It is happening!

It has been eight years, but the National Restaurant Menu Labeling Law (part of the Patient Protection and Affordable Care Act) will be in effect on Monday. Restaurant chains with over 20 locations will be required to post the calorie content of their standard offering on menu boards and print menus. The goal is to raise awareness of the amount of calories in the items we choose - and to do so before we make that choice. This law has the potential to change our behavior as consumers as well as the behavior of those providing us with food and beverages. Will the calories available to purchase decline? Will we purchase AND consumer fewer calories? If the answers are yes, will the country's obesity rate plateau or decline? I sure hope so - but that's a lot of ifs. 

Meanwhile, the recommended changes to the Nutrition Facts Panel have been delayed to 2020 - here we go again. The main change on those labels is an emphasis on total calories and added sugar and a de-emphasis on total fat. 

On a personal note, sorry I don't post much anymore, but my students require a substantial amount of my time!

Eating for the 'wrong' reasons and important links

Even though I don’t have time to maintain my blog, I am reluctant to shut it down. So today I am writing for two reasons. The first is to remind readers about the danger of eating when you aren’t hungry and the second is to share a couple of health news sources. These news sources will be of particular interest to those who have enjoyed my blog topics, and I will share the links at the end. The sources have free email subscriptions and I believe they are two of the best (i.e., credible, relevant, current) out there.

As I thought about writing (my posts often percolate in my head a few days), I remembered that I started my blog as a newsletter back in 2004 (approximately) when I was working at a hospital and taking classes to earn my Master’s in Public Health. Many readers followed my journey from that point (i.e., to Florida as a Tobacco Treatment Specialist, to UNCG for more graduate studies in Public Health, to Beasley School of Law to complete a post doc in Public Health Law Research) to now – 13 years later.

Today, I am an Assistant Professor at Temple University in the Department of Social and Behavioral Sciences. My teaching responsibilities include a course about substance use disorders and addiction (that should make sense if you’ve read the blog over the years) and a course on nutrition as it relates to the health of populations (i.e., I am still not a registered dietician and do not give individual diet advice). I teach additional courses and conduct research/program evaluations, but this blog has foremost been about behaviors that impact our health and the laws that make those behaviors harder or easier to accomplish (e.g., that darn national menu labeling law that can’t seem to be implemented, soda taxes, new food labels). 

Dietary intake and health status (including obesity) has probably been of most interest to my readers, and to me. So, I want to talk about a specific area of risk regarding dietary intake. Eating for non-hunger reasons. It is often when we eat for the ‘wrong’ reasons that we gain weight. I think what sets me apart from a lot of people is that I don’t do that. I primarily eat to fuel my body when I am hungry. Or better put: I do not eat to socialize. I do not eat because I am bored. I do not eat because I am sad. I do not eat because I am high (haha, just kidding – bc I don’t get high). I do not eat just because everybody else is eating or to be polite. To be clear, I LIKE food, and enjoy meals and snacks and alcoholic beverages, but I don’t respond to social (including work meetings) or familial pressure to eat for the sake of fitting in.

Now that I think about it, I did blog about this many years ago – about how to eat in a social context without gaining weight. I suggested that when you are going to an event (family traditions included) where it is expected that you ‘eat to be social,’ or you know your favorite foods will be available, you plan it so that the food you eat at the event is part of your daily intake (and if its occasional, maybe it’s a little more than your daily intake). But eating when you are sad, bored, or unexpectedly confronted with someone’s ‘oh I had to get these out of my house, please have some’ cookies is a sure path to over consumption/excess calories. This over consumption is especially likely because the food associated with those ‘eating but not for hunger’ reasons are usually high in sugar, saturated fat, salt and calories. So, just think about that – and decide how you want to handle it.

That’s all I have for you on diet and health today. Most importantly are the links I promised you at the start of this post. Here they are:

STAT News Morning Rounds

ConscienHealth blog   (the subscribe option is on the top right of the page)

Added sugar and other changes to the back of the pack nutrition label

     I wrote this post on May 20 -21, 2016 after the FDA announced new labeling requirements for packaged food manufacturers. The manufacturers will be required to provide additional information and modified information on the Nutrition Facts Panel (NFP). This applies to all companies, but smaller ones have longer to comply. The FDA announced July 2018 as the official effective date, but we know from past FDA associated labeling initiatives that this date could change.
     The FDA press release - which you can access here - offers highlights of the changes, and many news sources have covered the story. What I want to do is put the changes in the context of my blog re: nutrition disclosures that help us consume fewer calories across venues.
     So does this change help? Probably - or to some extent. First, the revised labels have an increased 'reference serving size'. The noted serving size may merely be a declaration to allow the nutrient content to be calculated, because people rarely (if ever) dole out cups, ounces, or grams and even if they did, it would be more cups, ounces, or grams than the label suggests. The update, a slightly larger serving size, appears to be a compromise between what people are actually eating and what they are supposed to be eating. In other words, it is probably still not realistic.  One example of a serving size change involves ice cream. Instead of a 1/2 cup, a label will say 2/3 cup. I imagine most people scoop out more than 2/3 a cup of ice cream for themselves, therefore, if a person wanted to know the actual calories or sugar they consumed, they'd have to do the math (just as before). Also people may think that the label refers to an actual cup of some sort, not a measuring cup. 
     A similar issue with serving sizes is unchanged. They are not exactly uniform across similar products - the serving sizes may all be a 1/2 cup but the weight - the precise measurement - will vary. Boxes of cereal and cartons of ice cream, as opposed to say, a can of soda, are actually figured by weight, grams usually. So a serving size might be 2/3 cup on five cartons of ice cream but the weight of each 2/3 cup could be different. So to be frugal with our calories like we are with our dollars, we  need to know the calories per unit. You don't get to see an orange shelf tag with this information but you can do the math, e.g. calories per serving divided by grams in a serving gives you the calories/gram.
     Another change on the NFP is that sugar grams will come with a % DV. I've never been much of a fan of the % daily value disclosure on a label. It is based on a 2000 calorie/day diet and the majority of women, myself included, require less, say 1500 to 1800, so again, math is required. There is a trick that can make the percentages useful. If the item on the label is a nutrient of concern (meaning we get too much of it, like calories, sugar and sodium), look for a low %DV.  Low is 10% or less. There are very few nutrients that Americans lack, but for those, look for high %DV. For example, it would be great to have products with vitamin D and calcium at 20% or higher.
    Small packages, ones that people are likely to consume all at once even if they 'technically' contain 2 or 3 servings, will now have dual labels. There will be a column with the serving size nutrient information and a column with the whole package nutrient information. For items like a 20 ounce soda, where the expectation or custom is to drink the entire bottle in one 'sitting' the nutrient and calorie content will only be for the entire package (who drinks 8 ounces of a 20 ounce soda and saves the rest for tomorrow?). BTW, that is why I go for diet sodas in 12 ounce cans, I do not need 20 ounces, its too much; and for some diet sodas, the trace calories will become meaningful beyond 12 ounces.
    There are a couple more changes, which are not as relevant to the theme of my blog. You can review them by clicking on the above link.
    I'll end with two important things the new labels do not address. The information is still on the back of the package and the rule doesn't amend the new vending machine law to include sugar grams with the point of purchase calorie disclosure. Because the Nutrition Facts Panel is still on the back of the package the prospective buyer has to pick up and turn each product around (the new rule does not mandate or standardize front of pack labels and this is a disappointment). And consequently, this rule won't help us purchase low 'added sugar' snacks from vending machines because we can't see the back of the package at the time of purchase.

What we eat still matters

Obesity is a complex disease. I have come to appreciate this even more over the last 5 years, and what I am about to say in this post is NOT a refutation of that complexity. Instead, I want to make a point that though obesity [whether becoming obese in the first place or remaining obese after an effort to lose weight] is an intricate mess of bad decisions, bad environment, genes, social pressure, family customs (not traditions, but the every day way of preparing foods or eating that we learn from our families), lack of physical activity, metabolism, gut microbes, infections, injury and things we haven't even discovered yet - even though this is true, on its own, what we eat still matters.

Yesterday, I  was waiting for my train to arrive at 30th St Station in Philadelphia PA. I had been traveling over the weekend. I had an hour wait and was standing - standing - at a table, eating a salad that I had prepared and carried with me. I am a small person, slight of build, low weight. I am this way purposefully, not genetically; I share the same food environment, social pressures, and family cooking practices as most of you - some of whom are normal weight, and if the CDC is to be trusted, most of whom are not. As I ate my salad (which I found delicious with its ample amount of lean protein), I looked across the room and saw a person who was not slight of build and they were also eating. Eating from a box. A box of dunkin donuts. This is not a judgement, several of the things I listed in the first paragraph factor into the decision for that person to buy donuts. My point is, the food we eat still matters and even if it is not that simple in the grand scheme, it certainly is at some level. The small person was eating the salad. Maybe the small person routinely eats low calorie foods and doesn't exceed the calorie requirements to maintain a normal weight - and the large person routinely eats calorically dense foods and does exceed the amount they need.

NB: I didn't post this right away, its been a week since I was at the train station. So I have another observation to add. I was at dinner with friends the other night where I ordered a beautiful steamed seafood and vegetable entree. The man to my left, who is somewhat overweight (we had to trade seats at the movies recently because he was too large to sit comfortably unless in the aisle seat) was the first to request and be disappointed that the restaurant did not serve dessert. Not a judgment, an observation.

Resisting a challenging food environment

As the years have progressed and research findings amassed, it has become obvious to most people – experts and non-experts – that obesity is not caused by one thing. However, certain factors seem to have a greater impact on whether or not a person consumes more calories than they need or burn than others. For example, genetics have less of an impact than lack of physical activity. And a combination of risk factors intensifies the impact of any one. For example, a genetic risk, not exercising (or being sedentary), being female and using antidepressants is a perfect storm for gaining weight.

The risk factor that my research and my public health efforts focus on is the environment – the food environment, which I define as anywhere we make a decision about what to eat immediately or what to buy to cook or eat at home.  Within this huge food decision space, individual level factors (knowledge, stress, social and family norms, income) interact to make it harder for some to ‘resist’ what is sometimes called a toxic or obesogenic (obesity causing) environment.

To advance my goals – reducing caloric excess in the population - I support policy that aims to change the environment. Policy that changes the space where we make so many food (and beverage) decisions. I have spoken a lot about information policy, but that doesn’t directly change the environment (indirectly it could lead restaurants to supply lower calorie meals through a change in recipes or serving sizes). Strategies/laws that directly change the environment would include the failed NYC serving cap on sodas.  Other strategies, softer ones some will say, fall into the category of ‘choice architecture.’ In other words, someone (and this someone can be a contentious issue) decides that in order to help a person choose the healthier (? – definition pending) option, this healthier option needs to be easier to access or displayed more attractively than the non-healthy one. For example, instead of the huge display of 50 cent white bread at the front of the store, the owner places a display of whole wheat bread. Strategies that I am particular enamored with include taxes (price manipulations), zoning restrictions (do we need 10 fast food restaurants w/in a mile of a neighborhood or school?), and advertising constraints (do transit busses really need to advertise 2 dozen donuts for the price of 1?). The point of these efforts is to change perceptions about food consumption and the pressure to consume more food than we need. The changes of what is normal developed in response to our environment over the past 30 years. We have new social norms.

Changing the environment means reducing the amount of or display of ‘desirable’ foods.

I hadn’t realized that what I was talking about is also called ‘desire reduction.’ In other words, if the things – no the triggers - that lead us to overconsume calories are taken away, then our desire to overconsume is reduced. Take my donut example. If the ads for donuts are taken off the bus, then this might reduce my desire to go buy donuts. Certainly, if your work place bans junk food at office meetings, this would reduce the desire to eat those junk foods. I like these strategies because they attempt to reverse something that happened without our asking it to happen. The environment changed around us and what was normal changed. Now it is ‘normal’ to be served supersized meals. It is ‘normal’ to sit for hours. It is ‘normal’ to drink a 20 ounce sugary beverage or an 8 ounce glass of wine. And pushing back against the new normal in our social context is often met with shock and disapproval. Still, this push back, this resistance, is yet another strategy – an individual level strategy that some people promote. I am not convinced. 

The ‘new’ term for this type of individual level strategy or intervention is ‘desire resistance.’ I became familiar with both of these terms (desire reduction and desire resistance, but not the concepts) only recently, when I read an article by Dutton, Fontaine and Allison (abstract here).  I am a pretty big fan of Dr. Allison, he is the co-director along with Dr. Fontaine, of the Nutrition Obesity Research Center at the University of Alabama, and I pay attention to what he has to say. This is one of the few times I disagree with him.

In their discussion of desire resistance, the authors offer this example of the skills an individual might need to posses in order to resist their ‘internal desires’ or ‘external challenges’ (eg those brownies someone left in the break room):

“Desire resistance skills include strategies such as self-monitoring, meal planning, asking for social support, wearing a physical activity monitor, cognitive restructuring, making a public social commitment, and preparing oneself to anticipate, tolerate, and accept feelings of deprivation when they are encountered.”

I understand that the authors are advocating for both desire reduction and desire resistance, but desire resistance, to me, is going back to the individual focus that others have already found to be extremely challenging. Programs that work at this level usually do not produce lasting change. Yes, there is some evidence that teaching people to count calories or plan their meals will work for the short term and maybe in the long term, for some people, but it is rare. In my experience and in the literature, finding people who can actively, consistently and perpetually resist this 'in your face, food pushing society’ is unusual. I AM one of those people, so if I am against desire resistance as an obesity prevention strategy, it’s worth noting!

This idea of resisting cues to eat calorically dense foods or drinks, or any food or drink when you are not hungry, reminds me of the time I spent teaching people how to resist the trigger to smoke a cigarette when they were trying to quit. What worked the best was when there were LESS triggers. In other words, successful quitters are more likely to be around others who did not smoke, work and recreate in smoke free environments and live in a ‘space’ where smoking is not ‘normal.’ The environmental changes – and taxes on tobacco – have done far more to assist in smoking cessation than all the desire resistance programs!

It’s also ironic to me that in the Allison article, where the authors introduce the desire reduction and desire resistance terms, that they also point to the 2010 Recommendations from the US Surgeon General regarding obesity prevention as misguided. They note that most of the strategies are in the desire reduction category, as if that were a bad thing. I see it as a response to the years – decades – of efforts that did not include the environment at all. Still, in the end, the authors suggest that both strategies – reduce desire by modifying the space and increase resistance by teaching skills – be employed. And in their closing comments they make a valid, important point. The same point is true with smoking or in their example, managing anger, and it is: there is no world in which all temptation or triggers will be absent at all times. In those situations where temptations exist, a person will either indulge, relapse or resist.

Personally, I plan to do a little indulgence in a few days…. Thanksgiving here I come!

Front of Pack Labels vs Labeling Laws

There is a difference in the requirements for vending operators when they post calorie counts for all items in their machines, starting December 2016, and what some candy, chips and pastry manufacturers are doing now - voluntarily.

According to the law, the font type, size and color have to be large enough and stand out enough to get the attention of the customer while the customer is deciding what to buy. I suppose if you go to the snack machine with nothing but Reese's peanut butter cups on your mind, you may not slow down to read calorie counts, but if you are browsing.....

The snack manufacturers, likely because they make their snacks for grocery and convenience stores too, have begun placing industry designed - industry criteria based - front of pack labels on their packages. On the face, this sounds really good. I love calorie disclosures as a general rule. And it looks like the manufacturers are giving counts for the full packages. 

From the pictures below, you can see some problems.

1. The labels are too small
2. The numbers do not stand out on the packages
3. If the package is not placed in the spiral correctly (especially this happens with beverages) you can not see the label at all
4. Sometimes the spiral actually covers the label
5. Only some of the items have labels - how can you compare? 
6. The labels are not in the same spot, so you can't really scan efficiently, and
7. In this particular machine, the snacks with the most calories do not have labels (eg honey buns and tasty kake)

By the way, there doesn't seem to be any detectable pricing scheme - two items of equal calories or 'healthiness' can cost from $ .60 to $1.00. Or maybe there is, the chips or salty snacks in the machine below are 60 cents and the higher calorie items, the honey bun and pop tarts, are a dollar. Contrary to what we are told - the worse items cost more, not less.

Here the Cheetos and Oreos are labeled, possibly the pop tarts too

Notice the different label placements, upper right hand corner and lower right hand corner, and even the small side of a package

Health Halos, Calorie Labeling, and Vending Machines

     Vending Times, a trade magazine for, you guessed it, the Vending Industry (machines, coffee service and micromarkets), recently announced that Mrs. Freshley’s has a new product, 7 Grain Cookies. You can read a little about them here, but the important information (i.e., nutrition content) is not yet posted. Other cookies by this company have, on average, 200 to 300 calories per package – the serving size.

     Without my explaining, can you guess the problem with a 7 grain cookie? Here is a hint and a term nutrition and obesity prevention researchers often use – “health halo.” You probably figured it out. By saying that this high sugar, high calorie item has 7 grains, people are distracted from the fact that it is still an item that should be consumed in extreme moderation. Cookies, pastries and such are in the discretionary category and I believe the latest version of US Dietary Guidelines suggest that discretionary calories take up no more than 10% of a day’s worth of calories (actually the new guidelines refer to added sugar not being more than 10% of calories). Therefore, if you were a small, active women consuming 1800 calories a day, this pack of cookies would be all you were allotted in discretionary calories for the day. The fact that the cookies might supply you with some whole grains, a positive thing, doesn’t change the fact that they are cookies. (BTW, other health halos you might see on discretionary food and beverage items, REAL sugar, raw sugar, honey, molasses– it’s all sugar, and in this context, not different than corn syrup or table sugar).

     Label declarations such as these (e.g., 7 grains) can give us a false sense of the healthiness of an item. Of course, healthiness is a moving target, but let’s stick with sugar and calories – we do want to limit them across the board, throughout each day. In a similar fashion to label 'nutrient disclosures', researchers have found that some Front of Pack labels (of which I am a huge fan) can also create a health halo! Hamlin, McNeill and Moore(2014) conducted an experiment on choices people make after seeing different types of Front of Pack labels and found that across all types (2), having a label led people to buy that product more often than if it did not have a label, regardless of what the label said. This is only one study, and others show that the labels can be helpful in leading to a reduction in calories, salt or sugar purchased, but it is definitely something that should give us pause, especially because one of the label formats tested was my favorite, the multiple traffic light. 

      When I think of this in the context of our soon to be implemented calorie disclosure law for vending machines, it occurs to me that maybe, simpler IS better. In other words, if every single product has a label and the only thing on the label is calorie content – then choosing the smallest number would be the (usually) right thing to do. I have that parenthetical usually, because a 100 kcal pack of cookies might not be a better choice than the 200 kcal package of granola bars, BUT – it would still be the least caloric.

      Lastly, the 2016 calorie label law (passed in 2010) is very specific about the placement, color, font and size of the calorie disclosure. If you take a look at the pictures below, you can see why that is important.

I took these photos at vending machines where I work and offer some comments in the captions.

This is industry criteria, notice the calorie, sugar and sodium limits to be called a Choice Plus snack

Notice the sodium  - its too high to be a Choice Plus but the snack is in a Choice Plus Slot. Also this snack has a Front of Pack label which could be a health halo.

Great example of how different a Choice Plus snack can be and if you look closely you see some calorie disclosures on the package. You have 250, 190 and 100 here.  Importantly, they are ALL the same price ~ busting that myth.

In my opinion, this is not as helpful as the machines with the calories on the front inside the picture of the sodas. I was within inches of this display when I took the picture and you can barely read the calories on these sugar sweetened ice teas (120 per 20 oz)

Calorie Awareness While Traveling

I recently spent a week at a Residence Inn in Alabama. I attended a research methods workshop for obesity prevention and treatment. On several occasions, I was aware of the 'conspicuous' absence of calorie disclosures. The biggest one... the hotel 'free breakfast.' Except for the cartons of yogurt and milk, nothing was labeled. Considering that a slice of bread can have as little as 40 calories (if you search hard) and as many as 100+, that's a big deal. I imagine the range for the available muffins, bagels and waffles make them equally hard to 'estimate.' Sure a day or two of incidental over consumption should't have lasting effects on your health, but if you travel  - and eat away from home - often, the information will come in handy. 
When I travel, attend workshops, meetings and just go to work, I try to keep within the bounds of what is healthy for me. That is another observation I had while at the workshop. It is not enough for the planners to serve 'healthy' food, because healthy, especially these days, is a relevant term and a moving target. Healthy for me mostly meets with the updated recommendations from the Dietary Guidelines Advisory Committee: 

The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meat;i and low in sugar-sweetened foods and drinks and refined grains. Vegetables and fruit are the only characteristics of the diet that were consistently identified in every conclusion statement across the health outcomes.

*The fruits and vegetables are highlighted as being prepared with spices and without adding salt and saturated fat. See the full report here.

So for me, healthy is not about organic or 'all natural,' and healthy doesn't mean no artificial sweeteners, but that is exactly how some others might define healthy for themselves. My healthy diet includes mostly whole foods, minimally processed; no meats, lots of vegetables, soy based lean protein, fish, almond milk and no or low fat dairy (yogurt, cheese, ice cream), fruit, coffee, plenty of whole grains, like popcorn!, fiber and yup, alcohol and diet soda. So to eat the way I like, I usually bring my own food, and in Alabama, though I ate out a few nights, I went to the grocery store and prepared my lunch and dinner in the nice hotel room kitchen.  (The reason the workshop lunches weren't 'healthy' to me is because they were often sandwiches, pasta, or meat based. I did enjoy the fruit and diet soda though!)
Interestingly, my friends and I were out walking one evening and one or two got very excited when we passed the Insomnia Cookies store. (remember this was an obesity prevention workshop, and cookies can be part of a calorie controlled diet). So, my friend was more than a little excited as she went into the store - there was quite a line at the counter - but she came right back out, with a brochure (for me) and disgust. WHY? THEY POSTED THE CALORIE CONTENT!  HAHAHAHA, she said that seeing the calories took all the fun out of it. Hilarious. (BTW, we have one of these Insomnia Cookie food trucks at Temple University, and the shop in Alabama was within a mile of the UAB campus. Sense a theme?)

Notice the ranges, also on the right is ice cream

The delay is NOT the demise of menu labeling

The FDA has granted restaurants and similar retail establishments a delay in posting calorie amounts  -  how that delay actually came about and why, warrants some clarification.

The National Restaurant Industry, like the National Automatic Merchandising Association for vending machines, supports calorie disclosures on menus and menu boards as mandated for large (20 or more) chain restaurants. Large chain restaurants are probably ready to roll with the disclosures - several cities and at least 1 state already have calorie (+) disclosure laws in place (though they are preempted by the federal law). It is not likely that restaurants need or even want the delay, after all, the industry(through its trade group) supported the federal law; a nationwide, preemptive law is good for them.

What is really going on is that the 'similar retail establishments,' ones that sell ready to eat food as a major part of their enterprise, for example, grocery stores, movie theatres, bowling alleys, convenience stores, tried to get out of the mandate. Once they realized the law did indeed apply to them, they asked for and received more time to get their act together.

I do not see the delay as a bad thing and I do not read it as the demise of the legislation. Too many big players AND consumers want calorie displays across the many places where food choices are made. 

Including the similar retail establishments (and vending machines) in the law makes it 1) fair to the sellers of the food - why should some have to disclose and other not? and 2) easier - possible - for us to monitor our calorie intake if we so choose. Whether we will choose to do it or understand how to do it, is a separate discussion.

Researchers and proponents of the law do not know if calorie disclosure by itself is going to change the behavior of people most in need of changing their behavior (i.e., people who exceed their average daily calorie needs), but it makes it possible and before we can do anything else (e.g., tell people how many calories, from which types of foods, are too many), we have to put the information out there. The early positive change that I, and many others envision, is that the retailers are going to reformulate recipes or reduce serving sizes in order to 'present' calorie counts that are more reasonable. Hey, there is a thought, maybe one of the things that 'similar retail establishments' will do with their extra year is reduce calories  - say in that bucket of popcorn!

Anyway, I am not disheartened and as a researcher, I hope to take advantage of the extra time to conceptualize some new evaluation studies!

Seen about town, ads pushing calorie dense items and calorie disclosures, etc

It was really challenging to come up with a title for this blog post, which is a good sign that I am trying to say too much in one post. Nonetheless, I am stubborn and have been holding on to these photos and these thoughts for at least a month.

First, calorie disclosures are coming, they will be the law of the land, but probably not fully so until 2016. In other words, the congress persons representing businesses will get the law delayed, but they will not get it appealed (I understand from my sources).

Second, it is becoming clear that 'a calorie is a calorie' is not quite true - even for weight. You may recall a post from me some years ago that implied that as far as weight was concerned 1800 calories of twinkie are the same as 1800 calories of vegetables. I went on to say, and this part remains true, that a person will be a lot healthier and feel much better if they refrain from eating 1800 calories of twinkie. I think we've all known that the body handles macronutrients differently, i.e., refined carbs are metabolized differently than fats or fibers - but more recently science has established that the number of calories might be the same in say a twinkie and a piece of salmon, but once our body digests and metabolizes these foods, the calorie end point is not the same.

Some people have suggested that calorie monitoring may be less necessary, and to that point I strongly disagree.  Many people who have lost weight and kept if off do eat better and maintain high levels of exercise but they also remain vigilant to consuming a sensible range of calories.

I am not abandoning calorie monitoring. However, I am not involved in research on metabolism - nor am I a nutritionist-  so I will stick to watching what happens when calorie disclosure laws go into effect. For example, I anticipate changes in availability of lower calorie options and changes in purchasing behavior. I am not going to keep trying to describe the science on the relationship between calories and weight gain. Instead, I assure you that we cannot eat with reckless abandon and many of our away from home meal purchases are ridiculously high in those wrong kind of calories.

Now my pictures and why I chose to take and share these in particular.

This ad was presented to me while I was listening to Pandora Radio - not so targeted considering I am a calorie controlled vegetarian!

I was 'exposed' to this ad on the Philly transit bus;  a bargain for two high calorie items. PLUS I am a NYG fan :)

You may have heard that grocery stores do not want to put calorie labels on their prepared food; that is unfair to restaurants and leaves customers lacking important information for food choices. 

Manufacturers update their labels from time to time, they may reformulate a product which changes the calorie amount, they may change the serving size which would change the calorie amount or they may fear scrutiny and revisit the accuracy of their label. These side by side boxes are both Jacobsens Blueberry Snack Toasts, but the calories INCREASED from 40 each to 45 each. Everything else appears to be the same. When I find older version with less calories listed, I buy them, but I am just fooling myself!

This is my favorite!  This restaurant is in Philadelphia where a calorie disclosure law has been in place for several years. The menus also have to display sodium/salt content. This is one positive outcome of calorie disclosures! 

The proliferation of calorie disclosures

In one of my recent posts, I mentioned that calorie declarations for restaurant items were beginning to show up on TV and in web based ads. It appears that the industry is gearing up for the calorie disclosure mandate that goes into effect this December (see the Final Rules for ACA sect 4205[1]).  I have noticed that up-front calorie disclosures are becoming more prevalent in grocery stores as well.

The grocery store calorie proliferation is likely due to several factors, including the Affordable Care Act’s wide reaching mandate. Food manufacturers began adding front of pack labels some years ago (with declarations THEY are comfortable with, i.e., not every manufacturer includes calories or sugar amounts on the front of every one of their products), but one voluntary version Facts Up Front does provide info on calories and select nutrients, and it has potential.  If you click on the link above, you can scroll through some of the examples. As an example, I have noticed that most sliced bread brands have Facts Up Front labels now - with the calories displayed - but BE CAREFUL sometimes its calories per 2 slices and sometimes per 1 slice. The Institute of Medicine has recommended a standardized, mandatory front of pack label with an interpretive design, for example, 3 stars vs 1 star (I wrote about this recommendation a few years ago).  I believe that the more customers see calorie disclosures, the more they will demand them - up-front.  (The new calorie disclosure law is about ready-to-eat foods at grocery stores, restaurants and similar establishments, not packaged foods. But again, people are now expecting to see calories more easily because of laws like this.)

One of the issues in labeling, especially for packaged or self-serving foods (e.g., ice cream), is a push to present easily, or commonly, understood serving sizes.  The serving sizes (usually) accompany the calorie counts on front labels, e.g., half a cup, 2 tablespoons. I think it would be a disservice to customers, however, not to also include the weight in grams or number of ounces of that particular ½-cup or tablespoon; a ½- cup of one item may not be commensurate with ½ a cup of another item.  Recently, I was choosing between cookie brands. For each brand, the calorie amount per 3-cookie serving was 130, but the serving for one brand had 20 grams and the other had 30 grams, so in essence, I would get to eat MORE food for the same calories if I chose the heavier product. I owe my ‘per unit’ calorie comparisons to lessons I have gleaned from using UPC shelf labels, price per ounce, as I’ve mentioned in the past. 

I think that emphasizing serving size can also be context specific.  One place it makes sense for the majority of people to see calories per serving ‘size’ instead of serving ‘weight’ is the vending machine.  I say this because, the usual serving size of a snack purchased from a vending machine, or the amount customarily consumed, is the whole package. The package is the serving size.  Most people intend to eat all the M&MS, Fritos, or Lays, so by scanning across all products and knowing how many cals per pack, a person can, if they choose, pick the lowest calorie package and be done with it.  (In time, I suspect, savvy customers will figure out that even here, they can get more or less calories per package based on weight/volume.)

So that is very cool.  Calories are showing up more (this is good for people who are trying to limit calories or who simply want to choose items with fewer calories - can’t do it if you don’t know the numbers!).  The national law (again see ACA section 4205) covers more than foods – restaurant chains under the laws jurisdiction will also have to display calories for their alcoholic beverages!  Not the gin and tonic you order at the bar, but the Bahama Mama or Margarita from places like Red Lobster and Chili’s.  This is one place that the restaurant industry in general, is not giving us a prelude with its on line menus.  I went to the websites of more than 10 restaurant chains while writing this blog, and only one, Red Lobster, had its alcoholic beverage calories posted. Some of these drinks have more calories than my meals; I expect many drinks will be reformulated when the law goes into effect.  If you want to get an idea, check out Red Lobster’s menu – see page 2. Else, stick with lighter beers and wine or traditional drinks, gin and tonic should have about 100 calories as does my favorite Dee Dee Sour (Seagram’s seven and Fresca).  BTW, the Red Lobster  Caramel appletini has 160 cals and the chocolate martini has 330 – how could anyone know this without a calorie disclosure on the menu, when you are ordering?  Unless of course, it’s that ONE day a year when none of this matters (smile face!)

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[1] https://www.federalregister.gov/regulations/0910-AG57/food-labeling-nutrition-labeling-of-standard-menu-items-in-restaurants-and-similar-retail-food-estab

https://www.federalregister.gov/articles/2014/12/01/2014-27834/food-labeling-calorie-labeling-of-articles-of-food-in-vending-machines

Label Claims

In the past, I have cautioned that ingredients, serving sizes, and calorie content can change over time, making it a good idea to keep a watch on even your staple products. For me, Smuckers All Natural Peanut Butter has been a staple for years. I noticed when I got home from the grocery store today that both the Nutrition Facts Panel in the back and the Front of Pack (jar) declaration had changed. To be truthful, I did not notice the Front of Pack calorie declaration on the jar in my fridge before today, but it says 210 cals per 2 tablespoon serving - kudos for 1) disclosing calories up front and 2) including a serving size that we can understand. Also, on the standard NFP, the type of fats are broken down on the older jar. I have often pointed out that Smuckers All Natural peanut butter is a source of 'good' monounsaturated fat, but the tides and the (interpretation of) science have changed on fat - and no matter the kind of fat - the calories are the same. (BTW, this is one of those rare occasions where the term natural really means natural.)

The reason I started comparing my two jars of peanut butter was because on the front of the jar I bought today there was a declaration of 8 grams of protein per serving. Peanut butter is usually a good source of protein  - that is not new- declaring the grams on the front of the label is though. I guess there is a shift underway and protein is the macronutrient of the day. Because it was highlighted, I did think maybe the amount changed, but no, both jars have 8 g per serving. The older peanut butter does have more calories, just a few, but its weird that it went from 210 to 200 - same serving size. AND, other nutrition related fads (oh I mean concerns) are addressed on the new label, too. I'll let you pick them out below. BTW, the ingredients - peanuts and salt - are unchanged.
  
Here are the two jars and yes, I still LOVE this peanut butter.

This picture shows that the newer label doesn't break down the good fats.

Old calorie declaration

New calorie declaration plus 2 more declarations

Protein highlighted

Calorie Stealth

Calories, calories, calories. That is all this girl talks about… well, mostly true. I also talk about making sure that you are as physically active as possible (that means sit less) and that you try to exercise every day. And a few other things, like not smoking or tanning… and, well by now, you can fill in the rest yourselves.

So YES, calories.  First, restaurant (and similar venue) menu labeling is coming and I have noticed an increasing number of commercials that include a calorie count within the TV (or internet) ad.  Here is the most recent:

Second, I want to pass along a ‘be on the lookout’ note:

Little Bites and mini donuts are not low calorie options, but calling something little bites sure makes you think so. Right? Actually, a serving of Little Bites muffins has 180 calories, a regular muffin 190 and a 'mini' cake 260.  All of these are made by Entenmann’s. TastyKake sells mini-donuts with over 200 cals per serving. Take home message: read the calorie AND serving size information regardless of the words, light, little, diet, mini, good for you, all natural, organic...etc.

And back to the lemonade: 240 calories for a beverage is a bit much… more than half those calories are from sugar - 39 grams or about 10 teaspoons. The rest is from protein and fat, which comes from the milk. Below is the ingredients list from ChickfilA. The ingredients in the “Icedream” read like a chemistry book.

Frosted Lemonade: Icedream (whole milk, sugar, nonfat dry milk, artificial flavor, corn starch, mono & diglycerides, microcrystalline cellulose, carrageenan, guar gum, Yellow 5 & 6), water, freshly-squeezed lemon juice, sugar.

Diet Frosted Lemonade: Icedream (whole milk, sugar, nonfat dry milk, artificial flavor, corn starch, mono & diglycerides, microcrystalline cellulose, carrageenan, guar gum, Yellow 5 & 6), water, freshly-squeezed lemon juice, Splenda® (dextrose, maltodextrin, sucralose).

SO – the picture above, with the 240 calories, that is the diet one…. the regular lemonade has 330 calories and 63g of sugar (16 teaspoons). Sigh…and by sigh, I mean that's crazy! (PS I didn't see the fine print in the picture at first, “starting at…. 240 cals.”)

The 2015 Dietary Guidelines: The Advisory Committee Makes Recommendations

I am not going to spend many hours of our time creating numerous posts to break down the newest (and pending) edition of the Dietary Guidelines for Americans, as I did 5 years ago.  Holy cows! Five years ago?!

I am not going to do it because others, with better nutritional backgrounds, have already been hitting the highlights and controversies and because you can read the report yourself.

But as is my style, I will say a few things before I link you to the document and one of my favorite blog posts related to it.

• Calories are as important as ever and a majority of the population - all ages - consume more than they need to maintain a health weight.  A healthy weight, better measured as waist circumference or waist to hip ratio than on a scale or BMI, is one in which the body does not have excess fat.
• Sugar quickly increases calories without adding nutrients - except naturally occurring sugar in fruits and vegetables - and dietary fat, though not necessarily harmful, has a lot of calories and therefore should be limited in the diet - animal sources and full fat dairy are a continuing concern in these guidelines.
• Plant based diets are still the best.
• Exercise is key to better health - better health.  Let's just stop talking about it as a way to lose weight or eat more, whether it helps with that or not does not matter as much as this:  Exercise in and of itself is a necessary component of good health!
• Taxes and info: Environmental strategies, the likes of which I focus my research on, are promoted in the recommendations. The Dietary Guideline Advisory Committee talks about the need for information disclosure at the point of purchase and taxes on sugar sweetened beverages.

Two excerpts from the full report of the Scientific Report of the 2015 Dietary Guidelines Advisory Committee

What to eat: 

Following a dietary pattern associated with reduced risk of CVD, overweight, and obesity also will have positive health benefits beyond these categories of health outcomes. Thus, the U.S. population should be encouraged and guided to consume dietary patterns that are rich in vegetables, fruit, whole grains, seafood, legumes, and nuts; moderate in low- and non-fat dairy  products and alcohol (among adults); lower in red and processed meat; and low in sugar-  sweetened foods and beverages and refined grains. These dietary patterns can be achieved in many ways and should be tailored to the individual’s biological and medical needs as well as socio-cultural preferences. 

The food environment:

Align nutritional and agricultural policies with Dietary Guidelines recommendations and  make broad policy changes to transform the food system so as to promote population  health, including the use of economic and taxing policies to encourage the production and  consumption of healthy foods and to reduce unhealthy foods. For example, earmark tax revenues from sugar-sweetened beverages, snack foods and desserts high in calories, added sugars, or sodium, and other less healthy foods for nutrition education initiatives and obesity prevention programs.  

Click here for a great blog post by Dr. David Katz 

Building a low calorie meal at Chipotle

Until the menu labeling that is mandated by law and regulated by the FDA blankets the US, there is still the option of using online nutrition information available for most large chain restaurants.  I expect the information to remain available on line after the law is implemented, which is great for planning ahead.  Information on site can help you make a healthy choice at an unfamiliar restaurant you.

I recently got the notion that I should have a meal in mind in case I ended up at Chipotle.  There is one near my office.  I tried several combinations on the interactive web menu and watched the total calorie count go up or down, a little or a lot, depending on the choices that I made.  You can explore the menu this way too, just click here.

I did not add any of the meats when I was exploring, but I did add the Sofritas (a soy product/meat substitute); I think I saw an add for the Sofritas and that might be why I started thinking about Chipotle.  I did toy with tortillas and dressings.

Here is a snap shot of my "meal."  I specifically included the vinaigrette on this salad so you could see how it impacted the calorie total - 270 calories just in the dressing!  The salad has almost 500 calories with the dressing, which of course I don't need because I have the tomato salsa.  In other words, if I were placing an order, I would use the salsa for the dressing, not the vinaigrette.

Next are examples where I chose a burrito (a tortilla w/300 calories!) and a taco (a crispy shell w/ 210 calories).

Calories as Currency

The reason I appreciate, support and take advantage of calorie disclosures on pre packaged, ready to eat, and bulk food items (see e.g., the USDA nutrient data base) and prepare 90% of my meals - over the course of a year - is because I LOVE to eat and want to stay thin.

Exercise is important - it is vital to health - but unless one can do moderate to vigorous physical activity for more than an hour a day every day - or be in some other way unusual (e.g., have genetically, hyper metabolism), exercise is not going to keep you thin - at best, it will allow you to eat a 100 or so more calories than you could eat without exercising, and maintain a certain weight.

So to meet my goals, I monitor - stay aware of - my calorie intake.  Calories are currency and I do not spend them lightly.  In other words, I would rather have a plateful of 200 calories than a tablespoonful.  To be truthful, it took me years of self education - reading and research - to understand what 200 calories means in relation to my daily needs.  I eat 5 or 6 meals a day and consume between 1500 and 1800 calories a day depending on my current level of physical activity and fitness. 

For all of us, calories have always mattered and up until recently, the calorie content for most of our foods has been hard to access. With new nutritional labeling requirements for away from home foods (e.g., snacks in vending machines and movie theatres, restaurant meals), existing labeling on packaged foods, emerging but imperfect front of pack labeling and unprecedented access to legitimate calorie information on line, people have a real opportunity to consume the right amount of calories for their bodies.  The information is there, but the understanding of calorie moderation and the desire to moderate are both lacking.

Now more than ever, we need health educators and promoters to:

• assure the public that calories do count, 
• educate the public on the amount of calories most people need in a day,
• provide the public with the reasons the amount of calories needed may vary, per person and per day, and
• note that food volume alone does not signify calorie amount - for example a CUP of kale and a TEASPOON of oil or butter have about the same amount of calories (30 to 40), such that more can sometimes be less and less can certainly and often is quite more..

The way I eat, this calorie as currency approach, is possible because I choose foods with low energy density - Dr. Barbara Rolls at Penn State terms it Volumetrics and has written books on the style - it is not a diet, it is a way of choosing and preparing foods - all the time.  I know January is diet focused but I encourage you to think instead about calories and nutritious foods on which to spend them.

[I did not discuss carbs, protein, fats and sugar - you understand there is a current debate and the evidence is contradictory, but calories have not changed - too many of them from any source is a cause of weight gain.  Most will agree that salty, sugary and fried foods should be substantially reduced if not eliminated from the diet, and that complex carbs and fat are important dietary components.]

Final Rule Part II Vending Machines

In my last post, I detailed some information related to menu labeling for restaurants and businesses that sell foods for immediate consumption (businesses like movie theatres and bowling alleys).

The FDA published a separate Final Rule to explain the requirements of nutrition labeling for the vending site. There are similarities to the restaurant regulations, but some differences exist.

The nutrition information to be disclosed at the point of sale (i.e., available before the snack is selected from the machine) is calorie content for the entire package.  The information can be placed on the machine, in the machine or on a sign near the machine. It can even be displayed electronically, as long as it is seen before money is spent.  Just like in menu labeling, no state or local law can preempt the federal law for covered vending operators  (i.e., those who own 20 or more vending machines), but the vending rule specifically says that vending operators MAY PROVIDE ADDITIONAL NUTRITIONAL INFO.  To be clear, the state cannot require them to do so, but they are allowed to do so. To put this in perspective, recall the last blog post. In Philadelphia, certain restaurants are required to post calorie and sodium information on the menu, but if those restaurants are covered by the federal law, they can no longer be made to post anything other than calories.  If a vending owner covered by the federal law himself chose to disclose more than calories, for example added sugar grams, for the contents of his machine, he or she could do so.  I don't know, maybe it isn't different than the restaurant rule.  I don't recall reading anything in the restaurant rule about voluntary disclosure, but I am pretty certain if Apple Bees, for example, decided to post sodium content on the menu in their restaurants, they could legally do so.

The Final Rule for vending does not require the qualifying statement regarding 2000 calories a day (but this is information the rule calls 'additional information' that can be added by the vendor as long as any info or statements are accurate.  Vending companies have 2 years, instead of 1, to post their information.

I have talked about package labeling and the need for revisions in the past.  For the most part (90%), vending machine snacks have nutrition information on them (unlike restaurant foods or movie popcorn); the problem is that the customer cannot see the information when the snack is in the machine.  The Final Rule for vending states that a vendor is exempt or a snack machine is exempt, if the customer can easily see and read the Nutrition Facts Panel before they select and purchase the snack.  In addition, if snack packages change and the calorie information - for the entire package - can be clearly seen in a front of pack label, the machine will be exempt.

I am not sure how this could impact the Institute of Medicine's Front of Pack labeling recommendations and the FDAs delay in implementing them.  On the one hand, vending companies and their professional organization, the National Automated Merchandising Association might lobby congress to get FOP labels mandated, in which case, snacks would come prelabeled and the vending companies wouldn't have to do anything.  On the other hand, the Grocery Manufacturers Association might push back -hard -against a front of pack law based on the IOM recommendations, because the IOM recommends a rating system - in other words, the snack could be rated as POOR.  I am for this type of labeling, as you know.  Here is one past post in reference.

I don't generally purchase snacks from vending machines, but I look forward to the implementation of this law. I'd much rather have information available if I needed it than be forced to make a decision without it.

See the rule in the Federal Register 

Federal Nutrition Labeling - Exemption from Preemption?

YES!  I know that the FDA released the final rule for the national restaurant menu and vending machine nutrition (i.e., calorie) labeling law.  I haven't blogged about it yet because I was a little busy and I was trying to find out more, if I could, about the preemption piece.  To be clear, the final rule does a lot of what public health advocates, such as myself, hoped it would do and importantly, it includes movie theaters and prepared foods at grocery and convenience stores. Many reporters and bloggers have been talking about the final rule, and I hope that my post offers a little more than the usual fare (pun intended).

The FDA has a good Q and A page where you can learn more about which places will have calorie info available for you.  Click here to see and search the Q and A.  I went to the website myself to see if I could find out about bowling alleys, which I consider a caloric cesspool; and I found this beautiful paragraph

Establishments such as restaurants that are quick service and/or sit-down, food take-out facilities, pizza delivery establishments, food facilities in entertainment venues (e.g., movie theaters, bowling alleys), cafeterias, coffee shops, superstores, grocery and convenience stores, are covered if they meet the criteria listed above. 

Now there are two important qualifiers to the rule and as I've learned from some friends in King Co Washington and Philadelphia PA; its not as simple as it first seems.  I also spoke - through email - to a legal counsel at Perkins Coie LLP in Colorado.

1) The rules only apply to businesses with 20 or more establishments (re the 'criteria listed above' comment in the FDA paragraph I quoted). So YES to McDonalds and AppleBees and no to that quaint family owned bistro by your house. Yes to the AMF bowling alley with more than 300 lanes in the USA, no to the vending company with 10 machines. [I cannot wait to see the menu boards at bowling alleys (maybe my sister will send me a picture!).  I suddenly feel compelled to research how calorie laws affect the eating habits of bowlers!]

2) As the NRA hoped, the final rule does preempt the 15 or so existing state and local menu labeling laws (there are no vending laws to preempt). On the face of it, preemption means that no state or local law can be different from the national law. The national law says the menu boards, food tags and print menus must list total calories for each item - next to the item and in font the same size as the font listing the price; establishments also have to provide a statement regarding the standard 2000 calories a day contextual statement, and provide additional nutritional information in print, upon request. (Frequent readers of my blog know I think the contextual statement should say many people need closer to 1500/1800 calories a day, but it doesn't).

These 2 things (businesses included and preemption) play into each other in a way you might not expect, and in a way I didn't really see until someone pointed it out to me.  First, it is believed that a restaurant under the jurisdiction of the federal law, like AppleBees, cannot be made to display anything more than calorie content. Two local laws that I am aware of, one in King Co Washington and the other in Philadelphia PA, mandate that restaurants of certain size, also display fat grams and sodium mg on their print menus. It is possible that the federal law has a floor preemption instead of a ceiling.  IN other words, the law could mean that restaurants have to have calorie info but state and local laws could require more.  Most people (including two lawyers) have assured me that the preemption is a ceiling and states/localities can't require more than calorie disclosure. States and localities who want to force restaurants, by law, to disclose other nutrient information can petition the FDA for an exemption from preemption (great phrase!).  Stay tuned for more on King Co and Philadelphia's laws.  I will say that Philadelphia has a strong health related case for forcing the disclosure of sodium, and they know it.

But here is the clever part(and I am not sure who bested who on this one, the FDA or the National Restaurant Association).  States and localities can require establishments that are not under the FDA rule (i.e., local, small chains) to comply with a more involved law - and establishments that are not under the FDA's jurisdiction can OPT IN to the FDA rule.  Restaurants (or vending companies for that matter) that operate less than 20 establishments can make themselves fall under the FDA law.  If they opt in, then they cannot be targeted by state and local law.  SO, the new rule actually encourages restaurants to get on board because it can protect them from having to disclose, on their menu and menu board, more information. That sort of thing was exactly what the Restaurant Association was trying to shield their members from - having to comply with a patchwork of laws.


*** BTW making a company tell its customers what is in the products it sells is NOT an infringement on liberty!  Watch out for that kind of fear mongering spin - consumers have always had a right to know the contents of their purchases.