Secrets of Restaurant Nutrition
What you need to know about nutrition and food safety in your favorite restaurants.
By Elizabeth Lee
Reviewed by Louise Chang, MD

Restaurant secrets often start with nutrition. And until now, those restaurant nutrition facts have been available on a hit-or-miss basis.

That's starting to change, as Congress considers two bills that would require chain restaurants to provide information similar to that on a nutrition facts label on packaged foods in supermarkets.

Beyond restaurant nutrition, there are other tips and tricks of the trade that many diners don't know. Want to find out more restaurant secrets about food safety, portion sizes, and which foods offer the most nutrition -- and value -- for the buck? Keep reading.
Calorie Counts

One of the biggest restaurant secrets is nutritional information. Think about it: How many diners would chow down on one of Outback Steakhouse's Bloomin' Onions if they knew it contained an estimated 2,130 calories?

But that may be changing. Of the two bills going through Congress, one would require restaurants with 20 or more outlets to provide nutrition information however they choose, such as on brochures or web sites; another would require restaurant nutrition information on menus or menu boards.

"If it isn't on the menu then it isn't worth doing, because nobody sees it," says Margo Wootan, director of nutrition policy for the consumer advocacy group Center for Science in the Public Interest.

In New York City, where restaurants with at least 15 outlets were recently required to begin displaying calories on menus or menu boards, diners have taken notice. Some 90% of restaurant patrons said calorie counts were higher than expected, according to a survey by Technomic, a Chicago-based market research firm.

That information is changing what 82% of diners order, according to the Technomic study. Sixty percent of those surveyed said it also affects what restaurants they visit.

Want more restaurant nutrition information now on what you're eating? Check web sites. Most fast-food chains already provide this information online, as do a handful of dinner-house chains. Yum Brands, which owns Kentucky Fried Chicken, Taco Bell, Pizza Hut, and other brands, is starting to place calorie counts on menu boards at all company-owned restaurants nationwide and will finish the work by 2011.
Off-Site Food Preparation

To cut down on labor costs, speed up service, and reduce the risk of food-borne illness, many chain restaurants and some independent restaurants serve food that is partially or fully cooked elsewhere, often in a central kitchen or food-processing facility. The practice helps restaurants solve training issues caused by the industry's high employee turnover rate.

"There are big labor savings," says Barbara Fields Brown, director of operations for Global Concessions, which owns 12 restaurants at Atlanta's Hartsfield-Jackson International Airport. "And we do not have to be worried about a lot of cross-contamination, because the food has already been cooked."

For diners, the benefits are less clear. They'll find consistently prepared food at chain outlets across the country. But if they'd like their steak prepared without seasoning or less salt in the chicken fajitas, they're out of luck.
How Clean Is the Restaurant?

Restaurants accounted for 41% of food-borne disease outbreaks between 1990 and 2006, according to a report compiled by the Center for Science in the Public Interest. Private homes accounted for 22%.

Checking out a restaurant's health inspection report offers just a snapshot of its cleanliness on one day. If you live in a state or region where inspection reports must be posted in a restaurant or grades placed on entry doors, take the time to check out the information. Some inspection forms show previous grades, giving a more complete picture of a restaurant's attention to sanitation.

Many states and regions are moving to put restaurant health scores online, too. Find out who inspects restaurants in your area, then go online and look for scores. Hint: Many are listed under the "environmental health" section of local health department web sites.

Many restaurants have stringent food safety policies and training programs. Check out their web sites or ask a manager for information. Find out if the restaurant offers sick leave to employees. Many don't, which means sick employees are likely to show up for work and potentially spread illness.
Economy's Impact on Restaurant Food

As restaurants adjust to having fewer patrons, they may be adjusting what's on the plate to keep prices low. That can mean reducing the portion size of more expensive foods, or substituting less costly items, all of which can affect restaurant nutrition.

Some restaurants are shrinking portions of meat and adding more vegetables and starches. More steamed broccoli is a good thing, but watch out for plates heaped with starches heavy in calories and saturated fat, such as buttery mashed potatoes and noodles in a cream sauce.

Other restaurants are leaving portion sizes alone but switching from more expensive, leaner cuts of meat, like tenderloin and pork chops, to fattier meats such as pork shoulder (Boston butt), spare ribs, beef short ribs, and chuck roast.

Here's another restaurant secret: For the best bargains and the most nutrients, stick to the center of the menu. Entrees usually have lower markups and more nutritional balance than other parts of a menu, like desserts, beverages and appetizers. A non-chocolate dessert may cost more than four times as much as the ingredients it contains. Lobster, on the other hand, is priced much closer to what it actually costs the restaurant, says Kevin Gillespie, executive chef at Woodfire Grill in Atlanta.

Small plates that are scaled-down versions of entrees can be a good deal. But watch how many you order, to keep calories and costs under control. Restaurants that have switched to small plates report higher check averages, because customers typically order more food.
Special Diets

On a special diet? Check a restaurant's web site before you go. Many restaurants, especially chain restaurants, include restaurant nutrition information about allergens, gluten-free foods, and diabetic exchanges online even if they don't disclose calories and other nutritional data.

Ask for a customized plate if you're on a restricted diet, but understand that not all restaurants can fulfill your request. While some chefs enjoy the creative challenge of preparing a low-sodium or low-fat meal, a special meal may be tougher at high-volume restaurants that may rely on meats or entrees prepared off-site.
Watch the Seafood

Be picky about seafood. Chef and author Anthony Bourdain clued foodies in to an unwritten restaurant secret -- never eat seafood on Mondays -- in Kitchen Confidential. That's because many restaurants, except a select group that specialize in fresh seafood, don't get deliveries over the weekend. And seafood deteriorates much more rapidly than meat and poultry.

Carvel Grant Gould, executive chef at Atlanta's Canoe, adds another warning. "I reject stuff all day long, and then they sell it to somebody else," she says. "You ought to eat your seafood in a place that's very reputable."

You can't check out a cooked piece of fish as you would a raw filet in the supermarket, but you can still evaluate it for freshness. When the plate comes to your table, smell the seafood. If it smells fishy, or of ammonia, it's not fresh.
Foods High in Sodium

Foods prepared in restaurants as well as packaged foods are often high in sodium, even those that seem healthier. A McDonald's Premium Southwest Salad With Grilled Chicken and Newman's Own Creamy Southwest Dressing has more sodium (1,300 milligrams) than a Big Mac (1,040 milligrams).

Sodium counts can be higher at dinner-house chains, where the portions are often large. An order of grilled pork chops at Romano's Macaroni Grill contains 3,540 milligrams of sodium, more than double the amount most adults should eat in a day. A child's portion of macaroni and cheese comes in at 1,980, according to the restaurant's web site.

Check nutrition information if it's available. Some restaurants provide sodium information or suggest lower-sodium options, even if they don't disclose complete nutritional data. Outback Steakhouse suggests that guests who want to cut sodium order salads without croutons or dressings, and get burgers and sandwiches without cheese, sauces, bacon, and dressings.

If you are trying to control how much sodium you consume while dining out, the American Heart Association recommends asking that your food be prepared without salt. It also advises using pepper or fresh lemon juice instead of salt to season your food. But if the food is prepared in a central facility rather than in the restaurant's kitchen, you may not be able to get a meal prepared without added sodium.


SOURCES:

Jacobson, M. and Hurley, J. Restaurant Confidential, Workman, 2002.

News release, National Restaurant Association.

News release, Technomic, Inc.

News release, Yum Brands

Margo Wootan, director of nutrition policy, Center for Science in the Public Interest.

News release, Center for Science in the Public Interest.

Center for Science in the Public Interest: "Dirty Dining."

Sarah Klein, staff attorney for food safety, Center for Science in the Public Interest.

Restaurant Hospitality: "Less is More."

Kevin Gillespie, executive chef, Woodfire Grill, Atlanta.

Carvel Grant Gould, executive chef, Canoe, Atlanta.

Arby's.

American Heart Association.

Romano's Macaroni Grill.

Outback Steakhouse.
Reviewed on February 25, 2009

High Cholesterol Treatment -- What Works?

High Cholesterol Treatment -- What Works?
Safe, effective treatment for high cholesterol isn't hard -- but it can be confusing. Get the facts.
By R. Morgan Griffin
Reviewed by Brunilda Nazario, MD

If you've just been diagnosed with high cholesterol, you may be worried. After all, along with your age, genes, and other factors, high cholesterol is a major contributor to cardiovascular disease, heart attack, and stroke. But while you can't turn back the clock or yank out unhealthy genes from your DNA, you can change your cholesterol numbers. That's because high cholesterol treatment works.

"We have good, safe treatments for high cholesterol," says Adolph Hutter, MD, a cardiologist at Massachusetts General Hospital and a professor of medicine at Harvard Medical School. "They can directly lower your risks of heart attack, stroke, and death. So why not take advantage of them?"

For many people, making changes to their lifestyle -- eating better, losing weight, and exercising -- will be enough to lower cholesterol. Others may benefit from medicines. Often, a combination of these approaches is the right choice.

But where do you start? "People tend to be very confused about treating high cholesterol," says Nathan D. Wong, PhD, director of the heart disease prevention program at the University of California, Irvine.

WebMD talked to experts to help reduce the confusion -- and help you sort through your high cholesterol treatment options.

* Is it time to consider medication? Take this quiz for cholesterol-lowering tips.

Finding the Best High Cholesterol Treatment

There's a lot of variability in how high cholesterol treatments work in a given person. Treatment that did wonders for your spouse may do nothing for you. Some of it depends on your genes. You and your doctor will need to come up with a custom-tailored approach.

For most people, the first high cholesterol treatment to try is three lifestyle changes:

* Eating better
* Maintaining (or losing) weight
* Exercising more

Some people, if they already have other risk factors -- such as diabetes -- may immediately start medication as well.

While lifestyle changes can really help bring your cholesterol down, Wong says that not enough people give them a real chance.

"The problem is that both patients and their doctors like immediate results," he tells WebMD. "Lowering your cholesterol with exercise and diet is just not like that."

So try to give high cholesterol lifestyle treatments time to work. If they do, you can avoid the hassle of being on a daily medicine for the rest of your life.
Eating Right as a High Cholesterol Treatment

We've all heard that diet has an effect on cholesterol, but there's much confusion about what you should or shouldn't eat. Here's a rundown of the current evidence.

* Fat. If you have high cholesterol, you should cut down on saturated fat -- found in fatty meats and whole milk dairy products like cheese, ice cream, and butter. You also need to reduce your intake of trans fats, a man-made fat found in many processed foods, like stick margarine.

But the message isn't as simple as "fat is bad." There are a number of foods with healthy unsaturated fats that will actually improve your cholesterol. They include fatty fish like tuna and salmon, walnuts, and almonds. Since even good fats are high in calories, you should still eat them in moderation.
* Calories. According to Wong, the importance of counting your calories is often overlooked by people with high cholesterol. No matter how much or how little fat or cholesterol is in a food, its calories still add up. Eating too much of it can lead to weight gain, and that increases your risk of high cholesterol.

* High cholesterol foods. Experts have long urged people with high cholesterol to shun foods loaded with cholesterol, like egg yolks, shrimp, and organ meats. While some recent evidence suggests eggs may not be quite as harmful as once thought, experts still generally recommend you limit all high cholesterol foods. Also, don't assume that a food labeled "cholesterol-free" is necessarily good for you.

So what sort of diet works as a high cholesterol treatment? Ask your doctor for specific recommendations. Some experts recommend a Mediterranean-style diet, which cuts down on saturated and trans fats, while boosting intake of healthy unsaturated fats from fish and nuts.

If an improved diet doesn't help your cholesterol, don't feel like a failure. Because of their genes, some people just don't respond as well to this approach.


Weight Loss & Exercise as a High Cholesterol Treatment

Being overweight or obese ups your odds of having high LDL (bad cholesterol) and triglyceride levels and low HDL (good cholesterol) levels. It can also lead to other serious risks like high blood pressure, diabetes, and heart disease. So it's crucial to keep a healthy weight.

As a high cholesterol treatment, physical activity can have a modest effect. Exercise can lower your triglycerides (and bad LDL cholesterol to a lesser extent) and boost your good HDL cholesterol. So you should aim to get some physical activity -- even just a brisk walk -- for 30-60 minutes most days of the week.

But there are limits to what exercise can do. "For most people, exercise by itself wouldn't be an effective therapy to lower cholesterol," says Laurence S. Sperling, MD, director of preventive cardiology at the Emory University School of Medicine, Atlanta, Ga. But it can keep your weight down and reduce other cardiovascular risks.


Medications as High Cholesterol Treatments

If lifestyle changes haven't been enough as a high cholesterol treatment -- or if you're at high risk of cardiovascular problems -- your doctor will likely turn to medications. In most cases, the first drug you will try is a statin.

Statins like Crestor, Lescol, Lipitor, Mevacor, Pravachol, and Zocor work by blocking the effects of an enzyme that helps make cholesterol. They can lower bad LDL cholesterol by an impressive 20-55%. They have a modest effect on triglycerides and give a mild boost to your good cholesterol, too.

But don't assume that taking a statin makes you invulnerable. They won't cancel out a diet of french fries and fondue. "Statins are a complement to dietary changes," says Hutter, "not a replacement for them."
As with any drug, there are side effects. They can cause muscle aches, an increase in liver enzymes, and other issues. But the risks are low and it's important to keep them in perspective.

"On one hand, statins can reduce your risk of death, heart attack, stroke by 30-35%," says Sperling. "On the other, they pose a 1-2% risk of generally mild side effects." The benefits are often worth the small risk, Sperling says.

Although they tend to be overshadowed by statins, other medicines are also important high cholesterol treatments instead of, or in addition to, statins. They include:

* Bile acid resins like Colestid, Lo-Cholest, Prevalite, Questran, and WelChol. They stick to cholesterol in the intestines and prevent it from being absorbed. They can lower LDL cholesterol by 15-30%.
* Ezetimibe (Zetia) blocks some of the cholesterol from being absorbed by your body. It can lower LDL levels by 18-25%.
* Fibric acid like Antara, Atromid, Lopid, and Tricor. They reduce your triglycerides and may give a mild boost to your HDL.
* Niacin, available as Niacor, Niaspan, and Nicolar. Niacin modestly lowers LDL cholesterol and triglycerides and can raise HDL cholesterol at low doses. LDL levels are usually cut by 5-15%.
* A combination medicine like ezetimibe with simvastatin (Vytorin) which uses a statin to block production of cholesterol and ezetimibe to prevent cholesterol from being absorbed.

Remember that medicines aren't right for everyone. Since they're often taken for life, you and your doctor need to carefully discuss whether you should use them.


Do Alternative High Cholesterol Treatments Work?

While lifestyle changes and medicines have been shown to lower cholesterol and reduce your risk of cardiovascular disease, the same can't always be said for many alternative treatments. Some of the various supplements and herbs that have been touted as high cholesterol treatments are garlic, policosanol, and guggul.

While a few studies of garlic have found a modest benefit, a recent study of policosanol found no effect. However, none of these studies have been large enough to be definitive, experts say.

Keep in mind that, unlike medications, herbal products are not regulated by the FDA. They are not evaluated to see if they work. They could also interact with other medicines you use.

"You just don't know what you're getting when you buy these products," says Wong. So if you want to take an alternative high cholesterol treatment, be sure to talk to your doctor.
Sticking to Your High Cholesterol Treatments

Many people find that their dedication to lowering their cholesterol fades over time. When they're first diagnosed, they're gung ho. They go on a diet and train like marathon runners. But after a few months, they get complacent. Their low-cholesterol cookbooks gather dust and their gym membership card lies in a sock drawer.
Sticking to Your High Cholesterol Treatments continued...

It is very easy to forget about high cholesterol. Even though it may still be doing damage, you can't feel it.

So how can you make healthy changes stick? The experts have some advice.

* Get tested regularly. All adults need to be tested at least once every five years. People with high cholesterol or other risk factors may need to be tested once a year or more.
* Know your numbers. "People need to know what the cholesterol numbers are and what their target numbers should be," says Sperling.
* If you've been prescribed medicine, take it. It's easy to get lax about taking a daily medicine. So do what you can to remember. Use a weekly pill box or an alarm to help you remember.
* Get help in making lifestyle changes. Changing the way you eat isn't easy -- you've probably developed some bad habits over the decades. But, unfortunately, Wong says that many doctors -- because they are so busy -- just don't give good guidance on this crucial part of treatment.

"Doctors might just tell a patient, 'Exercise more and eat less,'" Wong says. "But making these changes requires a lot more than vague advice."

So ask specific questions about what to do. If you find you're having trouble making changes to your habits, check back in with your doctor. If possible, Wong suggests having a few meetings with a dietician who can help guide you.

Perhaps most importantly, you need to stay involved. Don't be a passive about your high cholesterol treatment. Partnering with your doctor will lead to better results, says Sperling.

So whether you've been just diagnosed with high cholesterol or have known for years (and never gotten around to doing anything about it) now is the time to get serious. High cholesterol treatment is safe and it works. It could even save your life.

Is There Sex After Heart Disease?

Is There Sex After Heart Disease?
Doctors have good news for heart patients hoping to resume sexual activity.
By Karen Springen

Reviewed by Louise Chang, MD

Four years ago, Emmetsburg, Iowa, insurance agent Jim Wirtz, now 65, had triple bypass surgery. Just 10 days later, he was back at the office. Three weeks after that, he received a clean bill of health from his doctors, who said he could do any physical activity -- except shovel heavy snow.

Wirtz took their advice, and he and his wife resumed having intercourse. "Stay in the game, whether it's sex or work," he says. "My own philosophy is, you just better live."

Wirtz is doing what doctors say most heart disease patients can and should do: having sex after heart disease. "We encourage people to stay physically and sexually active," says Vincent Bufalino, MD, a cardiologist and spokesman for the American Heart Association and president and CEO of Midwest Heart Specialists. "They tend to be happier folks."

That's good news for the 80 million Americans with one or more forms of cardiovascular disease, including the 7.9 million who will suffer from a new or recurrent heart attack this year.

There are, of course, some caveats to resuming sex after heart disease. Here's what else people need to know:
Stress Tests

It's important to remember that sex is a workout. So doctors typically tell patients to abstain from sex after heart disease until they can withstand the cardiac workout.

"The concern is if somebody has absolutely no physical activity and then with sexual activity is more physically active than any other time," says Peter Schlegel, MD, chairman of urology at New York-Presbyterian/Weill Cornell Medical Center.

But patients who can handle the stairs or walk six minutes on the treadmill should be OK. "They shouldn't have any fear," Bufalino says. "I tell them if you can pass your stress test, you are more than comfortable to do anything you want -- have intercourse, play tennis, or go for a light jog around the block. We shouldn't have intercourse be one of the things we stay away from."
Sex After a Heart Attack or Bypass Surgery

Not surprisingly, some patients, or their partners, are afraid that sex will trigger a heart attack.

"After a heart attack or any kind of heart disease, they're frightened about whether or not they can have a sexual life," says Wei Jiang, MD, an internist and psychiatrist at Duke Health Systems at Duke University.

But the reality is that most patients can have a sexual life. Although you can't jump into sex the day after a heart attack or surgery, most people can resume sexual relations three to six weeks afterward, as long as they are free of chest pain or other complications.

Sex also gives heart disease patients a good incentive to change their lifestyles. "What's bad for the heart is bad for the penis," says Harry Fisch, MD, a urologist at Columbia University, and author of Size Matters. And what's good for the heart -- exercising, maintaining an ideal body weight, not smoking -- is good for the bedroom. "Everything that is healthy for your heart is healthy for your erection," Schlegel says.

If concerns persist, "You may want to seek out a psychologist to speak with about some of your fears," says Susan Czajkowski, PhD, program director for the NHLBI's division of prevention and population sciences. "The goal really is to get people back to as close as possible their normal set of activities and feeling good about themselves and feeling pleasure… Quality of life is important."
Erectile Dysfunction

Although heart disease is a risk factor for erectile function, erectile dysfunction can be an early warning sign of cardiovascular disease. The reason: the tiny arteries that go into the penis are about half the diameter of the ones that go into the heart, so they "clog up" first, says Craig Niederberger, MD, a urologist at the University of Illinois at Chicago. "The penis is like a red flag…You generally get about three years between symptoms of erectile dysfunction and symptoms of heart disease. Every man with ED should be considered a man with potential heart disease."

People with heart disease also likely have other risk factors for ED such as hypertension, diabetes, smoking, and obesity.
Medications

Beta-blockers, used for irregular heart beats after open heart surgery and to lower blood pressure, are the biggest culprit that can interfere with sex after heart disease. They lower blood pressure -- and the "hemodynamic fill of the penis," says Paul Turek, MD, a retired professor of urology at the University of California at San Francisco and director of the Turek Clinic in San Francisco. "Think of it as a hose. If you lower the pressure, you're effectively … turning off the hose. The inflow is lower."

Doctors also can try to adjust the drug's dosage over time, which can also help, or switch patients to a different medication.

An erectile dysfunction drug may help, but some men may not be able to take ED drugs because of other medications.
Using ED Drugs

Viagra, Levitra, and Cialis are OK -- with some exceptions. Phosphodiesterase inhibitors (Viagra, Cialis, and Levitra) do not increase heart attack or death rates and are considered safe for most men wishing to have sex after heart disease. One exception is in men taking nitrates (usually for angina, the sense of tightness in the chest), because the combination of the two drugs can cause a large and sudden decreases in blood pressure.

Another caveat: "the pill enables them to perform activities that will tax the heart the way it hasn't been before," Turek says. Many men feel timid and hesitate to ask about these types of medications, Niederberger says. He reassures them by explaining that the erection problem is related to the heart problem and that "sexual activity is a healthy thing to do." Sometimes a man will say, "my wife is afraid for me to take it," Niederberger says.

If ED drugs don't work, doctors may offer alternatives such as injections (which patients give themselves five or 10 minutes before intercourse and which last 15 to 60 minutes), vacuum-erection devices (a plastic cylinder that draws blood into the penis, and then a ring is placed at the base of the penis) or surgery (a prosthesis can be surgically implanted).
Depression and Psychological Issues

Men and women may suffer from depression after a heart attack, which can cause a lack of interest in sex, Jiang says. But some antidepressants may also affect sexual desire and function.

"We are truly in a dilemma," Jiang says. And not surprisingly, men with erectile dysfunction typically feel depressed, which decreases the desire to have sex after heart disease.

Therapy to deal with psychological issues can also help with sexual problems.
Lifestyle Changes Can Help

Men who take steps to live healthier can help their hearts and their sex lives. Sex also gives heart disease patients a good incentive to change their lifestyles.

Exercise increases blood flow everywhere, including to the penis, Fisch says. He recommends walking 10,000 steps a day, or 30 minutes of moderate exercise every day.

Losing weight helps patients lower their blood pressure and their cholesterol levels. Smoking constricts and damages the arteries, including those going into the penis. Heavy drinking can lower libido and lead to erectile dysfunction.

The bottom line on sex and heart disease? Patients need to talk to their doctors about their individual cases because someone who has bypass surgery is different from someone who has a mild heart attack. "They should have very open and honest conversations with their physicians," Czajkowski says. Ideally, she says, bring in a significant other.

Patients with any fear of having sex after heart disease might want to remember that intercourse is psychologically -- and apparently physically -- healthy and can have a "protective effect" on men's health.