Do calorie recommendations make a difference in calories purchased?

   I want to mention a few things from the study I cite below.  Here is the most important one. A conclusion statement in the summary is misleading.  The statement, "Posting calorie benchmarks had no direct impact..." implies that the benchmarks were posted on the menu or menu board, but they were not. The study did not assess the effect of posting daily or per meal calorie recommendations (i.e., the benchmarks) ON A MENU.  It tested the effect of handing someone a piece of paper with this information on it as they walked into a restaurant.  That is a huge difference.  The researchers do not try to say otherwise.  It is just the one sentence that is wrong.  Unfortunately, a lot of people will not read the study to find out the difference.  In addition, it is that conclusion that most of the popular press headlines are touting.

   This was not a study on whether or not menu labeling works.  The study tested the effect of telling someone how many calories they might need in a day and the effect of telling them how many calories they might need in a meal.  In other words, would  people given either piece of information purchase a lower amount of calories than people not given any information.  (This was tested in a situation where calories were listed on menus and in a situation where calories were not listed on menus. That condition did not make a difference.)

    The slips of paper they handed the customers did not seem to help.  But I caution you not to conclude that the information isn't helpful.  There is a big difference in a menu board disclosure and a piece of paper someone hands you.  Still, it fuels my argument for something more powerful and less mathy... traffic light labeling. 

   There was something else I found interesting in this study.  The researchers asked the customers how many calories a doctor or nutritionist would recommend that they consume in a day.   Both men and women substantially UNDER estimated their own caloric needs, by 200 or 300 calories.. and YET, they ordered enough to far exceed their own estimated daily number.

E.g.,  a person who thought they needed 1100 calories for a whole day ordered 900 calories for their lunch.  Again, too much math.  Too much thinking at the point of purchase when other factors, like taste, cost, time, etc are more important.  (isn't it crazy that people think they need 1300 to 1600 hundred calories when our packages refer to a 2000 calorie diet AND people tend to actually consume 2000 or more a day  - more than most people need)

   STILL, the menu item calorie information should be available to every one every where.  Consumers have the right to know what they are eating. However, the best chance for changing the number of calories purchased may come when the restaurants start revising their recipes and the calories AVAILABLE to us become fewer.  Traffic light labels and lower calorie meals.. that's the ticket :)

 (Also, note - the people in this study were all eating at McDonalds.. there might be something about McDonalds customers that is different than other restaurant customers)

Article cited:

Downs, J. S., Wisdom, J., Wansink, B., & Loewenstein, G. (2013). Supplementing menu labeling with calorie recommendations to test for facilitation effects. American Journal of Public Health, e1-e6. doi: 10.2105/AJPH.2013.301218

Summary

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.

More on labels and calorie disclosures

   Packaged food labeling is one of my research interests and my research interests are informed by my personal dietary goals. 
I believe that in order for the population (and me) to apply the nutrition recommendations offered by our government, we need to assess the foods available to us.  In order to assess them and choose the best, we need information.  We don't need a lot of information, but we need some.  We need enough to make an informed, but quick decision among many options.  
   I prefer the multiple traffic light system for any item, but at this time that isn't likely to occur.  The multiple traffic light (MTL) grades a food on imprortant attributes, e.g., saturated fat, salt and sugar.  A food gets either a red, yellow or green light in each category.  To eat well, you choose more foods that are green from all categories.
   The Institute of Medicine (IOM) has given the FDA a proposal that will make assessing the nutrient value of packaged food easier than our current Nutrition Facts Panel. I have discussed this at length in the past, so this is a bottom line refresher.  Instead of a MTL, the IOM suggests that each food item - if it first meets an overall eligibility criteria - be given one, two or three stars for each nutrient (saturated fat, sugar and sodium/salt). An example of something that wouldn't meet the eligibility criteria is candy.  Otherwise, a food item could have 1 to 3 stars.  ALL products, per the recommendation MUST list the calories per usual(practical) serving.  Whether or not something meets the eligibility criteria for stars, the calories per serving must be placed in eye catching text on the front of the package.
   It was that part of the recommendation I was thinking of as I shopped for groceries over the weekend.  You see, one of the main reasons for the IOM report is to address the confusion caused by food makers and grocers using their own front of package labels.  It is amazing how many do not include calories, and instead tell us things we can't intrepret or do not need to know.  For example, a grocery store shelf tag in Florida said, "20 carbs per serving".  SO WHAT??  That is not enough information to help me.   Another example, "contains 10 grams of fat".  SO WHAT?  Is it the kind of fat that is good for my heart?  If so, I want to buy it.  But no matter what it is, if it is energy dense (high in calories) I will probably avoid it (unless it is loaded with good fat, like salmon). We need our standardized, scientifically governed front of pack labels and we need them NOW.

  My other nutrition information interest is meals away from home  -  you need to see this new report from CSPI for some jaw dropping belly popping calorie counts.

 (If you are curious, my overall field of study is best explained this way - Public Health Law Research specific to Food Policy, specific to Policy that makes unhealthy (nutrient poor) foods less attractive > such as, information, price increases, zoning laws on fast food places, taxes, display bans/restriction, advertising limits.)

Eat like you mean - WHAT Exactly?

   Organizations that represent bowling alleys and movie theatres are trying to get the establishments exempted from the National Menu Labeling law.  They do not want to post the calorie content of the items they sell on the menu boards (next to the names and prices).  The photo below was taken at a Florida bowling alley.  I really am curious about the caption.,,. eat like you mean what exactly?   
   At the concession stand of this bowling alley there was a poster advertising a burger combo that you could modify by adding cheese or bacon to the french fries or onion rings, in addition you could add another whole burger - make it a double - for ONLY 2$.  My thought as I stared at this poster was,  I bet if I asked them to keep the extra burger AND the french fries but give me a salad -  they would charge me an EXTRA 5$.  
   YES ?! - and this is  exactly what the barber meant (old post) when he said, "they keep pushing the bad stuff on us, all the time, everywhere."

Like you mean to spend your older years with chronic disease and disability, of course

Can You Trust Your Vegetables?

I am not sure if I can return to daily or regular blog posting, but I do remain your observant food policy, diet quality advocate.   

Two recent observations are of particular importance when it comes to dining out.  IF you are interested in avoiding extra calories from saturated fat or sugar than they may interest you.

1) Cracker Barrel soaks its carrots in sugar.  I was told this by a spouse of an employee.  The person shared that Cracker Barrell is set to post all calorie information on its menus in January (to conform with the national menu labeling law).  My informant told me that the chain was changing some of its items in order to get ready.  I laughed, saying, surely there wasn't anything on the menu that wasn't loaded in saturated fat.  Then she mentioned the vegetables and I said, oh BUTTER and she said NO, Sugar!  I was stunned.
2) Elsewhere: Steamed vegetables may come served in butter unless you specifically request otherwise.  Sometimes butter free isn't an option.  For example, I was at a restaurant/sports bar called Kickback Jacks and the menu offered steamed vegetables.  I ordered these, but just to be safe, I added that I did not want any butter on them.  The waitress came back to the table and said that the cook said that was not possible.  The vegetables were already in the kitchen sitting in butter.  He did offer to rinse them off but could not guarantee that they would be butter free.  On the positive side - the waitress admitted that.  I am not unhappy if a restaurant cannot oblige me, but I am angry when they try to fool me. (I have had vegetables served "dry" but somehow glistening and greasy). For this dinner, I simply chose a side salad instead.  It was a very nice salad served with a nice balsamic vinegar.  (Note: A tablespoon of butter has over 7 grams of saturated fat)
  

Energy Density, Diet Quality and Eating Out

    A diet low in energy density is recommended in the Dietary Guidelines for Americans and by most nutrition scientists.  Energy density is the amount of calories per gram in a food.  (here are 2 past posts written about energy density and the DGA)
    It best to fill our plates with foods that contain less than 1 calorie per gram, with a few exceptions. Lean proteins (e.g., peanut butter, fish, legumes), whole grains (e.g.,wheat flour, bulgar, quinoa) and mono/poly unsaturated fats and omega 3 fatty acids (e.g., olive oil, salmon) have 2 to 3 calories per gram.  More commonly,  foods with high energy density are composed of unhealthy solid fats (trans fats and saturated fats) and sugar.  On average, meals prepared away from home are higher in energy density than meals prepared at home.  This is likely due to the frying, sauteing and use of sauces, condiments and sugars (and red meat; beef and pork).
   The quality of a person's overall diet can be assessed based on its adherence to the Dietary Guidelines and its energy density.  This is usually done with the Healthy Eating Index or the Alternative to the Healthy Eating Index.  Read more about them here.
   A majority of Americans, Britains, Australians, Mexicans and such  have diets that are poor or need improvement based on the indexes.  
   While reading a report from the US Economic Research Service (Variyam, 2005), I came across a chart that combined these factors.  The findings were quite telling.  People who were classifed as having a good diet spent more money eating away from home than those with diets lesser quality diets (poor or needs imrovement).  However, the people spending less money on meals away from home were actually consuming MORE of their daily calories from those meals.  They also ate meals that were higher in energy density than the good diet group both away from and at home.
   You can draw your own conclusions, but here was my take away:
The cheapest foods have the most energy density.  A grilled fish dinner with steamed vegetables will have lower energy density than a burger and fries or fried chicken and mashed potatoes and the fish dinner will cost several dollars more.  Less money spent, worse food consumed.  Those who get more of their calories from away from home foods have higher energy density and poorer diet quality.

Do Menu Labels Matter?

   I am certain that you have heard the news that starting next week all of McDonald's indoor and drive through menu boards will show calorie content of all foods. Recently I shared a study by Christina Roberto regarding the percent of customers who actually use the drive through lane.  Her study informed the decision to include both menus.
   There are a few things in the news that are wrong or otherwise worth noting.  First of all, McDonald's IS doing something that it will have to do anyway.  The National Menu Labeling law has been passed.  A reporter from USA Today said that the law had merely been proposed.  That is untrue.  What is pending is the final rule.  I have also seen some negative response to McDonald's.  I feel that is inappropriate.  I am not fooled into thinking that they will become a healthy eating establishment, and I think that they are mostly interested in sales.  But why make an enemy out of a restaurant that I assure you is NOT going to disappear.  
   I love that McDonald's made a decision to post early.  They made preparations when the law was passed.  The law has been supported by the National Restaurant Association.   Others will follow their lead, to move forward now.  This gets the conversation back into the public where it needs to be and may get the FDA moving on that final rule.
   McDonald's will respond to its costumers.  They are planning on introducing more fruits and vegetables.  They were the first to rid their oils of trans fats and to offer fruit in the happy meal.  I only hope that people will buy the new items.  Most of us do not go to McDonald's for their salads and such.
   Which brings me to another issue that needs to be cleared up.  Some have said, in response to McDonald's actions, that menu labeling does not have an impact on purchases.  That is not true.  We do have a number of studies that show no effect, but the ones that show a change in behavior help us to understand why the others do not.  Most people who see the information, understand the information, and know the relevancy of calories to a their daily diet will choose the lower calorie items.  However, there are also those who decide to go to McDonald's or Burger King to get that Bic Mac or Whopper and they do not look at anything... they order what they came to order.  There is nothing wrong with that.  
   We do have evidence that the public wants the information and will use the information when the conditions are conducive to this use.  Remember too that anybody can do a study and share their result with reporters, but not every study meets scientific rigor.  If you hear a news report that says the labeling does not work, ask yourself a few questions.  How do they know that?  Did they go to a restaurant and watch people?  Did they survey people?  Did they compare a restaurant's sales before and after labeling went into affect?  Did they call people on the phone?  Who did they call?  Did the people they called or watched or had fill out a form understand how calories impact their weight and health?  How many establishments or people were in their study?  1?  30?
   Check out this fact sheet for some evidence and this website for a list of research studies.

Did we become overweight on purpose?

   In the September 2012 issue of the American Journal of Public Health, Mary T Bassett, MD MPH, discusses the role of government in "leveling the playing field" so that consumers have a real choice when choosing a food item.  A level playing field could increase consumption of higher quality foods.
   This statement, her article and my own studies lead to the same conclusion.  Most of us make food choices based on taste, cost, marketing shaped preferences, availability and convenience.  Healthiness comes in last - after these attributes have been considered - by us or for us.
   Dr. Bassett made mention of the food industry's support for initiatives that encourage physical activity as a strategy to reduce obesity.  This is clear by the placement of actual exercise icons on some food packages.  
   Here is a sad truth.  Exercise is not a popular way to spend leisure time.  Two hundred years ago that didn't really matter, we moved for sustenance and survival.  In the more recent past, our physical activity levels during work and non work hours has decreased.  We have become sedentary and for that reason alone need to exercise.      
   Both of these energy expenditure issues play a role in our obesity (over fatness) epidemic, but a much smaller one than you'd expect.  Trends of weight status in the US and similar countries show a steady and sharp rise beginning in 1970 and continuing to this date.  It has occurred in every age group - infants included.
   Certainly, the entire country did not have a sudden cellular shift  that made us ALL genetically predisposed to gain weight.  And with regard to burning less calories from work and travel, the best estimates from scientific studies suggest at most a decrease in 100 calories expended.
   Could it be then, that the entire country made a conscious and deliberate decision to gain weight?  Even before we learned of the connection between fat and disease, we knew that being too large for our bones was uncomfortable and stigmatizing.  Few of us would invite those things. So I say NO, we did not seek out calorically dense, nutrient poor, portion inappropriate foods. They came to us.
   Sure, our changing culture had us looking for convenience and increased the number of meals we purchase away from home.  We did not however, know that our 200 calorie meal had doubled into a 400 calorie one- before adding the super sized sized milk, juice or soda.
    Today, we find ourselves in need of a few less calories (compared to 1970) but consuming a WHOLE lot more - often passively.  Calorically dense foods are what the food industry offers  - at a price we can't refuse.
   Our environment changed around us, we got fat, our heart disease, diabetes, cancer and stroke risk went up.  Indeed the playing field from which we make our choices became leveled against us.

The article referenced in the opening paragraph : Mary T. Bassett.  Of Personal Choice and Level Playing Fields: Why We Need Government Policies on Food Content. American Journal of Public Health: September 2012, Vol. 102, No. 9, pp. 1624-1624.

Flawed Study is Encouraging

   Today I read about a menu labeling intervention that took place in 1990.  It involved 4 restaurants within a small geographical area (adjacent counties in one state).
   It is an older study so we have to give the researchers a break for promoting low fat meals, instead of meals low in saturated fat.
   For the intervention a heart symbol was placed on certain menu items that were lower in fat and thus "healthier."  This was based on the science we had at the time.  The researchers planned to collect sales data at baseline (before the labels) and after the labels.  They would check to see if the proportion of labeled items sold to non labeled items increased.  
   They had a nice research design in mind.  Their plan included NOT labeling menus at one of the restaurants - at least not at first.  They wanted to compare the results to a "control" group.  It is similar to a drug study where two groups are alike but one gets the drug and the other doesn't and then you check some outcome, like blood pressure.  IF the drug group has better BP, you have reason to believe it was the drug that made the difference.  SO, if the percent of low fat menu items sold increased in the restaurant using the labels as compared to the other, then it suggests that the labeling caused the increase.  Got it?
   The second design feature that they planned to use was taking away the labels to see if the sales of those items stayed the same or decreased.  If they decreased, that would add evidence to the importance of the labels.
   Well - these two features just didn't happen.  They didn't happen because the restaurant managers would not cooperate and that is the encouraging part of this flaw!
   The restaurant manager of the store that was not supposed to use labels used them anyway - without checking with the researchers first.  In all restaurants, when it was time to remove the labels, no one wanted to.  This supports the idea that both customers and restaurant owners/managers find value in identifying healthier items.

Of note - I did check back on the FDA website today to see if another report had been filed on the status of implementing sec 4205 of the ACA   - i.e. the menu labeling law.  I found one sentence dated June 13, 2012.

Policy options in response to comments on the proposed rule are under consideration.

What does your body tell you about that meal?

   It is quite interesting to read articles about diet and health that were written between the 70s and 90s compared to those written in the last ten years.  Our ability to measure - whether it be the items that people eat or the metabolic processes that certain foods trigger - has gotten much sharper over time.  This better measurement has led to changes in what is recommended for health and left many of us confused about what to eat.
   One thing has remained consistent for the last 30 years... the majority of people in developed countries are eating too much food and gaining weight because of it.  
   Scientists are now challenging the notion that a calorie is a calorie - even for weight gain (since we already knew that some calorie sources were bad for our health).  It is very likely that the body is doing something different with foods that are high in SoFAS - saturated fats and added sugars, especially if these foods are highly processed.  Refined grains tend to be high in both sat fat and sugar and even contain the dreaded trans fat.  
    People frequently go out to eat lunch when they are working or attending conferences. The majority of foods served in chain and fast food restaurants are calorically dense - made so from the SoFAS.  YES? So, what does nearly every one say about work and presentations after lunch?  "I don't want to be the presenter after lunch, everyone will fall asleep."  OR, "I don't feel like doing any work, I just want to take a nap."  
   I used to feel that way after lunch, too.  I don't now because I eat food that is not calorically dense.  My meals are always low in saturated fat and added sugar. They have a low glycemic load (are not starchy).  I never feel lethargic after I eat.  
   Think about how you feel after you next few meals.  Eating too much of any food will make you uncomfortable, but eating certain foods, even reasonable portions, trigger a different kind of discomfort.  I believe that the way you feel after you eat something - after the taste rush has passed - is a clue as to whether or not it was a healthy food.