# Presentation: 817498

**Can increased portion sizes ****affect ****how much ****we eat?**

**Notes:**
This presentation was prepared by the Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.

The presentation is based on “Do increased portion sizes affect how much we eat?” This is the second in a series of Research to Practice briefs prepared for practitioners and is available on CDC’s Web site:
www.cdc.gov/nccdphp/dnpa/nutrition/pdf/portion_size_research.pdf

## This presentation examines:

**This presentation examines:**

- Science underlying portion size and amount of food we eat in America
- How practitioners can counsel about portion size

**Notes:**

This presentation will review the following:

 What science underlies the notion that large portion sizes have contributed to weight gain among Americans
How practitioners can counsel their patients or clients about portion size

## Portion Size vs. Serving Size

**Portion Size vs. Serving Size**

**Portion size** is the
- amount of a single
- food item served in a
- single eating
- occasion; such as, a
- meal or a snack.

**Serving size** is a
- standardized unit of
- measure of foods:
- For example, a cup
- or an ounce is used
- in dietary guidance,
- such as the Dietary
- Guidelines for
- Americans.

**Notes:**
Portion size is the amount of a single food item served in a single eating occasion, such as a meal or a snack.  Many people confuse portion size with serving size, which is a standardized unit of measure of foods: for example, a cup or ounce is used in dietary guidance, such as the Dietary Guidelines for Americans.  

Portion size is the amount offered to a person in a restaurant, the amount offered in the packaging of prepared foods, or the amount a person chooses to put on his or her plate.  For example, bagels or muffins are often sold in sizes that constitute at least 2 servings, but consumers often eat the whole thing, thinking that they have eaten 1 serving.  They do not realize they have selected a large portion that was more than 1 serving.

## Portion Size: Then and Now

**Portion Size: Then and Now**

- Portion sizes of many foods have increased significantly over the past 2 decades
- Larger portions are now offered all around us, including in —
- restaurants
- vending machines
- packaged foods in grocery stores

**Notes:**
It is no secret that portion sizes, as well as waistlines, in this country are expanding.  All types of restaurant meals have gotten larger with an emphasis on getting more food for the money.  However, the rise of portion sizes is not limited to restaurants alone.  Bags of snack foods or soft drinks in vending machines and the grocery store are offered in larger and larger sizes that contain multiple servings in contrast a 1-ounce bag of snack food or an 8-ounce soft drink, which are the recommended single serving sizes, are very difficult to find.   

## Does Portion Size Matter?

**Does Portion Size Matter?**

**The basic rule of weight management is that people gain weight when they eat more calories than they expend.**

- Large portion sizes do not matter if a person:
-  chooses to eat only an appropriate serving       size rather than the whole portion served
- 			OR
-  eats fewer calories in subsequent meals and snacks to control overall calorie intake

**Notes:**
People gain weight when they eat more calories than they use in daily activities.  Certainly, large portion sizes do not matter if a person chooses to eat only an appropriate serving size rather than the whole size served, or the person eats fewer calories in subsequent meals and snacks to control overall calorie intake.  

## But...

**But...**

- Do people intuitively assess how much is an appropriate serving size?
- Do people actually eat only the appropriate serving size when more is offered?
- Do people adjust what they eat at subsequent meals after consuming large portion sizes?
- Research shows
- people often eat the amount in front of them
- people difficulty assessing whether or not it is an appropriate amount

**Notes:**
However, are the previous statements true, that is.....
Do people actually can assess what a appropriate serving size is?
If they eat only the correct serving size rather than what is offered to them?
If they eat more than a correct serving size, whether or not they adjust their calorie intake in subsequent meals?

The research that will be covered shows that people often eat what is in front of them.  In addition, they often have trouble assessing whether or not what is in front of them is an appropriate amount.

## Portion Size Matters

**Portion Size Matters**

- 	Short-term studies show that people eat more when they are confronted with larger portion sizes.

**Notes:**
The first set of studies will show that people do eat more when they are confronted with larger portion sizes.  These studies describe what happened in only one or a few eating occasions in a short time frame.  

Research studies have yet to assess the impact of portion sizes over longer time periods.

## Portion Size Affects ConsumptionMacaroni and Cheese Study  

- Portion Size Affects ConsumptionMacaroni and Cheese Study

- 51 adults received 4 meals of different portion sizes of macaroni and cheese on different days
- Ate more as portion size increased
- Consumed 30% more energy (162 cal) when offered the largest portion (1000 g) compared to the smallest portion (500 g)
- Reported similar ratings of hunger and fullness despite the intake differences
- After the study, only 45% of participants reported noticing differences in portion sizes served
- Rolls et al. *AJCN* 2002.

**Notes:**
A study by Rolls et al. tested how adults responded to meals on different days of four different portion sizes of macaroni and cheese. They found that the bigger the portion, the more participants ate.  Participants consumed 30% more energy (162 cal) when offered the largest portion (1000 g) compared to the smallest portion (500 g).  They also reported similar ratings of hunger and fullness after each meal despite the intake differences.  After the study, only 45% of the subjects reported noticing that there were differences in the size of the portions served. 
[i] Rolls BJ, Morris EL, Roe LS.  Portion size of food affects energy intake in normal-weight and overweight men and women. Am J Clin Nutr 2002;76:1207-1213.

## Portion Size Affects Consumption

- Portion Size Affects Consumption

**Submarine sandwich study**
- Subjects received different size (6-, 8-, 10-, and 12-inch) submarine sandwiches for lunch on 4 different days
-  Men and women ate significantly more as the size of the sandwich offered increased
**Pasta study**
- In a restaurant setting, a pasta entrée was served in different portion sizes on different days
- People ate more when offered larger portions
- Rolls et al. *JADA* 2004.
- Diliberti et al. *Obesity Res* 2004.

**Notes:**
Another study by Rolls et al. gave the same subjects different size sandwiches on several occasions to look at the effect on energy intake of increasing the portion size of a food served as a discrete unit (sandwich). Men and women who were offered different size (6-, 8-, 10-, and 12-inch) sub sandwiches for lunch on four different days participants ate significantly more as the size of the sandwich offered became larger.  

A study by Diliberti et al. in a restaurant setting showed that when a pasta entrée was served in different portion sizes on different days, people ate larger amounts when they were given larger portions.
[i] Rolls BJ, Roe LS, Meengs JS, Wall DE. Increasing the portion size of a sandwich increases energy intake. J Am Diet Assoc 2004;104:367-372. 
[ii] Diliberti N, Bordi, PL, Conklin MT, Rolls BR. Increased portion size leads to increased energy intake in a restaurant meal.  Obesity Res 2004;12:562-568.

## Does awareness of portion size matter? 

**Does awareness of ****portion size matter? **

- Participants ate soup from normal bowls to determine typical intake for 3 days
- On 4th day, researchers secretly substituted bowls that slowly refilled from a hidden reservoir
- Both obese and lean participants ate more than their usual portion
- Participants were informed of the trick
- Over the next 6 days,
- Normal-weight participants adjusted their intake
- Obese participants continued overeating.
- Pudel and Oetting. 1977.

**Notes:**
This tendency to eat more when offered more was observed nearly 30 years ago when Pudel and Oetting conducted a study that was designed to observe participants as they ate soup.  They first served people soup for 3 days from normal bowls to determine their customary intake. 
On the 4th day, researchers secretly substituted trick bowls that slowly refilled from a hidden reservoir under the table.  Both obese and lean participants ate more than their usual portion.  The participants were then told about the trick, and their intake was measured over the next 6 days.  Normal-weight individuals adjusted their intake while obese participants continued to overeat.  
Pudel VE, Oetting M.  Eating in the laboratory: behavioral aspects of the positive energy balance.  Int J Obesity 1977;1:369-386.

## Portion Size and Snacks Study 1

**Portion Size and Snacks ****Study 1**

- Participants received snacks of potato chips in identical bags  increasing in size (from 28g to 170g)
- Men and women, intake increased significantly as package size increased
- Women ate 18% more and men 37% more from the 170g bag than when served an 85g bag
- Participants did not adjust their intakes at dinner to compensate for the differences in snack intake
- Combined calorie intake was much greater when they consumed the larger snack
- Rolls et al. *Appetite* 2004.

**Notes:**
Studies on portion sizes of snacks have had similar results. 
Researchers on five different occasions gave men and women an afternoon snack of potato chips that were packaged in bags that looked the same except that they progressively increased in size (from 28 g to 170 g). For both men and women, the snack intake increased significantly as the package size increased. From the 170 g bag, women ate 18% more and men 37% more than when served the 85 g bag.  

When dinner was served several hours later, participants did not adjust their intakes to compensate for the differences in snack intake.  Therefore the combined calorie intake from the snack and dinner increased significantly for both men and women when the larger snack was consumed.  
Rolls BJ, Roe LS, Kral TVE, Meengs JS, Wall DE.  Increasing the portion size of a packaged snack increases energy intake in men and women. Appetite 2004;42(1)63-69. 

## Portion Size and Snacks Study 2

**Portion Size and Snacks ****Study 2**

- People in a movie theater were given medium (120 g) or large (240 g) buckets of popcorn.
- Subjects were divided into 2 groups based on whether they thought the taste was favorable or unfavorable
- Larger portion sizes increased the amount eaten regardless of how participants rated the popcorn’s taste
-  Wansink and Park. *J Database Marketing* 1996.

**Notes:**
In a study by Wansink and Park, people in a movie theater were given a medium (120 g) or large (240 g) bucket of popcorn.  Subjects were divided into two groups based on whether they thought the taste was favorable or unfavorable. 
Larger portion sizes had the effect of increasing the amount eaten regardless of how the participants rated the taste of the popcorn.
[i] Wansink B, Park SB. At the movies: how external cues and perceived taste impact consumption volume. J Database Marketing. 1996;60:1-14.

## Influence of Portion Size on ChildrenStudy 1

**Influence of Portion Size on Children****Study 1**

- Study participants
- 30 preschool-aged children
- mean age 4 years; range 2.9-5.1
- Received either an age-appropriate portion or a doubled portion of an entrée and side dishes
- Larger portions led to significant increase in energy intake.
- Intake from entrée rose by 25%
- Total energy intake from meal by 15%
- Increases were not significantly related to sex, order of the portion sizes served, or age.
- Fisher et al. *AJCN* 2003.

**Notes:**
Some studies show the same behavior in children.  In a study by Fisher et al., 30 preschool-age children were evaluated during two series of lunches in which either an age-appropriate portion or a doubled portion of an entrée along with side dishes was served. 
Doubling of an age-appropriate portion resulted in a significant increase in the energy intake from the entrée by 25% and total energy intake from the meal by 15%. 
These increases were not significantly related to sex, order of the portion sizes served, or age. 
Fisher JO, Rolls BJ, Birch LL. Children’s bite size and intake of an entrée are greater with large portions than with age-appropriate or self-selected portions. Amer J Clin Nutr 2003;77(5):1164-1170.

## Influence of Portion Size on ChildrenStudy 2

**Influence of Portion Size on Children****Study 2**

- Study participants
- 32 preschool-aged children
- mean age 4 years; range 3 - 4.3
- Received 3 different amounts of a macaroni and cheese entrée over 3 weeks
- Larger portions led to significant increase in intake of entrée and total energy from the meal in the older children, but not the younger children
- Increases were not significantly related to sex, order of the portion sizes served, or age
- Rolls et al. *JADA* 2000.

**Notes:**
Some studies show the same behavior in children.  In a study by Fisher et al., 30 preschool-age children were evaluated during two series of lunches in which either an age-appropriate portion or a doubled portion of an entrée along with side dishes was served. 
Doubling of an age-appropriate portion resulted in a significant increase in the energy intake from the entrée by 25% and total energy intake from the meal by 15%. 
These increases were not significantly related to sex, order of the portion sizes served, or age. 
Fisher JO, Rolls BJ, Birch LL. Children’s bite size and intake of an entrée are greater with large portions than with age-appropriate or self-selected portions. Amer J Clin Nutr 2003;77(5):1164-1170.

## Influence of Portion Size on ChildrenStudy 3 and 4

**Influence of Portion Size on Children****Study 3 and 4**

- Two analyses of cross-sectional national data
- 	1. Related portion size z-scores to body weight and energy intake in children aged1-2 years
- concluded that children may adjust their food intake based on portion sizes throughout the day to sustain their energy intake
- 	2. Evaluated relationship of portion size to total energy intake among children 2-5 years
- suggested that portion size served to children does influence their caloric intake.
- McConahy et al. *J Pediatr* 2002.
- McConahy et al. *JADA* 2004.

**Notes:**
McConahy et al. conducted a study that compared data from the Continuing Survey of Food Intake of Individuals (CSFII 1994 -1996, 1998) and the Nationwide Food Consumption Survey (1977-1978) of children 1 to 2 years of age.  They assessed portion size z-scores and related it to body weight and energy intake. Average portion size z-scores were positively related to both body weight and energy intake, but there were no differences in number of eating occasions or number of foods eaten. The authors concluded that children may adjust their food intake based on portion sizes throughout the day to sustain their energy intake.   

Another study by the same researchers,[ii] evaluated the relationship of portion size and other food behaviors to total energy intake among children 2 to 5 years of age who participated in the CSFII, 1994-1996, 1998. Energy intake was positively related to number of eating occasions, number of foods consumed, and portion size z-score (composite value for each child) for the most commonly consumed foods (milk, bread, soft drinks, cereal, juice, cookies, French fries, banana, peanut butter, and macaroni and cheese). In multiple regression models predicting energy intake, portion size as a single predictor explained the greatest amount of the variance in energy intake, suggesting portion sizes served to children influences their caloric intake. 
[i] McConahy KL, Smiciklas-Wright H, Birth LL, Mitchell DC, Picciano MF. Food portions are positively related to energy intake and body weight in early childhood. J Pediatr 2002;140(3):340-347.
[ii] McConahy KL, Smiciklas-Wright H, Mitchell DC, Picciano MF. Portion size of common foods predicts energy intake among preschool-aged children. J Amer Diet Assoc. 2004;104(6):975-979.

## How accurately do we assess portion size?

**How accurately do we assess portion size?**

- Generally people incorrectly assess how much they eat
- Gender, age, weight, and level of education cause differences in estimating portion size
- Food cues may override physiologic satiety cues, including
- Large portions
- Easy access
- Sensory attractiveness of food

**Notes:**
Even though there is information available about appropriate serving sizes, people generally do not correctly assess the amount they are eating.  Often people are unable to tell the differences in portion size when offered different sizes on different days. Young and Nestle concluded that characteristics of people (gender, age, body weight, level of education) cause differences in the way they estimate portion size, and error in estimating becomes greater as portions increase.  In addition, physiologic satiety cues are readily overridden by food cues, such as large portions, easy access, and the sensory attractiveness of food.  
Young LR, Nestle M.  Variation in perceptions of a “medium” food portion: implications for dietary guidance.  J Am Diet Assoc 1998;98:458-459.
Rolls BJ. The supersizing of America: portion size and the obesity epidemic.  Nutr Today 2003;38(2):42-53.

## What factors are associated with increased food consumption?

**What factors are associated with increased food consumption?**

- Other cues also cause people to eat more than they need, such as
- restaurant setting
- convivial atmosphere
- choosing foods with high energy density
- alcohol consumption

**Notes:**
In addition to food cues, other factors add to the effect of portion size, causing people to eat more than they need, particularly in a restaurant setting.  Eating out can affect energy intake not only because of portion size, but also by convivial atmosphere, tendency to choose foods with high energy density, and alcohol consumption.
Rolls BJ. The supersizing of America: portion size and the obesity epidemic.  Nutr Today 2003;38(2):42-53.

## Research Gaps

**Research Gaps**

- Long-term studies to determine the impact of portion size on energy balance or weight management
- Intervention studies on portion size and weight control, such as training people to recognize and select appropriate serving sizes to assess if that impacts total intake and body weight

**Notes:**
Because of the importance of portion size, it would be helpful to understand more clearly certain aspects of its impact on weight and weight management.  
For example, there have been no long-term studies published that determine the impact of portion size on energy balance or weight maintenance. 
Also, there have been no published intervention studies on portion size and weight control, such as those that would train people to recognize appropriate serving sizes and incorporate that knowledge into their eating behavior. In that, would this lead to lower energy intake sand result in weight loss? 

## Implications for Calorie Intake 

**Implications for Calorie Intake**

**Larger portion sizes... **
- are pervasive in our culture
- increase calorie consumption in the short term
- hinder individuals’ ability to accurately assess how much they are eating
**As a result, we must promote...**
- awareness of portion size can affect efforts to control calorie intake
- strategies for avoiding common pitfalls

**Notes:**
As shown from the research covered, portion sizes in this country have increased over the past two decades.  The research also shows that portion size influences how many calories a person consumes in the short term, and may hinder the ability of individuals to accurately assess how much they are eating.  
Because oversized portions are pervasive in our culture it is important to make people aware of the ways in which portion size can affect efforts to control calorie intake, and to give them strategies for avoiding some common pitfalls. 

## Portion Control Strategy #1: Raise Awareness of Portion Distortion

**Portion Control Strategy #1:**** Raise Awareness of Portion Distortion**

- Oversized portions are common in grocery stores and vending machines in addition to restaurants.
- Help clients understand how increased portion size can translate into excess calories.
- Read food labels to help track portion sizes.
- 	_[http://](http://www.cfsan.fda.gov/~dms/foodlab.html)__[www.cfsan.fda.gov/~dms/foodlab.html](http://www.cfsan.fda.gov/~dms/foodlab.html)_
- 	http://www.cfsan.fda.gov/~dms/flquiz1.html
- The Portion Distortion Quiz from the National Heart Lung and Blood Institute (_[http://](http://hin.nhlbi.nih.gov/portion/)__[hin.nhlbi.nih.gov](http://hin.nhlbi.nih.gov/portion/)__[/portion/](http://hin.nhlbi.nih.gov/portion/)_) illustrates how portion sizes of common foods have changed over the years.

## Portion Control Strategy #2:Manage Large Restaurant Portions

**Portion Control Strategy #2:****Manage Large Restaurant Portions**

- Many restaurants serve more food than is appropriate for one person.
- Some tips that may help clients control portion amount include:
- splitting an entrée with a friend
- asking the waiter to put half of the meal in a carry-out container before it’s even brought to the table

**Notes:**

Many restaurants serve more food than is appropriate for one person. Encourage your clients to control the amount of food that ends up on their plate by splitting an entrée with a friend, or asking the waiter to put half of the meal in a “doggie bag” before it’s even brought to the table. 

## Portion Control Strategy #3:Manage Portions at Home

**Portion Control Strategy #3:****Manage Portions at Home**

- To reduce the temptation of overeating at home, give clients the following tips:
- Serve reasonable portions on individual plates
- Avoid putting serving dishes on the table.  Keeping excess food out of reach can prevent inadvertent overeating.

**Notes:**

To minimize the temptation of second and third helpings when eating at home, serve reasonable portions on individual plates, instead of putting the serving dishes on the table.  Keeping the excess food out of reach may discourage inadvertent overeating. 

## Portion Control Strategy #4:Monitor Snacking While Watching TV

**Portion Control Strategy #4:****Monitor Snacking While Watching TV**

- When eating in front of the TV, suggest your clients
- Put a reasonable amount of food into a bowl or container
- Leave the rest of the package in the kitchen

**Notes:**

When eating or snacking in front of the TV, encourage people to put a reasonable amount of food into a bowl or container, and leave the rest of the package in the kitchen.  It’s easy to overeat when a person’s attention is focused on something else.

## Portion Control Strategy #5:Manage Hunger between Meals

**Portion Control Strategy #5:****Manage Hunger between Meals**

- Encourage clients to eat a snack, like a piece of fruit or small salad, if they feel hungry between meals to avoid overeating during the meal.

**Notes:**

Encourage your clients to eat a snack, like a piece of fruit or small salad, if they feel hungry between meals to avoid overeating during the meal. 

## Portion Control Strategy #6:Assess the Right Amount to Eat 

**Portion Control Strategy #6:****Assess the Right Amount to Eat**

- These web sites can help in gauging portion sizes accurately
- Serving Size Wallet Card from NHLBI helps estimate the right amount to eat:
-  (http://hin.nhlbi.nih.gov/portion/servingcard7.pdf)
- NHLBI Visual Reality Quiz tests skills in estimating serving sizes:
- (http://nhlbisupport.com/chd1/visualreality/visualreality.htm)

## Portion Control Strategy #7:Control the Environment

**Portion Control Strategy #7:****Control the Environment**

**Package size may influence consumption**
- Divide contents of large packages into smaller containers
- Place appropriate portions in a bowl instead of eating from the package
**Out of sight, out of mind **
- Replace the candy dish with a fruit bowl.
- Put tempting foods out of sight.
- Put healthy fare in easy reach.
- Store excess food from bulk purchases in out-of-the-way places.

**Notes:**
Different aspects of the environment may act as cues to consume more food than people realize.  It is important that people understand how their surroundings can influence their calorie intake so they can make simply changes within their environments.
Package size may influence consumption.  The larger the package, the more people consume from it without realizing it.  To minimize this effect, encourage clients to
·         Divide up the contents of one large package into several smaller containers to help avoid over-consumption.
·         Don’t eat straight from the package.  Instead, serve a reasonable portion in a bowl or container.  
Out of sight, out of mind.  People tend to consume more when they have easy access to food. Advise clients to make their home a “portion friendly zone.”
Get rid of the candy dish, or better yet, replace it with a fruit bowl.  
Place especially tempting foods, like cookies, chips, or ice cream, out of immediate eyesight, like on a high shelf or at the back of the freezer.  Move the healthy fare to the front at eye level.
When buying in bulk, store the excess in a place that’s not convenient to get to, such as in a garage or basement.  

## It’s All about Balance

**It’s All about Balance**

- The bottom line
- 	Number of calories consumed must not exceed number of calories expended
- 	Monitoring portions is one way to control calorie intake
- Daily logs can help
-   	USDA’s My Pyramid Plan (www.MyPyramid.gov)
- 	is a fast, easy way to track food intake and physical activity