He Said, She Said: Menu Calorie Counts

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He Said

Nutrition information has its upsides, but the data are only as useful as their interpretation. Context and framework matter; without a solid foundation, food labels and menu calorie counts can do more harm than good.

Maslow’s hierarchy of needs suggests that we, as humans, have basic needs that must be met before we can fulfill more advanced needs. Nutrition has a similar structure. At the base, someone has to have food – period. If food security is an issue, whether it is due to financial limitations, self-imposed restriction, or any other factors, then not much else matters. At the structure’s very top rests the hard science of nutrition as it relates to whatever medical conditions we may have; this is where we might talk about grams, calories, or various micronutrients. In between are issues of eating behavior that often go overlooked and yet are critical to address. Many people want to jump right to the top, but the danger in doing so is that without a solid middle, the structure is likely to fall apart.

Nutrition labels on packaged food can be helpful to someone with a healthy relationship with food and their body, but in the hands of an individual who does not have the solid middle that I previously discussed, the information can be misinterpreted, maybe reinforce a good/bad food dichotomy, and lead to or exacerbate issues like weight cycling and disordered eating.

In grocery stores, at least, we have a certain level of privacy and ambiguity that may mitigate the damage. Few shoppers probably recognize the yogurt in your cart as being higher in calories than its counterparts, and ultimately neither your fellow shoppers nor the cashier know whether that ice cream you are buying is for your kid’s birthday party or for yourself. Such uncertainties can help comfort people who fear judgment from the people around them.

Calorie counts on restaurant menus present a more complex problem. We place our orders in front of friends, family, co-workers, acquaintances, waitstaff, and fellow patrons who are primed for judgment because they – thanks to the menu – know how many calories you have elected to order for yourself.

Certainly, not everyone judges, and some of us are coated with more Teflon than others, but for many people, even the mere fear that the person across the table may be thinking “No wonder you are so fat/skinny/slow/etc.” can be enough to cause problems. The middle layer of the nutrition hierarchy involves making food decisions based on internal cues rather than external constructs. Issues of guilt, virtue, judgment, praise, and fear cloud the picture and make the establishment of this kind of relationship with food that much more difficult to attain.

Of course, restaurant nutrition information can be helpful sometimes – for example, I remember looking at the Bertucci’s website with a patient of mine in search of menu items that would mesh with his sodium restriction – but it can be provided in ways that are cognizant of potential harm. My suggestion: Post nutrition information online, as many chain restaurants already do, and have it available on site per customer request, but leave it off the menus.

 

She Said

When Jonah and I went to Bertucci’s Italian Restaurant the other night, we both realized that the menu had been redesigned (Clearly, we are regulars at Bertucci’s!). In addition to new entrees and different graphics, I was dismayed to see calorie counts prominently displayed above each and every menu item. I remember when the law was passed requiring all chain restaurants to publish their calorie information on their menus, but for some reason I had forgotten about it. (I feel like the law was passed a few years ago and just now is being implemented.) In any case, it was jarring for me to see this information, and it also made me quite concerned for my patients with eating disorders (ED).

Most, if not all, of my clients with EDs have engaged in some sort of calorie counting. Whether tallying up carbs, “macros,” or points, these patients have misused the nutrition information available to them in order to help them engage in ED behaviors. Much of my work with these individuals is around helping them to move away from the counting because it is completely antithetical to intuitive eating.

As Jonah and I have discussed before, intuitive eating is the practice of using one’s internal cues rather than depending on external factors to make food decisions. That means that someone who is an intuitive eater will (most of the time) eat when they are physically hungry and eat what they are hungry for in an amount that is satisfying. It’s about trusting your body to tell you what it needs and then honoring your body’s needs by fulfilling them.

Most of my patients with ED struggle with the idea of intuitive eating because it flies in the face of what their ED is telling them – food is to be carefully monitored and planned, certain foods are bad for you and should be off-limits, you can’t trust your hunger cues, etc. Many of these patients use calorie counting as a way to gain some control, to feel like they know exactly what they are putting in their bodies. One of my patients who is doing quite well in her ED treatment says that she still can’t shake the calorie counting habit, and she notices that this behavior ramps up when she is anxious, stressed, or overly hungry. One could say that calorie counting is a coping mechanism for many people because it helps to alleviate unpleasant feelings by giving them something concrete to focus on.

In any case, I often encourage my patients to ignore nutrition labels as it can trigger their ED. And in many cases, it is possible to (mostly) avoid this information – by purchasing unpackaged foods, buying prepared food from smaller restaurants or stores, etc. However, with this legislation, many more people will be exposed to calorie information at restaurants that they have gone to for years, and it is inescapable. I know that much of the nutrition information for chain restaurants has been available online for years and that anyone could just look up the calories on the restaurant’s website, but that at least takes a bit of effort. If someone really does not want to see this information, they will avoid it, but printing it directly on the menu makes that nearly impossible (short of never visiting the particular restaurant again).

In my opinion, I think that calorie information should be made available if the customer requests it. Everyone has the right to know what they are putting into their body. But it would be great if restaurants could also provide menus without the calorie information in order to prevent triggering individuals with ED or a history of disordered eating. It could make a number of people feel safer in these establishments, and that would make a big difference in many people’s lives.

He Said, She Said: 1,500-Calorie Diet

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A patient sent Joanne the following email. “I overheard a coworker talking about food/calories/etc. and noted her saying, ‘We should all be on a 1,500-calorie diet as women.’ For some reason this really got to me and I normally don’t let these stupid comments affect me, especially when I know better. Thoughts?”

 

He Said

Yes, I do have thoughts about this, several in fact, but for the sake of time and space, I will leave aside tangential issues of practicing dietetics without a license (If someone without a medical license made a statement along the lines of, “As women, we should all be taking [insert name of a medication] daily,” would you be cool with that?) and the virtually-constant propagation of nutrition myths throughout our culture. Instead, let’s focus on just how incorrect this coworker’s assertion is.

Caloric needs are surprisingly difficult to determine. The most accurate method is direct calorimetry, which utilizes a metabolic chamber in which the subject occupies a compartment that measures the heat that he or she emits during whatever state of activity happens to be taking place at the time. Unless you enroll in a research study that involves one of these chambers, you will most likely never gain access to one in your lifetime.

Indirect calorimetry, which involves measuring oxygen and carbon dioxide intake and expulsion, respectively, is less invasive in some ways and easier to utilize. Large hospitals typically have metabolic carts that can perform such measurements in their research laboratories, and lesser models exist for office settings. The tradeoff, however, is accuracy, as even the best indirect calorimetry tools are a step down from direct calorimetry.

Next we have the Fitbits of the world, devices that use algorithms to estimate caloric needs based on a crude set of variables. Dietitians use similar equations sometimes as well, and when I do, I always stress to patients that the results are just rough estimates that cannot and should not be taken too literally.

These equations have numerous sources of error, such as the reliance on subjective measures of physical activity. Anybody can Google how many calories certain activities supposedly burn, but really these numbers are general rules of thumb at best. Running a mile burns 100 calories, we are told, but is this right? What about the size and body composition of the runner, or his or her mechanics? Does he or she have short, quick strides or long, less frequent steps? What about swings of the arms, point of contact between the foot and the ground, head bobbing, or any number of other factors that can influence the results?

One of my patients occasionally asks me how many calories one burns during sex. Unless you get two people to have intercourse in a metabolic chamber, who knows? Even then, the heat generated would pertain only to those unique individuals in that specific encounter, so what do you do, divide by two and make the assumptions that their efforts were equal and that these results apply at other times and to other people as well? Logistical hurdles and the countless variables involved make estimating caloric expenditure a guessing game not just for sex, but for pretty much any activity.

As a consequence, estimates of caloric needs are just that – estimates – and vary widely from person to person. My degree in mathematics reminds me that I like numbers as much as the next guy if not more, and I can certainly understand the appeal of having a short, sweet, and specific target for which to aim, but really the best method to determine your caloric needs is to set quantifiable data aside and look internally to your hunger and fullness signals. Despite all of the proliferating nutrition myths and overarching messages we are taught from childhood on that we cannot trust ourselves regarding food, our bodies are actually pretty good at telling us what and how much they need. We just need to relearn how to pay attention and trust those signals again.

 

She Said

Ahhh, the 1,500-calorie diet. It’s amazing how some arbitrary number has gotten stuck in the minds of so many people. 1,200 calories is also a popular number. Flip through any of your typical women’s health magazines and you are likely to read that all women should be consuming no more than 1,500 calories per day to be “healthy.” Unfortunately, there really is no such thing as the “perfect” number of calories for each and every person. 1,500 calories (or 1,200 calories or 1,750 calories) is a myth. It makes no sense to say that every woman should be on a 1,500-calorie diet; we all are unique human beings with unique needs.

As I tell my patients over and over – every body has different caloric needs. Age, height, weight, gender, muscle mass, and activity level are just some of the factors that can affect our calorie needs. Even the Mifflin-St. Jeor equation, the equation most often used by most dietitians to determine calorie needs, does not take into account all of these factors. Our caloric needs will vary over our lifespan for a number of reasons. Women who are pregnant or breastfeeding need many more calories, while as we age, we typically need fewer calories. Anyone who has lived with a teenager can attest to the fact that calorie needs go way up during adolescence! When someone is recovering from an injury, his or her caloric needs might be elevated. For instance, the caloric needs of burn patients can be as much as double what the “average” person’s needs are. The best way to figure out what your calorie needs are? Eat as you normally would. If you see no large shifts in your weight (think plus or minus five pounds), you are meeting your calorie needs!

When working with patients who struggle with eating disorders, I try to steer clear of talking about calories. Many of my patients have spent countless hours logging the calories they ate (and burned), and most of these patients would say that they were “obsessed” with doing so. I had one patient who would log her calories daily, and if she consumed more than 1,300 per day, she felt like she had “failed.” Another patient would try to stick to no more than 1,800 calories per day, and if she went over by just a few calories, she would binge because she had “blown it.”

Instead of talking about calories, I try to use the “exchange” system with my patients. Exchanges are groups of foods that have similar nutritional profiles. For instance, a carbohydrate exchange (sometimes called “grain” or “starch” exchange) contains approximately 15 grams of carbohydrate per serving. This might look like an average piece of bread, a ½ cup of cooked pasta or rice or ½ of a large potato. By using exchanges, we can take the focus off of calories and how we need to limit them and instead talk about making sure we get enough carbohydrates, protein, fats, vegetables, etc. Calories have a negative connotation for many of my patients, while exchanges feel a bit more abstract and neutral.

In short, instead of setting an arbitrary calorie goal for oneself, I think it would be much more beneficial to set other goals. Getting five fruits and vegetables per day, being physically active for 60 minutes per day, and eating intuitively would be much better goals (in my opinion) than making sure one never goes over 1,500 calories per day.

Day 305: Calories In, Calories Out

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One of my patients and I continually have discussions regarding the myth of weight control boiling down to calories in versus calories out. In other words, expend more calories than you take in and you lose weight. Consume more calories than you burn and you gain weight. Because he has heard this presented as fact for so long from a wide variety of sources, accepting this as a fallacy is difficult for him.

My lifestyle changed dramatically with last March’s surgery. No racing up mountains during my recovery. No running at all, actually. No swimming either. No weight lifting for several months. Certainly no tennis, not even at a recreational level. My high volume of intense exercise was initially replaced with walking, months and months of just walking. Due to a lack of vigorous exercise, my cardiovascular fitness is deplorable compared to what it was not too long ago.

My eating has changed as well. Since I could tolerate more food in my stomach during a walk than, say, a run, the size of my breakfasts increased. While my food choices are almost exclusively vegetarian for ethical reasons, I reincorporated chicken and beef during the first few months of my recovery to ensure that I provided my healing body with the protein that it needed. Since my surgeon reminded me of the importance of calcium in promoting fusion in the bone grafts, I significantly increased my dairy intake, mainly in the form of ice cream.

What I did not do is weigh myself, track my weight, monitor my calories, attempt to quantify my caloric expenditure, or buy into any sort of nonsense about my weight or fitness level saying anything about my value as a person or my competence as a dietitian.

With all of the radical changes in my lifestyle, do you know how much my weight changed from before the surgery until now? Exactly zero pounds. According to the weights that my doctors recorded at my appointments, I am the same weight now as I was before the operation 10 months ago.

If one pound of body fat is worth 3,500 calories (I am not saying this assertion is accurate, but it represents another myth that continues to float around.) and the calories-in-calories-out theory is true, I would have had to have balanced my energy intake and expenditure within less than 12 calories per day on average for the last 305 days. That, ladies and gentlemen, is impossible.

Yet the calories-in-calories-out ridiculousness is not widely recognized for what it is. Recently, someone posted on Facebook a printout that her doctor gave her containing weight loss advice. “Change your diet,” it says. “Eat 500 fewer calories a day. This can lead to weight loss of one pound per week.”

PrintoutIn nutrition, sometimes a little bit of knowledge is worse than no knowledge at all. The notion that calories in versus calories out dictates weight is nutrition 101, but what they tell you in nutrition 102 is that it is not really true. It has some merit as a general concept, but it should never be taken literally, as weight regulation is vastly more complex than that.

During my recovery, I have moved my body in the ways that have felt most comfortable at the various stages of my healing and consumed the foods that my body seems to be asking for in the quantities that are satisfying. When I have missed the mark by overeating, for example, I do not feel guilty or beat myself up; rather, I look at the episodes as learning experiences to figure out what happened and what I can do differently in the future.

Because of these behaviors, plus genetics and other factors that are out of my hands, my weight has happened to stay the same. If it had changed, would I have cared? Sorry, I know this might be hard to believe in the context of our weight-obsessed culture, but my interest is elsewhere.

My plan is to make my comeback to competitive racing at this June’s Mount Washington road race. This is where my attention is focused. I have five months to ramp up from virtually no running to racing 7.6 miles up the highest mountain in the northeast. Can I do it? We’ll see. But I can tell you this: I am excited and looking forward to the challenge.

Physical Activity: So Much More Than Burning Calories

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“Just finished a seven-mile run – definitely earned the right to splurge at the party tonight!”

“I play tennis six times per week to keep my weight in check and to be able to eat what I want.”

“Just gorged at my friend’s Fourth of July cookout – looks like I will need to hit the gym extra hard to burn all those calories off!”

The above are just some of the comments I have either seen posted on Facebook or heard in conversation over the past few weeks. While these types of comments are quite common and universally agreed upon, I have a problem with them for a few reasons.

There is an abundance of evidence that exercise improves one’s health. It not only has been proven to improve blood pressure, blood lipid profiles, inflammation, and heart health in general, it has also been found to help the processing of glucose and insulin as well. But despite all of these positive findings, there is very little scientific evidence that exercise is an effective way to control weight and that exercise by itself does not have as much of an impact on our metabolism as most people think it does.

In one study, a group of volunteers from a hunting and gathering tribe in Tanzania were studied to see if there was a link between their activity levels and the number of calories they burned in a day. While it was true that the tribe members were much more active than the average American, walking about 7 miles per day on average, their metabolic rates were about the same as the average metabolic rate for Westerners. That means that despite the fact that the tribe members were doing significantly more physical activity than Westerners, they were burning the same number of calories as Westerners. Their increased activity did not mean they burned more calories.

Aside from the problematic idea about using exercise as a weight control mechanism, the bigger problem I have is the common belief that exercise’s only benefit is to burn calories. I know so many people who run regularly, not because they love to run, but rather because they are repenting for their dietary “sins.” Whatever happened to being physically active because we enjoy the way it makes us feel? Whatever happened to playing a friendly game of pick-up basketball for the sheer fun of it? Or jumping into the pool on a hot summer day to cool off and splash around? So many of us view exercise as a way to punish our bodies into submission rather than as a way to feel more alive and appreciate what our bodies can do.

How about we start using physical activity as a way to connect with our bodies and enjoy what they can do for us? How about engaging in exercise as a way to improve our health and help our bodies to function at their best? Or taking up a sport for the thrill of the game? The benefits of physical activity are so much more than simply burning off last night’s nachos. And no one needs to “earn” the right to eat what he or she wants. That is no way to live life.