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Joel Marion and Tim Skwiat, Pn2

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11 FOODS TO NEVER EAT AT ANY

RESTAURANTAccording to the United States Department of Agriculture, in 1970, 25.9% of all food spending (in America) was on food away from home (i.e., dining out). By 2012, that number rose to its highest level: 43.1%. Restaurants served over 70 billion meals in the United States in 2005. Of all the money spent on food in the United States, 47% is spent in restaurants. Four in 10 Americans eat in restaurants on any given day, and 1 in 6 eats more than 5 meals per week in restaurants.1

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Between 1977-78 and 2005-08, the average American’s consumption of food prepared away from home increased from 18% to 32% of total calories. Along those lines, meals and snacks prepared out-of-home contained more calories per feeding opportunity than those made at home. Even more, away-from-home food was also higher in nutrients that Americans overconsume (e.g., fat, saturated fat) and lower in nutrients that Americans underconsume (e.g., calcium, fiber, iron). In other words, eating out typically means eating more calories and fewer nutrients.2 Not good.

Not surprisingly, dining out on a regular basis is associated with weight gain. In a comprehensive review published in the journal Nutrition Reviews, researchers from Brazil analyzed 28 cross-sectional and prospective cohort studies, and they found that the overwhelming majority of studies found a positive association with eating out and body weight.3 In other words, eating out more frequently is associated with weight gain. Again, that’s nothing surprising considering that food choices when dining out are typically high in calories, and most people tend to eat more when eating out-of-home.

Along those lines, there are some fairly obvious menu items to avoid when dining out if you value your health and want to protect your waistline. In other words, you already have a pretty good idea of what’s “healthy” and what’s not. For instance, you know that a double cheeseburger, large order of French fries, and milkshake is probably not your ally in the battle of the bulge. Likewise, a massive creamy pasta dish washed down with a bottle of wine is a far cry from the Mediterranean Diet.

While some of the probable suspects will be discussed, the goal of this report is not to regurgitate things you already know. Rather, we encourage you to exercise some mindfulness—both when making your food choices and when you’re eating—and sensibility. As far as this report goes, we want to cover some of the less suspecting foods that are more commonly consumed when dining out.

One aspect of eating out that we’ll cover that is often overlooked is foodborne illness, which causes about 76 million illnesses and about 5,000 deaths in the United States each year. According to the Centers for Disease Control and Prevention, 52% of all cases of foodborne illnesses reported between 1998 – 2004 were associated with restaurants.

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Sources of foodborne disease outbreaks reported to the Centers for Disease Control and Prevention during the period 1998–2004. “Restaurants” includes delicatessens, cafeterias, and hotels.1

With those things in mind, let’s review some foods—some common, some less suspecting—to avoid when dining out.

ENTRÉE SALADS

When you think about salads, what ingredients come to mind? For us, it’s a litany of delicious, wholesome, fresh vegetables:

• Leafy greens including spinach, bibb, romaine, kale, cabbage, green leaf, red leaf, mache, treviso, endive, frisee, arugula, dandelion greens, radicchio, chard, and more.

• Cruciferous veggies including cauliflower, broccoli, Brussels sprouts, rutabaga, bok choy, turnips, radishes, watercress, and more.

• Sweet peppers• Tomatoes• Cucumbers• Carrots• Onions• Scallions• Mushrooms• Sprouts• Beets• Fresh herbs (e.g., basil, parsley, cilantro)

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Beyond that, there are some additional salad toppings that not only provide delicious flavor but also heart- and brain-healthy fats, appetite-satisfying and gut-friendly fiber, metabolism-boosting and fat-burning protein, and health-boosting phytochemicals:

• Avocados• Eggs• Grilled, roasted, braised, seared, etc., proteins (e.g., chicken, pork, tuna)• Legumes (e.g., lentils, garbanzo, black)• Fresh fruit (e.g., berries, apples, pears)• Nuts and seeds (preferably raw)• Vinaigrettes made with healthy oils (e.g., cold-pressed extra-virgin olive,

avocado, sesame, and nut oils) and vinegar

While that’s a good general template for building a super salad, the unfortunate reality is that the majority of store- and restaurant-bought salads have some serious waist-expanding problems with them:

• They’re doused with salad dressings made with cheap, highly refined vegetable and seed oils (e.g., soybean, safflower, sunflower), which are loaded with pro-inflammatory fats.

• They’re topped with fried meats and other calorie-dense, nutrient-sparse accoutrements.

• They’re served in massive portion sizes.

Believe it or not, many of restaurant entrée salads pack between 1200 and 1500 calories—sometimes more. To put that into perspective, that’s equivalent to a 1/2-pound double cheeseburger, order of French fries, and a soda. Yikes!

ICEBERG LETTUCE

As mentioned above, there’s no question that salads and veggies are healthy, and even though iceberg lettuce provides relatively less nutritional value than the leafy greens mentioned above, it’s still very much a healthful option. The reason iceberg lettuce makes our

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list is because it’s a massive rip-off.

To put it into perspective, the average retail price of iceberg lettuce is around $0.95 per pound (often even less), or about $0.15 per cup or about $0.28 for a quarter of a head of lettuce. Compare that to a wedge salad, which may cost $10 or more. Sure, a wedge salad has some other ingredients (e.g., bleu cheese, bacon, onions, tomatoes, and salad dressing), but even at half that price, it’s still marked up around 20 times its original cost.

If you’re going to spend some money on a salad, a better bet is to look for one that’s packed with nutrient-dense veggies.

BEST SELLERS & SPECIALS

As strange as it sounds, to keep up with demand, the reason these make the list is because many restaurants make their top sellers before the lunch rush hour or busy dinner times. That means that the food is sitting around collecting bacteria and harboring potential food-borne illnesses.

A better option would be to choose a different item than the “special of the day” or “best seller,” as it is more likely to be made fresh and prepared to order. According to Howard Cannon, author of The Complete Idiot’s Guide to Starting a Restaurant, “Anything sitting in holding, covered with mayonnaise, is probably not that great.”

WATER

Cannon, who’s also the CEO of Restaurant Expert Witness, says, “One of the most dangerous items in a restaurant is water.” Typically, water sits at the perfect temperature (between 40 and 140 degrees Fahrenheit) to harbor bacteria.

If you find that there’s already water on your table—either in a glass or a carafe—or if you’re served a glass of water any warmer than ice-

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cold, it’s a good idea to ask for a new glass. You might also consider asking for bottled water, but you might need help drinking it considering that you’ll probably be charged an arm (and a leg) for it.

BAR SNACKS

If you’re a fan of eating bar snacks (e.g., pretzels, nuts), here’s a little trick for you to try next time you’re eating out. Ask a random person who’s just walking out of the restroom to grab a handful of bar snacks. Then, proceed to eat them out of his/her hand.

As disgusting as it sounds, that’s basically what you’re doing when you’re eating the complimentary snacks that are set out at the bar. Any number of people may have put their hands in that bowl of pretzels and peanuts, and according to researchers at Michigan State University, upwards of 95% of people don’t wash their hands properly.4 Some research even suggests that 40% of women and over 60% of men don’t even wash their hands at all.5 Yikes!

You can certainly ask for a fresh bowl, but there’s no guarantee that it’s truly “fresh.” Your best bet may be to forgo the bar snacks, or if you need something to munch on, order something fresh from the menu.

SEAFOOD

Seafood is delicious and packed with nutrients, and it’s very likely that a restaurant’s offerings are going to be far more expansive than the average home kitchen. There are tons of potential healthy options, including mollusks (e.g., oysters, scallops, clams), shellfish (e.g., shrimp, crab, lobster), and fish (e.g., salmon, tuna).

The problem, however, is something referred to as “seafood fraud,” which the international organization Oceana defines as “practice of misleading customers

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about their seafood in order to increase profits.” Simply put, restaurants (knowingly or unknowingly/ignorantly) substitute cheaper fish for more expensive fish to increase profit margins.

For example, Oceana collected 82 salmon samples from restaurants and grocery stores and found that 43% were mislabeled. In fact, 69% of the samples marked as “wild-caught” salmon were farmed Atlantic salmon. Because farmed salmon are typically fed commodities like soy and corn, which have dramatically higher concentrations of omega-6 fats compared to omega-3 fats, the fatty acid profiles of the salmon change markedly relative to wild-caught salmon, which feed on other omega-3-rich fish (e.g., sardines, anchovies) lower on the food chain.

The ratio of omega-3 to omega-6 fats (i.e., more omega-3 fats, fewer omega-6 fats) in wild-caught salmon is upwards of 266% higher than that of farmed salmon, which is lower in omega-3 and higher in omega-6 content.6 But that’s not all; farmed salmon also contain high concentrations of potentially health-damaging contaminants (e.g., PCBs, dioxins, chlorinated pesticides).

According to Oceana, here are some examples of commonly mislabeled seafood:

Examples of Commonly Mislabeled SeafoodYou Purchased You Received

Red SnapperSlender Pinjalo, Channel Catfish, Rockfish, Tilapia, Nile Perch, Mahi Mahi, Mullet Snapper, Malabar Blood Snapper, Atlantic Cod

Mahi Mahi Yellowtail

Grouper Channel Catfish, Hake, Tilapia, Alaska Pollock, Nile Perch

Wild Salmon Farmed Salmon

Swordfish Mako Shark

Bluefin Tuna Bigeye Tuna, Yellowfin Tuna

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White Tuna Escolar

White Snapper White Hake

Atlantic Cod Alaska Pollock, Norwegian Pollock, Whiting, Saithe, Escolar

Chilean Sea Bass White Bass, Striped Bass

Shark Meat Nile Perch

Red Drum Black Drum

Halibut Sea Bass, Deep-water Cape Hake

Haddock Saithe

Anchovies Icefish

Orange Roughy Oreo Dory, John Dory

Red Mullet Spotted Goatfish

Monkfish Pufferfish

Jacquet and Pauly 2008, Lowenstein et al, 2009, Wong and Hanner 2008, Miller and Mariani 2010, CBC News.

LEMONS

Lemons are an excellent source of vitamin C, and like other citrus fruits, lemons are also a good source of phytonutrients, which possess a variety of health properties (e.g., antioxidant, anti-inflammatory). It’s also well-established that lemons possess powerful antimicrobial properties, with studies showing inhibition of bacterial growth with lemon juice, oil, and extracts.

Unfortunately, according to a study published in the Journal of Environmental Health, 70% of lemon slices out of 76 total samples tested were contaminated with bacteria.7 The authors stated that certain species of pathogenic bacteria found “could have come from the fingertips of a restaurant employee via human fecal or raw-meat or poultry

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contamination.” Even more, the microbes found on the lemon samples “all have the potential to cause infectious diseases at various body sites.”

With that in mind, it’s probably a good idea to pass on the lemon as garnish or flavor enhancer. In the case that a lemon is added to your drink without your request, you might consider asking for a new drink sans lemon.

FRIED FOODS

Two words: Trans fats. If you’re not completely familiar with trans fatty acids, a good starting point is the recent determination by the United States Food and Drug Administration (FDA) that partially hydrogenated oils are not safe for human consumption.8 While this is definitely a step in the right direction, it’s important to note that the FDA has given food manufacturers and establishments until June 2018 to remove partially hydrogenated oils from their products.

Nutritionally speaking, trans fatty acids serve no purpose, and as Erin Russell, Assistant Editor of the Canadian Medical Association Journal, puts it, “Partially hydrogenated oils are entirely artificial and would not be in our food supply if they weren’t economically attractive to the food industry.”9 Why are partially hydrogenated oils so attractive to the food industry?

Production of partially hydrogenated vegetable oils was developed because of low cost, long shelf-life, and suitability for commercial frying and transport.10 Many restaurants use partially hydrogenated oils when they fry foods because these types of oils, which are the major dietary source of industrial-produced trans fats, can be used many times in commercial fryers.

The Institute of Medicine (IOM) recommends that consumption of trans fats is as low as possible.11 In essence, industrial-produced trans fats are like tobacco in the sense that they’re not beneficial at any dose. For instance, the IOM cites evidence that any intake of industrial-produced trans fats (above zero) will increase one’s risk for cardiovascular disease.

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But the problems don’t start and stop with an increased risk of heart disease. In fact, there’s evidence that suggests that a number of negative health outcomes are correlated with trans fat intake, including weight gain and obesity.12,13 Trans fats have also been associated with an unhealthy inflammatory response, endothelial dysfunction, and decreased insulin sensitivity.14

Along the lines of weight gain, trans fat intake has been associated with abdominal obesity.13 Even in the absence of excessive caloric intake, controlled animal studies have shown that trans fats are an independent factor for weight gain, including enhanced storage of abdominal fat.15 In one study published in the journal Obesity Surgery, Brazilian researchers discovered that there was a higher content of trans fatty acids in the visceral fat of obese folks, suggesting that trans fats may be preferentially stored as deep abdominal fat.16

This is particularly worrisome because visceral fat (i.e., abdominal obesity) is associated with a laundry list of negative health outcomes and a “constellation of metabolic abnormalities,” including:17,18

• High triglycerides• Low levels of “good” cholesterol (i.e., HDL)• High levels of apolipoprotein B (which is considered a better predictor of

cardiovascular risk than the more commonly used LDL19)• Small, dense LDL and HDL particles (small, dense particles are considered more

detrimental than large, fluffy particles20)• Unhealthy levels of inflammation• Insulin resistance• Poor carbohydrate tolerance and metabolism• Leptin resistance

Unfortunately, the news gets worse. If it wasn’t bad enough that the partially hydrogenated oils found in processed foods and used in restaurants contain trans fats, the base oils are industrial vegetable and seed oils (e.g., corn, soybean), which are rife with omega-6 fatty acids. These fats contribute to an unhealthy inflammatory response, particularly when consumed out of balance with omega-3 fats.

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Researchers attribute this imbalanced intake of omega fatty acids to an increase in virtually all inflammation-related conditions including cardiovascular disease, diabetes, obesity, metabolic syndrome, irritable bowel syndrome, inflammatory bowel disease, rheumatoid arthritis, asthma, mood disorders, mental illness, autoimmune disease, and more.21 What’s more, excess omega-6 intake has also been shown to be associated with shorter telomere lengths and accelerated aging.22,23

CHIPS, SALSA & BREAD BASKETS

At most restaurants, chips and salsa or bread baskets are complimentary and refills are “free.” The fact of the matter is that the overwhelming majority of people eat the food that’s in front of them.

This is what Cornell researcher Dr. Brian Wansink, a leading expert in behavior change, refers to as “mindless eating.” Dr. Wansink has countless solutions to eliminate mindless eating, and on this topic, he says that you should ask the waiter to remove the chip bowl or bread basket either early in the meal or altogether.24

While we’ve all seen how this can work against you, this is actually a strategy that you can use to improve your nutrition. Dr. Wansink says that the real secret to healthier eating isn’t about willpower; instead, it involves what he calls the “CAN” approach. Specifically, Dr. Wansink says that healthy foods should be Convenient (visible and readily available), Attractive (enticingly displayed), and Normal (the obvious choice).25

In one study, Dr. Wansink found that folks who have a fruit bowl in the house weigh, on average, 8 pounds less than their next-door neighbor who doesn’t. To be most effective, add at least two different types of fruit to the bowl and keep it in a high-traffic area. Other than your fruit bowl filled with colorful options, it’s a good idea to remove other less healthy foods from your kitchen counter.

In a separate study, Dr. Wansink found that people who had chips or cookies on their countertops (i.e., visible) weighed about 10 pounds more than people with bare counters. Even more surprising, folks who kept boxes of breakfast cereal on the counter weighed about 21 pounds more, and those people who had soft drinks readily available

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weighed 25 pounds more!

You may have heard this before, but eating off smaller plates can make a tremendous difference. Dr. Wansink recommends using 9- to 10-inch plates, and his research suggests that downsizing from 12-inch to 10-inch plates reduces portion sizes by 22%.26

BUFFETS & SALAD BARS

Given everything discussed thus far, you might already have an idea as to what some problems may be with buffets and salad bars. For starters, buffets are typically “all-you-can-eat” style, and not surprisingly, most people make a decision (either conscious or unconscious) to get their money’s worth.

Interestingly, in a recent study published in the journal BMC Nutrition, researchers found that diners who paid less for an all-you-can-eat buffet gave higher ratings for overeating, feelings of guilt, and physical discomfort that diners who paid twice as much—even if they ate the same amount.27

Research shows that, with buffet foods, the first ones offered/seen are the ones most selected.28 This doesn’t typically bode well for your waistline considering that most restaurants place cheaper, less healthy, and more calorie-dense foods at the beginning of the buffet line.

Another interesting point to note is that overeating may be contagious. That’s right, in another one of Dr. Wansink’s studies, he found that women, in particular, may be led to eat more when those around them are overeating at a buffet-style meal.29

In addition to encouraging overeating, buffets are also a hot bed for bacterial contamination. Most people recognize that shaking hands is one of the most common ways that disease is spread. Well, that’s basically what you’re doing when you visit the buffet. Essentially, you’re “shaking hands” with (and collecting the bacteria from) everyone else who’s touched the serving utensils prior to you.

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EGGS

Perhaps a better sub-heading for the section would have been “egg substitutes.” Make no mistake about it, real eggs are quite nutritious and can indeed be included as part of an overall healthy diet. Real eggs—including the yolks, and in particular the yolks—are an excellent source of protein, healthy fats, vitamins, minerals, and antioxidants. On the other hand, mechanically-separated, low-fat, chemically-altered “eggs” are the result of food manufacturers preying on consumer fears, which are based on outdated, inaccurate health information (e.g., cholesterol).

Egg substitutes are not a superior replacement for real eggs. Unfortunately, a number of restaurants, particularly chain restaurants, don’t use real fresh eggs. Rather, the restaurants nuke their previously frozen egg patties in the microwave. In other cases, kitchens use dehydrated eggs combined with liquid. Even more, some chains use additives (e.g., pancake batter) to bulk up their eggs and increase profit margins.

Eggs provide one of the highest quality proteins of any whole food available; in fact, researchers frequently use the eggs as the standard in measuring the quality of protein from other foods. In addition to being a low-calorie source of high-quality protein, eggs also contain a variety of vitamins (e.g., A, B, D, and E), minerals, nutrients (e.g., choline), and monounsaturated fatty acids that can reduce the risk of CHD.30

As previously mentioned, it’s important not to dismiss the yolks, as that is where all of the (healthy) fats are stored, and along with them, all of the important fat-soluble vitamins (e.g., vitamins A, D, and E) and nutrients (e.g., choline). What’s more, while the whites of eggs contain a higher percentage of protein, the yolks have higher levels of the essential amino acid leucine, which, as previously discussed, plays a key role in muscle growth and recovery.

That being said, not all eggs are created equally. Specifically, research from Mother Earth News suggests that eggs from pasture-raised hens provide a superior nutrition profile compared to standard store-bought eggs.31 For example, compared to typical supermarket eggs, the eggs from pasture-raised hens may contain:

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• 1/3 less cholesterol• 1/4 less saturated fat• 2/3 more vitamin A• 2 times more omega-3 fatty acids• 3 times more vitamin E• 6 times more vitamin D• 7 times more beta-carotene

As far as ordering eggs from a restaurant, it won’t hurt to ask the server to confirm that the kitchen uses real eggs and to ask if eggs from local, pasture-raised hens are an option. Also, it may be a good idea to order eggs hard-boiled, sunny side up, over easy, etc., to make sure that you’re getting real eggs—and only eggs. It’s a bit easier to disguise egg substitutes in the form of scrambled eggs and omelets.

BON APPÉTIT!

Obviously, eating out is a bit more “dangerous” than eating at home. It’s easier to overeat, and the food choices are typically less nutritious. Having said that, you don’t have to be a hermit and never eat out-of-home again. However, if you value your health, then take some time to exercise some mindfulness—both when making your food choices and when you’re eating—and sensibility. Make the best choices, and most importantly, enjoy your food, your company, and your experience!

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and smoking with 9-y gain in waist circumference among 16 587 US men. Am J Clin Nutr. 2003;78(4):719-727.

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15. Kavanagh K, Jones KL, Sawyer J, et al. Trans fat diet induces abdominal obesity and changes in insulin sensitivity in monkeys. Obes Silver Spring Md. 2007;15(7):1675-1684. doi:10.1038/oby.2007.200.

16. Bortolotto JW, Reis C, Ferreira A, et al. Higher content of trans fatty acids in abdominal visceral fat of morbidly obese individuals undergoing bariatric surgery compared to non-obese subjects. Obes Surg. 2005;15(9):1265-1270. doi:10.1381/096089205774512375.

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20. Toft-Petersen AP, Tilsted HH, Aarøe J, et al. Small dense LDL particles - a predictor of coronary artery disease evaluated by invasive and CT-based techniques: a case-control study. Lipids Health Dis. 2011;10(1):21. doi:10.1186/1476-511X-10-21.

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24. Wansink B. Mindless Eating: Why We Eat More than We Think. New York: Bantam

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29. Wansink B, Just D, Smith L. Peer Effects in the Buffet Line: Is Overeating Contagious? J Nutr Educ Behav. 2011;43(4):S45. doi:10.1016/j.jneb.2011.03.133.

30. Djoussé L, Gaziano JM. Egg consumption in relation to cardiovascular disease and mortality: the Physicians’ Health Study. Am J Clin Nutr. 2008;87(4):964-969.

31. Long C, Alterman T. Meet Real Free-Range Eggs. Mother Earth News. November 2007. http://www.motherearthnews.com/real-food/free-range-eggs-zmaz07onzgoe.aspx.