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)

Start the New Year Informed

Like many or most of you, I am preparing for the new year. What might be different is that to be healthy I simply (or not so simply) need to keep doing what I have been doing. Whereas, many others start every year pledging - resolving - to do things differently. With that in mind, I want so share some truths with you.

The most important things that any of us can do are these (listed, not necessarily, but maybe, in order of impact):

1. Do not smoke tobacco (don't start or do quit).
2. Exercise - everyday (30 to 60 minutes of activity that increases your heart rate).
3. Maintain a healthy weight (this is relative, but for most people it means losing weight).
4. Eat within a calorie appropriate (controlled) recommended dietary pattern, e.g., the Mediterranean Diet, which is plant based.
5. Get some sun, but not more than 10 minutes without protection (also relative to time of year, your skin pigmentation and where you live).
6. Avoid alcohol in excess (for some this means any alcohol, for others excess means more than 1 or 2 a day or 7 to 14 a week (never more than 3 or 4 in one day).
7. Get vaccinated according to the CDC recommendations for your sex and age (and take your children in for their shots).
8. Practice safer sex - i.e., use condoms and discretion.
9. For those suffering from any substance use disorder, SAMHSA can direct you to supportive services
10. Do not fall for diet and supplement scams - nutrition comes from food and weight control comes from balancing intake with expenditure. If whatever supplement or plan you are hearing about was as much of a break through as the ad says, we would NOT have an obesity epidemic. Please believe me.. there is NO pill for you. Reread numbers 1 - 9 above, this is the key to health.
11. Remember these final words of truth:
1. Non-GMO only means something does not contain genetically modified ingredients, not that its low calorie or necessarily good for you.
2. Organic means something has been raised according to specific standards, and so the plant or animal was not treated with chemicals or antibiotics. Organic foods are not scientifically better for you than conventional foods (though there IS concern about antibiotics in the food chain). Organic foods are not necessarily or ever lower in calories than similar non-organic foods.
3. All natural is finally being defined by the FDA - but stay tuned for the final rule and then years before companies have to comply.  Even if something is truly natural - not at all processed - that does not mean it is good for you, wont' hurt you, or is low in calories.
4. There are legal definitions for low calorie, low fat, low sodium, etc.. and 'lower' means something different than low.
5. Read the nutrition facts panels, think about serving sizes.. pay attention to calories (usually a lower calorie item will also be low in sugar). Hopefully, the added sugar declaration will be added to labels this year and that will lead manufacturers to reformulate their products.
6. Some fat is good for you! Especially consider adding omega 3 fatty acids from food, like salmon.
7. ONLY 1% of white people in the United States have CELIAC DISEASE, and even fewer people of other races/ethnicities do. That means, YOU probably don't need a gluten free diet.
8. Gluten free does NOT mean low in calories or good for you.
9. The health promoting property of olive oil is destroyed when you cook in it. To get the nutrition you are seeking, drizzle a teaspoon over your cooked veggies instead.
10. Get your fiber from plant based foods and whole grains, not mixes and pills.

On a sad note, the national vending and menu labeling law which is NOW set for compliance in May of 2017 is part of the Affordable Care Act - and may or may not survive the next presidency. That means that local and state laws could once again begin to populate which could be better for us and a nightmare for industry. Stay tuned

Lastly and sincerely,  I wish you the healthiest of New Years....remember, though I focus on food, physical activity is the sine qua non of health... make sure you get plenty this year... all year.

~ Deirdre

Why we focus on food deserts and not food swamps

Most people have heard the term food desert. A food desert is a place where people live and do not have reasonable access to whole foods, or fresh produce. Often this is measured by some distance to a grocery store. For example, in some places people live close to convenience stores and fast food restaurants, but would have to travel several miles, sometimes 10 or 20, to get to a grocery store. In these same areas, there may be high rates of obesity - however, there are high rates of overweight and obesity across the USA. Some speculate that not living close to a grocery store where one can access produce is a 'cause' of obesity (i.e., they associate food deserts with obesity). And it is not just availability, it's affordability, too. If the fresh produce costs more than processed foods, they are less accessible. If children have to try foods several times to like them, and a parent is on budget, it makes it hard to buy more expensive items that might not be eaten.

Access and affordability are things that public health advocates work to change AND that the electorate/society supports. Right? Of course we should make sure everyone has access to nutritious foods that are often low in calories. YAY! Let's do it.

Research has not always supported the intuitive, however, and sometimes people who have access to fruits and vegetables still don't purchase or consume them. Why not? Well, my educated/informed opinion is because a good many people live in food swamps. I am not sure where I first heard or read the phrase, but I describe a food swamp as an area where high calorie foods - often low in nutrients - are in abundance, are cheap, easy to locate, highly advertised, branded (e.g., KFC, Doritos, Pepsi) and popular among children, adolescents and adults. Actually, these foods and their promotions (e.g., all you can eat buffets, $1 hamburgers, 3 for 1 honeybuns, 32 ounce sodas) are hard to avoid.  

As noted above, the popular strategy for dealing with a food desert is to bring more fresh foods in - build a grocery store or a farmers market, add produce to the convenience store checkout, send in a mobile produce truck - and hope people will purchase, prepare wisely and eat more nutritious foods. Oh and here is the most important part... eat them instead of the high calorie non-nutritious foods they have been eating. Every one agrees, yes - those are all good strategies... yay, lets fund them! [They don't work so well, but they seem smart and non-paternalistic, therefore, it must be right.]

The strategy for food swamps (which is as unpopular as the food desert strategy is popular) is policy and regulation. I believe that food swamps are the bigger problem and that regulation and policy are our best bet at trying to reduce over consumption of calories (often occurring passively, i.e., not intentionally eating extra calories). Examples include, limiting the number of fast food/quick casual restaurants that can surround neighborhoods, schools, and worksites (zoning laws), putting a sales tax on high calorie, low nutrient items, like sugar sweetened beverages (specifically I say a sales tax because consumers are more likely to notice a sales tax than an excise tax and sales taxes cannot be 'eaten' by the manufacturer unless they literally lower the prices of their products), putting calorie counts out in front on everything, everywhere (menu boards, front of packages, sodas) and educating people on what is considered a 'high' amount of calories (e.g, a dinner entree over 500 calories is high, if it is part of a days worth of meals), portion caps - like suggested in NYC might work, and limiting ads for high calorie foods or ad space (e.g., TV, public transit, magazines, websites, social media). I think our grocery stores should have makeovers as well. The cheap, high calorie foods should not get prominence and promotion. This is one of the main reasons I believe that strategies to add fruits and vegetables to neighborhood stores or whole grocery stores to neighborhoods, fail. It is hard to get through the mire of junk - physically, emotionally, socially, parentally - to the better for you items. 

And before anyone points out that the food swamp policies I mentioned are regressive (i.e., they will have a bigger impact on persons of lower income) I say YES, and obesity and its related disease conditions is also regressive and has a greater impact on persons of lower income. 

My point is, that though it might sound good (especially politically) to make fruits and vegetables and other nutritious foods available and accessible, what we really need is to make low nutrient (junk) foods and drinks LESS available and accessible (less cheap, less popular, less in our face).  And as that annoying prince on the TV show Outlander says, "mark me" I am right about this.

Exercise for Weight Loss?

No.
Exercise for exercise. Exercise for a long, healthy, active live.
Exercise for functional capacity, mood stability, improved attention and learning.
Exercise to prevent disease. Exercise to improve your quality of life.
Exercise because not exercising increases your risk of all causes of death and all disease states.

If you exercise only because you think it will help you lose weight, and exercise is your only weight loss strategy, chances are you won't lose weight. And then you will think exercise failed you. You will be wrong. Exercise is the sine qua non of health; it will never fail you. if you do it for the right reasons.  There are many reasons, see the first paragraph and the research studies below.

If you want to lose weight, change your eating patterns. Many people need to lose weight.
If you want to be healthy, exercise - daily.. Everyone, regardless of their weight status, needs to do this.

(NB. this was posted a few weeks later http://www.vox.com/2016/4/28/11518804/weight-loss-exercise-myth-burn-calories)

Janssen, I., & LeBlanc, A. G. (2010). Review Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. International Journal of Behavioral nutrition and physical activity, 7(40), 1-16.

Nocon, M., Hiemann, T., Müller-Riemenschneider, F., Thalau, F., Roll, S., & Willich, S. N. (2008). Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. European Journal of Cardiovascular Prevention & Rehabilitation, 15(3), 239-246.

Penedo, F. J., & Dahn, J. R. (2005a). Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Current opinion in psychiatry, 18(2), 189-193.

 Warburton, D. E., Nicol, C. W., & Bredin, S. S. (2006). Health benefits of physical activity: the evidence. Canadian medical association journal, 174(6), 801-809.

February Reminder: You said you would eat 'better' this year!

It's the middle of February, how are you doing with your goals to eat healthier in 2016?

Here are a few reminders and helpful hints:
Remember that calories still count and there are plenty of ways to eat delicious, full plates of food if you make some clever choices. For example, when eating out you can order your fish or meat with little to no oil, butter, glaze or sauce and ask for your vegetables to be steamed without butter. (note, pasta is never low calorie and bottomless bowls of it are a mistake) At home, you can prepare your food the same way - without lots of sauces, breading or butter.

Some vegetables are more nutritious than others - high in nutrients but not high in calories, as long as you do not bread, fry or coat them in butter.  For example, summer squashes, spaghetti squash, eggplant, cauliflower, broccoli, asparagus, butternut squash, Brussels sprouts, green beans, greens (kale, broccoli rabe, etc). Use this link to find other low calorie foods, and remember just because they start out low calorie doesn't mean they end up low calorie (how you or the chef prepares them is a crucial factor).

Alcohol and caffeine(particularly in coffee) can be a part of a health promoting diet, but be mindful of two things: 1) excess alcohol and caffeine can have adverse effects on your health (excess is more than one or two drinks a day depending on your sex and size, and probably 3 to 4 8-ounce cups of coffee); 2) both alcoholic beverages and coffee that is flavored with cream and sugar, bring in calories and those calories count towards your individual daily requirements. 

I enjoy a good cup of arabica coffee, black no sugar in the morning (okay 2) and decaffeinated, almond milk infused cappuccino in the evening. (sugar free milk ~ 30 cals a cup). For alcohol, I stick to one 12 ounce light beer, one 4 to 6 ounce glass of wine OR one shot of liquor mixed with a no calorie beverage. I recently made a batch of limoncello which I am enjoying several nights a week! Pictured above.

I hope this post has helped get you back on track or keep you on track and given you some new information for meeting your goals.

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.

Food as tradition vs Food as reward

Food has many meanings and purposes. Food can soothe the soul as well as sustain the body. It may even heal and restore. It is a source of nourishment, especially, or perhaps only – when it contains protein, carbs, fats and nutrients, not empty calories (e.g., high sugar, high salt and high saturated fat). And food is a source of pleasure, helping us to recall happy moments, favorite people, and traditions.

For many of us, the act of preparing, cooking and serving food is an expression of love: familial, social, charitable. Within cultures, broad and refined, certain foods celebrate, symbolize, crystalize (as in rites of passage, milestones). There is room in all our lives for these occasions[1], these moments of food as something more than or other from, sustenance. There is no room in any of our lives for abandoned consumption of even our cherished foods. To be honest, gluttony sort of ruins the whole appeal. But this blog post is not about moderation or counting calories. I am hoping that in time, soon, it will no longer be necessary to even mention calorie moderation, not because we have found a magic pill that lets you eat whatever you want, or because exercise suddenly causes easy weight control, but because we will have learned, as a nation, that calories MUST be part of the strategy.[2]

These other than sustenance reasons for eating that I described above, fall into the appropriate practices of most societies throughout time. But there are less salubrious reasons for eating and sadly, these unhealthy, psychologically damaging reasons are often situated and cemented in childhood: pacification, reward, boredom. Recently, I observed one of these unhealthy uses of food, which I’ll describe in a moment, and that scene triggered a few other memories of the misuse of food, memories that are at least 20 to 30 years in the past – I’ll share them too.

The first and recent example uses food as reinforcement. This particular example can be thought of as either negative or positive reinforcement, which is unusual and psychologists might disagree with me, but I’ll explain my reasons and why I call it negative reinforcement. Negative reinforcement is an action that takes away an unpleasant thing, while positive reinforcement provides a reward or something pleasant when a particular behavior is exhibited. In my interpretation, one is meant to extinguish and the other is meant to encourage. I think that using food to take away an unpleasant emotion would be using it for negative reinforcement – a really bad idea. In the case I witnessed, a child was crying – throwing a pretty good tantrum – and the dad said to the mom, “Give her a lolly pop.” WHOA. – I most certainly did cringe. More distally, when I was a young adult babysitter, I observed what the parents clearly meant to be positive reinforcement when they gave their child a cookie for using the potty. To this day I have wondered if that girl grew up to have an eating disorder. And a little more recently, but still 20 or more years ago, I remember watching a friend constantly hand her son food to eat as they rode around in the car – visiting people. He was bored and eating chips and drinking soda kept him occupied. He is a (heart breaking) morbidly obese young adult now.

Food is not meant to drown out our feelings, teach us to do things, or keep us from being bored.  Parenting is hard -  I get that, but food as a parenting strategy is a dangerous mistake. Though I am firm in my belief that food not be a reward, food can certainly be a pleasure and serving it rewarding. When foods become embedded with our culture, our traditions, and our families it is a good thing. But using food to treat a bad mood, stress or mental illness is ineffective and it’s unhealthy. If you’ve found yourself using it this way, instead, try exercise, talking to confidants or professionals, writing, meditating, praying, and other positive coping mechanisms. Heck, even medicine if all else fails, but not food. Food is not the answer nor the treatment for emotional or physical pain.

---

[1] Note: this is not the same thing as having style of cooking that consistently creates excess calories or uses large amounts of nutrients/substances of concern (i.e., sugar, fatty and or fried/breaded foods and salt/sodium)

[2] Forgive me for another small aside, but as I wrote the sentence above regarding the pill that lets you eat whatever you want, I had a little epiphany. The ads for pills and supplements do say, ‘eat whatever you want and lose x pounds.’ And that is not the real issue. It is less about WHAT one eats and a lot about HOW MUCH; so the magic pills have to let us eat what we want, as much as we want and keep us thin and metabolically healthy – good luck waiting on that.

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!

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)

Food Purchases and a Right to Know

Some while back, I listened to an interview of Richard Cordray, head of the Consumer Financial Protection Board, on the Diane Rhem Show. During the conversation, he said something about consumers having a right to full information when they were making a purchasing decision, whether that was an appliance, house or a loan. I made a note to myself to go back and find the transcript when time allowed, because what he was saying also made sense as an argument for why we should disclose information about the foods we purchase, even if  - or especially if - they are completely prepared by a third party. I do not focus on vaguely defined terms like All Natural or Organic, and though I don't think a product with GMO (genetically modified organisms) is bad simply because it contains GMOs, I do concede to my friends who insist the products be labeled as such.

Instead, my labeling interests are about ingredients (and their amounts) and caloric content - at the very least calorie amounts, because that seems to be the best place to start with regard to weight control. I did find the recording and transcript of the interview, you can view both here, and I believe it is this excerpt that caught my attention back in July.

For consumers, the ability to understand more clearly what the costs and risks are that they face as they make choices, I have great confidence in consumers' ability to make decisions for themselves. Nobody can stand in their shoes and understand their circumstances as well as they do themselves. But at the same time, there are things they need to know about what the choices really are and whether the choice that's being presented to them is the deal that they will actually be able to live with next year or the years after or whether it will have changed in ways that are not clear to them in the fine print.These are all ways in which consumers, if they have their eyes open and if they can clearly see the futures, will make pretty good choices for themselves. But if the future is obscured, if they're being tricked and if there's deceptive marketing, as was often the case, then they will make bad decisions and they'll regret them and none of us wants to see that and consumers most of all. 

A lot of what Mr. Cordray discusses has to do with loans - its a great interview regarding financial protection and regulation. I encourage you to listen.

But if you think about all the decisions we make regarding food - every day - the same message applies. Do we know what will happen to our future selves if we eat, for example, meals with very high calorie, sugar or salt content? And if we do know what will happen - for example, that we might gain weight or our blood pressure become dangerously high - shouldn't we be able to make an informed choice? A choice made by easily identifying the foods and beverages that are high or low in those things? It is our future 1) to understand and 2) to protect.

Full disclosure is a purchasers legal right.

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

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! 

Calorie Mindful or Drunkorexia

I recently came across a research article discussing a phenomena (possible 'disorder') called drunkorexia. The term and what it means caught me off guard and to be honest, disturbed me. It disturbs me for a couple reasons. The first is that I am loathe to think that my advising persons - as a public health educator - to consider how they spend their calories in a given day might in some way suggest that I think people should drastically cut their calories in order to 'fit in' highly caloric (and dangerous) binge drinking. Of course, I expect that the primary audience for my blog and YouTube channel are not mostly college aged females - the group that engages in this behavior the most - and is instead, people doing their best to consume the right amount of calories to keep themselves at a health promoting weight. So when I say that I personally consider the 1 beer, glass of wine or alcoholic beverage (~ 100 cals) in my daily total, and thus have a smaller lunch or breakfast in order to have that drink, I am NOT advocating skipping meals or 'starving' in order to 1) drink on an empty stomach for a quicker high or 2) or to consume 500 or more calories in alcohol and not gain weight.

I am also concerned when people medicalize/diagnose behaviors, like the dumb one I just described, into psychological problems - at least too quickly. Labeling people, in my experience as a social worker (not a psychiatrist/psychologist or nutritionist), too soon or maybe at all, can cement the problem; the person becomes the problem - the illness manifests because someone said it was there.

My area of expertise and research is not eating disorders. The main point of this post, and the point I will reiterate and end with is: being smart about the calories you consume does not include - never includes - not eating. It is easy to reduce a breakfast and or lunch by 50 to 100 calories by changing its ingredients. I do not advocate any of the behaviors associated with this 'drunkorexia.'

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

Learning how to maintain a healthy weight - from our pets

It is not a secret. We have obese cats and dogs, a good many of them. And I will gander a guess - an educated one, I've read research - that pets gain weight when we give them people food - in addition to their pet food.  I have also read that ad libitum feeding is better than intermittent feeding. Pets - maybe the study was on cats - eat less when the food is left for them all day (I'm sure it was cats, dogs are sort of dumb), than when the food is presented and taken away. Sound familiar?  Its a bit of a take on restriction and forbidden foods - if you think you wont' get to eat that again, you want to eat a lot of it when you have the chance, especially, it seems, if you are a cat.

Anyways, I recently adopted one, a cat, after not having one for several years. My cat will not get people food - ever. I did buy him some treats though - good for his teeth.  And imagine my surprise (delight even) at this label instruction:

As with any treat, always adjust amount of main meal to compensate for calories delivered by treats.

In addition, the label tells you how many calories per treat, and how many treats a day your cat should have based on his or her weight.  But the instruction to compensate is priceless and relevant: you can't just keep adding calories - even good ones - and not expect to gain weight.

If its important for a cat, isn't it important for you?  Sure - have a glass of wine, but those 150 to 200 calories COUNT towards your daily total, they are not supposed to be 'add ons' - you must compensate... pretend you're a cat.

I am referencing Feline Greenies, BTW, and my cat likes them - in moderation!

The case of South LA, Obesity and the Meaningless Law

You may have heard about the 'absolute failure' of a fast food zoning ban in South Los Angeles, California.  The ban on new, stand alone - very distinctly defined - fast food restaurants did not lead to a loss of weight for city residents, in fact, overweight/obese rates went UP after the law was 'on the books.'

Notably, the rates of overweight and obesity went up for ALL of Los Angeles and LA County. According to the study authors (Sturm and Hattori), South Los Angeles residents - ones whose behaviors and weights were captured in the California Health Interview Survey- had a higher rate of overweight obesity to begin with and their rates increased faster - or to a higher degree - than either the whole of Los Angeles city or LA County (their behaviors and weights were also assessed through the survey).

Whether or not a ban on new fast food restaurants - and it was not a total ban - was a good idea is for someone else to argue, but whether or not the study results are conclusive or even meaningful falls into the bailiwick of this (increasingly infrequent) blogger.  Yes, I end up giving an opinion about the law, I can't help myself sometimes.

This LA Times article provides a bit of information, though it does not describe the study methods. I accessed the journal article, the abstract is here. My main interest was in how the researchers went about collecting their data and answering their research questions. Sturm and Hattori (2015), used two main sources of data. They used establishment/restaurant permit records from the Department of Health and existing survey responses from a recurring/repeating survey - the California Health Interview Survey.  The survey responses (people) could be categorized by city, county, zipcode etc, so the researchers compared results between 3 groups, only one of which, South Los Angeles, was 'exposed' to the new regulation.

The regulation didn't really do much, I mean literally - it didn't do anything.  Fast Food Restaurants (FFR) still opened in Los Angeles, new business rose about 2% in all three locations. So from time 1 to time 2 there were actually MORE not less places for residents (or commuters?) to eat foods that were likely very high in calories. Between the time that the law went into effect and when the researchers evaluated the survey respondents FFR patronage frequency and their BMIs a second time, the environment did not change 'for the better'. There were not fewer FFR at time two, but would that have mattered? Research has shown that even sit down restaurants, fast casual or otherwise, serve foods that are calorically dense.  All away from home eating is associated with excess calorie consumption - so a law that prevents a certain sub category of FFR from adding more locations might make sense on its face, the result won't necessarily - or likely - be lower weights for the people who live in that area,

With an understanding of what did and didn't happen as a result of the law - i.e., FFR locations did not decrease or remain stable, they increased - how can one say that restricting FFRs does not lead to less FFR patronage or less calories consumed.  The law was flaccid at best - the first outcome - a decrease in number of restaurants or restaurant density did not happen. There was NO change in the obesogenic environment - people had as many if not more options for calorie dense food as before the law. So the answer to the first question: "Does a law restricting FFR lead to fewer FFR?" is no. Therefore, we can't answer anymore questions! But lets say the answer was yes, that five years later there were less restaurants in the area; the second question is: "Did the law lead to less consumption of fast food - or even better, much better, did it lead to few calories purchased/consumed?"

Now, is this the right policy?  Banning restaurants?  In some ways, it makes sense.  If there isn't a FFR on every corner, then FFRs become less popular, less 'normal.' And if FFRs were the only source of our passive overconsumption of calories, fewer of them might change our intake.  But they are not - there are plenty of sources of too many calories. The goal, in my opinion, should be to get existing establishment to reduce the amount of calories - across the board - that they put out for sale.

NB. Another possible 'confounder' for South LA is that people may not eat where they live - so capping the number of fast food restaurants does not change behavior if people are not eating where they live. 

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Mom, you would be happy to know that I had three more paragraphs, but I realized I had already said what I needed to say so I deleted them.

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