Monthly Matters:

• Menu Labeling to Combat Obesity
• Family Matters: Childhood Asthma
• Office Notes

GreenField Health’s Health Matters

April 2009

Menu Labeling to Combat Obesity

(This was adapted from the Oregon Public Health Division, Department of Human Services.)

Morgan Spurlock’s 2004 documentary film “Supersize Me” provided an irreverent look at America’s obesity problem, but the facts behind the film are no laughing matter. Six in 10 Oregonians (that’s 60% of the population) are either overweight or obese putting them at risk for preventable conditions such as high blood pressure, high cholesterol, heart attacks, strokes, and diabetes. Fast food and other restaurant meals are important contributors to the obesity epidemic.

Eating Out and Weight Gain

Restaurants loom large in the daily lives of Americans. In 1955, Americans spent about a quarter of their food dollars on meals made outside the home. In 2009, that number has doubled. The average American eats four restaurant meals each week and consumes about one-third of his or her total calories away from home. Home-cooked and restaurant meals are not equivalent. Food eaten away from home, particularly those from fast food and other chain restaurants, tends to be more calorie-dense and nutritionally poor than food prepared at home, and diners tend to eat more of it. A recent study at fast food restaurants in New York City found that, on average, customers purchased over 800 calories per meal, with more than one third purchasing 1,000 calories or more.

Portion sizes in restaurants are simply bigger. Since the 1970s, the typical fast food meal comprised of a soft drink, french fries, and hamburger has increased by over 200 calories. Thus, adults who frequent fast food restaurants consume more calories per day than those who do not, and the problem is even worse for children. Children eat almost twice as many calories in a restaurant meal compared to eating at home.

Does this seem obvious? The bloated calorie count of most restaurant meals is not widely known. People invariably underestimate the calories packed into restaurant meals, particularly fast food restaurants but also chains such as PF Changs, the Olive Garden, the Cheese Cake Factory, Shari’s and Applebee’s.

Facing the Facts of Lunch

Fortunately, there is evidence that people want nutritional information and will use it to make choices when it is available. Numerous national polls demonstrate that a majority of Americans want nutritional information at restaurants. In Oregon, more than 2 in 3 people say they support a policy requiring fast food restaurant chains to post the number of calories of food items on their menu boards. For examples, see the Center for Science in the Public Interest at: www.cspinet.org/menulabeling/resources.html and the Harvard Forums on Health at: www.phsi.harvard.edu/health_reform/poll_results.pdf. Oregon data can be found at: www.upstreampublichealth.org/NWHF_Nutr_Label_Poll.pdf.

Multnomah County has taken the lead in creating a healthier food environment by adopting a nutrition labeling policy in chain restaurants. The policy requires chain restaurants located in Multnomah County to post calorie information for standard menu items on printed menus, menu boards, and food tags. They also must provide information about sodium, carbohydrates, trans fat, and saturated fat for standard menu items by consumers who request it at the time of ordering. By providing nutrition information to customers when they are making their food selections, restaurants play an important role in enabling the public to make informed choices about what they eat.

Multnomah County is part of a national trend towards menu labeling. Other jurisdictions, such as New York City and Seattle/King County, have already implemented menu labeling policies. Philadelphia passed its menu labeling policy in 2008 and is scheduled for implementation in 2010; the State of California will implement their menu labeling policy in 2011. In addition, more than 20 other jurisdictions throughout the U.S. have introduced or passed menu labeling requirements. In Oregon, an effort is currently underway to introduce a bill to Oregon legislature to enact menu labeling statewide.

Does Menu Labeling Help?

Studies show that consumers use nutritional information to select lower calorie menu items. According to advertising industry data, fast food customers in New York City who saw calorie information at the time of purchase bought about 50 fewer calories on average than those who didn’t see the information. A study by the Chicago based food industry consultant, Technomic, found that point-of-purchase choices translate to long-term behavior change: more than 8 in 10 New Yorkers said they were changing their consumption habits because of menu labeling by choosing lower calorie alternatives.

As clinicians know, the health benefit of reduced calories can be profound. A health impact assessment conducted by the Los Angeles County Department of Public Health, using conservative assumptions, found that if menu labeling helped just 10% of restaurant patrons order reduced calorie meals, 39% of average annual weight gain in the population age 5 and older could be averted, providing significant health advantages. In addition, disclosure of calorie information will likely prompt restaurant chains to reformulate both the portion size and calorie content of their offerings, similar to the way processed food manufacturers reformulated their products to contain less trans fat when the Food and Drug Administration mandated they list trans fat content on packaged foods.

With the reformulation of menu items, all Oregonians who eat at chain restaurants will benefit, even those who do not use the calorie information. Here are two specific things you can do to help your patients, regardless of your geographic locale:

• Multnomah County clinicians can seize the opportunity to counsel patients (the majority of whom eat out and want nutrition information) on using menu labeling to make healthier choices to support their obesity prevention/weight management goals.

• Clinicians in other counties can ask patients about restaurant patronage and encourage their patients to become better informed about their food choices. Many chains have nutritional information available on their websites; gathering it just takes a little extra effort.

Obesity Prevention

Obesity has become a significant problem in Oregon and nationally, and we need more effective prevention strategies. Clinicians do their part in medical offices every day, but obesity prevention must include multiple levels of intervention, including strategies that patients can use in their daily lives, particularly when making food choices at restaurants. Menu labeling will contribute to reducing caloric intake at chain restaurants because of changes in consumer selections and/or modified menu offerings. Menu labeling by itself will not solve the obesity problem, but it will create an environment that is supportive of healthier choices and eventually lessen the burden of obesity and obesity related diseases.

Recommendations:

1. Make your lunch and make lunch for your kids so you know what they are eating.

2. Eat at home, and teach your children healthy eating habits.

3. Avoid all fast food restaurants and most chain restaurants – if you think they are healthy and even if they market themselves as being so, that may well not be the case.

4. Check the websites for some of the restaurants that you frequent to see if they post calories per meal, but be careful, you may be shocked.

Family Matters: Childhood Asthma

Asthma is a chronic disease of the lungs and is the most common chronic disease in childhood in developed countries. Symptoms of asthma include cough, shortness of breath and wheezing and are usually related to specific triggering events. Asthma triggers can include allergens (i.e., dust, mites, pollen), irritants (i.e., smoke, perfumes, cleaners), physical environment (i.e., exercise, cold air, changes in barometric pressure), viral infections and some medications. A study in Lancet in 2002 suggested air pollution as another possible trigger, and some scientists believe that cockroaches may also be a trigger.

The symptoms of asthma are due to airflow obstruction which results from the added effects of smooth muscle constriction around lung airways, airway wall swelling, and accumulation of mucus in the airways and inflammation of the airways. Chronic inflammation of the lung airways is an important component of asthma even in those with mild symptoms.

The prevalence of asthma is increasing across the population. Asthma experts and researchers aren’t sure of the exact reasons for this. Data from the CDC-based National Center for Health Statistics show an increase in asthma prevalence from 1980 to 1996 of greater than 50 percent, with the largest increase in people younger than 18 years. Most children with asthma develop it before the age of 5 years.

Asthma is more likely to occur in family members. It is more common in boys, urban dwellers and the socioeconomically disadvantaged. It is often seen in older children who had eczema as infants and then allergies as toddlers.

Not all children with respiratory symptoms go on to develop the chronic disease known as asthma. When the airways are infected with an agent like a virus, they respond with inflammation that can lead to swelling of the airways and production of mucus. Infants and toddlers have smaller airways than adults because of their small size. Therefore, very young children may develop asthma-like symptoms more than adults but never actually have asthma. Infants are often diagnosed with bronchiolitis, which means an infection or inflammation of the bronchioles. Bronchioles are very small divisions of the lung airways. Not all infants with bronchiolitis will develop asthma later in life.

It has been estimated that between 30 and 70 percent of children who develop asthma are markedly improved or asymptomatic by early adulthood. One study showed that sixty percent of children with wheezing in the first three years of life had no wheezing at six years of age. For most children, wheezing before the age of six years is probably a benign condition reflecting smaller airways that will improve or resolve in a few years as the airways enlarge with age. A subgroup of children will have persistence of symptoms and will eventually develop clinical asthma. This subgroup is characterized by the diagnoses of eczema and allergies at a young age, relatively severe and persistent asthma-type symptoms after developing eczema and allergies, and a maternal history of asthma. Maternal smoking may also contribute.

Older children and adults with persistent wheezing and cough can be diagnosed with asthma by performing spirometry, a type of breathing or lung function test. However, this kind of testing is difficult in young children (younger than age 5-6) because of the complicated directions that need to be followed during testing. Practically speaking, the infant with three or more episodes of wheezing should be considered at risk for the development of asthma and followed more closely.

Next month we will review medications that are used to treat asthma in children.

Office Notes

• Desi Lowder, one of our health coordinators, went back to school full time in March to become a surgical technician. We applaud this career move for him. Desi has been a fantastic and productive member of our team and we wish him the best. Like other staff who move on, we will miss him and wish him all the best.

We’re delighted to see our old friend the sun returning, and look forward to the beautiful summer weather. For now, we’ll take the sunshine when we can get it, and enjoy every minute. As always, we are thankful to you for the continued support you give to GreenField, and the trust you place in us to assist you with your healthcare.

Sincerely,

Beth Davis, your Business Office Manager (email)
Chuck Kilo, MD (email)
Connie Turner, MA, your Health Coordinator (email)
Cynthia Ferrier, MD (email)
Dana Lee, MA, your Clinical Supervisor (email)
David Hays, MD (email)
David Shute, MD (email)
Elizabeth Hays, MD (email)
Jill Arena, your COO (email)
Joel Swartzmiller, your IT Manager (email)
Kate Griggs, your Administrative Assistant (email)
Kim Walgraeve, your Marketing Manager (email)
Kristin Walker, your Program and Executive Assistant (email)
Malcolm McAninch, MD (email)
Maria Soutavong, MA, your Health Coordinator (email)
Meena Mital, MD (email)
Pam Mockenhaupt, CMA, your Health Coordinator and Biller (email)
Paula Koeller, MD (email)
Peter Casey, your Consultant (email)
Samantha Charles, your Clinic Administrator (email)
Todd Canon, MD, (email)

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