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Fast Road to Fat City

What price all those cheap burgers & fries? Science starts to find the unsettling answers.

I've stepped into the fire-grilled world of Burger King with a mission to order the healthiest meal on the menu. It's 12:30 in the afternoon, the line is six deep, orders from the drive-thru crackle over the intercom, and nine workers hustle to keep the burgers moving. Glossy posters of golden-crusted chicken and juicy bacon burgers hang everywhere. The unmistakable aroma of French fries and crispy chicken surrounds me.

I am tempted. A cashier dressed in a maroon uniform looks at me expectantly from under his black cap as I peer over his head at the brightly lit menu board.

"Do you have any nutrition information about the meals?" I ask. He raises a brow and silently points to a poster on the wall behind me. I turn to squint at row after row of tiny listings -- 88 statistics for each menu item with calories, fat, saturated fat, cholesterol, sodium, fiber and more. To order lunch, I have almost 5,000 numbers to review. I turn back, confused.

"You probably want the Chicken Whopper," he offers, "or maybe the Veggie Burger." Then he flips his thumb at the poster. "If I looked at that poster," he says, rolling his eyes, "I'd probably never eat here again."

But people do come back, and in droves. The average American consumer eats three burgers and four orders of fries each week. A typical American child now gets one-fourth of his or her vegetables in the form of French fries or potato chips. Half our nation's family food budgets are spent in restaurants, with fast-food operations and chains getting the lion's share of the spending.

According to new studies, those patterns have devastated public health, directly feeding the obesity epidemic and increasing risk of life-threatening disease. Trans fats, massive portions and highly refined carbohydrates along with fast food's ubiquitous presence and incessant advertising, say health experts, have collectively created a dangerous scenario for unwary consumers.

On the Junk Food Trail

For two months I've been on a quest, frequenting fast-food joints from McDonald's to KFC, from Taco Bell to Quiznos. Over and over again, I confront the same problem: even when healthy options do exist, it's awfully difficult to decipher the menu to find them. The salad I chose at McDonald's was laden with cheese and bacon, surprisingly high in saturated fat and calories. The "wheat" bun I ordered at Subway turned out to be refined, not whole-grain, and I didn't realize that the 410 calories they listed did not include the mayonnaise (another 110 calories) that the girl slathered on the bun. The BK Chicken Whopper recommended to me actually delivers more calories and fat than the classic Double Hamburger from the same menu.

At Burger King I sit down with my grilled chicken salad near a young, heavy woman who urges her 16-month-old, a sweet-faced boy named Joshua, to take another bite of a breaded chicken sandwich. She has already finished a hefty bacon cheeseburger and large fries and is sipping on a large Coke.

Certainly it isn't simply the foods we choose that determine our weight. Americans are also eating more and burning fewer calories in work, play or just getting from place to place. Hours in front of computers and televisions exaggerate an increasingly sedentary lifestyle. Physical education in school has been cut dramatically in favor of more academic courses, and a car-centered culture does little to encourage walking. The environment has complicated both the cause and the solution to the obesity crisis.

As I hop from Wendy's to Pizza Hut, I'm plagued by two questions: Is fast food really a threat to our health? And why do people continue to come back, time and time again?

Science Finds a Smoking Gun

I find the answer to the first question at Children's Hospital Boston. Here children come to seek treatment for leukemia, for brain tumors, for crippling asthma and for heart conditions. And they come in increasing numbers to pediatrician David Ludwig to be treated for what has fast become the most ominous threat to childhood health -- severe weight problems.

To Ludwig, a renowned endocrinologist, the only good fast food is no fast food. Thus he has declined an invitation to meet me at a burger franchise. Instead we climb four flights of stairs to his office where he slumps into a chair, exhausted from a week of travel. But as he begins to describe his research, Ludwig's passion rallies. He and a group of colleagues have just published a groundbreaking study in The Lancet medical journal that directly links fast-food consumption to both obesity and an increased risk of type 2 diabetes.

In this study, over a 15-year period Ludwig and his colleagues tracked the fast-food consumption of more than 3,000 adult men and women between the ages of 18 and 30 living in four large cities: Birmingham, Alabama; Chicago; Minneapolis and Oakland, California. Every two years, the participants were weighed, their blood was drawn and tested for insulin and glucose concentrations (indicators of diabetes risk), and they answered extensive questionnaires about their physical activity (including the number of hours spent watching television), years of education, and whether they smoked. They were also interviewed about what they ate and where they ate. Among the questions was "How often do you eat breakfast, lunch or dinner at places such as McDonald's, Burger King, Wendy's, Arby's, Pizza Hut or Kentucky Fried Chicken?"

Most of the participants gained some weight during the 15-year study period, but the researchers found that those who ate fast food more than twice per week gained an additional 10 pounds, and their insulin resistance, a precursor to diabetes, increased twice as fast as that of participants who ate fast food once a week or less.

The findings are alarming to observers who have watched obesity statistics skyrocket.

Each year, 350,000 Americans die from obesity-related illnesses. Sixty-five percent of the U.S. adult population is currently overweight, with 30 percent of those people classified as obese. (Obesity is officially defined as having a Body Mass Index of 30 or more -- roughly 40 percent above ideal weight.)

While statistics involving adults are ominous, Ludwig, who regularly sees 400-pound teenagers and whose obesity clinic has a 6-month waiting list, worries more about the trends he is witnessing among children, of whom 15 percent in this country are already obese, a number predicted to climb steadily.

"Virtually every organ system in a child's body can be influenced by excessive weight," Ludwig says. Among the life-threatening complications are a condition called pseudotumor cerebri, in which the pressure of fluid around the brain increases; sleep apnea, in which breathing during the night periodically stops for 15 seconds or more at a time; and the ever more common type 2 diabetes.

"The estimated lifetime risk of type 2 diabetes is 35 percent for all children born in America today, 50 percent for Hispanic and African American children," Ludwig says. As young adults they will be vulnerable to heart attacks and may require coronary bypass surgery (the arterial damage that leads to cardiovascular disease begins in childhood). And a recent study showed that many adolescents who develop type 2 diabetes require amputation and kidney dialysis before their 30th birthday.

These numbers were unheard of 20 years ago when pediatricians first started seeing children with type 2 diabetes, a disease previously restricted almost entirely to older adults. For the first time in American history, experts predict, this generation of children may die at an earlier age than their parents.

"We're in the midst of a public-health crisis," Ludwig warns. "With an estimated lifetime medical cost exceeding $100,000 for anyone diagnosed with diabetes, we're looking at an epidemic that can mean the difference between solvency or bankruptcy of our Medicare system -- and that's before we ever address the human toll."

Formula for Obesity

But just what is it about fast food that makes it more of a scapegoat than any other food?

"Fast food, defined as convenience food purchased in self-service or carry-out eating places, has the worst of all possible dietary factors imaginable," Ludwig says. "In addition to the very large serving sizes, it has very high energy density, in other words, a lot of calories in a small volume. It is highly processed, with an absence of fiber so that it can be chewed and swallowed very quickly, quicker probably than the body's natural regulatory mechanisms can respond."

In contrast, studies have found that when meals are eaten at home, people tend to eat more nutritious foods, and they may eat more slowly, allowing the body a chance to respond to incoming calories and generate a sense of satiety, feedback that lets people know when they've eaten enough. According to Ludwig, that mechanism is short-circuited with fast food.

A study published last summer by Ludwig and a team of researchers found that a third of all children eat at fast-food restaurants on any given day, and on those days they take in an extra 187 calories. If a child were to eat that way every day with no increase in exercise, over the course of a year he or she could gain an additional 20 pounds.

On top of that, many fast-food products, including French fries and deep-fried chicken nuggets, are rife with partially hydrogenated fats, also known as trans fats, which are considered more dangerous to the heart than saturated fat, and which can also increase the body's vulnerability to diabetes. Add those qualities to the fact that fast food is highly available, tastes good, is cheap and is marketed intensely, and you've got a formula for disaster, says Ludwig.

Primordial Appetites

He ticks off several more connections. Fast food appeals to humans' primordial taste preferences for sugar, fat and salt, the preferences that an infant is born with. As children grow, they develop increasing tolerances and preferences for hundreds of different taste sensations that nature offers, but when fast food becomes the major dietary pattern, Ludwig speculates, it keeps taste buds in an infantile state.

"If you take a child who has been subjected to endless advertising for fast food, to peer pressure from friends who frequent fast-food restaurants and to the presence of fast food in schools, it's not a big surprise that when given a choice between a plate of French fries or a bowl of blueberries, that child would choose the fries," Ludwig says.

There may be another factor at work as well. Animal studies have shown that foods with poor nutritional quality can lead to nutritional deficiencies that might in turn lead to overeating. "If the diet doesn't allow access to key nutrients," Ludwig explains, "it's possible that in an attempt to solve the nutrient deficiency, the body begins increased eating of everything."

Found in gas stations, high schools (80 percent of schools sell pizza, hamburgers and French fries, and many now have commercial fast-food franchises on campus), shopping malls, airports and dozens of hospitals around the country (including the Cleveland Clinic and Children's Hospital of Philadelphia), fast food exists everywhere.

"Fast food is so ubiquitous that it has given people permission to eat junk food whenever they want, in as great a quantity as they want," says Marion Nestle, professor of nutrition and food studies at New York University and author of Food Politics: How the Food Industry Influences Nutrition and Health.

Mapping the Epidemic

But if fast food is one of the culprits behind obesity, why doesn't every state in the country have the same rate of obesity? That's the question Jay Maddock, a public-health expert with the University of Hawaii (Honolulu), found himself pondering as he studied statistical maps from the Centers for Disease Control that have tracked obesity's alarming progression, state by state, from 1988 to 2003. While all states' obesity levels have risen significantly, they vary tremendously in the speed of their progression.

For clues, Maddock plotted state populations against the numbers of McDonald's and Burger King franchises in each state. Together the chains represent the majority of fast-food sales. Maddock found that the more fast-food restaurants there are per person, the higher the obesity rate in the state. In Louisiana, for example, with 24 percent obesity, there are twice as many McDonald's and Burger Kings per capita as there are in Colorado, with an obesity rate of 15 percent.

"If you're in an area that's dense with opportunities for cheap, calorically dense food, you're going to be more likely to eat it," says Maddock.

Maddock is the first to admit that the study has its limitations. It could be that in states with populations more likely to eat fast food, these chains find their best customers. Or there might be a third, unidentified factor at work. But if future studies confirm his results, Maddock suggests that communities might consider zoning rules to limit the number of fast-food restaurants in any given region, and to prevent drive-thrus from dominating the scene. "We have communities in Hawaii that don't allow drive-thrus. That reduces the number of people who frequent fast-food restaurants because they actually have to get out of their car. The public really needs to think more about the way the environment is structured and how it affects us."

Portion Explosion

One item I failed to find in my home state of Vermont was Hardee's new Monster Thickburger, with two-thirds of a pound of meat, four strips of bacon, three slices of American cheese and "butter-flavored shortening." The 1,400-plus calorie package, about two-thirds of the average sedentary adult's daily caloric needs, requires "two hands, a firm grip, and a serious appetite," according to the company. A customer would also need serious exercise to prevent it from adding pounds to his or her body. Even the kids' Happy Meals at McDonald's now come in bigger portions dubbed "Mighty Kids Meals."

"There's a perfect parallel between portions getting bigger and people getting bigger," says Lisa Young, a professor of nutrition at New York University and author of The Portion Teller, a weight-loss guide due to be published this spring. Young has tracked the growth of portion sizes over the past 30 years across all categories of the food market, even in classic cookbooks like the Joy of Cooking, where the same tray of brownies that served 30 people in 1975 now serves only 16.

"Portions have gotten so much bigger since the '70s that if you were used to finishing everything on your plate then, and you still do now, you're going to be eating twice as much food," says Young.

"In 1969, you could get only one size of fries (around 2.4 ounces), a hamburger with approximately 1.5 ounces of meat and a 12-ounce soda," she says. "Today you can go into the same hamburger chain and get 6 ounces of French fries, a burger with 8 ounces of beef and a 32-ounce cola." That's 1,250 additional calories.

To be fair, fast-food restaurants generally do offer a variety of portion sizes. You don't have to choose the larger portion when there are more modest options, but much of the appeal, according to Young, is in the pricing. Why buy the "medium" soda when you can get twice as much in the king size for only 20 cents more?

Smokescreen of Health

The same value pricing that works for larger portions works against many of the "healthful" choices on the fast-food menu. "Look at the salads on one of these menus," Young says. "They sell for, say, $4.99. For the same price you can buy five hamburgers. So you're poor, you need to feed your family, what are you going to do, buy five salads or five hamburgers?"

Skeptics also caution that what might look like healthy food can be deceptive. A salad with dressing, bacon and cheese can have as many calories as a supersized burger. Fast-food reformers would love to see calorie counts right up next to the items on menu boards. It's a tactic no fast-food franchise has adopted, despite the nutrition community's insistence that it would help consumers make wiser choices.

In fact, expect the restaurant industry to oppose anything that draws attention to calorie counts. According to Dan Mindus, a senior analyst at the Center for Consumer Freedom, which describes itself as "a coalition of food companies, restaurants and consumers dedicated to promoting personal responsibility and protecting consumer choice," placing calorie counts on menu boards could produce unintended consequences.

"Trial lawyers focusing on obesity have already made it clear that mislabeling is one of the areas they'll look at," Mindus says. "Unless you use an eyedropper to measure out the soup, it's almost impossible to standardize calorie counts and sodium counts in every dish on the menu. There's a big fear that this will bring on frivolous litigation."

Burger King, McDonald's and Taco Bell explain that they do publish nutrition information on their websites and in pamphlets available at the restaurants. But the numbers are given in such an overwhelming, hard-to-decipher form that "you need a magnifying glass to see them and a Ph.D. to understand them," quips NYU's Marion Nestle.

Cathy Kapica, global director of nutrition at McDonald's and a registered dietitian, says that when her company asked focus groups what they thought about listing the total calories of foods on the menu board, the response was surprisingly negative. "People consider that personal information," Kapica says. It appears they don't want anyone knowing how many calories they are ordering.

Giving people healthy options, Kapica says, is often like this -- not as simple as it sounds. Last year, McDonald's announced with great fanfare that it was reducing trans fats in its French fries. Very quietly, six months later, it admitted that the initiative was on indefinite hold. "We thought it would be easier," Kapica says. "The change is going to take longer than anticipated. Our customers have taste expectations that we have to meet," she says, adding that to complicate matters, currently the volume of heart-healthy oil produced in the U.S. is inadequate to supply restaurants.

Joe Camel, Ronald McDonald

Portions, availability, value-pricing all help a burger's popularity, but perhaps the most insidious of tactics behind the success of the fast-food industry, say many public-health experts, is advertising to children.

The average American child sees 10,000 food advertisements a year, and most promote foods with questionable nutrition profiles. Research has shown that for each hour of television watched per day, a low-income preschool child's risk of being overweight increases by 6 percent. Children in the U.S. watch an average of 3 hours of television per day. A study in the medical journal Pediatrics found that, for each hour of television watched by 11-year-old children, fruit and vegetable consumption decreased by 10 percent. The investigators concluded that the relationship "may be the result of the replacement of fruits and vegetables in youths' diets by foods highly advertised on television."

Mindus at the Center for Consumer Freedom cautions people to look at the studies more closely. "Remember, television is not just advertising. It's also sedentary activity. We're suffering a huge physical-activity deficit in America right now."

But child-advocacy groups like the American Academy of Pediatrics have concluded that "Advertising directed toward children is inherently deceptive and exploitive." In addition, they question the disproportionate budgets promoting unhealthy foods.

"Look at the amount of energy and money that is harvested to sell ads," says Kelly Brownell, director of the Yale Center for Eating and Weight Disorders and author of Food Fight: The Inside Story of the Food Industry, America's Obesity Crisis and What We Can Do About It. "Take SpongeBob, for example, a massively powerful commercial icon. Let's say Nickelodeon licensed SpongeBob only to companies selling healthy foods. If all that power and persuasion were used in the direction of public health, we'd be better off." But so far, sports stars and celebrities appear where the money takes them, promoting soft drinks like Pepsi and other big-brand foods.

For the $40 billion that Madison Avenue spends on food advertising each year, the federal government has $2 million to promote nutrition education. "You don't see Britney Spears promoting zucchini," says NYU's Lisa Young.

"We need to step in and protect children from the food industry that is preying on them. We need to protect them from social conditions that promote unhealthy food intake," Brownell says. There are governments, including those of Sweden and the province of Quebec, that have made advertising to children illegal.

Counters industry spokesman Mindus: "The vast majority of the American people believe that parents are primarily responsible for the food choices of their kids, not advertising or any other factor. A lot of people are proposing very radical, so-called solutions to a problem that they have trumped up. Those solutions include extra taxes on foods they don't like, zoning restrictions on restaurants and junk-food outlets, lawsuits and a whole host of draconian regulations that will take away our food choices and that will limit the amazing options that the American people have today."

When David Ludwig hears arguments that food choice is an issue of personal responsibility, he shakes his head. "This is a questionable argument at best when it comes to adults, but it breaks down entirely when we're talking about kids. Where is the personal responsibility for the 6-year-old who sees an average of 10,000 food commercials a year, the 10-year-old who is offered soft drinks and fast food at school, the inner-city child who walks home past a dozen fast-food restaurants and can't find a single healthful alternative? Where is the personal responsibility there?"

Enlightened Self-Interests

"In this climate, how is it that we tolerate the incessant advertising and marketing of the most unhealthful products, fast food and soft drinks, and even allow their placement at schools? I think that it's an example of the interest of private profit taking precedence over public health," Ludwig says.

When I ask McDonald's Cathy Kapica about the company's policies, she says, "We only advertise foods that are appropriate for kids from a portion-size perspective. Our most popular Happy Meal, 4-piece Chicken McNuggets, small fries and a Sprite, is a third of the daily calorie requirement for a 6-year-old girl who is inactive." When I point out that the meal doesn't have vegetables, Kapica responds, "Technically, according to the USDA, French fries are a vegetable. I don't buy that, but we've tried celery and carrot sticks, and we recently tested 30 different vegetables with kids. Guess how many they liked? Zero! We respond to customer demand."

"It is not my intention to demonize the food industry," Ludwig says, leaning back in his chair. "There are clearly some segments that are taking a more responsible, proactive role. The problem is that with a few irresponsible players, it tends to lower practices across the industry."

All we need do is look at his patients, Ludwig says, and the years of data linking fast food and ill health. "There is nothing in our work that suggests a minimum safe level: the more fast food is consumed, the greater the risk. We need to influence the food industry to establish minimal standards with regard to food quality and marketing. If they do, the whole industry will benefit. If they don't, then ultimately this may lead to a backlash and the imposition of regulations that the industry may find distasteful. This is really a chance for the industry to take action in its own enlightened self interest."

Back at Burger King, Joshua and his mother pack up to leave. I can't help but wonder, if he continues to lunch here several times a week on items like the breaded chicken and fries his mother fed him, will he too join the obesity statistics? After two months of frequenting endless fast-food restaurants, I know very well how confusing and difficult it is to pinpoint the healthier choices and how tempting it is to order the deep-fried favorites.

Between the drive-thru and the sit-down area, the pace hasn't slowed over the hour I've been here. Through the window I see a McDonald's down the road, a gas station pushing two hot dogs for the price of one, and never-ending traffic.

A Tax on Fries?

What would happen if unhealthy food suddenly took a price hike? If a burger came in at $3 but a fruit salad could be bought for only $1.25?

With an eye toward changing the uneven pricing scale, Kelly Brownell, a behavioral psychologist at the Yale Center for Eating and Weight Disorders, thinks that a tax on unhealthy foods could make a difference in how much people ate them. Opponents have dubbed the proposal the "Twinkie Tax" and harshly criticize Brownell for attempting to limit consumer choice. Brownell sees it as simply leveling the playing field.

"Economics are an important driver of human behavior," Brownell reasons. "The problem is that the economics of food are the reverse of what they need to be: healthy foods cost more and unhealthy foods cost less."

Subsidies explain a large part of the price discrepancy, say public-health experts. The farm subsidy bill directs $100 billion per decade to commodities like corn, used for both fattening beef cattle and to make high-fructose corn syrup, a major ingredient in soft drinks. Some suggest the subsidy creates a reverse tax on healthier foods, such as fruits, vegetables, nuts and legumes, that are more expensive to produce and receive very little from the subsidy program.

"If you were starting the world from scratch you'd want to have healthy foods inexpensive and unhealthy foods cost more as a disincentive to buying them," Brownell says. Some states have experimented with taxes on unhealthy foods and found that a tax of 7 to 8 percent affects consumption. In fact, taxes have significantly affected the use of cigarettes and alcohol.

The list of foods Brownell would tax starts with soft drinks, followed closely by fast foods. "The money you could raise from just taxing those could be enormous," he says. "If you taxed one penny for every soft drink sold in this country, you'd raise $40 billion a year." Brownell envisions nutrition education, promotion of public exercise programs and healthy foods, and money for obesity-prevention treatment programs.

"You can do a lot with $40 billion."

Fast-Food Survival Tips

Beverages: Opt for low-fat milk or water.

Skip the breading: Grilled chicken is always a better choice than anything coated and deep-fried.

Mind your fries: Reduce one of the worst sources of calories and trans fat by skipping the fries or opting for small.

Watch the salad dressings: Often half a packet is plenty; the dressings may be surprisingly high in calories, fat and sodium.

Hold the mayo: Avoiding toppings and sauces is an easy way to save fat and calories.

Seek out the veggies: Some fast-food chains offer more veggie choices (e.g., Boston Market, KFC, Subway, Quiznos).

Eat like a kid: Choose drinks and meals from the children's menu for smaller portion sizes.

Be informed: Check out Nutritional Facts sheets and online menu calculators that many chains now offer.

Related Links:

  • Miracle Up North
  • EatingWell Preventing Heart Disease




This news arrived on: 05/22/2007

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