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HEART Insight:
doi: 10.1097/01.HEARTI.0000281889.75311.6b
Departments: Nutritition Know-Knows: Menu Minefields

What To Order — And What To Avoid — When Eating Out

Palkhivala, Alison

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You're health-conscious, so nothing goes into your shopping cart until you check the nutrition label. You know exactly how many servings are in the package, and how many calories and grams of saturated fat and sodium you're getting per serving. No one can pull the nutritional wool over your eyes!

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Unless you're in a restaurant. You may as well be wearing a blindfold, because you have no idea how many fat grams are in your grilled cheese and tomato sandwich, whether the mound of coleslaw on the side of the plate is a single serving, or whether that delicious-looking whipped cream-topped dulce de leche latte contains more calories than you should eat over the course of the entire day (maybe the next day, too).

“You never know what you're going to get until it's temptingly placed in front of you,” notes Steven Aldana, Ph.D., a professor of lifestyle medicine at Brigham Young University in Provo, Utah, and author of The Stop & Go Fast Food Nutrition Guide (Maple Mountain Press, 2007). He likens restaurant dining to “the wild, wild West.”

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The More You Know

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The Center for Science in the Public Interest (C.S.P.I.) recently reported on Chinese food and found many popular dishes are loaded with fat, sodium and calories. For instance: Egg rolls are 200 calories each, with 400mg sodium; eggplant in garlic sauce has 1,000 calories, and 2,000mg of sodium; and an order of General Tso's chicken—which is batter-dipped and deep fried—packs 1,300 calories, 3,200mg sodium and 11g of saturated fat.

According to the American Heart Association, a healthy adult should get 30 percent or less of his daily caloric intake from fat, and no more than 8 to 10 percent from saturated fat. The average 2,000 calorie-a-day diet, should include no more than 600 calories of fat, with just 140 of those fat calories coming from saturated fat. And the daily limit of sodium is 2,300mg or less.

Now, New York City—which famously banned trans fats from restaurant food in December 2006—is trying to help consumers make informed choices when they dine out. Starting July 1, 2007, a new Board of Health regulation enacted last December will require some restaurants to post the caloric value of each of their standardized dishes on their menu board or paper menu. The number of calories can be listed as a single number or as a range, to take into account optional ingredients or toppings, such as a burger with or without cheese.

Typically, this nutritional information is available on the Internet, in pamphlets, or other ways that are not immediately obvious or available to consumers when they have a menu in their hands and are trying to decide what to eat. The new regulation allows consumers to see how many calories each menu item contains before they order.

“We wanted to look at policy initiatives that could help inform consumer choice, to make people more aware of the calories that they were consuming away from the home,” says Candace Young, M.S., director of physical activity and nutrition at the New York City Department of Health.

“This is ... similar [to] providing calorie [information] ... when you buy a packaged [food],” Young tells Heart Insight. “It [should] help people look at their consumption patterns a little bit better, or [at least] in a more informed way. ... They might still eat at the same establishments, but they might choose ... a little bit smaller portion.”

The regulation targets the roughly 10 percent of restaurants (mainly chains) that have already been voluntarily providing nutritional information about the standardized items they serve since March 1 of this year. As a practical matter, the regulation will apply to these restaurants because they have already done the required nutritional analysis of their offerings, explains Young. In addition, chain restaurants typically standardize the type and amount of ingredients used, as well as preparation techniques, for their menu offerings. Fancier restaurants or hole-in-the-wall diners often alter their recipes at the whim of the chef, depending on the freshness of available ingredients—and even his or her mood.

A survey by the California Center for Public Health Advocacy conducted in April had people look at a grouping of menu items from Chili's, Denny's, Macaroni Grill and McDonald's and asked which dish in each chain restaurant's grouping was lowest in calories, salt and fat.

Not one of the 523 survey respondents got all four questions right, and 68 percent of them got every question wrong. Not surprisingly, 84 percent of those participating in the survey favored requiring restaurant chains to post nutritional information.

Alice Lichtenstein, DSc, Gershoff Professor of Nutrition, Science, and Policy at Boston's Tufts University, applauds the new regulation. “You'll see how many calories it's going to cost you to go from a medium to a large fries or to choose those fries over a side salad. In some cases [customers] might get some education, [for instance] that the fried fish fillet is not really saving them any calories relative to the hamburger.”

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But the regulation has its opponents, too. “We certainly understand the Board of Health's intentions in providing information to the people of New York, and we certainly support that,” says Sheila Weiss, R.D., a registered dietician and director of nutrition policy at the National Restaurant Association. The trade group takes issue with the regulation's “inflexibility” on how caloric information is presented. Weiss explains some restaurants offer so many customization options that a calorie range would be meaningless.

Young counters that restaurants may submit their own method to display the caloric content of their offerings for approval.

A new bill introduced to the New York City Board of Health on February 28 by New York City Councilman Joel Rivera would amend the current regulation by simply requiring that calorie counts be provided in a conspicuous location at the point of sale, leaving compliance details to the restaurants.

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New York's Not Alone

Washington, D.C. At-Large Councilmember Phil Mendelson has proposed requiring restaurant chains with 10 or more outlets to print the caloric, fat, carbohydrate and sodium content of their standardized dishes. Chicago is also considering a similar calorie-consciousness measure. Alderman Edward M. Burke (14th Ward) would like menus and menu boards in Chicago restaurants that gross $10 million or more in annual sales to display the number of calories each item contains—along with the sodium, saturated fat and trans fat content.

“Firms large enough to have $10 million in gross annual sales would likely have that nutritional information available,” says Donal Quinlan, a spokesperson for Alderman Burke. The proposal is currently under review by the Council License Committee. If it passes, it goes to the Council Floor, where it will need a majority vote to become law. As of yet, no date has been scheduled for this vote.

Other cities and states are looking into mandating nutritional labeling of restaurant food. C.S.P.I.'s Web site includes a summary of pending state and local bills relating to nutritional labeling of restaurant food:

When you go out to get a good meal, you can also get a good-for-you meal—if you have the information you need to choose wisely and well.

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You're More in Control Than You Think

A 1999 U.S. Department of Agriculture (U.S.D.A.) study found that full-service restaurant meals tend to be lower in saturated fats than fast food meals, but are often higher in fat, cholesterol and sodium than fast-food fare.

Even when you're at a white tablecloth restaurant, you can lighten up on fat, cholesterol and calories by choosing entrées that are steamed or poached, instead of deep fried or sautéed in butter, swimming in a cream sauce or topped with cheese. Steering clear of sodium is a bit trickier. In general, the saltiest foods on the menu are likely to be soups, sauces, dressings and anything with cheese.

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Tufts University nutrition professor Alice Lichtenstein shares 10 tips on eating out without pigging out:

1. Try to stay away from the bread basket—most restaurants ask whether you want bread on the table. If you're famished and must indulge, ask for a whole grain bread and skip the butter or dipping oil.

2. Don't rely on menu descriptions to figure out which selections seem to be less fat-and-calorie packed than others. It's best to ask your waiter how an item is prepared, and whether butter, cream, cheese or trans fats are used. Sometimes, the chef can use alternate ingredients and cooking methods to suit your nutritional needs.

3. Knowing that you will be served more than you should eat at one sitting, split an entrée with your dinner companion or ask for a doggie bag. Some restaurants offer half portions of entrées—though they sometimes charge full price.

4. Ask your waiter to hold the sauce or salad dressing —or to serve it on the side, so you can control the amount you use.

5. Ask your waiter if a starchy side dish, such as rice or potatoes, can be replaced with vegetables. But you'll need to be flexible and allow the chef to substitute whatever vegetable dish is on hand that evening.

6. Ask that vegetables be prepared without butter or drizzled in olive oil, to keep the calorie count down.

7. Take the skin off chicken, duck and other fowl, no matter how it is prepared.

8. Avoid highly marbled meat, and cut any visible fat off.

9. If you must eat dessert, choose fruit instead of a fruit tart, or sorbet instead of ice cream.

10. If you go to a restaurant where the waiter is helpful, the chef is accommodating and the food is healthy and delicious, it pays to become a regular and to develop a relationship with the staff.

Getting what you want and how you want it in a restaurant takes creativity, self-control, choosing the right menu items and a chef's willingness to accommodate small requests, says Lichtenstein. “Even if you're in a place that [serves only] fried chicken, you [can] slip that skin and coating off and just eat the chicken. ... If worse comes to worst, just decrease the amount of food you eat.”

And remember that when you're making special requests, “service with a smile” means you smile so you're more likely to get good service.

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The Bloated Burger And The Plentiful Pasta

When you go out to eat, you know exactly how much a meal is going to cost you in dollars and cents-but no idea what it's going to cost your heart health.

A Pennsylvania restaurant is proudly submitting paperwork to the “Guinness Book of World Records” to have its 123 lb. burger-which wedding parties or other large groups can order right off the menu-officially recognized as the largest in the world. For those who aren't that hungry, the eatery will serve up a three-pound burger. That's three pounds. Of meat.

While this is an extreme case, a 2002 New York University study found that portion sizes doled out at eateries have increased dramatically since the 1970s. A typical serving of pasta is now nearly twice the healthy portion size recommended by the Food and Drug Administration and nearly five times the portion size recommended by the United States Department of Agriculture.

According to Brigham Young University's Steven Aldana, “almost without exception, [restaurants are] going to serve you pretty close to twice what you should really eat. Don't hesitate to take [it] home and have it for lunch tomorrow.”

Portion sizes of foods eaten outside the home have been so out of whack for so long that people can no longer tell what a “regular” portion looks like. In a 2006 study at Rutgers University participants helped themselves to nearly 20 percent more cornflakes with 30 percent more milk and 40 percent more orange juice than participants did in a similar 1984 study.

“The amount of food served determines, to a certain extent, how much [someone] will eat. Hence, the trend towards increased portion size of meals eaten outside the home has likely contributed to the obesity epidemic currently occurring in the United States,” adds Alice Lichtenstein, of Boston's Tufts University.

The New York University study revealed that since the 1970s our waistlines have been expanding right along with our serving sizes. Back then, obesity rates were under 20 percent nationwide, according to the Centers for Disease Control and Prevention. By 2005, only four states had obesity rates under 20 percent- and in 17 states at least one-quarter of the population is obese.

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© 2007 American Heart Association, Inc.