 What's the best way to stay healthy in the face of so much conflicting nutrition information? Well, ideally you would go to the source, the gold standard, the peer-reviewed medical literature, and read through the stacks of the latest medical journals. But who's got time for that? I do! Welcome to the Nutrition Facts Podcast. I'm your host, Dr. Michael Greger. Today we look at how adding a healthy option can actually drive people to make even worse choices thanks to a mind-blowing glitch of human psychology. In 2017, into much fanfare, menu labeling for calorie counts began to be mandated in national chain restaurants. I mean, shouldn't consumers have the knowledge needed to make healthy eating choices outside the home? It just makes sense that caloric information on menus will help consumers limit food intake to stay within daily energy needs. But it didn't work. Turns out calorie labels are not effective. Perhaps shaving on average an insignificant 8 calories off a meal. You could have totally predicted that. Why? Just as one might define the value of front-of-back traffic light labeling from the ferocity of the food industry response against it, one could probably gauge the futility of calorie labeling by the ease at which some regulations have been passed. McDonald's voluntarily started publishing calorie info nationally back in 2012 after a labeling mandate in New York City was found to have no overall effect on consumer behavior, so states suggest such labeling could boost perceptions of the restaurant's concern for consumers' well-being, while carefully not undermining any Big Mac attacks. At the same time, McDonald's announced plans for adding seasonal produce to their menu. How cynical do you have to be not to at least recognize that is a good thing? Ironically, adding a healthy option can actually drive people to make even worse choices. Ready to have your mind blown? If you offer people a choice of side dishes, something unhealthy like french fries, or something more neutral like a baked potato, only about 10% of individuals with high self-control will splurge for the fries. Good for them. French fries are so unhealthy, though, that as a public health do-gooder, you add a third option, an even healthier option than the baked potato, a side salad, to appeal to their better natures. So then, instead of choosing between an indulgent choice and the more neutral baked potato, they have their pick of the indulgent choice, the neutral choice, or an even healthier choice. Even if everyone doesn't choose the salad, more will go for the middle ground baked potato over the fries, right? So how much farther does french fry fancying fall by adding the salad option to the mix? It shoots up tripling to 33%. Without the salad option, only 1 in 10 chose the fries, but that jumped to a third of people just at the sight of salad. The same thing happens when you offer people the choice between a bacon cheeseburger, a chicken sandwich, or a veggie burger. In a no-healthy option scenario where people were offered the cheeseburger, a chicken sandwich, or a fish sandwich, 17% chose the burger. Swap out the fish sandwich for a veggie burger and bacon cheeseburger preference doubled to 37%. How can just seeing a healthy option push people to make unhealthier choices? The paper describing these series of experiments was entitled, Vicarious Goal Fulfillment, when the mere presence of a healthy option leads to an ironically indulgent decision. The thought is that seeing the salad or veggie burger, people make the mental note to choose that it's some nebulous next time, thereby giving them the excuse to indulge now. See, there's a fascinating glitch of human psychology called self-licensing. This is when we unwittingly justify doing something that draws us away from our goals after we've just done something that brings us towards them, like justifying eating a doughnut because you lost so much weight last week. We reward ourselves with an indulgence that sets us back. If you give smokers quote-unquote vitamin C supplements, they subsequently smoke more cigarettes than if you give smokers what you explain are placebo pills, even though both groups were given identical sugar pills. The group who thought they were taking supplements smoked nearly twice as much, perhaps thinking at some subconscious level that since they had just done something good for the health, they could afford to live a little, which may have in effect indeed occasioned them to live a little less. You can see how this could translate into our lifestyle arenas. Those given placebo pills, they believed to be dietary supplements. Now they expressed less desire to subsequently engage in exercise, but followed through by walking about a third less. Compared to those who were told the pills were placebo pills, misled participants were also more likely to choose a buffet over what was described as a healthy organic meal. Would they eat more too? A seminal study entitled Deliberating Effect of Weight Loss Supplements on Dietary Control put it to the test. Participants were randomized to take a known placebo or a purported weight loss supplement, actually just the same placebo, and later covertly observed at a buffet. Not only did the supplement subjects eat more food, they chose less healthy items. They also ate about 30% more candy and a bogus taste test and ordered more sugary drinks. Hence, the investigators concluded, people who rely on dietary supplements for health protection may pay a hidden price, the curse of licensed self-indulgence. So circling back, what the vicarious goal fulfillment studies added is that not only does making progress towards a goal rationalize decision-making that undermines us, but even just considering making progress can have a similar licensing effect. Note the study subjects were not only moved to make the unhealthy-er choice, but the unhealthy-ist choice. You'd think that even if people didn't go for the salad or veggie option, the presence of a healthier alternative might have at least encouraged them to choose something in between. Not as healthy, but not the unhealthy-ist, but instead it moved people in the opposite direction. Compared to the no-healthy option of chocolate-covered Oreos, regular Oreos, or golden Oreos, adding a lower calorie Oreo option doubled the likelihood that the study participants would go straight for the most indulgent chocolate-covered option. This is attributed to another illogical quirk of human psychology indelicately named the What the Hell Effect. This is when one forbidden cookie can lead dieters to eat the whole bag. Once you've already strayed from your goals, well then, why not go all the way? So once people decide they're going to get that salad next time and spoil themselves just as once, they might as well go for the most indulgent choice. The halo of healthy foods can even warp our perceptions. Show weak conscious people a burger and nothing else, then ask them to estimate the number of calories, and the average answer is 734 calories. Now show folks the exact same burger accompanied by three celery sticks, and they guess the total comes out to 619 calories. Did they think the celery had negative calories? No, most knew the celery had calories too, but just the juxtaposition of the burger with the celery made the burger seem healthier. The same thing happens when you add an apple to a bacon and cheese waffle sandwich, a side salad to beef chili, or some carrots next to a cheese steak. About 100 calories appear to disappear. Health halo effects may explain why people are more likely to order dessert and more sugary drinks with a quote-unquote healthier sub at Subway versus a Big Mac at McDonald's, even though the sub used in the study, filled with ham, salami, and pepperoni, had 50% more calories to begin with. Even just a reference to healthy foods can do it. Show people a picture of a Big Mac, and people estimate it has 646 calories. Okay, then just add the words for your health, eat at least five fruits and vegetables per day, and all of a sudden, the same burger and the same ad was thought to have only 503 calories, merely offering or even promoting salads and fruit can bring McDonald's accolades and bolster consumer loyalty without, ironically, helping their health. In our next story, we look at how mandating healthy eating messaging on fast food ads ironically only makes things worse. Denmark ended up canceling its saturated fat tax on meat and dairy and shelving their sugar tax because the farming and food company interests claimed too many jobs would be lost if people ate healthier. Apparently, a healthy economy was more important than a healthy citizenry. Ironically, the fact tax was abolished just when evidence of the effects started to appear. The intake of saturated fat among Danish customers from some meat and dairy products was declining, but not from sour cream. The public ended up eating so much more low-fat sour cream that it ended up outweighing the smaller reduction in high-fat sour cream, so you always have to think about the unintended consequences. If incentives have people swapping out sugary cookies for salty chips, for example, it might not be doing the public's health many favors. One field study of attacks on soda found that you can drop soft drink purchases, but households may just end up buying more beer. Another study found that calorie labeling of sugary drinks ironically led to an increase in consumption, presumed to be because the consumers may have previously overestimated their calorie content. Stark warnings about the risks of unintended negative consequences of obesity-targeted health policies are trumpeted by those with ties to the likes of Coca-Cola Craft, PepsiCo, Wrigley, Red Bull, the World Sugar Research Organization, National Cattlemen's Association, Mars, and corn syrup giant Archer Daniels Midland, and that's just a single scientist. The concern about unintended consequences shouldn't paralyze our efforts, but should serve up a healthy dose of humility when considering policy proposals. How about releasing a video game for kids that promotes fruit? Sounds good, right? Well, what do you think happened when kids were sat down in front of bowls of fruit and candy and randomized to play one of three different computer advert games, advertising game hybrids incorporating product placements, promoting either candy, fruit, or toys? The pro-candy game group ate more candy, but, disappointingly, the pro-fruit group didn't eat more fruit. But then it gets interesting. They ate more candy in the fruit game, too. Compared to the toy promotion control group, having a kid play a video game promoting fruit led them to eat more candy. Presumably both the candy and fruit games just made them think about food and they naturally gravitated to their preferred snack. One of the most fascinating phenomena I came across was the boomerang effect of remedy messaging, one might presume that the advertising of smoking cessation aids like nicotine gum would help make quitting easier. After all, the vast majority of smokers want to quit, and so availing them of helpful options couldn't help but help, right? Instead, such remedy marketing can create a vicarious get-out-of-jail-free card that ends up reinforcing risky behavior. Exposure to nicotine replacement product advertising was found to undermine quitting intentions, especially among the heaviest smokers, the very ones who needed it the most. The thought is that smokers may subconsciously interpret the remedy as evidence that the hazards of smoking are more manageable, hence less risky, and thereby help to justify their habit. You can see how easily this would translate to the weight loss arena. Previously, I explored how self-licensing could cause those taking slimming supplements to inadvertently eat more, but just exposure to a fat-fighting pill advertisement appeared to have a similar type of effect. So even when companies are ostensibly selling health rather than disease, they still may be inadvertently making the problem worse. In the marketplace, there's just no incentive for risk avoidance messaging. Nobody makes money selling just say no, unless it can be somehow linked to saleable products and services. A policy in France where burgers now outsell baguettes may represent an interesting real-world example of this counter-intuitive remedy messaging effect. Industry lobby morphed a valiant effort to ban the advertising of junk into a mandate for preventive health messaging on junk food advertisements. So now on products like Leigh's chips, savapoulé roti, chicken-flavored potato chips, you'll see messages like—I'm not going to try to pronounce that in French— but basically, for your health practice, regular physical activity, hey, sounds good, right? But any time an industry agrees to a regulation, one should get skeptical as to its effectiveness. To see if such messaging might lead to a boomerang effect, research subjects were randomized to view a Big Mac advertisement with or without the preventive health message, eat five fruits and vegetables a day. I mean, hey, wouldn't it be great if McDonald's was forced to advertise healthy food? The participants then filled out some BS questionnaire, and before they left, were allowed to choose one of two McDonald's coupons as a reward for their participation— a free sundae or a free bag of fruit. Guess who was more likely to pick the fruit? Only one in three of those who just saw the Strait Burger advertisement chose the fruit over the sundae, but that number fell to only one in six among those who'd been prompted to eat healthier. Let that sink in for a second, isn't that crazy? The absence of the health message doubled the choice of the healthy snack. The health message made things worse. This may be the remedy-messaging boomerang effect in action. By simultaneously offering a temptation with a reminder about how they can dig themselves out later, justifies the excuse to indulge. Subconsciously, it may give the chickeny chip eater the rationalization that they can just work it off the next day, even if the next day at the gym never comes. The advised antidote to avoid justification effects is to instead use negative framing. Instead of offering a way out to compensate for indulging just this one time, cautionary messages may be more effective. For example, on your next ham and cheese or chocolate-filled croissant, a message like, For your health, avoid foods that are too fatty, too sweet, or too salty. Now that's a message for which I doubt William McDonald's would be as enthusiastic. Learning about this rebound effect has made me reflect about my work on nutritionfacts.org, distilled into how not to die. It doesn't get much more remedy-messaging than that. If we can get such dramatic benefits with diet and lifestyle changes so late in life, in such short amount of time, why can't we just live lives of gluttony and sloth, and then around 50 or so clean up our acts? The reason is because it may be too late. Our first symptom may be our last. Most people know the number one killer of both men and women in the United States is heart disease. What people may not know, though, is that, according to the American Heart Association, for the majority of Americans that die of heart disease, their first symptom occurs not years before they die, but literally minutes before they die. Sudden cardiac death is the first manifestation of heart disease for the majority of individuals, particularly among women, meaning you have no idea you even had heart disease until you're literally dying from it. Heart disease reversal is great, but that's why prevention is the key. When it comes to sudden death, an ounce of prevention truly is worth more than a pound of cure because there is no cure for dead. We would love it if you could share with us your stories about reinventing your health through evidence-based nutrition. Go to nutritionfacts.org slash testimonials. We may be able to share it on our social media to help inspire others. To see any graphs, charts, graphics, images, or studies mentioned here, please go to the Nutrition Facts podcast landing page. There you'll find all the detailed information you need plus links to all the sources we cite for each of these topics. For a vital, timely text on the pathogens that cause pandemics, you can order the e-book, audio book, or hard copy of my latest book, How to Survive a Pandemic. For recipes, check out my new How Not to Diet Cookbook. It's beautifully designed with more than 100 recipes for delicious and nutritious meals. And of course, all the proceeds I receive from the sales of all my books go to charity. NutritionFacts.org is a non-profit, science-based public service where you can sign up for free daily updates. In the latest in nutrition research, there will be a bite-size videos and articles. Everything on the website is free. There's no ads, no corporate sponsorship, no kickbacks. It's strictly non-commercial, not selling anything. I just put it up as a public service as a labor of love as a tribute to my grandmother, whose own life was saved with evidence-based nutrition.