Exploring Restaurant Nutrition: A Growing Part of the Diet

September 10, 2008

Sonia Angell, MD, MPHDirector, Cardiovascular Disease Prevention and Control ProgramLynn D. Silver, MD, MPHAssistant Commissioner, Chronic Disease Prevention & Control

NYC Department of Health & Mental Hygiene

People Are Eating Out More

• Expenditure on foods eaten away from home increased since 1960.

Eating Out Is Associated with Obesity

• Calorie Intake Increasing – 200 calories/dayincrease from 1977 to 1996.

• ~1/3 of our calorie intake comes from food prepared outside the home

• Eating out is associated with higher calorie intake and obesity– Children eat almost twice as many calories in

restaurant meals compared to meals at home (770 vs. 420 calories)

The Food Industry:Individual Responsible

• “No unhealthy food, only unhealthy choices”

OR• “It’s lack of physical activity that tips the

calorie expenditure balance”OR• “We need more studies”

Suppose 19th Century Public Health Experts Focused on Behavior?

• “Responsible people boil water”• “Know your butcher”• “Get fresh air”• “Avoid crowds”• “Keep a tidy house”• “Take care of your refuse”

Is This a Food Safety Issue?

Is This a Food Safety Issue?Obesity Trends* Among U.S. Adults

BRFSS, 2007

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Shifting to a Healthier Food Environment

NYC’s Approach to the Problem:Make healthy food the default,

a not a niche

“Healthy food” vs. “health food”

Key issues when thinking about food in restaurants:

the good

the bad

Changing Restaurant Foods to Reduce Chronic Disease

Progress to date in NYC:

Trans fat Menu Posting

79% ArtificialSource: Partially Hydrogenated VegetableOil

21% Naturally OccurringSource: Meat and Dairy Products

Gram For Gram: Most Dangerous Dietary Fat

Source: FDA Consumer magazine. September-October 2003 Issue. Pub No. FDA04-1329C

Average daily intake 2.6% of total calories (approx 5.8 grams)

Data Source: http://www.fda.gov/fdac/features/2003/503_fats.html

Major Food Sources of Artificial Trans Fat for American Adults

Household Shortening

5%Potato Chips, Corn Chips,

Popcorn6%

Fried Potatoes10%

Margarine22%

Other6%

Cakes, Cookies, Crackers, Pies,

Bread, etc.51%

Major Food Sources of Artificial Trans Fat for U.S. Adults

Denmark: 1st Country to Restrict Trans Fat

• March 2003: Denmark issued new regulations limiting the amount of trans fat in all industrially processed foods.

• Processed food can only contain 2% of trans fat for every 100 grams of fat.

Trans Fat Still Invisible in Food Service

• Food labeling led to massive reformulation of grocery store products by 2006

• BUT…restaurants & bakeries continued to widely use products containing trans fat

Like lead in paint, it’s invisible, dangerous, unnecessary and

won’t be missed

• Unavoidable in Restaurants

• Replaceable

• Policy to Phase Out Use is Feasible

Reducing Heart Disease Risk in NYC§81.08 Foods Containing Artificial Trans Fat.• Prohibited all foods containing

artificial trans fat (>0.5gm per serving) in restaurants

• Effective: July 1, 2007 for oils, shortenings and margarines containing artificial trans fat that are used for frying or in spreads.July 1, 2008 for oils or shortenings used for deep frying of yeast dough or cake batter, and all other foods containing artificial trans fat:

Trans Fat Regulation Spread

NYC’s Trans Fat Restriction:Success!

• In June 2008, 99% of FSEs inspected were in compliance with the first phase

• Violations largely due to failure to order new products, not technical difficulties with product reformulation or supply issues.

• Many companies shifting over nationally, following earlier lead of grocery manufacturers

• 2nd phase began July 1, 2008

Calorie Labeling in NYC

1. Consumers underestimate calories in restaurant food and over consume

2. Availability of calorie information leads to healthier choices

Lots of Calories…Little Information

• Except at Subway, only 4% of patrons reported seeing calorie information as currently provided

Does nutrition information on a tray liner work? According to our study, not as much as fast food chains would like you to believe.

Bassett MT, Dumanovsky T, Huang C, Silver LD, Young C, Nonas C, Matte T, Chideya S, Frieden TR. Purchasing Behavior and Calorie Information at Fast-Food Chains in New York City, 2007. American Journal of Public Health, 2008;98:1457-1459.

Calorie Information Makes a Difference in Amount People Eat

Bassett MT, Dumanovsky T, Huang C, Silver LD, Young C, Nonas C, Matte T, Chideya S, Frieden TR. Purchasing Behavior and Calorie Information at Fast-Food Chains in New York City, 2007. American Journal of Public Health, 2008;98:1457-1459.

NYC Calorie Labeling Regulation

• Round # 1 2006 rule – based on voluntary disclosure. Judge ruled it preempted but reaffirmed local governments right to require posting

• Round #2 – 2008 Rule - applies to all chains with >= 15 locations. NYSRA sues again, judicial decision favorable for City, appeal pending. The law is in effect.

What is in the law:

• Applies to all chains with > 15 locations nationally

• Calories must be posted prominently on menu boards and menus is association with menu item

• Calories must be posted on item tags as well where present

• Calories must be posted for combos

NYC Now Has Calorie Information Posted!

Starbucks, 2008

Chipotle, 2008

Most Covered FSE’s Have Posted Calories

McDonald’s, July 21, 2008

Preliminary Signs of Menu Reformulations…

Success Already…“Some restaurants have had their own sticker shock and started offering lighter options. Cosi had a nutritionist look for ways to save on every item. Switching to low fat mayo brought the Cosi Club from nearly 800 calories to 447… “Having to post this information in New York really focused us on paying attention as well”says Chris Carroll, the chain’s chief marketing officer”

- Wall Street Journal July 29, 2008

Estimated Impact of Calorie Posting Regulation in NYC

• If calorie reduction in covered FSEs is similar to Subway’s reduction, over the next 5 years: – at least 150,000 fewer New

Yorkers would be obese, leading to

– at least 30,000 fewer cases of diabetes,

– and many other health benefits

Calorie Labeling from Coast to Coast

Future Challenges:Sodium

Saturated FatPortion Sizes

Ubiquity

High Blood Pressure Leads to Heart Attack and Stroke

• One quarter of adults have high blood pressure

• High blood pressure is the single largest contributor to health disparities

• Even people without high blood pressure benefit from lower blood pressure

• High salt intake is associated with increased blood pressure

Sodium Intake:US Dietary Sodium 1970-2000

•Sodium consumption has increased an average of 56% between 1970 and 2000

• Current estimates, depending on survey method, range from 3,300mg to over4,000mg

• Sodium intake is almost twice the recommended amount

Briefel RR, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr. 2004;24:401-431 (NHANES data)

Reduce Salt in Processed and Prepared Foods by 50% in the US

150,000lives saved

annually with 1,300mg lower lifetime intake

Decrease salt intake

=

Blood pressure drops within weeks of salt reduction –so does the risk for heart attack and stroke

Decrease in blood pressure

Source: CSPI. Adapted from: http://www.cspinet.org/salt/saltreport.pdfData: Mattes, RD. Journal of American College Nutrition, 1991, 10:383-393.

The Challenge: Most Salt Comes From Processed and

Restaurant Foods …

Home cooking

Naturally occurring

Processed and

restaurant foods

77%

12%

While eating 6%

5%

How Salt is different from trans fat and menu labeling…

• Salt is a standard nutrient – it must remain in our diet

• We can’t “demonize” salt (unlike trans fat but like calories)

• CHALLENGE – reduce not eliminate

Some Policy/Regulatory Options(can be locally or federally led)

• Voluntary target setting/reductions• Regulatory target setting• High salt warnings• Salt content disclosure in food service

A “growing” part of our diet…

• With the increase in away-from-home food intake, comes over consumption of calories, sugar, salt and unhealthy fats

• Public Health policies and activities directed at restaurant food are necessary to reverse the obesity epidemic

Conclusion

• Local government has many avenues to act:– State and Local Laws– Health Codes– Zoning and other regulatory approaches– Community Programming– Economic Development

Public Health Authorities in local government can act

effectively to reduce chronic disease risk associated with

the food environment.