are continual (dynamic). The external environment can make it easy or hard to be physically active (built environment) and easy or hard to eat too many calories (especially nutrient poor ones) (i.e., food energy availability). These two factors are also impacted by social cues (preferences, norms, advertising, ' peer pressure' - i.e., the social milieu).  Behavior is what we do - exercise or not, choose certain foods or drinks, and development is the body changing over time.  Genes, or heredity, are usually activated by some interaction with the outside environment (epigenetics) and together impact how the food a person eats is processed by the body - whether or not one gets high cholesterol, or diabetes for example.

That is a lot to process.  The simplest truth is that one should not eat too much, and a very complex set of circumstances determines if one eats too much and whether their eating too much causes a bad outcome (illness).   I would point out one last thing from the article.. the authors say that it is social and environmental factors, NOT genes, that have had the greatest influence.

So here are 3 interesting links about calories.
Link 1 This is a story about peoples desire for calorie information and how some restaurants are starting to provide lower calorie meals.  It actually summarizes a lot of the research I have used in my literature reviews and in this blog.  I love how it mentions Dardens Restaurants use of nutritionists and calorie counts when creating new entrees.  Also, it points out some REALLY high calorie entrees ~ over 2000.  Oh one problem, the writer keeps referring to the national menu law as a proposed law.  The law is a law.  It has been passed.  The rule - how to follow the law, is being proposed. 
Link 2  This links to a 3 item quiz on which item has the lowest amount of calories... I scored 100.
Link 3  This links to a story about smoothies and juices, both of which I personally avoid at all costs.