How menu labeling can help you detect good food gone bad

Last night I ate dinner out with a dear friend at a local Applebee's.

   This particular Applebee's had calorie information for a few items on its print menu.  It had comprehensive nutrition information on its website.  You can see that information here.  I accessed (and assessed) the information prior to my visit, but I could have seen it from my smartphone while at the table.  Not everyone can do either of those two things.
  While dining, I told my friend that I saw some items on the menu that had over 2000 calories.  This was in reference to the research articles I talked about here, which showed the average restaurant meal has over 1000 calories, more than half a days worth for many of us.
   She asked me which items, but I could not remember at the time.  I looked again today and it was the appetizer sample and two dishes with riblets.
   My friend and I both ordered the blackened tilapia meal which had a very reasonable 410 calories (as opposed to the fish and chips which had 1690!).  My meal had less than 410 calories because I asked the chef not to use butter and I replaced the potatoes with steamed broccoli (great service from the wait person and manager, Winston Salem, NC).  My friend and I ate similar volumes of food but I had fewer calories (I make these choices because I like to eat many times a day).  
   The tilapia looked like a good choice and it was a good choice. I can't say the same for the grilled chicken salad which had 1290 calories.  There was also this great find on the children's menu.  The item was titled 'Kids Celery Side with Dressing."  In case you didn't know, 3 whole cups of chopped celery has less than 50 calories.  This 'low calorie' vegetable side item had 220 calories - I am guessing that about 200 of those calories were from the dressing.  To be fair, the celery - even with this dressing - had half the calories of the kids french fries.
    Speaking of kids meals, remember this post regarding the nutrition in children's meals at certain restaurants.  Applebee's did make it to the low end of the upper half of the list with 4 to 8 % of its children meals meeting expert nutrition standards.  It paled in comparison to Subway and even Red Lobster and IHOP.

Oh and btw - I just started a twitter feed so if you want to follow me there you can. I expect I will mostly tweet photos of volumetric meals and maybe an occasional research update, esp related to diet quality and public health policy.  @DeirdreDingman

The Silk v Almond Breeze Battle Wages On - and We Win

   I have written about the virtue of almond milk 3 or 4 times in the past year.  I believe it has a lot to offer as a replacement for cow's milk.  It has a better nutrient profile, zero sugar (unless you buy a version that is sweetened.. and why would you DO that?), and it has  good fat from almonds.
    In the second or third post, I spoke about one brand having slightly more calories than the other. If your interested in why that might matter  here is that post.
     Not only was there a calorie difference between the two brands but a significant price difference as well.  I was, initially, paying 50 cents more for the lower calorie milk (and I use two cartons a week). 
    I followed up sometime later to tell you that the other brand miraculously determined or changed so that it didn't have those 10 extra calories after all.  This was great news.  I could buy the cheaper milk  because the producer changed its recipe! YAY 
    I must not be the only calorie sleuth in the almond market nor the only one who sacrificed money to get less calories. Once the calories were equal I switched to the lower priced milk.  That must have been the behavior of many customers because the higher priced milk is now only 10 cents more.  In other words, the other company also changed based on the behavior of customers.  We had an effect on the producers.
So this is fantastic. Consumers driving healthier options.
   This is exactly the type of response we are starting to see and hoped to see with restaurant menu labeling.
If I can get a lower calorie (read healthier) meal at one restaurant then I will go to that restaurant. If restaurants want my business they will smarten up and give me more lower calorie choices - and prices will even out just like they did for the milks.  (if there are lots of people making choices this way)

Menu labeling proceeds without the FDA

    I have noticed that my blog gets the most views when I stick with calorie and menu labeling stories. (don't worry I only see the absolute number of viewers not WHO is viewing the blog.. that's not my department  ha ha)
   Good news.  Two more restaurants have decided to go ahead with menu labeling for all their stores, not just in states or cities where it is already the law.  I don't blame them. Even as the government drags it feet - new estimated date is 2014, the demand from customers is there.
    The two stores in the news are Taco Bell and Starbucks.  I just have a few comments and then I think you should click this link to a great USA Today interactive.  It lets you guess the calories in some of the 2 restaurants meals and beverages.
   My first comments are about Starbucks. The company has now decided to label the items in its pastry cases as well as the beverages.  They have been labeling the beverages for some time. After NYC passed a menu labeling in 2008, researchers conducted a study to compare the amount of calories purchased by Starbucks customers before and after the law and in locations without a law (like Boston at the time).  The law did seem to have the intended effect. The amount of calories purchased did go down after the menu labeling was introduced.  However, when the researchers looked more closely, they found that the customers were buying less food calories, not less beverage calories.  You will see in the USA Today 'game' that the beverages are a substantial source of the calories.
   Now about Taco Bell.  They are also going to post calories on their menus but with great fan fare.....also announced that they would include the amount of protein (in grams) each item contains. REALLY?  Because we don't get enough protein?  The only rationale I see for this is that they want to distract the customer from the fact that most of the items have ridiculous amounts of calories.
   Trust me - Americans as a group are not protein deficient.  What we don't get enough of is vitamins, nutrients, antioxidants and fiber from complex carbohydrates like those in whole grains, fruits and vegetables.  Do I think they should list the amount of carbs in an item - lord gosh NO... That is more confusing than the protein label. (sugar and starches are also carbs).  
   Best ideas for all of us is

•  choose the lower calorie option that has more vegetable than meat and cheese, 
• watch out for too much fat (which you will be doing if you choose the lower calories),
•  choose fruit over potatoes, etc.  
• And try not to drink your calories - unless its a (as in one) glass of beer or wine, maybe.

Here is the citation for the study I mentioned.
Bollinger, Bryan, Phillip Leslie, and Alan Sorensen. Calorie posting in chain restaurants. No. w15648. National Bureau of Economic Research, 2010.

And here is the link again if you waited.  

The Obesity WHAT?

The obesity paradox.  I want to say a few words about it today.  I think I recently mentioned this phenomenon in passing with the plan to return to it.
I am especially sensitive to the issue because I am a low to low-normal weight person to whom the paradox applies.

Some 13 years ago, researchers and physicians began noticing something odd regarding differences in outcomes between low weight and overweight people who were in the hospital with certain diseases.  The diseases included diabetes and several manifestations of heart disease, e.g., heart failure, peripheral vascular disease, coronary heart disease - especially at end stages or  during severe acute episodes.

When people get sick enough that they end up in hospital intensive care units, low weight people (like me) are more likely to die than obese people.  That is the paradox. Its a paradox because being overweight is bad for people (so bad the AMA has just today determined that obesity is a disease) but seems to 'protect'  from death in the ICU.

There are several "ideas" for what is going on here.  One that gets a lot of press and one that food companies LOVE is ...."being thin is  actually a bad thing".  

Before you go grab that box of donuts, there are a few things to consider.  First a disclaimer... as much as I want to read all the studies and give this issue its proper due, I just don't have the time right now.  

This blogger did a good job explaining the history of the issue and some of the actual studies that led to the term.  He does not conclude that being overweight is a good thing - just in case you were looking for that.

My thoughts:

• We have already established that something about obesity - inflammation, fat processing, metabolism, etc increases the risk for the diseases I mentioned (and several others).  This means that more overweight and obese people have diabetes and heart disease.  There will be more of these people in the hospital to begin with..  
• It is also possible that the thin person in the hospital with end stage renal failure from diabetes - is thin because they have diabetes, but he or she was not thin when diagnosed.  One study I saw refutes what I just said.  However, they looked at people who were low weight at diagnosis but were over the age of 40.  (what if a person is low weight in their 20s, 30s, 40s, i.e, their normal weight is low?)
• I also 'wonder' about the person who was a low or normal weight because they followed recommendations on nutrition and physical activity but still got diabetes or heart disease.  Suppose that person got sick for genetic reasons and their disease was more progressive than the one the obese person got which was related to their lifestyle?
• I would like to see a study that was able to compare people based on some of these factors.  Especially looking at the thin person who is in the ICU with heart disease or diabetes complications.  What was that persons lifecourse?  Were they always thin?  Did they eat right and exercise?  Did they smoke?
• I believe people who are thin because of a healthy lifestyle are much less likely to end up in hospital.  I do agree that once in the ICU they have less reserve (fat store) to call upon to fight off hospital acquired infections and prolonged periods of supplemental feedings (ng tube, etc).

Bottom line for me?  For goodness sakes, stay out of  the hospital!

The Sunscreen Study

A few weeks ago, the popular press (print, online and TV) was a buzz about a study that showed a reduction in the look of skin aging with regular use of sunscreen.  I made a note to find that study because I wondered how the finding was determined.  I wanted to know who the comparison group was.

Here is the study citation:
Hughes, M. C. B., Williams, G. M., Baker, P., Green, A. C. (2013). Sunscreen and prevention of skin aging: A randomized trial. Annals of Internal Medicine, 158(11), 781-790. doi: 10.7326/0003-4819-158-11-201306040-00002

The study took place in Australia and involved about 900 adults who were under the age of 55.  The authors noted, and I found interesting, that having old looking skin when you are under age 55 is related to the affect of the sun only, not that of the sun and getting old.  

Otherwise and to be honest, the research design in this particular study was hard for me to follow.

People in the study were randomly assigned to one of two or four conditions (my confusion). The study was not just about sunscreen and aging. The researchers also wanted to know if taking a beta carotene supplement would reduce the signs of photoaging.  It looks like people were assigned to a group where they were asked either to apply sunscreen every day (and they were supplied with the sunscreen) or to use sunscreen on their own and at their will.  These same people (2 groups) or more people (4 groups) were assigned (blindly) to take beta carotene pills every day or to take a placebo  pill.  In other words, the people did not know which pill they were taking. I can't tell if the people in the sunscreen group were the ones randomly assigned into pill groups.  It would make more sense to have 4 groups, but then it would also make more sense to report it as two separate studies.  However, the pills didn't help and they are not the point of this blog.

The main point is that no one was assigned to a no sunscreen  group (because that would be unethical) and more importantly, no one was assigned to a lotion only group.

All the people in the study were assessed for the signs of aging in 1992 before they began the study and most of them were assessed again four years later.  The assessment consisted of a visual exam of the skin on their hands.  The exam was done by trained professionals and they graded the skin on a scale from 1 to 6.  People in the daily sunscreen group had lower grades on this visual inspection than those in the other groups - at the second time.  Lower grades are good.  There was no difference in the grade for those who took the supplements.  (They also answered questions about their daily sun and other lifestyle habits).

I am 100% in favor of sunscreen and I do believe that it prevents damage from both UV A and B rays.  From this study alone, I am not convinced that sunscreen is as effective or more effective than  body lotion for preserving a youthful skin appearance.  

I am especially baffled by using the hands as the assessment.  It would seem that the face would get more sun exposure and that the hands would tend to get washed a lot during the day so as not to be truly 'sun screened.'

I have youthful skin - so say I :).  I attribute mine to stopping smoking many years ago, eating healthy, getting daily exercise (blood and oxygen flow) and by applying body lotion from my head to the bottom of my feet every single day - because my Mom told me to.

So wear your sunscreen, hats and glasses but do these other things as well.

French Toast Compare

    My last post highlighted research that supports the idea that restaurant meals, in general and regardless of type (quick service, fast casual, sit down, chain or independent) contain excessive amounts of calories.  Recall that one study showed how eating all  3 main meals at restaurants, would lead someone to consume 1000 extra calories a day.
   
   Well I love to cook and show off my talent for calorie reduction so lets compare my french toast breakfast to two others.  One from IHOP and one for Denny's. 

   IHOP has several versions of French Toast.  One of them is called  Simple and Fit - so we can expect that one to be their least caloric version.  Some versions have over 800 calories!  You can check them all here. 
The Simple and Fit, shown below has 490 cals and 23 g of sugar.
   

  Denny's has a Fit Fare section on its menu, but doesn't include French Toast there.  Just in case your curious, they do have Fit Fare pancakes - how fit?  Not so much...780 calories.  Interestingly, that is the SAME amount of calories in their one French Toast dish.  See below.

    So how does the French Toast meal from Deirdre's Kitchen compare?  Quite exceptionally - I'd say... calorie and sugar wise.  None of these meals could be considered faultless.  For example, mine uses processed sugar free products  (Walden's Farms) and bread that isn't whole grain.  That being duly noted, we are talking about low calorie and low sugar today and so I WIN! 
 (with < 200 calories for my whole meal)

To be fair, this is a picture of a real plate of food that I quickly ate.
I did not use a food picture editor -or stage this with fake food!

   French Toast, Egg Beaters, Strawberries, and a Cereal Bar.  

  Find more ideas on my You Tube Channel.

Why do we have to count calories at restaurants?

    Three studies recently published speak to the nutritional content of away from home meals and the public's lack of awareness of just how 'unhealthy' those meals can be.
   I am going to give you a brief bottom line summary from the research.  The citations for the studies are:

Block, J. P., Condon, S. K., Kleinman, K., Mullen, J., Linakis, S., Rifas-Shiman, S., & Gillman, M. W. (2013). Consumers’ estimation of calorie content at fast food restaurants: cross sectional observational study. BMJ, 346. doi: 10.1136/bmj.f2907

Urban, L. E., Lichtenstein, A. H., Gary, C. E., Fierstein, J. L., Equi, A., Kussmaul, C., . . . Roberts, S. B. (2013). The energy content of restaurant foods without stated calorie information. JAMA Internal Medicine, May 13, 1-8. doi: 10.1001/jamainternmed.2013.6163

Scourboutakos, M. J., Semnani-Azad, Z., & L’Abbe, M. R. (2013). Restaurant meals: Almost a full day's worth of calories, fats, and sodium. JAMA Internal Medicine, 1-2. doi: 10.1001/jamainternmed.2013.6159

    In the Block study, researchers found that American's continue to underestimate the amount of calories in quick service (counter service) restaurants, in general, but do an especially poor job estimating calories in restaurants perceived to be healthier (e.g., Subway, Panera Bread).  There was a slight difference in how accurate people were based on whether they were adults, children or teenagers, but everyone underestimated the total calories by about 200 calories.  Most interestingly, teenagers and adults were off by 300 and 400 calories, respectively, for Subway meals. The more calories a meal had, the worse people did at guessing them.  By the way, the average calorie content for a meal at KFC and Wendy's was less than the average calorie content for a meal at Subway.  Adult meals from McDonald's, on average, had more calories than Burger King (606 v 530).  This study supports the need for onsite, in your face, nutrition labeling.  The restaurants in this study are covered by the national menu labeling law.

   The Urban team reviewed the calorie content of meals at restaurants that will not be covered by the national law. They studied independent or small chain restaurants (less than 20 stores nationwide), that were within 15 minutes of downtown Boston (USA).  They included 9 popular types of restaurants (e.g., Italian, Indian, Vietnamese, American) in their study.  They determined which 4 meals were the most popular at each establishment and focused on those.  They ordered each meal, with one side item, and brought the food back to a lab.  They determined the exact number of calories in each meal through chemical analyses.  They also determined the number of calories per gram of food (energy density).  In their paper, they provided the average total calories and density for each of the 9 restaurant types. In some instances, they were able to make a direct meal comparison between an independent, local restaurant and a national chain.  For example, a lasagna dinner at a quaint Italian bistro in Boston, compared to a lasagna dinner at Olive Garden or Macaroni Grill.  The average calories for one meal at all but the Vietnamese restaurant was more than a third of a days worth of calories!  The average calorie content (1327 kcal) was HIGHER than the average for chain restaurants covered by the law (890 kcal)!  The highest averages of the local restaurants were at the Italian, Indian, Chinese and American restaurants.  Italian was the worst - 1755 calories for an average meal.  That is just about what I consume in a whole day but  I split it up so I can eat about 8 times.  The average amount of calories for a Vietnamese meal was 922 and they had the lowest calorie per gram.  When the researchers matched meals to a national chain, there were still more calories in the independent restaurants, but the difference was less.  Bottom line - too many calories in restaurant foods and your local restaurant isn't doing any better.

   Lastly, and quickly, Scourboutakos looked at more than just calories in 24 sit down chain restaurants in Canada.  Her team found that for breakfast, lunch and dinner - each average meal provided over 50% of a days worth of calories, total and sat fat, sodium/salt and trans fat.  If you ate your 3 main meals at these restaurants, you would consume over 3000 calories in one day and I bet you are not Michael Phelps.

   When did it become necessary to count calories at a restaurant?  When we started eating at them several times a week instead of several times a year.

Are you on a path to ideal aging?

   What is really cool about this recent study from Akbaraly et al is not what they found but what they were looking for and how they defined those things (the constructs).
Here is the citation:

Akbaraly, T., Sabia, S., Hagger-Johnson, G., Tabak, A. G., Shipley, M. J., Jokela, M.,  Kivimaki, M. (2013). Does Overall Diet in Midlife Predict Future Aging Phenotypes? A Cohort Study. The American Journal of Medicine, 126(5), 411-419.e413.

And you can see the study summary abstract by clicking here  

   My goal today is to explain the variables they used and the assumptions behind them such that you might consider your lifestyle in the same context.

   The researchers wanted to see if a persons diet pattern and score on the Alternative Healthy Eating Index (AHEI) in mid life - 30 to 60 years old, impacted how they aged, beginning at age 60.  First of all, seeing a study that used the AHEI made me happy and the index should sound familiar to you.  See past posts and a good explanation of the system that scores your diet's quality here.

   Akbaraly et al studied more than 5000 adults.  At one time during the 16 years of study, they asked the participants to complete a food frequency questionnaire (FFQ).  They used a statistical program to assign people to one of two dietary patterns based on their FFQ.  They also  gave them a score on the AHEI.  The two dietary patterns were "Healthy Foods" and "Western Type".  You might already guess that the Healthy Foods group also scored best on the AHEI. 

   The Healthy Foods group consumed more fruits and vegetables, whole grains, and fish while the Western Type group consumed more fried foods, processed food and red meat, plus pies, sweetened desserts, chocolates, refined grains, high-fat dairy products, and condiments (like that crazy fattening mayonnaise!).  

   You can consider the diet patterns the predictors.  What do they predict?  The type of aging one might experience.

   The researchers created 5 categories of aging.and assigned people to one of them at the end of the study (2007-2009). The first is IDEAL aging, next is where a person has nonfatal heart and circulation diseases, then fatal heart and circulation disease (i.e., the person died from heart attack or stroke before 2007), the fourth type is death from another cause, and the fifth is referred to as usual or natural aging - these people have the usual chronic diseases (e.g., heart disease, diabetes, cancer) that are NOT really normal as in many cases they could have been prevented.

   The Healthy Foods diet was associated with better health and functioning in older age.  A high score on the AHEI reduced the chances of dying too soon.  A premature death is one that  occurs before age 75 in most high income countries.  (BTW -In this study they concentrated on the diet and 'made like' everyone weighed the same and exercised the same).

   But don't you most want to know what it means to have aged Ideally?  I will tell you - as I am well on my way of doing just that thing :)  - knock on wood please.

At the end of the study, the ideal agers:

1)  were alive, and

2)  did not have any chronic diseases (e.g., diabetes (or blood sugar levels requiring medicine), cancer, coronary (heart) disease, or stroke risk/history, or 

3) mental health problems (determined by responses to  questions on a trusted survey)

4) had good thinking and memory skills (they were tested for this - including word recall and basic math), and

5) normal blood sugar levels (for ones age and sex), and

6) good lung function (for age and sex), tested with the forced expiratory volume (FeV1) Remember that?  See this post.

and 

7) had normal or above normal walking speed for age and sex

   There are things that happen to us when we get older that we have no control over - like our hair turns grey or gets thinner, we get some wrinkles and age spots (more if we don't take care of our skin), but disease in old age is NOT inevitable - you can reduce your chances of some of the 'usual' diseases of aging by eating well and exercising - NOW.

   Remember too, it's only a healthy lifestyle if you engage in it everyday - and it only helps you as long as you do it (minor and infrequent indulgences allowed :))