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.

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.