Counting calories to make healthy choices in fast-food restaurants

Michelle Obama gave a good nutrition lesson to the kids who helped harvest crops in the White House vegetable garden last week. Talking about obesity she said, “When I was growing up, fast food was a rarity. It wasn't something you did every day. It was a special treat, and we would beg to get it, and it was exciting if we drove into a fast-food place and got a hamburger…Eating out was a luxury because at least in my family we couldn't afford it. If we got pizza on a Friday night, that was a treat.”

Our first lady sees fast food as one of the culprits of the obesity epidemic. Most health experts are with her.

Obesity rates have doubled in the past thirty years in parallel with an increase in caloric intake. At the same time, there’s been a major shift in the average American diet—in 1970 about one-quarter of food dollars were spent on prepared food; in 2001 it went up to nearly one-half.

A major part of these made-out-of-the-home food dollars go to fast-food chains. Not only do people visit these outlets more often than they used to (one in four Americans eat fast food on any given day) they’re also served more food on any given meal.

Many studies have shown that eating fast food is associated with overeating and a poor diet, I’ll cite just a few. A study in the Journal of the American Dietetic Association shows that adults eating at fast-food restaurants consume 205 more calories per day than those who do not eat out; children consume 155 more calories, and all age groups who reported eating fast food had a higher intake of fat, saturated fat, sodium, carbonated soft drink, and a lower intake of vitamins A and C, milk, fruits and vegetables than those who did not report eating fast food.

A large study published in the Lancet followed young adults for 15 years and showed that those who ate at fast-food restaurants more than twice a week had gained an extra ten pounds and had twice the risk of insulin resistance (a risk factor for type 2 diabetes) compared to those that ate fast-food less than once a week.

Recently, new laws mandating calorie posting on menu boards were introduced in two states (California and Massachusetts) and several cities (including New York City and my hometown, Philadelphia). Will calorie posting change the way people order in fast-food outlets?

A new study in Obesity takes a different approach in investigating what people eat at fast-food in New York City just before these laws were set in place. While most studies rely on individuals’ recall of what they ate, this study is based on customers’ detailed receipts for 7,318 lunch meals (consumed between 12-2pm) in 167 fast-food locations. Caloric values for the specific meals were obtained from the companies’ websites.

Here are some of the findings:

• Customers bought an average of 827 calories for lunch. When excluding single-item purchases (people coming in for just a drink, a side order or a sandwich), the average calories per customer rose to 961 calories.

• More than a third of all customers ordered more than 1,000 calories for lunch. When excluding the single-item purchases 44 percent of customers ordered more than 1000 calories.

• At chicken-oriented fast food chains (KFC, Popeye’s) —which averaged the highest calorie purchase (931 calories) —almost half of the customers ordered more than 1,000 calories for lunch.

• At hamburger-oriented fast food chains (McDonald’s, Burger King, Wendy’s) about 40 percent of the customers ordered more than 1,000 calories for lunch.

• At Domino’s and Pizza Hut, the mean purchase was more than 1,000 calories.

• The two sandwich chains in the study had lower average calorie purchases: Subway at 749, and Au Bon Pain at 555.

The study also looked more closely at the three hamburger fast food chains:

• Combo meals (consisting of a sandwich, side order and drink) were bought by about a third of the burger chain patrons in the study, and had an average of 1,100 calories. Burger King wins the prize, with an average of 1,271 calories; McDonald’s comes in second with 1,187, and Wendy’s is third with 1,106. French fries and other sides comprise about a third of combo-meal calories; beverages account for about 20 percent.

• Most meals (58 percent) included a beverage, and three out of four of these drinks were soft drinks, consisting of about 200 calories. Diet drinks comprised only seven percent of drink receipts at McDonald’s and water only two percent.

How many calories should people eat for lunch?
There is no right answer to this question. The way one divides the daily allowance of calories (an average of 2,000/day is about all most people need) is a matter of personal preference and habits. One can argue that Burger King’s combo lunch can be recipe for weight loss—provided it’s the only food you have that day.

I think most people can see that subtracting a combo meal (with no dessert) from the daily allowance of 2,000 calories doesn’t make staying within the limits of a balanced caloric intake easy or realistic. On top of that, I’d argue that our nutritional needs are far from met by fast-food, and to balance this rather empty meal one would have to eat super healthy nutritious food for the rest of the day.

Room for change

The Obesity study authors discuss several modifications fast-food restaurants can easily make to cut some calories, such as reducing the portion sizes or abandoning the practice of discounting combo and value meals when one buys more calories.

They write:

"Customers can modify their fast-food selections to reduce calorie intake. The most popular combination meal at McDonald's was the Big Mac, "medium" order of French fries and "medium" size non-diet soda, totaling 1,130 calories and priced at $5.59... Downsizing only the French fries and soft drink to "small" sizes would save 190 calories but cost only 10 cents less than the standard combination meal. This suggests a built-in economic disincentive to downsizing, a simple modification that could reduce calorie intake.

Substituting water or another non-caloric drink for a sugar-sweetened soft drink, or the selection of smaller sizes of sandwiches, hamburgers or sides can cut hundreds of calories. Selection of grilled rather than fried items also reduces calories, although grilled items typically are more expensive. A request to "hold the mayo" can cut 100–200 calories from a meal. One common misconception is that salads are always lower in calories, when, in fact, they are often filled with high-calorie ingredients. Some salads on fast-food menus are more than 600 calories without dressing, and dressings can range from 40 calories for low fat up to 270 calories.

Calorie-conscious modifications are hardly encouraged in quick-service settings where consumers contend with a wide array of high-calorie options. Portion sizes at fast-food chains have increased over time; with these larger servings, there has been a corresponding increase in the calorie content of purchases.”

The authors will be repeating this study to see what effect—if any—New York City’s calorie posting have on purchase. It will be interesting to see whether calorie posting changes what fast food outlets offer and what people actually buy. There are indications that small changes are already happening—I wrote about some in a previous blog post, and New York Times’ Tara Parker Pope had an interesting post about some positive changes in the offerings and choices at fast-food outlets this week. I’ll keep you updated as new studies come out.

By the way, I think most people know fast-food isn’t healthy. Eric Schlosser’s book "Fast Food Nation" certainly drove that point home. Morgan Spurlock’s movie “Super Size Me” painted a vivid picture of what happens to one’s weight, liver function and stamina when one eats fast-food on a regular basis. The calorie posting right next to the products’ price will certainly reinforce that notion. Still, fast-food meals are very popular mostly because they’re convenient, cheap and have taste appeal. Not only is fast-food here to stay, we’re also very successful at exporting it abroad, so I do hope modifying fast-food offerings and providing nutritional information can save consumers here and around the world a few hundred calories.

I also hope Michelle Obama’s little ambassadors—the kids who enjoyed the fresh, simply prepared food from the White House garden—will follow her guidance and show their friends and family just how easy it is for kids to think differently about food.

Dr. Ayala