COMMENTARY

How to Reduce Portions: What to Tell Patients

Henry R. Black, MD; Lisa R. Young, PhD, RD

Disclosures

October 10, 2011

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Controlling Portion: An Introductions

Henry R. Black, MD: Hi. I am Dr. Henry Black, Clinical Professor of Internal Medicine at the New York University School of Medicine, member of the Center for the Prevention of Cardiovascular Disease at that institution, and immediate past president of the American Society of Hypertension. I am here today with my colleague, Dr. Lisa Young, who is an outstanding nutritionist. Tell us a little bit about yourself and what you do.

Lisa R. Young, PhD, RD: I am a nutritionist in private practice and also an adjunct professor in the Department of Nutrition Food Studies and Public Health at NYU. My research area was the growing portion sizes in America. I got interested in this topic when the average American adult gained 8 pounds in the 1980s, according to a survey, but we hadn't changed our weight prior to that. I couldn't help but notice that it was the portions. I had been counseling overweight individuals for several years. All of the literature said, "It's the carbs. It's the fats. It's the proteins."

Dr. Black: Everybody is looking for an answer.

Dr. Young: Right, but in fact, it was size, because a bigger portion, unless it's lettuce or water, is going to have more calories.

Dr. Black: Back when I was seeing a lot of patients as a primary care doctor, when they asked about eating I would say, "Well, put what you want on your plate and then just eat half of it."

Dr. Young: Excellent.

Dr. Black: But don't put twice as much as you want. That wouldn't solve the problem.

Dr. Young: Exactly. Don't pile. You talk about having a 9-inch plate or a 10-inch plate instead of a 12-inch plate because plates have grown as well. So I tell people not to pile it so high that pieces of food fall off.

Teaching Patients About Portions

Dr. Black: I've seen some interesting slides of the French fries at McDonald's; they used to be this big, and now they are this big. What do we do about that? How do you help doctors tell patients what they should be eating?

Dr. Young: The first step is awareness. That's a good question, because you don't want to just say to them, "Eat less." That's too generic.

Dr. Black: That doesn't work.

Dr. Young: The first thing we need to do is to be aware. People should become aware of how much they are eating and then learn to scale back. Things like fruits and vegetables -- I'm not worried if you eat too many carrots or bananas. That's not really the cause of the problem. It's the salad dressings, the fried foods, the French fries. I try to help people gauge how much they should eat. In my book, The Portion Teller Plan, I isolated different visuals. Three ounces of meat, for example, looks like a deck of cards. So, what I say to patients is, "You don't have to eat a deck of cards' worth, but are there 6 decks of cards on your plate?"

Dr. Black: One of the things in your book -- and this is your book, which I think is wonderful -- is that if you know you're going to have pasta, don't have bread. That's a very nice bit of advice.

Dr. Young: I like to educate people on the food groups and learning the substitutions. It's the same thing if you are going to have a steak; you don't need a roast beef sandwich the same day. If you're having pasta, you don't need the bagel that's equal to eating 5 or 6 pieces of bread.

Dr. Black: I've been to some meetings in hotels in New York lately, and the bagels are this big instead of that big.

Dr. Young: I spoke at a conference, and I said, "How are the muffins?" because they were little 1- and 2-ounce muffins instead of those big ones, and now they just sell muffin tops.

Calorie Counts in Restaurant Menus: Is Public Policy Useful?

Dr. Black: What do you think about the New York City initiative to have calorie information in every restaurant or food service that has more than 10 outlets?

Dr. Young: It's a very good idea. It's now national.

Dr. Black: Is it?

Dr. Young: Across the board, according to the healthcare reform, every state is going to require that for chain restaurants.

Dr. Black: The libertarians say, "Don't tell us what to eat." We're not telling you what to eat. We're simply giving you the information so you can make an intelligent choice. That's a very different thing.

Dr. Young: That's a very different thing. The research hasn't been so positive that people have made major changes. However, my hope is that the restaurants, because they have to disclose the calories, will start offering healthier choices.

Dr. Black: We have to be patient. I like the analogy of smoking. The first study that suggested that smoking was bad for you was in 1937. It wasn't until the early 1950s when some English epidemiologists, using doctors as their subjects, showed all the evils associated with smoking. It wasn't just cancer, which people expected; it was also heart disease. In 1964 the Surgeon General talked about it, but it was 20 years before the smoking rates went down. Now, it's pretty unusual to see somebody smoking because we have had the political will to make it difficult -- and expensive. Would you tax soda that had sugar in it more than soda that didn't?

Dr. Young: I actually do support the soda tax. The reason is that soda is so cheap -- it's sugar water. If you made it a little bit more expensive, even by a penny an ounce, you would think twice before you would buy that 64-ounce.

Dr. Black: What's happened is that we have known that taxing cigarettes tends to discourage teenagers from starting to smoke. If we trained children to eat different things, we would have some chance to overcome the obesity epidemic.

Dr. Young: Yes, I agree. But the problem, of course, is that they complain, and in trying to get it passed, how do we define junk food? Why soda? How about juice? I went to an event and the soda people were there and, of course, they were saying, "But orange juice has sugar." Orange juice has nutrients, too, so you're getting vitamin C. You're also getting potassium, whereas soda is purely wasteful calories. You're not getting any healthy benefits from it. You really can't compare orange juice to soda.

The New Plate Icon: Why It's Helpful

Dr. Black: I like your idea of the deck of cards. How do you think the circular plate, as nutrition advice relative to the pyramid, is going to affect things?

Dr. Young: I don't know that it's going to affect things much because the people who need it may not pay attention to it. But the one thing that I like about the plate is that half of it should be fruits and vegetables. That's one piece of advice that I could give to a client: "See, half of your plate should be fruits and vegetables."

Dr. Black: Some make the point that the very people who need fresh fruits and vegetables have the hardest time getting them, and they're more expensive. They shouldn't be more expensive. They should be less expensive, if anything.

Dr. Young: They shouldn't be more expensive. But frozen fruits and vegetables, as long as there is no sugar added to the fruits, and as long as there are no sauces and salt added to the vegetables, are cheaper and should also be encouraged.

Making Food Labels Work

Dr. Black: How do you train people -- and I'm talking about training other healthcare providers, not just doctors -- to train their patients to read a food label?

Dr. Young: The first thing is, food labels have so much information. You look at it and you think, should I focus on the calories, or the sodium, or whatever the buzzword of the day is? The most important thing to look at is the serving size and to determine the number of servings per package. If you would eat the entire package -- the serving sizes are very small, but there are 4 servings per package -- you need to do the math.

Dr. Black: I have a colleague in my group who bought a package and was very proud of himself. It was potato chips, and it was only 37 calories. Of course, that little package had 4 servings. You have to be a sophisticated reader. Should we simplify the food label?

Dr. Young: There is talk about simplification. What appears to be a single-serving package might have 2 or 3 servings (such as a 20-ounce bottle of soda, of which 8 ounces is the standard serving). They are going to be required to put the total number of calories of the package on the front of the label. That is one excellent step in simplification. The problem, of course, is that to simplify we would need to take something away, and who decides? Is saturated fat important? Is trans-fat important? Is sodium important? That's the challenge.

Dr. Black: There are different ways you might do that, and I think we ought to see what happens with the color of milk cartons.

Dr. Young: That's a good idea, yes.

Dr. Black: We now know that if it's red it's whole milk, and if it's blue it's likely to be skim milk.

Dr. Young: Right.

Dr. Black: So maybe we could have green packaging for people who worry about diabetes or red packaging for people worried about osteoporosis. Use other techniques that I'm sure marketing people could easily come up with to help people do the right thing if they would like to, without making them do it. But if they would like to, we have to make it simple and easy for them to do.

Dr. Young: Right, and it has to be done by the US Food and Drug Administration because every supermarket in this country will come out with their own labeling standards and that becomes very confusing.

Dr. Black: Unless a market leader comes along and says, "We're doing this. We don't really care what you do." Companies tend to follow the market leader. So we have to convince the market leader to be out there.

It's like the advertisements we see on New York City buses now. I won't mention the delicatessen company or the meat company that responded to the low-salt initiative and said, "Big deal. We've been doing that for 25 years." You know which one I'm talking about. If people consider the market leader, and you see that on the bus and say, "Gee, I'd better ask for that brand because I know they have less sodium," then there's some hope.

Advice to Patients: A Summary

Dr. Black: What other tips would you give doctors to give their patients?

Dr. Young: To eat more fruits and vegetables, to limit liquid calories because liquid calories don't register as quickly and you tend to guzzle them down. Now, I know orange juice is still healthier than soda, but an orange is healthier than orange juice. Try to eat foods that don't come in a package. Limit processed foods. Eat whole foods and even cook a little bit. You don't have to cook all the time, but cook some of the time, and leave over half your plate if it's junk.

Dr. Black: In the kind of family structures we have, where 2 people have to work, whoever is going to be the cook is going to come home between 5:00 and 6:00 and dinner is expected at 6:30 -- maybe not for you, but for your children. How do you do that? Do you cook the night before and just heat it up?

Dr. Young: Yes. Some people even cook a lot on Sunday. They make chicken and brown rice and then they sauté vegetables. Or you can have one thing that's cooked and just quickly sauté something else. Making food doesn't take forever.

Dr. Black: You have recipes in your book, which I think is a very good way to start.

Dr. Young: They are simple, too. You don't have to be a gourmet chef and you don't need 4 hours. You could grill a piece of fish.

Dr. Young: Maybe you'll be the new Julia Child.

Dr. Young: I doubt it. Julia Child is not replaceable.

Dr. Black: There are many things we need to do, and I'm hopeful that we can, if we can get the political will to do them. They have to be done at the economic level because that's what controls everything. I really appreciate you coming here.

This has been fun, and maybe we'll talk some more.

Dr. Young: It's a pleasure. Educating doctors is so important because patients don't always get to the nutritionists.

Dr. Black: These days, without reimbursement for nutritional care, very few offices can really afford that, and the doctors only have 7-10 minutes to deal with a variety of complaints. So that message has to be quick, precise, and useful -- or get an app.

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