Prevent Obesity w/ More exercise - less fast food

Morales, Gordon-Larson and Guilkey (2014) conducted a simulation experiment where they statistically modeled several factors that are related to the probability of a person being obese in the future.  The model tested their assumptions by predicting who would become obese. You can read the study here .- Several statistical equations were used to simulate decisions about smoking, physical activity, starting a family, and fast food consumption.  In addition, the researchers added a neighborhood level factor.

The data used were real - information came from the National Study of Adolescent Health (USA) which contains several years of information following people from high school through young adult hood.  During those years, people in the study usually transition from a home environment chosen by their parents, to one they chose themselves.  The choice of environment is based on some unknown personal preferences or necessities of the person.  Since many researchers speculate that where a person lives has a direct impact on whether or not that person becomes obese, these researchers felt it important to capture neighborhood choice in their model predicting obesity.  In fact, Morales, et al knew exactly where the participants lived at all times and added the number of parks, complete streets and fast food restaurants in each persons neighborhood to their simulation model.

The results of the study are interesting and give public health advocates, researchers, policy makers and the general public some things to consider.  The researchers tracked people over time in their simulation model, too, so they carried forward things about the person that had been learned at the previous time point.  They found that the best or most powerful predictor of whether or not a person would be obese at time 2 or 3 or 4 was whether or not they were obese the time before that.  In fact, the researchers assert that the most important thing to do is prevent obesity in the first place, because a reversal just isn't seen.  In other words, if a person was obese at any of the previous times it is very unlikely that they will be normal weight at any point in the future.  I agree that prevention is the key.

Other findings that seemed important to me, include; the more fast foods a person consumed the more likely they were to be obese; and physical activity reduced the probability of obesity, but in a nuanced way.  The researchers found that at least 30 minutes of physical activity 5 days a week were needed to keep a person from becoming obese and that the greatest impact on weight - or the best chance of not being obese - came from maintaining that level of physical activity from adolescence (i.e., high school) throughout adulthood.

Neighborhood characteristics, a main focus of this study, did have an impact on the probability of being obese, but the magnitude of the effect was much smaller than physical activity and fast food consumption.

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.

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.  

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.

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)

Words Are Hardly Necessary

We continue to be in the midst of an obesity epidemic in many a Western country. Though pharmaceutical companies and their scientists strive to convince us that it's our genes or our metabolism (and thus modifiable with drugs) - the public health folks - my ilk, KNOW that regardless of ones genes or ability to burn calories, too much food equals too much weight. It is especially easy to over consume if your diet is high in processed foods.

Cheap junk food is a significant factor in the world obesity rate. I believe it should be taxed and gone after much the same way tobacco was. At the very least, we might pull back on the advertising, or I KNOW, add warning labels to ads, such as the one below. The warning might read:

You can fuel your road trip as pictured, and when you do - don't blame your genes for your heart disease