Under the new legislation, restaurant chains with more than 20 outlets will be required to furnish caloric information as well as guidelines for how many calories a healthy person should consume daily. That means, whenever you go to McDonald’s, whether in Oregon or Oklahoma, you will know just how many calories your Big Mac really contains. Will this change people’s eating habits? No one knows, but as I chronicled in Calories On The Menu–Coming Soon!, research suggests that caloric information, in the context of recommended daily caloric intake, does influence food choices.

So when will these changes take effect? That’s up in the air. The Health Care Bill requires that the FDA propose specific regulations no later than a year from now, but legal challenges could tie up the legislation after that. So, for the time being, you’ll just have to get your caloric info online or in the brochures some chains have available.

On another note, every once in a while the public health doc in me chuckles at a news story that crosses the wire. And yesterday, I had to laugh at Last Supper Paintings Supersize the Foods. As you know from reading my blog, portions and plates have gotten bigger over the last seventy years (see January’s Avoiding Portion Distortion). But I never thought distortion of the portion would insinuate itself into the Last Supper! As reported yesterday in the Associated Press, a new study which examined paintings of the Last Supper over the last one thousand years shows that food and serving ware have indeed gotten bigger. By as much as 69%! Scientifically meaningful? I’m not sure. Kinda funny? You bet. Check below and decide for yourself.

Leonardo Da Vinci's Famous Fresco, 1495-98

Supersized by Bassano Jacopo in 1542?

The study, published in December 2009’s American Journal of Public Health, divided study participants into three groups. The first group was given a regular menu at a restaurant and told to order dinner. The second group was given a menu with caloric information and was similarly told to order. The third group was given the caloric information menu that also contained the statement, “the average daily caloric intake for an adult is 2000 calories.” Not surprisingly, the two groups with the caloric information menus wound up eating less calories at dinner than the regular menu group. But did they wind up eating less calories overall during the day? The answer, surprisingly, is no. The group with the caloric information menu but no daily caloric intake statement went home and had an after-dinner snack, overall ingesting the same amount of calories as the  regular menu group. However, the caloric information menu group that also had the daily caloric intake statement, did not snack after dinner as much, and on average ate 250 calories less than the other two groups. The take home message: context matters. Remind a diner of their daily caloric needs and not only will they eat less at dinner, but they will likely eat less when they go home.

Now, what do you do if you want to make smart choices, but the menu doesn’t show caloric counts? As of January 1, 2011, all chain restaurants in California will be required to list caloric information on menus and indoor menu boards. You won’t have to hunt around for brochures. That means when you order your reduced-fat banana chocolate chip coffee cake at Starbucks, the sad facts will be up front and center: reduced fat doesn’t mean reduced calories. That delicious thing has nearly 400 calories!

As for the daily caloric intake statement, there are no requirements that it be included on menus. Although maybe it’s not a bad idea given that 16 million Californians are considered overweight or obese…

“Jack,” I said. “You can have three pieces of candy a day. That’s it.”

At that rate, it would take a year to get through all that candy, so my son helpfully offered up some other options. “You could buy it from me so I don’t eat it. Or you could just let me sell it to my friends.”

I love that he’s at the age where his greatest vice is eating candy, but as a doctor I didn’t like either of his offered solutions. I bought two bags of candy to hand out myself. Why should I buy more candy from my son? And if I did buy it from him, what would I do with it? Throw it away? Or eat three pieces a day myself for the next ten months?

It turns out that I was a bit of a candy under-buyer this year. I did an informal poll with my neighbors to see how many bags of candy they bought to hand out. The going range seemed to be about six to eight bags of candy. Naturally with so much candy, these friendly people were giving out two to three little snack-sized bars to each little goblin and witch who came to their door. No wonder my son, who views trick or treating as a sort of acquisition sport, was able to gather seventeen pounds in a little less than two hours.

Which brings up a health issue: too much sugar is bad for you. The American Heart Association took the bold step this year of actually making specific sugar intake guidelines. I say this is bold because there is an enormous amount of industry pressure to stop such guidelines. It could cost our multi-billion dollar food industry millions in lost revenue if people cut the amount of sugar in our diet.

So what exactly are the guidelines? Women should eat no more than 25 grams of added sugar each day. Men should limit it to 37.5 grams. Admittedly these aren’t guidelines for children, but if you crudely extrapolate you can figure out that kids should eat even less.

So what are added sugars? They are sugars that are added to foods, not the naturally occurring sugars like fructose in fruit or lactose in milk.  Unfortunately our food labeling system doesn’t distinguish naturally occurring sugars from added sugars. They all fall under ‘Sugar’ on the nutrition facts label. To distinguish between the two requires a little detective work. Look at the ingredients list. Any product that has syrups (corn, high fructose corn, or malt), sugar, honey, molasses, evaporated cane juice, or fruit juice concentrate has added sugar. That includes a lot of products.

To get back to our Halloween candy, I decided to investigate exactly how much added sugar there is in a snack-sized candy bar. Each candy differs, but here are some examples to consider: one Snickers fun size candy bar has 7 grams of sugar; one Reese’s Peanut Butter Cup has 8 grams of sugar; a Hershey’s Milk Chocolate fun size candy bar has 7.6 grams of sugar.

So, if my son eats one of each of the above he will have 22 grams of added sugar right there. His three fun-sized candy bars a day nearly equal the recommended daily limit advised for grown women.  There’s no additional room for the added sugar in his yogurt or applesauce or peanut butter or ketchup. He’s blowing his sugar limit just with his Halloween candy. 

I worry about our country. 64% of Americans are either overweight or obese. The data available doesn’t implicate added sugar as the sole culprit for our runaway obesity rates. But with added sugar in so many products now, it’s hard to deny that sugar doesn’t play a role in the fattening of America.

Maybe that three pieces a day rule isn’t such a good one after all.

The answer is not entirely straightforward. If you’re sitting next to a sick person, yes. You’re strapped in at 30,000 feet for the long haul. All those germs your seatmate are spewing out are heading your way. But what if someone is coughing ten rows ahead of you? Will you breathe those germs, too?

The answer is in the cabin air. Airlines mix fresh air from outside the airplane with recirculated air from inside to ventilate the cabin. The ratio is typically 50:50 but can vary to as much as 80% recirculated air, 20% fresh. Airline industry groups claim that this is a safe practice because the recirculated air is subjected to HEPA filtration, and cabin ventilation blows from the top of the plane to the cabin floor and not lengthwise from one end of the plane to the other. In other words, the ventilation system will not blow droplets from somebody’s cough  in Row 1 all the way to Row 30.

There are several concerns regarding this information, however. First of all, HEPA filtration removes most microscopic particles, but does not necessarily filter out small viruses like swine flu. This is alarming news when you consider that cabin air is recirculated thirty times during a one hour flight.   Second, there is evidence that despite the ventilation system, germs still do travel throughout the cabin. James Bennett, a research engineer for the National Institute of Occupational Safety and Health, has shown that within seconds of a person coughing, droplet germs spread outward with nearby passengers receiving the heftiest exposure. Within 15 minutes of the initial cough, germs can spread as far as ten rows away.

But do these facts mean that you’re doomed to be sick the minute you step on an airplane? Fortunately, the answer appears to be no. A  2005 research article by Dr. Mark Gendreau reports an increased risk of onboard transmission with close personal contact (e.g., your seatmate coughs near you) or being seated within 2 rows of a sick passenger on a flight lasting longer than 8 hours. This suggests that if you’re flying domestically and you’re not seated next to a sick person, you’re probably all right.

That being said, there are things you can do to protect yourself when you fly (since you never know who you’ll be seated with):

1) Don’t touch your eyes, nose, or mouth while in flight. Most flus and colds are spread by respiratory droplet, and you don’t know what microscopic germs are located on your tray table or arm rests.

2) Sanitize your hands with antimicrobial gel periodically.

3) Stay hydrated. Airlines purposely keep cabin air dry. Moist mucous membranes help protect you from germs. Drink water to avoid getting “dried out.”

4) Avoid the center seat, if you can.

5) Bring your own blanket and pillow.

6) If you’re forced to sit next to a sick person, the following is not proven, but some experts do it themselves: turn on the airblower in the panel above your head and direct the air stream into the space in front of your face. Some people believe that this will help blow germs away from you. Who knows?

7) Above all, if you’re sick, don’t fly. It reduces the risk to others.

Remember, nearly two billion people fly annually, and there are few if any reports of widespread outbreaks associated with flying. But that doesn’t mean you’re not at risk of catching something on a plane. Use the tips above to keep the skies friendly to your health.

Michael Pollan, as you may know, is the author of several bestsellers about the food we eat: The Omnivore’s Dilemna and In Defense of Food, An Eater’s Manifesto. Since I just happened to be reading the latter book, I was particularly delighted  to be invited to hear the author speak.

And speak he did. Pollan is articulate and forceful, making a strong argument for reform of what he calls “industrial agriculture.” Throwing out statistics designed to make your eyes pop, Pollan proceeded to illuminate why our country’s agricultural practice of focusing on commondity foods, such as corn, soybean, and wheat, has threatened our ecosystem: “monoculture” requires the widespread use of petrochemical-derived fertilizers, which burns through fossil fuels; clearing fields, using massive farming equipment, and transporting and processing commodity food pumps greenhouse gases into the atmosphere; the quantity and quality of these relatively “cheap calories” threatens our national health.

The crowd was suitably awed and appreciative, although one man asked Pollan about what seemed like a dust-up in San Luis Obispo some time ago in which an academic in the beef field took Pollan to task. Pollan skated over the details of the confrontation, but did acknowledge that elevated food prices are the main argument against his proposed reforms. We grow a lot of food cheaply now, he says, so that the equivalent of one hour’s work at minimum wage can “buy you thousands of calories at a fast food restaurant.” But what, he asks, is the quality and true cost of those cheap calories?

Regardless of where your opinions fall on the food policy spectrum–and people certainly seem to have passionate, wide-ranging views–The Omnivore’s Dilemna should be required reading for all. If nothing else, Pollan will make you think about where your food comes from and the seeming ubiquity of processed food that has become of staple of the Western Diet.

Meanwhile, The Botany of Desire, a visually beautiful film about the adaptive strategies of plants, premiers on October 28 at 8 pm on KQED. Check your local public television listings to see when it’s showing near you.

As I mentioned in my last post, the head of the National Institute of Allergies and Infectious Disease says the swine flu shot is as safe as any flu shot becaue it’s made the same way with the same manufacturers. That may be true, but what people ought to know is that many of the flu shots available contain the mercury-containing preservative Thimerosal.

What’s the big deal, you ask? Mercury is a known neurotoxin, and there are some strong believers that Thimerosal in vaccines is linked to the rising rates of autism in our country. This theory has been discredited by the Institute of Medicine, a not for profit, non-governmental organization associated with the United States National Academy of Science, which was tasked with investigating any possible link.

That being said, as a precautionary move, our government phased out Thimerosal as a preservative in children’s vaccines back in 2001. Influenza vaccine is one of a handful of exceptions. Flu shots in multidose vials contain Thimerosal. Single dose flu shot vials and the nasal vaccine do not.

So what should you do? I’ll probably have my kids get the nasal vaccine. It doesn’t contain Thimerosal, and it doesn’t involve a poke with a needle. Now, this isn’t recommended for asthmatics or anyone with a compromised immune system since the nasal vaccine contains live attenuated virus. Other people who should steer clear of the nasal vaccine include pregnant women and people with heart disease or diabetes.

And myself? I’ll take the regular shot, with or without thimerosal. The amount of mercury in the flu vaccine is about 25 micrograms. To compare, a tuna fish sandwich contains about 28 micrograms of the heavy metal. I’m not worried about eating a tuna fish sandwich. Why should I worry about a shot? On the other hand, as a health care provider, I do worry about swine flu. I’m exposed to it at work and out in the community. The benefits of a flu shot clearly outweigh the risks in my eyes.

If you find yourself troubled about mercury and are ineligible for the nasal vaccine, you can request a flu shot from a single-dose vial (which doesn’t contain Thimerosal). These shots are in limited supply, so you may be forced to wait to get vaccinated, but Thimersosal-free shots are out there. Contact your primary care physician for further details.

If you’re a pregnant woman, DEFINITELY get vaccinated. For some reason, H1N1 is particularly nasty in pregnant women. These women have six times the risk of dying from swine flu as compared with the general population. Tragically I have seen such a case in my own practice. A previously healthy pregnant woman contracted H1N1 and died a drawn out and ugly death. This is a no-brainer. If you’re pregnant, get vaccinated.

Get your child vaccinated if he or she has underlying health conditions. This year’s swine flu is a young person’s disease, disproportionately affecting people under 40. Children are excellent germ-spreaders and hang out in groups– the ideal set-up for flu transmission.  A note of caution, however. The only available vaccine currently is the nasal spray variety. If your child has asthma, skip the nasal spray, as there is some risk that it could trigger an asthma attack. Wait for the “shot” form of the vaccine, which should be available later this month.

Older people with underlying health conditions should also get vaccinated. Interestingly, people born before 1957 have some immunity to H1N1. That’s because H1N1 circulated before 1957. Oddly, the H1N1 version of flu disappeared for 20 years after 1957, leaving a huge window of people with no previous exposure to the disease and thus no protective antibodies. That being said, this H1N1 is still different from earlier H1N1. Previous exposure (especially if it was sixty years ago) doesn’t guarantee full immunity. If you’re vulnerable, and people with underlying health conditions such as lung and heart disease are vulnerable, get the swine flu shot.

Lastly, a word about vaccine safety. I must admit that I feel some qualms about vaccinating my children with a new and rushed-to-service vaccine, but Dr. Anthony Fauci, the director of the National Institute of Allergies and Infectious Disease, says, “The H1N1 pandemic flu vaccine is made exactly the same way by the same manufacturers with the same processing, the same materials, as we make seasonal flu vaccine, which has an extraordinarily good safety record.” That’s encouraging. The WHO is reporting that vaccine trials in China, in which 39,000 people were vaccinated, are very reassuring. Only four recipients reported side effects such as muscle cramps and headache.

I’m getting my flu shot next week. I’ll let you know how it goes.