Fish Oil Supplements Revisited - briefly

     I was recently reminded that in past posts, I had shown support for the use of fish oil supplements.  My opinion has changed as newer research has failed to support an association between fish oil pills and a reduction of inflammation as it relates to heart disease, stroke and/or arthritis.  In other words, I now find the body of research that I used to make my decision less convincing.  As indicated more recently, I only 'take' vitamin D and just in the winter.  The best source of D is sun (risks duly noted).
   To the best of my knowledge, studies on the effect of fish oil supplements and the treatment of heart disease, prevention of second heart attacks and control of atrial fibrillation are still being conducted.
   I AM sure about this.  There are protective effects from the consumption of oily fish, high in omega 3s.  People who consume fish, such as salmon, once or more per week appear to have better cardiovascular health - meaning less inflammation and improved oxygenated blood flow - than those who do not consume fish. 
   Be advised, not all fish contains this good fat (tilapia does not) and some fish that does is also toxic due to mercury levels.  Fish to avoid include shark, tuna, tilefish and sword.  A newcomer for Americans is barramundi - found in Australian and South Asian waters. Barramundi is a type of sea bass.  I have found conflicting reports on its mercury content, unfortunately, at least one of them considers it in the same category as swordfish. I believe that some farm raised and thus carefully fed, barramundi is not high in mercury. Either way, my sister cooked some when I last visited her and it was quite yummy and low in calories, if you care about such things.

Menu Labeling - Just What IS a Similar Establishment?

   The final rule for the restaurant (and similar establishment) menu labeling law (sec. 4205, pl 111-148), has yet to be published.  We are waiting on the FDA.  As of today, restaurants do not know the logistics of how  to present the information nor when the deadline for compliance is (6 months after the rule is published).
   The latest contention (there are so many) is what counts or what should count as a similar establishment.  As expected, public health professionals, consumer advocates and restaurants want an inclusive definition and individual industries want to an exclusive one.  The Food Market Institute, via its council Erik Lieberman, argues that grocery stores, for instance, should be excluded while myself, Rudd (Center for Food Policy), and CSPI argue that entertainment venues should be included and forced to comply.
   The problem is two fold and related to the way similar has been defined.  The FDA defines an establishment as NOT being similar to a restaurant if it serves the same type of food (like a prepared meal) but its primary business purpose is NOT the sale of food.  From this definition it is clear how grocery stores get included and movie theaters and bowling alleys do not.  
    The issues I see are these:

1. Grocery stores which sell food as their primary purpose provide predominently packaged products.  Those products, even the ones sold in the deli and bakery, should be covered by the NLEA (1990).  The ready to eat meals that they serve, well - I don't see the argument for not including them under the new law (2010).  Just put the calorie counts on the steam table and order boards.  I understand that the FMI is fighting being included in section 4205 of the ACA.  What I find dubious is the argument that putting nutrition information on packaged cookies in the bakery is too burdensome.  Those cookies were NEVER meant to be excluded from the original labeling law.
2. Entertainment venues like movie theaters, sports arenas and bowling alleys sell precisely the type of foods that the new law was meant to address.  They sell calorically dense, nutrient poor foods which are high in added sugar and saturated fats.  These foods are associated with the rise of obesity in the USA and other countries.  One strategy for reducing the rate of obesity in the USA is providing nutrition information at the point of purchase or sale.  This should mean the place of ALL food sales.  How much sense does it make to include a vending machine and not a cinema?  We, as consumers, need nutrition information available to us at all the places we make food choices. 

An article by Josh Long on a website called Food Products Design inspired this post.
 
   

National Menu Labeling Update

   Funny that I should be the one posting an update on menu labeling when I regularly troll the internet searching for the updates myself.  The rule to post calorie information on restaurant menus and menu boards was adopted in 2010 when President Obama signed the Patient Protection and Affordable Care Act (PL 111-148). Section 4205 of PL 111-148 has not been enacted because the FDA hasn't issued the final rule.  The final rule will explain how the restaurant and vending industry are to go about getting that nutrition information to us - in a standardized, effective and reasonable manner.
   Recently the FDA commissioner, Margaret Hamburg was quoted as saying that the menu labeling issue had become "thorny."
The National Restaurant Association  is not the cause of the delay.  They supported the legislation that made its way into the law (to protect themselves from a plethora of differing city and state policies).  
   The latest snag comes from the pizza industry. 
I read about the industry concern in a news brief from PizzaMarketplace.com. It told about a recent trip that executives from the nations largest pizza chains (e.g., Dominos, Pizza Hut) took to DC.  They went to talk to members of the Domestic Policy Council.  I had not heard of the DPC before I read the article.  You can read about the council here.

   The pizza group made some good arguments.  They did say that they were not trying to get out of providing the information (that would be bad PR, yes?).  They are trying to find the best way to provide customers with nutrition information.
   Some of their argument centered on the issue of made-to-order 'ness'.  For example, the toppings that can go on a pizza, the number of slices one makes from a pizza and how both of those things can differ by restaurant.  To supply calorie information for all the combinations would be incredibly expensive and space intensive.      
   The group also expressed concerns about the public having to do math in order to figure out the amount of calories in the particular slice of pizza they ordered.  For example, the restaurant could post the calories for a basic 12 inch cheese pizza and tell the customer to add 50 for sausage, 50 for pepperoni, and 20 for onions (etc ).  Then they could instruct the customer to divide that total pizza calorie number by however many slices they cut the pizza into to get the total number of calories in one slice of the pizza they ordered... well that would be too burdensome. Heck it was too much of a sentence even!.
    I believe it was implied in the comments that some customers were not capable of basic math.  It is true that the calculations are a problem.  This is mostly because we (health educators, etc) have learned that when customers have to do math - they won't.  It takes too long OR they don't know how.  Maria Topliff (quoted in the news piece and representing a Chicago pizza chain), asked if instead of having the customers do it, we would ask the 16 year old behind the counter to do math.  She indicated that this would be a bad idea.  [this really points to a need for a dialogue on the lousy math skills of Americans.  Maybe we ought to do it this way so people will learn to add and divide!]   
  Ms. Topliff is right though.  There is great variability in a pizza restaurant.  I liked her idea of an onsite meal calculator - or even an on site IPad.  In fact, I think that might be a very good idea in this technological era.  It would be a lot cheaper for the restaurant and easier to update.  However, from menu labeling research we learned that people need to see the big picture (calories) at the same time they are reading the food choices.  Her idea doesn't do that.  It may be a necessity for pizza places, but I would not recommend that we allow non-pizza chains the same option.

Obesity Studies... What is a Cause?

   It isn't often that I refer you to an article in full that has been written by someone else, or in this case, a couple of someones.  You can trust that I am doing it for a good reason.  The article published in the NY Times addresses a point often made here.  Headlines and research should be interpreted carefully.  
   I believe that these two journalists get it exactly right (one hails from Union College - yay).  I only have one or two things to add, but I really think you should read the article first... click HERE. 
 Okay - I feel like you didn't listen to me.  The article is about junk food advertising and soda sizes causing obesity.   Read it HERE.


OK.
The only big problem I had was with the journalists' assertion that we do not know what causes obesity.  Of course we do.  A lot of people eating more calories than they need (and the number they need is personal).  There are reasons that people eat more calories than they need and some of those reasons are ones that I want to study.  I want to use the exact type of research design that the journalists advocate.  But, I do not think randomization into conditions will always (or ever) be possible.  Lagged interventions, or lagged policies may allow me to make good inferences. By this I mean, if one state adopts a public health policy before a similar state does, I can compare the two states on the outcome (calories purchased, BMI, etc). Most of the time,  my work will speak to associations, relationships, correlations and that is ok. I hope I  can get to cause, but I won't pretend that I did when I did not.
     I would reword some of the journalists language about the studies they referenced.  It is true that advertisements do not cause weight gain - but they may entice people.  Ads may lead people to establishments where they over consume. Once inside the restaurant, is there any hope?  Maybe.  It is possible that putting the number of calories per item on a menu might encourage people to chose an item with fewer calories.  Having to put calorie numbers on a menu might encourage the restaurant owner to offer more low calorie items.  
   Having less billboards, less fast food places, higher prices on nutrient poor foods, removing sodas from WIC and SNAP benefits...Polices like these might reduce consumption of foods that are very high in calories... but at the end of the day.. it will always be about a choice that a person makes.  If that choice includes too many calories.. weight gain is likely to follow.   
(ps if you think that the government wants to manipulate you and the food industry doesn't, you are woefully naive)

Differentiating between the healthy thin and the sick thin

    Just a quick post regarding the uproar over the study that indicated lower weight persons did not live as long as mildly overweight ones and the somewhat associated Mortality Index.
   Unfortunately, the current issue of the Nutrition Action Healthletter is not yet available on line.  It does a great job breaking down the recent study published in JAMA.  The research findings got a lot of people excited and a few scientists upset.  Recall that Walter Willett referred to them as "rubbish."  Read more at Harvard School of Public Health HERE.
   The problem, many scientists agree, is two fold.  One is including smokers or former smokers into the study and the other is not excluding people with chronic diseases that cause weight loss.  I appreciate the desire to leave out former smokers, but I think instead of ruling out all former smokers, another criteria could be set.  For example, a person who smoked 15 years or less and has been completely tobacco free for 15 years before the study.  That could be further nuanced by adding a pack per day limit. What is clear, smoking is a big problem.  It makes people sick and smokers have lower weights than nonsmokers, in general.  (I read that all the time, but I sure know a lot of obese smokers).
    The second issue is the Mortality Index constructed by researchers at UCSF.  This assessment is meant to be used by physicians and only with patients over the age of 60.  Of course, you know that if we have access to it, we are going to "test" ourselves.  I did.  The issue again is the weight question.  Here if your BMI is under 25 you get a point and "low score wins!"  To handle this possible error, my thought is this:   A physician giving this test to a patient he or she knew, could decide whether or not the patient's normal or low normal weight was healthy or concerning. If the patient was not ill (points for smoking are in another question) and had a normal or low normal weight for most of their adult life, they should not get penalized.  The problem with low weight is its association with wasting diseases or smoking and nothing more.
   Remember you are not supposed to take this test yourself, but don't you want to know what the fuss is about?  Click here.  

Choosing the Lower Calorie Option

    In the current version of the Dietary Guidelines for Americans  everyone is encouraged to deliberately choose the lower calorie option at home and when eating away from home (USDA/DHHS,2010).  This recommendation is made because the majority of Americans are overweight and more than 30% are obese.  These numbers are supported by new ones just released from the Gallop and Healthways poll .  It found that only one state had an obesity rate below 20% in 2012 and the average rate of obesity in most states was well above 20%.
   I take the "choose the low calorie option" very seriously - as most of you know.  It is the foundation of my volumized plate and informs how I choose meals at restaurants.  It also has an influence on the choices I make at the grocery store.  I have a great example and I share it because I think that the grocery food industry might have realized that there is more than one Deirdre in the world.
   In a recent post showcasing almond milks, I noted that the Almond Breeze brand had a greater amount of good fat and was, in that respect, the better choice between it and Silk Pure Almond.  It was also the less expensive of the two brands.  Almond Breeze costs nearly 50 cents less.  
   I buy 2 cartons of almond milk each week.  I have been buying the more expensive, technically less healthy brand, (Silk) because it has 30 calories per cup and Almond Breeze had 40.  YES - I am that stubborn.  And yes, I said had.
   I think people like me are growing in number.  I say this because NOW the Almond Breeze has the same amount of calories as Pure Silk and the same grams of fat.  I don't know why they changed, but I assume it was competition.  What they did not change was the price, so NOW I buy 2 cartons of Almond Breeze  each week.  [note: in both cases I am referring to unsweetened almond milk, (vanilla or original]
   This is example of why it makes sense to occasionally recheck the label of a product you buy all the time.  Things change.
OH - I think this is also an example of the power of front of pack labels!  The milks are sold from a cooler where they exist side by side.  The calorie per serving info is broadly displayed on the front of the cartons.  In this side by side comparison 10 calories is enough to make one look worse or better.  The sad thing is, the 10 extra calories were coming from good fat-  a nutrient we need.  Sadly, I like most people who consider calories, fall prey to the lower is better mentality when it isn't always the case.  Here is really isn't (wasn't). 
 

Breast Cancer Rise and Significance

   Last week it was reported in the popular press that a new study had found a rise in the number of younger women (ages 25-39) who were being diagnosed with advanced breast cancer.  I did not seek out the actual research, but what I did hear on the news (likely NBC Nightly News) is important to clarify.  We were told that in the last 30 years, the rate of diagnoses per 100,000 women went from 1.5 to just about 3.  That means for every 100,000 women in that age group, almost 3 were found to have advanced breast cancer in 2009.  The news reporters and scientists have noted that this is a small but significant increase in cases. (the significance statement is being questioned by some researchers, but lets say it is not).
   When you read a study and see that it is significant what that means is that it is 'real'.  It does not mean it is big or even important. You need both the effect size and whether or not it was 'real' to make your assessment.  Is 1.5 more cases a big deal?  That is for you to decide. In the statistics world, the significance means that the finding (here more cases of breast cancer) is very likely due to something other than chance. 
    When comparing two values (here at two time points) the assumption is that there is no difference.  The p value tells you the percent of times you could expect to find a real difference if there  wasn't one.  How many times you'd be making a mistake.
  The study researchers think that the finding in this case is real.  It could be that more women are obese and that obesity somehow increases the risk, or that as women are starting puberty earlier this could be upsetting hormone levels and increasing the risk.  The scientists who published this current study do not KNOW the reason.  They are only saying that the cases increased and something is behind it.  (Usually scientists or statisticians set a level of .05 or .01 at the start of a study and only accept 'significance' if they have a p < .05).   I am thinking you wish I had stopped talking about a paragraph ago!
Just eat right and exercise, ok!?  ( and of course, don't expose yourself to cigarette smoke, first hand or otherwise)

Can a menu change behavior?

   In one of the most recent experiments to test the effects of including calorie information on restaurant menus, Ellison et al found that both menus with calories listed numerically and menus listing calories in the context of the traffic light system, led to fewer (entree) calories purchased.  
    For their study, they manipulated menus in one restaurant for about two weeks. The restaurant was divided into three sections and as people came in to be seated, they were randomly placed into one of these three sections.  Everything was the same except the wording on the menus.  In one section of the restaurant the menu was as usual, in another the menu had the number of calories written next to each item and in the third, the calorie number was accompanied with a color (remember Go Slow Whoa).  Entrees with 400 or less calories were coded green,  with 401 to 800 calories were coded amber and with more than 800, red.  They used smaller calorie ranges to code the side items .
   Since the customers were randomly placed in the sections, each section should have contained people who were otherwise similar (any difference in the people is merely by chance).  This type of design makes it easier for one to say that what they did (put calories on a menu) caused the outcome (purchase less calories).  In fact, that is what they found. The customers who had either calorie menu purchased less calories from entrees than those that had no information.  
   The researchers made a good point in their writing.  I had not thought of this, but which makes perfect sense.  It applies to people like me.  People like me are going to order the low calorie item no matter which section of the restaurant they sit in.  People like me go in with the intention of choosing the lower calorie item and generally know what the low calorie items are.  But this is very good news, the menu information helps the people who need it the most!  The people who were not "health conscious" chose lower calorie items when they were in the restaurant sections with calorie counts and not when they were in the section with regular menus. (a side note - if all the people in the restaurant were like me, then the researcher would have found that the menus made no difference.  That finding would have been misleading, right!?!)

Ellison, B., Lusk, J., & Davis, D. (2013). Looking at the label and beyond: the effects of calorie labels, health consciousness, and demographics on caloric intake in restaurants. International Journal of Behavioral Nutrition and Physical Activity, 10(1), 21.