- Email: [email protected]
JCL Roundtable: Fast Food and the American Diet
Journal of Clinical Lipidology (2015) 9, 3–10
Clinical Lipidology Roundtable Discussion
JCL Roundtable: Fast Food and the American Diet W. Virgil Brown, MD*, Jo Ann S. Carson, PhD, RDN, FAHA, Rachel K. Johnson, PhD, MPH, RD, FAHA, Penny Kris-Etherton, PhD, RD, FAHA, FNLA Emory University School of Medicine, 3208 Habersham Rd., NW, Atlanta, GA 30305, USA (Dr Brown); Department of Clinical Nutrition, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390–8877, USA (Dr Carson); Department of Nutrition and Food Sciences, The University of Vermont, Burlington, VT 05405, USA (Dr Johnson); and Department of Nutritional Sciences, Pennsylvania State University, 110 Chandlee Laboratory, University Park, PA 16802, USA (Dr Kris-Etherton) KEYWORDS: Fast food; Nutrition; Heart disease; Saturated fat; Cholesterol
Abstract: The availability of food quickly prepared at lower cost and with consistent quality and convenience has made a variety of restaurant chains extremely popular. Commonly referred to as the fast food industry, these companies have stores on virtually every street corner in cities large and small. Fast foods contribute to energy intake, and depending on the food choices made, provide foods and nutrients that should be decreased in the diet. As Americans have become more conscious of their risk factors for heart disease and recognized eating patterns as a contributor to blood cholesterol levels, high blood pressure, obesity, and diabetes, the fast food industry has attempted to adjust their menus to provide more healthful choices. The Roundtable discussion in this issue of the Journal will focus on the importance of this industry as a source of foods that could help address our population-wide efforts to reduce cardiovascular disease. Ó 2015 National Lipid Association. All rights reserved.
Financial disclosures Dr Kris-Etherton was on the advisory board for the California Walnut Commission and received advisory board honoraria from McDonald’s Global Advisory Council. Drs Johnson and Carson have no disclosures to report.
This Roundtable was recorded on November 14, 2015, during the American Heart Association Scientific Sessions. Three expert academic nutritionists have kindly joined me to share their knowledge: Jo Ann Carson, PhD, RDN, FAHA (University of Texas Southwestern), Rachel K. Johnson, PhD, MPH, RD, FAHA (University of Vermont), and Penny Kris-Etherton, PhD, RD, FAHA, FNLA (Pennsylvania State University). All 3 have been major contributors to the dietary guidelines that have been issued by various organizations/agencies. * Corresponding author. E-mail address: [email protected] Submitted December 4, 2014. Accepted for publication December 4, 2014.
Dr Brown: Thank you for joining me and helping us to consider the opportunity offered by the ‘‘fast food’’ industry to continue improving the nutritional profile of our diets. Americans began to change their diets to reduce heart disease after the American Heart Association Dr Brown recognized the population-based research and made strong recommendations regarding reduction of saturated fat and cholesterol in our diet some 50 years ago. We are still on that journey and continued improvement is possible. I would like for you all to comment on your estimation of the size of the contribution possible from ‘‘quick serve’’ or ‘‘fast food’’ outlets. Keeping in mind that a quick serve restaurant is one characterized by its fast food cuisine and minimal table service, what is your estimate of the actual contribution of calories provided from fast food outlets to the average American adult or child?
1933-2874/$ - see front matter Ó 2015 National Lipid Association. All rights reserved. http://dx.doi.org/10.1016/j.jacl.2014.12.002
4 Dr Rachel Johnson: The National Health and Nutrition Examination Survey (NHANES) data report that it is somewhere between 10% and 20%. It varies by age with children who are 6 to 11 years old obtaining an average of Dr Rachel Johnson about 12% of their total energy intake from fast food. Teenagers get the most, an average of 18%, whereas on average people over age 50 consume only 8-9% of their calories from fast food outlets. Those are the percentages based on a recent NHANES analysis. These are average values but there’s a large variation in calories consumed from fast food. There are income and racial disparities in terms of the amount of calories that are consumed in fast food with the lower income groups, African Americans, and Mexican Americans consuming higher amounts. Another concern is that the nutrient composition of the fast food consumed is quite different from other components of the food supply in America. There are higher amounts of saturated fat and added sugars from fast food. Thus, we should look at the nutrient breakdown as well as total calories contributed from any given source. Dr Brown: It is clear that there is a range of values for different companies and different menu items. Focusing on the entire meal, can we derive an estimate of the percentage of saturated fat in the average major food items served at popular outlets? Dr Johnson: When you look at food sources and quick serve restaurants, the highest percent of total calories comes from pizza, sugary drinks, potatoes, and cheese. Dr Brown: The meals could vary in saturated fat calories from 10 to 30% percent? Dr Johnson: Right. It obviously comes down to consumer choice. So it is possible to get a fairly healthy meal in many of these quick serve restaurants. This can be driven by what and how the food items are marketed to consumers. Dr Brown: There is a common belief that these quick serve restaurants do indeed make a significant contribution to unhealthy components in our diet. That they not only load us with saturated fat and cholesterol but are high in sodium, as well. Their offerings are believed to be deficient in important nutrients such as potassium, calcium, and fiber. So when you look at the entire fast food industry is this a fair assessment? Are these restaurants a major contributor to a less healthful food intake than the remainder of the American diet? Dr Johnson: For some people who eat fast food frequently, they are getting more sodium and more saturated fat than are recommended. Dr Carson: Let’s consider the 8.6% of daily energy that fast food contributes to the diet of adults who are 51 years or age or older. That portion of their food intake may contribute significantly more Dr Carson
Journal of Clinical Lipidology, Vol 9, No 1, February 2015 than 8.6% of their sodium and saturated fat and perhaps less of their vitamin and mineral intake. Dr Johnson: That leads me to a fascinating paper on calorie changes in chain restaurant menu items. The researchers surveyed 19,417 items. What they found was that when new menu items were introduced that provided lower calorie options they tended to be items that were not core to the restaurants’ customer base and mean calorie consumption did not change. These restaurant chains are introducing new and potentially more healthful items, but the core is still hamburgers, French fries, pizzas, and soft drinks and that volume is maintained. Dr Brown: How can we suggest improvements in those core items that are the center piece of their sales? Dr Johnson: I would rather critique what they market and how they market. Such as including toys in unhealthy children’s meals as a marketing technique. Dr Brown: Are they succeeding in selling less healthy food by doing that? Dr Johnson: They’re succeeding in promoting these foods. Dr Brown: My question is what they are putting in peoples’ stomachs. Dr Kris-Etherton: Okay. Let’s look at the nutritional profile of kid’s meals in quick serve restaurants. A good example is McDonald’s. They have decreased calories in the Happy Meal by cutting the serving size of the fries. They are now 100 calories, which is a Dr Kris-Etherton 50 calorie reduction. Dr Brown: Have they changed calories in other ways? Dr Kris-Etherton: They’ve changed the fat. It used to be tallow. Then it was switched to hydrogenated oils, which were high in trans-fat. Now they use vegetable oil that is trans-fat free. I think that’s a significant improvement in terms of the saturated and trans-fat content. French fries are healthier now because they are no longer fried in partially hydrogenated oil. Of course, the American diet has improved in terms of trans-fats. It’s not because Americans said I’m going to stop eating French fries. Rather, this has happened because of changes in food preparation. Dr Carson: Because their reach is so huge, these represent tremendous changes that are possible in populationbased nutrients. Dr Brown: That is why this is important. Dr Kris-Etherton: The fast food industry is experimenting with changes that could lower calories, saturated fat, and salt. They have tried a number of different strategies but many do not stay on their menus. An example of this is Satisfries that were prepared with less fat. If this product had been accepted by consumers, it would have positively affected the ‘‘French fry world’’ and led to beneficial changes in the standard French fry formulation. In turn, this would have had a beneficial effect on the diet. But this is not what happened. Consumers did not purchase the product and it was withdrawn from the market.
Brown et al
Fast food and the American diet
Dr Johnson: In a publication reporting on changes in food composition in 70 fast food restaurants, sodium increased by 2.6% from 2005 to 2011. During that period, no progress was made in terms of sodium. In the European Union, sodium limits are mandated in processed foods so there’s a level playing field. We know that over time consumer taste can adapt. But if the restaurant down the street is serving fries or pizza with a certain level of sodium and you attempt to lower the sodium in your meals, you lose the competition on taste and you lose your customer base. There is this natural tension with voluntary changes that are market driven. Some believe that regulatory changes are necessary to reduce sodium levels in the restaurant industry, particularly in these large chains that feed millions of people with a standard menu. It would seem to be most important to have nutrient standards for meals with toys that are marketed for children. Dr Brown: One might put the toys in foods that are the most healthful? Dr Johnson: In Santa Clara County, California they passed an ordinance that says the meals have to meet certain nutrient standards in order for them to include a free toy. They can sell the toys, but they can’t include them for free unless the meals meet certain standards in terms of nutrient quality. Dr Brown: Do we know whether that is successful? Dr Johnson: It appeared to positively influence marketing of healthful items as well as toy distribution practices at restaurants affected by this ordinance but did not affect the number of healthful food items offered. They didn’t really change their menu. They just stopped offering the toys. Dr Brown: How much sodium is contributed to the diet from this industry? Do we have figures on that as well? Dr Kris-Etherton: The number one source of sodium in the US diet is bread. I was talking to the nutritionists at McDonald’s, and asked if there is any way to decrease the amount of sodium in their quarter pounder. The major problem is the bun, not the condiments, cheese, and added salt (during preparation of the burger). Dr Carson: Or they could reduce the size of the bun. That’s something that I’ve noticed some attempting. Dr Kris-Etherton: Some fast food chains provide options for less bread for people who are concerned about carbohydrate calories. In so doing, less bread equates to less sodium. Dr Brown: So there is ongoing work on the sodium issue. Do you think that there is progress? Dr Johnson: Not according to the publication I mentioned before. That was published in 2013. Dr Kris-Etherton: Well, I am thinking about the efforts of the American Heart Association with their Heart-Check Program and their program to certify restaurant foods. We have seen that some companies are reducing the sodium content of their foods. It is not as low as our goal but there are efforts ongoing that are in the right direction. I just came from the Healthier Diet Business Management Committee meeting, and there are a number of examples now where the American Heart Association has certain
5 standards for sodium. The fast food industry was saying we just can’t achieve these goals. Surprisingly, 6 months to a year later some have reached the targets. One example is Subway. All of their meat, for the most part, is high in sodium, but they were able to ratchet some down to be part of an exclusive partnership with American Heart Association to promote a healthy Subway meal. Dr Johnson: I think the American Heart Association (AHA) Heart-Check program is a tremendous success story. Consumers trust the Heart-Check mark. Consumers look to AHA to be science-based. Subway reformulated some menu items to meet the AHA Heart-Check standards. That was a great win-win, I think. Dr Kris-Etherton: For the individual customer, the sugar content is driven largely by purchase decisions (eg, soft drinks). Many fast food restaurants have a number of items on their menu that meet the saturated fat goal. Meeting the sodium goals has proven to be more challenging. Dr Brown: Do we know how these alterations change the number of these items that are ordered and consumed? Dr Kris-Etherton: Well, in fact, some statistics show an uptick on the Heart-Check items by about as much as 20%, especially in certain population groups like Hispanics. But I think there is often initial resistance on the part of customers. There are many examples where restaurants have designated heart healthy foods on the menus, and sales of the healthier items have been sluggish. Then heart healthy items were quickly exited off the menu because few would order them. So maybe the environment has changed in recent years. Dr Johnson: Subway is one of those restaurants that has a health halo. So it may be driving the consumer base that goes into the restaurant to begin with. Dr Carson: I can see a consumer saying, ‘‘I am going to this restaurant because they have healthy food.’’ Sometimes they may not pick the healthiest menu items, but if they pick that restaurant because it offered healthy food choices, they are more likely to look for a healthy choice. Dr Kris-Etherton: I believe many people go to some ethnic restaurants because they believe they are healthy. Chipotle is an example where you can create a meal that is essentially vegetarian but when you analyze what many people add in building their burrito, the nutrient content frequently does not meet the definition of a healthy meal. Personal taste will continue to drive food choices that are based on familiar flavors that reflect habitual consumption of sodium, sugar, and fat. Dr Johnson: Brian Wansink from Cornell has studied this health halo issue around food choices. People will go in thinking that something is healthy, but it actually may not be. It can work in reverse. The McDonald’s plain hamburger may be acceptable in terms of calories and saturated fat and might be much better than other menu items that have a health halo. Dr Brown: Could you give us an overview of the HeartCheck program?
6 Dr Kris-Etherton: There is the standard Heart-Check program, which has been in existence since 1995. It started with criteria that food companies could implement so they could have the Heart-Check ‘‘stamp’’ on their food. Perhaps we should review what’s happened over the years? Dr Johnson: The criteria for the Heart-Check front-ofpack program have been updated to reflect emerging science, and the new criteria went into effect in January of 2014. So we now have a categorical approach to sodium based on food category items. For example, main courses have a higher sodium level than side dishes. We also have sugar limits on cereals, for example. If the cereal is an excellent source of fiber, the sugar content can be a little higher than a cereal with less fiber. Dr Brown: Are other restaurant chains attempting to modify their menu items in conjunction with volunteer health agencies such as the AHA? Dr Carson: At this point you only have Subway. So, Penny, you could speak to the problem from the Dietary Guidelines. Dr Kris-Etherton: So what are the nutrients of concern beyond fat, sugar and sodium? They are potassium, calcium, vitamin D, and dietary fiber. Dr Brown: Is calcium deficiency a problem and one being addressed in quick serve restaurants? Dr Johnson: Well, we don’t have a standard that specifically recommends a certain amount of calcium. Dr Kris-Etherton: Or potassium—that might be one that could also be addressed. What I would like to see is a nutrient density score that takes into account the entire nutrient profile. Dr Johnson: In terms of participation in the American Heart Association Heart-Check, it’s one thing to be eligible. It’s another thing for a company to decide to participate in this voluntary program. Dr Johnson: We recognized that most people are not going to eat a fat-free plain unflavored yogurt, so we set a calorie limit on the 6 ounce size of yogurt, which then automatically sets a cap on the amount of sugars that can be added. We feel it’s a very nutrient-rich food, high in calcium, potassium, and protein, and many are vitamin D fortified. We did the same thing with fish, for example, because we want to promote fish consumption because of the omega-3 fatty acids. But we learned that canned fish such as tuna fish may have a substantial amount of sodium. Some sodium has to be there from a food safety perspective. So we set the sodium limits keeping in mind that we want to promote consumption of fish. Dr Brown: We may need a little more sodium to get more fish in the diet. Fish provides a source of food that in epidemiologic studies has been shown to be related to lower vascular disease prevalence even if it doesn’t have significant omega-3 fatty acids in it. Dr Brown: Have we over-emphasized sodium restriction for the general population, particularly for young healthy people with normal kidney function?
Journal of Clinical Lipidology, Vol 9, No 1, February 2015 Dr Kris-Etherton: When you look at age-related changes in high blood pressure (ie, hypertension) you see that it increases with age. Greater than 72% of people 75 years and older in the US have high blood pressure. Dr Brown: Older people are definitely more sensitive to high sodium intakes. Blood vessels tend to become less compliant and kidney function declines with age. Dr Kris-Etherton: The other argument is that there are populations that have lifelong low sodium intakes and do not develop high blood pressure like we do in the US. Dr Brown: But they are not as obese, and often are more active, eat low saturated fat and lower caloric diets. Would you not agree that excess body fat appears to be more important than sodium in blood pressure onset? However, I agree that there is a very sizable number of people who are sensitive to salt regarding their blood pressure. Dr Kris-Etherton: Certainly, excess body fat is a major contributor to high blood pressure. Of note, relative to helping consumers control calories is that the calorie value of a quick serve meal has decreased by about 100 calories in recent years. Dr Brown: That sounds like progress. Dr Johnson: The study I was talking about is a supply side study where they looked at the mean calories on menu items. So with some of these things you have to understand dietary assessment methods. With NHANES you have selfreported intakes that tend to be under-reported. Dr Carson: A very positive change in the restaurant industry is that the default choice is the healthier choice. Years ago whole milk was the default option in many fast food restaurants. Now the default choice is 1% or 2% milk. For example, at Disney World milk and fruit are the default options for the children’s meals (and not a soft drink and fries). I have watched families in quick serve restaurants order the equivalent of the kid’s meal. The child gets milk and grapes instead of fries and a soda. I do not see anyone complaining about the food. This is a step in making the meal healthier with the default option. Dr Kris-Etherton: This is what happened with the happy meals. Fewer calories were purchased and consumed after fruit and the 100 calorie fry became the default side item options rather than a typical serving of fries. Dr Brown: What are the beneficial effects of fiber in our diet? Dr Carson: It may make little difference in your low density lipoprotein (LDL) cholesterol, but I think it makes a fair difference in your overall calorie consumption. Dr Brown: Is this because of gastric filling? That could certainly be important, particularly in older people. It may also help in colonic function. However, I sometimes wonder if we are attributing more to this dietary component than it deserves. Dr Johnson: I think that really speaks to portion sizes. I want to make sure that we talk about a paper published on portion sizes in the American Journal of Public Health in April. The amounts served per person in restaurants are consistently greater than the calorie levels that are
Brown et al
Fast food and the American diet
recommended. So in restaurants we tend to order more than we need. The serving sizes of many popular combination meals could change dramatically if portion sizes were adjusted. The authors of this paper argue for the need for standardized portion sizes in restaurants. Dr Brown: What changes are restaurants making to deal with this issue of calories per meal? Dr Kris-Etherton: Because what is evolving is an uneven playing field. One restaurant chain decreased their portion sizes and decreased pricing as well. However, the price reduction was disproportionate (not as great) compared to the reduced portion size. They served a half portion for three fourths of the price. They lost sales, and so the smaller portions were not profitable and the menu items were discontinued. Dr Carson: People thought they were not getting their money’s worth. Dr Kris-Etherton: How often do you hear people say ‘‘go to this restaurant because you get so much to eat’’? Dr Brown: It seems clear that some restaurants use portion size to attract customers. Dr Johnson: Some research suggests that there are people who choose not to go out to eat because the portion sizes are so large. So that segment of the market could be missed. A restaurant chain called Seasons 52 has nothing on the menu more than 475 calories. They have been successful by focusing on flavor and limited portion sizes. Dr Carson: And they serve dessert in shot glasses. So they are basically 2 or 3 bites. Most are 200 to 300 calories. Dr Kris-Etherton: On the other hand, there are menu items that one thinks of as being healthy but that are actually very high in calories. Salads are sometimes ‘‘loaded’’ with high fat foods such as cheeses and processed meats and lots of dressing, all of which add calories, saturated fat, and sodium. Of note, is that Wendy’s offers a half salad. However, it is important to pay attention to what is on the salad and the amount of dressing that is added. Many quick serve restaurants offer an unlimited number of salad dressing packets. Dr Brown: I like this idea of serving a number of cheaper but smaller portions that you could mix as a part of your meals. Are there restaurants attempting to develop this, perhaps like the old Spanish custom of tapas meals. Dr Kris-Etherton: One of the ideas is to offer fruits and vegetables because they increase volume and decrease calories. Decreasing energy density can help people reduce calories consumed. Dr Brown: Do you believe that having some real research in this area to determine successful tactics would be helpful? I know that marketing studies are underway at all large fast food chains but they rarely publish this. They consider it totally proprietary and do not tell us what they have learned in a more generic sense. Dr Johnson: The main driver is that it has to taste good. I think combining the key features of fast, fresh, quick, healthy items is a growing theme in new restaurants.
7 Dr Kris-Etherton: Personalized sandwiches, burgers, burritos and salads, and so forth, made with the freshest array of ingredients is what everybody wants. If you go back to the basic Subway concept that’s been available for a long time. Consumers can select the vegetables they want and typically end up with more vegetables than would be on a standard hamburger. Dr Carson: Restaurants are popular where you select the ingredients and watch them assembled. You are not getting a tuna salad sandwich that has been sitting there a long time. The burrito at Chipotle is another example. At some places the burger has been sitting under the heat lamps for a while. Dr Kris-Etherton: We have standardized portion sizes for alcohol. When people consume a drink they know they are getting a certain amount of alcohol. So one gauges drinking and driving in terms of how many drinks they can have. There is some control whether it is beer, a glass of wine, or a shot of alcohol. But when each restaurant has their own serving standards and there are no broadly agreed on portion sizes across eating establishments, we are left in the dark about how many calories have been consumed. Dr Kris-Etherton: There are growing numbers of health and weight conscious consumers that affect the market. One example is the health conscious mothers who do not want to take their children to fast food restaurants. Twenty to 25 years ago it seemed to me that many parents were taking their kids to fast food restaurants. I think they still are very popular, but one of the things we have seen is that some parents have decided that a kid’s meal at a fast food restaurant is not the preferred option. This is not because they are paying attention to nutrition; rather, it is their perception of the nutritional quality of the food offered. Dr Brown: This would seem to be an opportunity for fast food purveyors not only to provide what the kids like with the happy meal and a small hamburger but also something that the mother can eat that will allow her to watch her weight. Dr Carson: Being creative with the salad options is an opportunity. Providing salad components so that you can add condiments in packets with calories labeled would be one approach. The nuts, raisins, croutons as well as the salad dressing in packets would allow this young mother to make decisions on calorie and nutrient content. Dr Brown: Your initial impression of a healthy item can be quite wrong if you are not educated about this issue. I would take my young children to McDonald’s for the hamburgers and order the fish sandwich for myself, thinking I was getting the healthiest thing on the menu. Then I found out the fish sandwich contained the highest calories of any sandwich on the menu. Breading and frying add calories like nothing else. Posting the calories in the store stopped that habit. Dr Johnson: Calorie posting was voluntary, now this is mandated under the Affordable Care Act. New regulations
8 require restaurants with at least 20 locations to display the calorie count of food items on their menus. Dr Carson: I know that calorie labeling has to be done as part of the Affordable Care Act if there are a certain number of outlets. So small delis and individual restaurants are exempt. There is some research on what difference menu-labeling makes. Anecdotally, I know of individuals who have conveyed that they stopped eating a menu item once they saw the number of calories it contained. This depends on the consumer. They are not 16-year-old boys. Dr Kris-Etherton: You’re right. I think a lot of people don’t know what the calorie count means. A friend of mine loves peach cobbler. At one of his favorite restaurants he saw that the peach cobbler had 1500 calories. He decided not to order it. He ordered a little bowl of ice cream instead because everybody ordered dessert. So he could translate 1500 calories to what his needs were, whereas most people don’t know that—they think this sandwich with 1000 calories is OK for lunch. They don’t have a clue what that means in terms of their total daily calorie needs. Dr Johnson: The research shows that it works for some people some of the time. It is quite variable depending on the demographics of the restaurant location. There’s really no harm in providing the calorie information, and I think it is one tool that we have in our toolbox as part of everything we need to do related to our obesity epidemic. Thus, I’m very supportive of calorie labeling. However, I think we need a massive and effective education program about energy intake and energy balance for the population. Believing that walking 2 miles will cause weight loss is common. Well, that’s only 200 calories and just a larger entree or a small dessert can easily provide that number of calories. Dr Carson: I am not sure if the fast food industry is paying attention to the Baby Boomers. I see more people in this cohort eating out and looking for affordable meals. These individuals are much more likely to be concerned about their LDL cholesterol, blood pressure, and glucose levels. Controlling body weight is a constant concern. They are trying to watch their sodium intake, portion sizes, and calories and their saturated fat intake. Thus, I think these are the people who are paying attention to the calorie postings on menus and changing their food purchasing behaviors. Dr Kris-Etherton: It might drive some reformulation like the trans-fats regulations did. People might be shocked by the number of calories in a single portion of certain foods, which may help guide food choice and eating behaviors. Dr Brown: I hope the fast food industry is actively studying and attempting to take into consideration this growing health consciousness. Are there imaginative and successful attempts to bring the wonderful flavors of ethnic foods into the fast food offerings? Pizza is an example of great flavor but a reversal to the wrong direction on almost every issue we have discussed.
Journal of Clinical Lipidology, Vol 9, No 1, February 2015 Dr Kris-Etherton: There are many fast food restaurants that focus on international cuisines such as Mexican, Italian, Chinese, and so forth. Some of these restaurants are more likely to serve fruits and vegetables. In some Asian restaurants, customers can personalize their stir-fry with lots of fresh vegetables. Dr Carson: I think you have to watch the sodium, though, in Asian restaurants. Dr Brown: Asian food tends to be high in sodium. It does. But, again, there are trade-offs here. I’m just wondering if we have to pay too much of a price with the sodium issue, particularly in younger people who are sweating and active. In older people, we must be concerned, particularly when you begin to have renal problems. So it’s hard to balance those issues. Dr Kris-Etherton: Well, it is. So, with a growing teenager who needs 3500 calories per day, it is going to be challenging for them to consume a diet that has 2300 mg of sodium in today’s food environment in the United States. Dr Johnson: To your question, it’s an emerging market, but the research on the food items at quick serve restaurants found that the top sources of calories are still pizza, burgers, sugar sweetened beverages, and sweetened grains. Dr Brown: Is pizza still growing in terms of volume of calories consumed? Dr Johnson: It’s in the salty six. So it is 1 of the top 6 sources of sodium in the American diet. Dr Brown: And saturated fat. How about that? Dr Kris-Etherton: Certainly, that is a good point about the saturated fat content of pizza. Pizza is the number 2 source of saturated fat in the American diet. It contributes about 6% of total calories from saturated fat. Clearly, different preparation methods and toppings can substantially change this. Dr Carson: Pizza is one example where additional calories are easily piled on. For instance, the cheese stuffed crust, or multiple meats like pepperoni, sausage, and bacon. Burgers that could be healthier are now doubled in size and cheese and even bacon are added. Dr Kris-Etherton: Those are the ones that are advertised. Dr Carson: Some are putting fries on top of the burger. Domino’s has its Frito pizza, a pizza with the Fritos on top. Dr Johnson: So what are we establishing in terms of the cultural norm? When you have seen these food items advertised in various media many times each day, it makes one think that this is an appropriate way to eat. That’s what bothers me about the marketing of these fast food items that are promoting the opposite of healthy eating. Dr Carson: And that’s my concern with the younger generation. I don’t believe they know what an appropriate portion size is. They’re used to being offered everything supersized and super rich in saturated fat. Dr Kris-Etherton: In Introductory Nutrition courses, students learn about Choosemyplate.gov and food portion
Brown et al
Fast food and the American diet
sizes. They are very surprised that a deck of cards is recommended as 1 serving of meat. Dr Carson: What’s happening then on the proposed new nutrition facts panel label is that serving sizes are changing. They are going to reflect what people are eating. So right now it might be 250 calories in a half cup of ice cream, but the new label would show it as 500 calories in 1 cup. Dr Brown: Another more positive role that the fast food industry might take is in promoting healthier items in their advertising. Are there examples where there is demonstrated effort to guide toward food items that have less of the undesirable components? Dr Johnson: There’s increasing pressure. We have celebrities who are promoting unhealthy food like that’s the norm. Then somehow we’ve connected it with athletic performance. Recently, a famous performer was paid tens of millions of dollars to promote a soft drink during halftime of the Super Bowl. It must be effective if it is worth so much money to a company. Dr Kris-Etherton: The fast food industry may put healthy foods as options on their menus, but they are not going to be the ‘‘stars’’ at this time. A major strategy that is making a difference is ‘‘stealth health’’ where sodium is decreased but this is not ‘‘trumpeted’’ to the consumer. If it is, the consumer will not like the new formulation. Thus, consumers are getting better nutrition without even knowing it. Dr Brown: Well you have made very important points. That is, it’s not just what you see when you walk into a restaurant. It’s what you’ve seen on television also that impacts what you put in your stomach. I believe that you feel that the fast food industry should become consistent and congruent in their advertising with a healthy menu offering. Dr Johnson: I went to a White House conference on food marketing to children. There is a big push for companies and media outlets to stop advertising junk food to kids. In the Scandinavian countries it’s illegal. You can’t do it. In this country, there are efforts to encourage voluntary bans on advertising junk food to children. With the new school nutrition regulations a beverage company can sponsor a scoreboard, for example, but it has to promote water not sugary drinks. It’s not just television. Food and beverage marketing to children is pervasive; it’s everywhere. It’s even on educational Web sites. Dr Kris-Etherton: What I would like to see is the promotion of healthy foods, a healthy happy meal along with physical activity—the kids on a bicycle or playing with a ball in some way so that they see both messages about good nutrition and physical activity. Dr Brown: How has the change to calorie restricted soft drinks helped in the effort to reduce total calories in fast food? Dr Carson: Unfortunately, 75% of Coca Cola is still the regular sugar sweetened variety. Dr Brown: I am amazed. Is it because people are suspicious about artificial sweeteners? Do they think they are
9 toxins? That they are not natural? There is little science documenting any harm. Dr Carson: Well, the latest study that just came out showed that artificial sweeteners are associated with a bad microbiome that makes you fat. Dr Johnson: It was an animal study, and animals may metabolize these sweeteners differently. The human arm of that study was very small; only 7 people. Four subjects showed changes in glucose tolerance. Dr Carson: So, it is an interesting study, but we definitely need more research before we act on this possible relationship. Dr Brown: For years people thought polyunsaturated fat caused cancer. It’s exactly the same issue. The studies involved animals on very bazaar diets with or without polyunsaturated fats added to the food. Human studies have failed to show harm. You can’t take animal data and apply it to human beings without appropriate further experiments. Dr Carson: The AHA has a scientific statement on artificial sweeteners. Dr Kris-Etherton: It is very carefully worded that sweeteners can play a role in helping to achieve and maintain a healthy weight if they are used prudently and there is not calorie compensation. Dr Brown: We must fight these biases. Our educational system seems so much less effective in preparing people for the real world with a rudimentary background in science. This leaves people subject to ideas that have no evidentiary basis. I want to thank our nutrition experts who have kindly shared their knowledge and experience regarding the contribution of the fast food industry to the American diet. The importance of this source of food cannot be denied. We all want to make progress in the reduction of vascular disease through every means possible and the nature of the food we eat remains a major area for improvement. The health consciousness of our population is in and of itself a powerful resource in changing the dietary habits and is helping to change the offerings at restaurants of all types. Improving the health education of our population is one important initiative in this process. The fast food industry in order to maintain their business must offer foods that are attractive in many ways. There seems little question that they will adjust their menu items to the desires of their customers. By using their powerful advertising efforts to guide our population to greater awareness of healthy choices could be one way to maintain both good business practices and to serve their customers in a more fundamental way over time.
Evolution of fast food: Recommended Reading 1. Jacobson MF, Havas S, McCarter R. Changes in sodium levels in processed and restaurant foods, 2005-2011. JAMA Intern Med. 2013; 173(14):1285–1291.
10 2. Bleich SN, Wolfson JA, Jarlenski MP. Calorie changes in chain restaurant menu items: implications for obesity and evaluations of menu labeling. Am J Prev Med. 2015;48:70–75. 3. Otten JJ, Hekler EB, Krukowski RA, et al. Food marketing to children through toys: response of restaurants to the first U.S. toy ordinance. Am J Prev Med. 2012;42(1):56–60. 4. Cohen DA, Story M. Mitigating the health risks of dining out: the need for standardized portion sizes in restaurants. Am J Public Health. 2014; 104(4):586–590.
Journal of Clinical Lipidology, Vol 9, No 1, February 2015 5. Drewnowski A, Rehm CD. Energy intakes of US children and adults by food purchase location and by specific food source. Nutr J. 2013;12(1):59. 6. Wansink B, Hanks AS. Calorie reductions and within-meal calorie compensation in children’s meal combos. Obesity (Silver Spring). 2014;22(3):630–632. 7. Gardner C, Wylie-Rosett J, Gidding SS, et al. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2012;126(4):509–519.
Clinical Lipidology Roundtable Discussion
JCL Roundtable: Fast Food and the American Diet W. Virgil Brown, MD*, Jo Ann S. Carson, PhD, RDN, FAHA, Rachel K. Johnson, PhD, MPH, RD, FAHA, Penny Kris-Etherton, PhD, RD, FAHA, FNLA Emory University School of Medicine, 3208 Habersham Rd., NW, Atlanta, GA 30305, USA (Dr Brown); Department of Clinical Nutrition, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390–8877, USA (Dr Carson); Department of Nutrition and Food Sciences, The University of Vermont, Burlington, VT 05405, USA (Dr Johnson); and Department of Nutritional Sciences, Pennsylvania State University, 110 Chandlee Laboratory, University Park, PA 16802, USA (Dr Kris-Etherton) KEYWORDS: Fast food; Nutrition; Heart disease; Saturated fat; Cholesterol
Abstract: The availability of food quickly prepared at lower cost and with consistent quality and convenience has made a variety of restaurant chains extremely popular. Commonly referred to as the fast food industry, these companies have stores on virtually every street corner in cities large and small. Fast foods contribute to energy intake, and depending on the food choices made, provide foods and nutrients that should be decreased in the diet. As Americans have become more conscious of their risk factors for heart disease and recognized eating patterns as a contributor to blood cholesterol levels, high blood pressure, obesity, and diabetes, the fast food industry has attempted to adjust their menus to provide more healthful choices. The Roundtable discussion in this issue of the Journal will focus on the importance of this industry as a source of foods that could help address our population-wide efforts to reduce cardiovascular disease. Ó 2015 National Lipid Association. All rights reserved.
Financial disclosures Dr Kris-Etherton was on the advisory board for the California Walnut Commission and received advisory board honoraria from McDonald’s Global Advisory Council. Drs Johnson and Carson have no disclosures to report.
This Roundtable was recorded on November 14, 2015, during the American Heart Association Scientific Sessions. Three expert academic nutritionists have kindly joined me to share their knowledge: Jo Ann Carson, PhD, RDN, FAHA (University of Texas Southwestern), Rachel K. Johnson, PhD, MPH, RD, FAHA (University of Vermont), and Penny Kris-Etherton, PhD, RD, FAHA, FNLA (Pennsylvania State University). All 3 have been major contributors to the dietary guidelines that have been issued by various organizations/agencies. * Corresponding author. E-mail address: [email protected] Submitted December 4, 2014. Accepted for publication December 4, 2014.
Dr Brown: Thank you for joining me and helping us to consider the opportunity offered by the ‘‘fast food’’ industry to continue improving the nutritional profile of our diets. Americans began to change their diets to reduce heart disease after the American Heart Association Dr Brown recognized the population-based research and made strong recommendations regarding reduction of saturated fat and cholesterol in our diet some 50 years ago. We are still on that journey and continued improvement is possible. I would like for you all to comment on your estimation of the size of the contribution possible from ‘‘quick serve’’ or ‘‘fast food’’ outlets. Keeping in mind that a quick serve restaurant is one characterized by its fast food cuisine and minimal table service, what is your estimate of the actual contribution of calories provided from fast food outlets to the average American adult or child?
1933-2874/$ - see front matter Ó 2015 National Lipid Association. All rights reserved. http://dx.doi.org/10.1016/j.jacl.2014.12.002
4 Dr Rachel Johnson: The National Health and Nutrition Examination Survey (NHANES) data report that it is somewhere between 10% and 20%. It varies by age with children who are 6 to 11 years old obtaining an average of Dr Rachel Johnson about 12% of their total energy intake from fast food. Teenagers get the most, an average of 18%, whereas on average people over age 50 consume only 8-9% of their calories from fast food outlets. Those are the percentages based on a recent NHANES analysis. These are average values but there’s a large variation in calories consumed from fast food. There are income and racial disparities in terms of the amount of calories that are consumed in fast food with the lower income groups, African Americans, and Mexican Americans consuming higher amounts. Another concern is that the nutrient composition of the fast food consumed is quite different from other components of the food supply in America. There are higher amounts of saturated fat and added sugars from fast food. Thus, we should look at the nutrient breakdown as well as total calories contributed from any given source. Dr Brown: It is clear that there is a range of values for different companies and different menu items. Focusing on the entire meal, can we derive an estimate of the percentage of saturated fat in the average major food items served at popular outlets? Dr Johnson: When you look at food sources and quick serve restaurants, the highest percent of total calories comes from pizza, sugary drinks, potatoes, and cheese. Dr Brown: The meals could vary in saturated fat calories from 10 to 30% percent? Dr Johnson: Right. It obviously comes down to consumer choice. So it is possible to get a fairly healthy meal in many of these quick serve restaurants. This can be driven by what and how the food items are marketed to consumers. Dr Brown: There is a common belief that these quick serve restaurants do indeed make a significant contribution to unhealthy components in our diet. That they not only load us with saturated fat and cholesterol but are high in sodium, as well. Their offerings are believed to be deficient in important nutrients such as potassium, calcium, and fiber. So when you look at the entire fast food industry is this a fair assessment? Are these restaurants a major contributor to a less healthful food intake than the remainder of the American diet? Dr Johnson: For some people who eat fast food frequently, they are getting more sodium and more saturated fat than are recommended. Dr Carson: Let’s consider the 8.6% of daily energy that fast food contributes to the diet of adults who are 51 years or age or older. That portion of their food intake may contribute significantly more Dr Carson
Journal of Clinical Lipidology, Vol 9, No 1, February 2015 than 8.6% of their sodium and saturated fat and perhaps less of their vitamin and mineral intake. Dr Johnson: That leads me to a fascinating paper on calorie changes in chain restaurant menu items. The researchers surveyed 19,417 items. What they found was that when new menu items were introduced that provided lower calorie options they tended to be items that were not core to the restaurants’ customer base and mean calorie consumption did not change. These restaurant chains are introducing new and potentially more healthful items, but the core is still hamburgers, French fries, pizzas, and soft drinks and that volume is maintained. Dr Brown: How can we suggest improvements in those core items that are the center piece of their sales? Dr Johnson: I would rather critique what they market and how they market. Such as including toys in unhealthy children’s meals as a marketing technique. Dr Brown: Are they succeeding in selling less healthy food by doing that? Dr Johnson: They’re succeeding in promoting these foods. Dr Brown: My question is what they are putting in peoples’ stomachs. Dr Kris-Etherton: Okay. Let’s look at the nutritional profile of kid’s meals in quick serve restaurants. A good example is McDonald’s. They have decreased calories in the Happy Meal by cutting the serving size of the fries. They are now 100 calories, which is a Dr Kris-Etherton 50 calorie reduction. Dr Brown: Have they changed calories in other ways? Dr Kris-Etherton: They’ve changed the fat. It used to be tallow. Then it was switched to hydrogenated oils, which were high in trans-fat. Now they use vegetable oil that is trans-fat free. I think that’s a significant improvement in terms of the saturated and trans-fat content. French fries are healthier now because they are no longer fried in partially hydrogenated oil. Of course, the American diet has improved in terms of trans-fats. It’s not because Americans said I’m going to stop eating French fries. Rather, this has happened because of changes in food preparation. Dr Carson: Because their reach is so huge, these represent tremendous changes that are possible in populationbased nutrients. Dr Brown: That is why this is important. Dr Kris-Etherton: The fast food industry is experimenting with changes that could lower calories, saturated fat, and salt. They have tried a number of different strategies but many do not stay on their menus. An example of this is Satisfries that were prepared with less fat. If this product had been accepted by consumers, it would have positively affected the ‘‘French fry world’’ and led to beneficial changes in the standard French fry formulation. In turn, this would have had a beneficial effect on the diet. But this is not what happened. Consumers did not purchase the product and it was withdrawn from the market.
Brown et al
Fast food and the American diet
Dr Johnson: In a publication reporting on changes in food composition in 70 fast food restaurants, sodium increased by 2.6% from 2005 to 2011. During that period, no progress was made in terms of sodium. In the European Union, sodium limits are mandated in processed foods so there’s a level playing field. We know that over time consumer taste can adapt. But if the restaurant down the street is serving fries or pizza with a certain level of sodium and you attempt to lower the sodium in your meals, you lose the competition on taste and you lose your customer base. There is this natural tension with voluntary changes that are market driven. Some believe that regulatory changes are necessary to reduce sodium levels in the restaurant industry, particularly in these large chains that feed millions of people with a standard menu. It would seem to be most important to have nutrient standards for meals with toys that are marketed for children. Dr Brown: One might put the toys in foods that are the most healthful? Dr Johnson: In Santa Clara County, California they passed an ordinance that says the meals have to meet certain nutrient standards in order for them to include a free toy. They can sell the toys, but they can’t include them for free unless the meals meet certain standards in terms of nutrient quality. Dr Brown: Do we know whether that is successful? Dr Johnson: It appeared to positively influence marketing of healthful items as well as toy distribution practices at restaurants affected by this ordinance but did not affect the number of healthful food items offered. They didn’t really change their menu. They just stopped offering the toys. Dr Brown: How much sodium is contributed to the diet from this industry? Do we have figures on that as well? Dr Kris-Etherton: The number one source of sodium in the US diet is bread. I was talking to the nutritionists at McDonald’s, and asked if there is any way to decrease the amount of sodium in their quarter pounder. The major problem is the bun, not the condiments, cheese, and added salt (during preparation of the burger). Dr Carson: Or they could reduce the size of the bun. That’s something that I’ve noticed some attempting. Dr Kris-Etherton: Some fast food chains provide options for less bread for people who are concerned about carbohydrate calories. In so doing, less bread equates to less sodium. Dr Brown: So there is ongoing work on the sodium issue. Do you think that there is progress? Dr Johnson: Not according to the publication I mentioned before. That was published in 2013. Dr Kris-Etherton: Well, I am thinking about the efforts of the American Heart Association with their Heart-Check Program and their program to certify restaurant foods. We have seen that some companies are reducing the sodium content of their foods. It is not as low as our goal but there are efforts ongoing that are in the right direction. I just came from the Healthier Diet Business Management Committee meeting, and there are a number of examples now where the American Heart Association has certain
5 standards for sodium. The fast food industry was saying we just can’t achieve these goals. Surprisingly, 6 months to a year later some have reached the targets. One example is Subway. All of their meat, for the most part, is high in sodium, but they were able to ratchet some down to be part of an exclusive partnership with American Heart Association to promote a healthy Subway meal. Dr Johnson: I think the American Heart Association (AHA) Heart-Check program is a tremendous success story. Consumers trust the Heart-Check mark. Consumers look to AHA to be science-based. Subway reformulated some menu items to meet the AHA Heart-Check standards. That was a great win-win, I think. Dr Kris-Etherton: For the individual customer, the sugar content is driven largely by purchase decisions (eg, soft drinks). Many fast food restaurants have a number of items on their menu that meet the saturated fat goal. Meeting the sodium goals has proven to be more challenging. Dr Brown: Do we know how these alterations change the number of these items that are ordered and consumed? Dr Kris-Etherton: Well, in fact, some statistics show an uptick on the Heart-Check items by about as much as 20%, especially in certain population groups like Hispanics. But I think there is often initial resistance on the part of customers. There are many examples where restaurants have designated heart healthy foods on the menus, and sales of the healthier items have been sluggish. Then heart healthy items were quickly exited off the menu because few would order them. So maybe the environment has changed in recent years. Dr Johnson: Subway is one of those restaurants that has a health halo. So it may be driving the consumer base that goes into the restaurant to begin with. Dr Carson: I can see a consumer saying, ‘‘I am going to this restaurant because they have healthy food.’’ Sometimes they may not pick the healthiest menu items, but if they pick that restaurant because it offered healthy food choices, they are more likely to look for a healthy choice. Dr Kris-Etherton: I believe many people go to some ethnic restaurants because they believe they are healthy. Chipotle is an example where you can create a meal that is essentially vegetarian but when you analyze what many people add in building their burrito, the nutrient content frequently does not meet the definition of a healthy meal. Personal taste will continue to drive food choices that are based on familiar flavors that reflect habitual consumption of sodium, sugar, and fat. Dr Johnson: Brian Wansink from Cornell has studied this health halo issue around food choices. People will go in thinking that something is healthy, but it actually may not be. It can work in reverse. The McDonald’s plain hamburger may be acceptable in terms of calories and saturated fat and might be much better than other menu items that have a health halo. Dr Brown: Could you give us an overview of the HeartCheck program?
6 Dr Kris-Etherton: There is the standard Heart-Check program, which has been in existence since 1995. It started with criteria that food companies could implement so they could have the Heart-Check ‘‘stamp’’ on their food. Perhaps we should review what’s happened over the years? Dr Johnson: The criteria for the Heart-Check front-ofpack program have been updated to reflect emerging science, and the new criteria went into effect in January of 2014. So we now have a categorical approach to sodium based on food category items. For example, main courses have a higher sodium level than side dishes. We also have sugar limits on cereals, for example. If the cereal is an excellent source of fiber, the sugar content can be a little higher than a cereal with less fiber. Dr Brown: Are other restaurant chains attempting to modify their menu items in conjunction with volunteer health agencies such as the AHA? Dr Carson: At this point you only have Subway. So, Penny, you could speak to the problem from the Dietary Guidelines. Dr Kris-Etherton: So what are the nutrients of concern beyond fat, sugar and sodium? They are potassium, calcium, vitamin D, and dietary fiber. Dr Brown: Is calcium deficiency a problem and one being addressed in quick serve restaurants? Dr Johnson: Well, we don’t have a standard that specifically recommends a certain amount of calcium. Dr Kris-Etherton: Or potassium—that might be one that could also be addressed. What I would like to see is a nutrient density score that takes into account the entire nutrient profile. Dr Johnson: In terms of participation in the American Heart Association Heart-Check, it’s one thing to be eligible. It’s another thing for a company to decide to participate in this voluntary program. Dr Johnson: We recognized that most people are not going to eat a fat-free plain unflavored yogurt, so we set a calorie limit on the 6 ounce size of yogurt, which then automatically sets a cap on the amount of sugars that can be added. We feel it’s a very nutrient-rich food, high in calcium, potassium, and protein, and many are vitamin D fortified. We did the same thing with fish, for example, because we want to promote fish consumption because of the omega-3 fatty acids. But we learned that canned fish such as tuna fish may have a substantial amount of sodium. Some sodium has to be there from a food safety perspective. So we set the sodium limits keeping in mind that we want to promote consumption of fish. Dr Brown: We may need a little more sodium to get more fish in the diet. Fish provides a source of food that in epidemiologic studies has been shown to be related to lower vascular disease prevalence even if it doesn’t have significant omega-3 fatty acids in it. Dr Brown: Have we over-emphasized sodium restriction for the general population, particularly for young healthy people with normal kidney function?
Journal of Clinical Lipidology, Vol 9, No 1, February 2015 Dr Kris-Etherton: When you look at age-related changes in high blood pressure (ie, hypertension) you see that it increases with age. Greater than 72% of people 75 years and older in the US have high blood pressure. Dr Brown: Older people are definitely more sensitive to high sodium intakes. Blood vessels tend to become less compliant and kidney function declines with age. Dr Kris-Etherton: The other argument is that there are populations that have lifelong low sodium intakes and do not develop high blood pressure like we do in the US. Dr Brown: But they are not as obese, and often are more active, eat low saturated fat and lower caloric diets. Would you not agree that excess body fat appears to be more important than sodium in blood pressure onset? However, I agree that there is a very sizable number of people who are sensitive to salt regarding their blood pressure. Dr Kris-Etherton: Certainly, excess body fat is a major contributor to high blood pressure. Of note, relative to helping consumers control calories is that the calorie value of a quick serve meal has decreased by about 100 calories in recent years. Dr Brown: That sounds like progress. Dr Johnson: The study I was talking about is a supply side study where they looked at the mean calories on menu items. So with some of these things you have to understand dietary assessment methods. With NHANES you have selfreported intakes that tend to be under-reported. Dr Carson: A very positive change in the restaurant industry is that the default choice is the healthier choice. Years ago whole milk was the default option in many fast food restaurants. Now the default choice is 1% or 2% milk. For example, at Disney World milk and fruit are the default options for the children’s meals (and not a soft drink and fries). I have watched families in quick serve restaurants order the equivalent of the kid’s meal. The child gets milk and grapes instead of fries and a soda. I do not see anyone complaining about the food. This is a step in making the meal healthier with the default option. Dr Kris-Etherton: This is what happened with the happy meals. Fewer calories were purchased and consumed after fruit and the 100 calorie fry became the default side item options rather than a typical serving of fries. Dr Brown: What are the beneficial effects of fiber in our diet? Dr Carson: It may make little difference in your low density lipoprotein (LDL) cholesterol, but I think it makes a fair difference in your overall calorie consumption. Dr Brown: Is this because of gastric filling? That could certainly be important, particularly in older people. It may also help in colonic function. However, I sometimes wonder if we are attributing more to this dietary component than it deserves. Dr Johnson: I think that really speaks to portion sizes. I want to make sure that we talk about a paper published on portion sizes in the American Journal of Public Health in April. The amounts served per person in restaurants are consistently greater than the calorie levels that are
Brown et al
Fast food and the American diet
recommended. So in restaurants we tend to order more than we need. The serving sizes of many popular combination meals could change dramatically if portion sizes were adjusted. The authors of this paper argue for the need for standardized portion sizes in restaurants. Dr Brown: What changes are restaurants making to deal with this issue of calories per meal? Dr Kris-Etherton: Because what is evolving is an uneven playing field. One restaurant chain decreased their portion sizes and decreased pricing as well. However, the price reduction was disproportionate (not as great) compared to the reduced portion size. They served a half portion for three fourths of the price. They lost sales, and so the smaller portions were not profitable and the menu items were discontinued. Dr Carson: People thought they were not getting their money’s worth. Dr Kris-Etherton: How often do you hear people say ‘‘go to this restaurant because you get so much to eat’’? Dr Brown: It seems clear that some restaurants use portion size to attract customers. Dr Johnson: Some research suggests that there are people who choose not to go out to eat because the portion sizes are so large. So that segment of the market could be missed. A restaurant chain called Seasons 52 has nothing on the menu more than 475 calories. They have been successful by focusing on flavor and limited portion sizes. Dr Carson: And they serve dessert in shot glasses. So they are basically 2 or 3 bites. Most are 200 to 300 calories. Dr Kris-Etherton: On the other hand, there are menu items that one thinks of as being healthy but that are actually very high in calories. Salads are sometimes ‘‘loaded’’ with high fat foods such as cheeses and processed meats and lots of dressing, all of which add calories, saturated fat, and sodium. Of note, is that Wendy’s offers a half salad. However, it is important to pay attention to what is on the salad and the amount of dressing that is added. Many quick serve restaurants offer an unlimited number of salad dressing packets. Dr Brown: I like this idea of serving a number of cheaper but smaller portions that you could mix as a part of your meals. Are there restaurants attempting to develop this, perhaps like the old Spanish custom of tapas meals. Dr Kris-Etherton: One of the ideas is to offer fruits and vegetables because they increase volume and decrease calories. Decreasing energy density can help people reduce calories consumed. Dr Brown: Do you believe that having some real research in this area to determine successful tactics would be helpful? I know that marketing studies are underway at all large fast food chains but they rarely publish this. They consider it totally proprietary and do not tell us what they have learned in a more generic sense. Dr Johnson: The main driver is that it has to taste good. I think combining the key features of fast, fresh, quick, healthy items is a growing theme in new restaurants.
7 Dr Kris-Etherton: Personalized sandwiches, burgers, burritos and salads, and so forth, made with the freshest array of ingredients is what everybody wants. If you go back to the basic Subway concept that’s been available for a long time. Consumers can select the vegetables they want and typically end up with more vegetables than would be on a standard hamburger. Dr Carson: Restaurants are popular where you select the ingredients and watch them assembled. You are not getting a tuna salad sandwich that has been sitting there a long time. The burrito at Chipotle is another example. At some places the burger has been sitting under the heat lamps for a while. Dr Kris-Etherton: We have standardized portion sizes for alcohol. When people consume a drink they know they are getting a certain amount of alcohol. So one gauges drinking and driving in terms of how many drinks they can have. There is some control whether it is beer, a glass of wine, or a shot of alcohol. But when each restaurant has their own serving standards and there are no broadly agreed on portion sizes across eating establishments, we are left in the dark about how many calories have been consumed. Dr Kris-Etherton: There are growing numbers of health and weight conscious consumers that affect the market. One example is the health conscious mothers who do not want to take their children to fast food restaurants. Twenty to 25 years ago it seemed to me that many parents were taking their kids to fast food restaurants. I think they still are very popular, but one of the things we have seen is that some parents have decided that a kid’s meal at a fast food restaurant is not the preferred option. This is not because they are paying attention to nutrition; rather, it is their perception of the nutritional quality of the food offered. Dr Brown: This would seem to be an opportunity for fast food purveyors not only to provide what the kids like with the happy meal and a small hamburger but also something that the mother can eat that will allow her to watch her weight. Dr Carson: Being creative with the salad options is an opportunity. Providing salad components so that you can add condiments in packets with calories labeled would be one approach. The nuts, raisins, croutons as well as the salad dressing in packets would allow this young mother to make decisions on calorie and nutrient content. Dr Brown: Your initial impression of a healthy item can be quite wrong if you are not educated about this issue. I would take my young children to McDonald’s for the hamburgers and order the fish sandwich for myself, thinking I was getting the healthiest thing on the menu. Then I found out the fish sandwich contained the highest calories of any sandwich on the menu. Breading and frying add calories like nothing else. Posting the calories in the store stopped that habit. Dr Johnson: Calorie posting was voluntary, now this is mandated under the Affordable Care Act. New regulations
8 require restaurants with at least 20 locations to display the calorie count of food items on their menus. Dr Carson: I know that calorie labeling has to be done as part of the Affordable Care Act if there are a certain number of outlets. So small delis and individual restaurants are exempt. There is some research on what difference menu-labeling makes. Anecdotally, I know of individuals who have conveyed that they stopped eating a menu item once they saw the number of calories it contained. This depends on the consumer. They are not 16-year-old boys. Dr Kris-Etherton: You’re right. I think a lot of people don’t know what the calorie count means. A friend of mine loves peach cobbler. At one of his favorite restaurants he saw that the peach cobbler had 1500 calories. He decided not to order it. He ordered a little bowl of ice cream instead because everybody ordered dessert. So he could translate 1500 calories to what his needs were, whereas most people don’t know that—they think this sandwich with 1000 calories is OK for lunch. They don’t have a clue what that means in terms of their total daily calorie needs. Dr Johnson: The research shows that it works for some people some of the time. It is quite variable depending on the demographics of the restaurant location. There’s really no harm in providing the calorie information, and I think it is one tool that we have in our toolbox as part of everything we need to do related to our obesity epidemic. Thus, I’m very supportive of calorie labeling. However, I think we need a massive and effective education program about energy intake and energy balance for the population. Believing that walking 2 miles will cause weight loss is common. Well, that’s only 200 calories and just a larger entree or a small dessert can easily provide that number of calories. Dr Carson: I am not sure if the fast food industry is paying attention to the Baby Boomers. I see more people in this cohort eating out and looking for affordable meals. These individuals are much more likely to be concerned about their LDL cholesterol, blood pressure, and glucose levels. Controlling body weight is a constant concern. They are trying to watch their sodium intake, portion sizes, and calories and their saturated fat intake. Thus, I think these are the people who are paying attention to the calorie postings on menus and changing their food purchasing behaviors. Dr Kris-Etherton: It might drive some reformulation like the trans-fats regulations did. People might be shocked by the number of calories in a single portion of certain foods, which may help guide food choice and eating behaviors. Dr Brown: I hope the fast food industry is actively studying and attempting to take into consideration this growing health consciousness. Are there imaginative and successful attempts to bring the wonderful flavors of ethnic foods into the fast food offerings? Pizza is an example of great flavor but a reversal to the wrong direction on almost every issue we have discussed.
Journal of Clinical Lipidology, Vol 9, No 1, February 2015 Dr Kris-Etherton: There are many fast food restaurants that focus on international cuisines such as Mexican, Italian, Chinese, and so forth. Some of these restaurants are more likely to serve fruits and vegetables. In some Asian restaurants, customers can personalize their stir-fry with lots of fresh vegetables. Dr Carson: I think you have to watch the sodium, though, in Asian restaurants. Dr Brown: Asian food tends to be high in sodium. It does. But, again, there are trade-offs here. I’m just wondering if we have to pay too much of a price with the sodium issue, particularly in younger people who are sweating and active. In older people, we must be concerned, particularly when you begin to have renal problems. So it’s hard to balance those issues. Dr Kris-Etherton: Well, it is. So, with a growing teenager who needs 3500 calories per day, it is going to be challenging for them to consume a diet that has 2300 mg of sodium in today’s food environment in the United States. Dr Johnson: To your question, it’s an emerging market, but the research on the food items at quick serve restaurants found that the top sources of calories are still pizza, burgers, sugar sweetened beverages, and sweetened grains. Dr Brown: Is pizza still growing in terms of volume of calories consumed? Dr Johnson: It’s in the salty six. So it is 1 of the top 6 sources of sodium in the American diet. Dr Brown: And saturated fat. How about that? Dr Kris-Etherton: Certainly, that is a good point about the saturated fat content of pizza. Pizza is the number 2 source of saturated fat in the American diet. It contributes about 6% of total calories from saturated fat. Clearly, different preparation methods and toppings can substantially change this. Dr Carson: Pizza is one example where additional calories are easily piled on. For instance, the cheese stuffed crust, or multiple meats like pepperoni, sausage, and bacon. Burgers that could be healthier are now doubled in size and cheese and even bacon are added. Dr Kris-Etherton: Those are the ones that are advertised. Dr Carson: Some are putting fries on top of the burger. Domino’s has its Frito pizza, a pizza with the Fritos on top. Dr Johnson: So what are we establishing in terms of the cultural norm? When you have seen these food items advertised in various media many times each day, it makes one think that this is an appropriate way to eat. That’s what bothers me about the marketing of these fast food items that are promoting the opposite of healthy eating. Dr Carson: And that’s my concern with the younger generation. I don’t believe they know what an appropriate portion size is. They’re used to being offered everything supersized and super rich in saturated fat. Dr Kris-Etherton: In Introductory Nutrition courses, students learn about Choosemyplate.gov and food portion
Brown et al
Fast food and the American diet
sizes. They are very surprised that a deck of cards is recommended as 1 serving of meat. Dr Carson: What’s happening then on the proposed new nutrition facts panel label is that serving sizes are changing. They are going to reflect what people are eating. So right now it might be 250 calories in a half cup of ice cream, but the new label would show it as 500 calories in 1 cup. Dr Brown: Another more positive role that the fast food industry might take is in promoting healthier items in their advertising. Are there examples where there is demonstrated effort to guide toward food items that have less of the undesirable components? Dr Johnson: There’s increasing pressure. We have celebrities who are promoting unhealthy food like that’s the norm. Then somehow we’ve connected it with athletic performance. Recently, a famous performer was paid tens of millions of dollars to promote a soft drink during halftime of the Super Bowl. It must be effective if it is worth so much money to a company. Dr Kris-Etherton: The fast food industry may put healthy foods as options on their menus, but they are not going to be the ‘‘stars’’ at this time. A major strategy that is making a difference is ‘‘stealth health’’ where sodium is decreased but this is not ‘‘trumpeted’’ to the consumer. If it is, the consumer will not like the new formulation. Thus, consumers are getting better nutrition without even knowing it. Dr Brown: Well you have made very important points. That is, it’s not just what you see when you walk into a restaurant. It’s what you’ve seen on television also that impacts what you put in your stomach. I believe that you feel that the fast food industry should become consistent and congruent in their advertising with a healthy menu offering. Dr Johnson: I went to a White House conference on food marketing to children. There is a big push for companies and media outlets to stop advertising junk food to kids. In the Scandinavian countries it’s illegal. You can’t do it. In this country, there are efforts to encourage voluntary bans on advertising junk food to children. With the new school nutrition regulations a beverage company can sponsor a scoreboard, for example, but it has to promote water not sugary drinks. It’s not just television. Food and beverage marketing to children is pervasive; it’s everywhere. It’s even on educational Web sites. Dr Kris-Etherton: What I would like to see is the promotion of healthy foods, a healthy happy meal along with physical activity—the kids on a bicycle or playing with a ball in some way so that they see both messages about good nutrition and physical activity. Dr Brown: How has the change to calorie restricted soft drinks helped in the effort to reduce total calories in fast food? Dr Carson: Unfortunately, 75% of Coca Cola is still the regular sugar sweetened variety. Dr Brown: I am amazed. Is it because people are suspicious about artificial sweeteners? Do they think they are
9 toxins? That they are not natural? There is little science documenting any harm. Dr Carson: Well, the latest study that just came out showed that artificial sweeteners are associated with a bad microbiome that makes you fat. Dr Johnson: It was an animal study, and animals may metabolize these sweeteners differently. The human arm of that study was very small; only 7 people. Four subjects showed changes in glucose tolerance. Dr Carson: So, it is an interesting study, but we definitely need more research before we act on this possible relationship. Dr Brown: For years people thought polyunsaturated fat caused cancer. It’s exactly the same issue. The studies involved animals on very bazaar diets with or without polyunsaturated fats added to the food. Human studies have failed to show harm. You can’t take animal data and apply it to human beings without appropriate further experiments. Dr Carson: The AHA has a scientific statement on artificial sweeteners. Dr Kris-Etherton: It is very carefully worded that sweeteners can play a role in helping to achieve and maintain a healthy weight if they are used prudently and there is not calorie compensation. Dr Brown: We must fight these biases. Our educational system seems so much less effective in preparing people for the real world with a rudimentary background in science. This leaves people subject to ideas that have no evidentiary basis. I want to thank our nutrition experts who have kindly shared their knowledge and experience regarding the contribution of the fast food industry to the American diet. The importance of this source of food cannot be denied. We all want to make progress in the reduction of vascular disease through every means possible and the nature of the food we eat remains a major area for improvement. The health consciousness of our population is in and of itself a powerful resource in changing the dietary habits and is helping to change the offerings at restaurants of all types. Improving the health education of our population is one important initiative in this process. The fast food industry in order to maintain their business must offer foods that are attractive in many ways. There seems little question that they will adjust their menu items to the desires of their customers. By using their powerful advertising efforts to guide our population to greater awareness of healthy choices could be one way to maintain both good business practices and to serve their customers in a more fundamental way over time.
Evolution of fast food: Recommended Reading 1. Jacobson MF, Havas S, McCarter R. Changes in sodium levels in processed and restaurant foods, 2005-2011. JAMA Intern Med. 2013; 173(14):1285–1291.
10 2. Bleich SN, Wolfson JA, Jarlenski MP. Calorie changes in chain restaurant menu items: implications for obesity and evaluations of menu labeling. Am J Prev Med. 2015;48:70–75. 3. Otten JJ, Hekler EB, Krukowski RA, et al. Food marketing to children through toys: response of restaurants to the first U.S. toy ordinance. Am J Prev Med. 2012;42(1):56–60. 4. Cohen DA, Story M. Mitigating the health risks of dining out: the need for standardized portion sizes in restaurants. Am J Public Health. 2014; 104(4):586–590.
Journal of Clinical Lipidology, Vol 9, No 1, February 2015 5. Drewnowski A, Rehm CD. Energy intakes of US children and adults by food purchase location and by specific food source. Nutr J. 2013;12(1):59. 6. Wansink B, Hanks AS. Calorie reductions and within-meal calorie compensation in children’s meal combos. Obesity (Silver Spring). 2014;22(3):630–632. 7. Gardner C, Wylie-Rosett J, Gidding SS, et al. Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2012;126(4):509–519.