The Myth that Mouthguards Prevent Concussions

A popular myth amongst the public, athletes, and some health care providers is that use of a mouthguard reduces the chance of sustaining a concussion (aka mild traumatic brain injury). As this article will demonstrate, however, the claim is often cited without reference to any empirical evidence or when evidence is cited, a review of the cited studies shows that a significant overstatement has been made based on available data.

An example of a claim that mouthguards reduce concussions that can be found in the popular press was the following statement by Ron Wilson, head coach of the Toronto Maple Leafs: "We're trying to get all our players to wear mouthguards. If you get hit and you're wearing a proper mouthguard, it lessens the chance of a concussion." The theory is that a mouth guard prevents concussions after a blow to the jaw (in which forces are thought to move upwards to the base of the brain) by positioning the jaw in such a manner that it absorbs the impact forces instead of the brain. Now let us examine what the data shows in terms of whether mouthguards actually reduce concussion.

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Review of the evidence

The most comprehensive scientific review on the topic of mouthguards and concussions was conducted by Knapik et al. (2007). Their conclusion was as follows: "However, the evidence that mouth guards protect against concussion was inconsistent, and no conclusion regarding the effectiveness of mouth guards in preventing concussion can be drawn at present.” (p. 118). Note that all underlined sections in this article are emphasized by myself and not the original authors. The authors also discuss “…a lack of evidence for concussion prevention (regarding mouth guards).  The inconsistency among studies is problematic and makes it impossible to determine conclusively whether mouthguards reduce concussion risk at present.” (p. 139). In fact, the authors even cite some evidence that concussion rates are higher among mouth guard users than non-mouth guard users. Lastly, the authors state, “There is currently insufficient evidence to determine whether mouthguards offer protection against concussion injury, and more work of good methodological quality is needed.” (p.140).

Review of specific studies

Here are some reviews of articles on the topic of mouthguards and concussions that were found during a literature search on PubMed, and what these articles say on the topic.

BARBIC ET AL. (2005).  These authors performed a multicenter randomized controlled study and concluded that, “In this study, concussion rates were not significantly different for varsity football and rugby players who wore the WIPSS Brain-Pad mouth guard compared with other types of mouth guards.” (p. 94). The American Academy of Neurology’s (AAN’s) definition of concussion was used. The based on observations by trained health care professionals, not a survey.

BLIGNAUT ET Al. (1987). The authors performed a cross-sectional study of 321 college rugby players who did or did not use mouthguards. The authors stated, “We conclude that injuries sustained at rugby in this study were not associated with the use or non-use of mouthguards.” (p. 5). These injuries included concussion. The study, however, is flawed because it is based on survey data and does not provide a definition of concussion.

GARON ET AL. (1986).  This study is based on survey data from 754 male football players who were asked about mouthguard use and history of various injuries, including concussion. The study is flawed because it is based on survey data and does not provide a definition of concussion. The authors found 15 concussions reported in the mouthguard use group and 14 reported in the non-mouthguard use group. This is not a significant difference and does not provide any evidence of mouthguard effectiveness for concussion reduction.

LABELLA ET AL. (2002).  In this study of male Division I college basketball players (also flawed due to survey data and not clearly defining concussion in the article) the authors concluded, “Custom-fitted mouthguards do not significantly affect rates of concussions or oral soft tissue injuries, but can significantly reduce the morbidity and expense resulting from dental injuries in men’s Division I college basketball.” (p. 41).

MARSHALL ET AL (2005).  This was a study of rugby players assessed weekly for injuries based on whether they did or did not wear mouthguards. The authors found that, “The risk of concussion was not lessened by the use of padded headgear (RR = 1.13, 95% CI: 0.40–3.16) or mouthguards (RR = 1.62, 95% CI: 0.51–5.11)”  (p. 113).  Unfortunately, no definition of concussion was provided by the authors and information was based on self-report only.

MIHALIK ET AL. (2007). These authors found that mouthguard use does not decrease the severity of concussion and that neurocognitive deficits after concussion did not differ between athletes who used mouthguards compared to those who did not. The study involved 180 athletes who were followed prospectively after a baseline cognitive assessment was performed. Unfortunately, the definition of concussion used in this study was not described. It was also not specified how a concussion was identified beyond having athlete’s complete self-report questionnaires.

TAKEDA ET AL. (2005). These authors performed experiments in which they struck an artificial skull model with a pendulum. They found that use of a mouthguard significantly decreased distortion of the mandibular bone and acceleration of the head. Based on this, the authors theorized that mouthguards may have the potential to reduce concussions. However, this is speculative and is not data that allows one to make any firm conclusions about this topic in living human beings.

WISNIEWSKI ET AL. (2004).  The authors studied 87 Division I College football teams and found no advantage of wearing a custom made mouthguard over a boil-and-bite mouthguard to reduce the risk of concussion. Concussions were recorded by athletic trainers but the definition of concussion was not described.

Why the Myth Continues

The main reason why the mouthguard myth continues is because people misread (or do not read) peer reviewed research articles, authors make misleading statements, and/or because authors cite flawed studies to support their claims without noting the caveats. An example can be found in the study by Kemp et al. (2008). If one were to just review the abstract of the paper, one would see the following statement: “Mouthguard and headgear usage was associated with a reduced incidence of concussive injury.” (p.227). However, it is not until one reads the actual manuscript where it is found that this statement is misleading. Specifically, the manuscript states, “The incidence of concussions sustained by players not wearing mouthguards was higher than those wearing mouthguards, but it did not reach statistical significance; the average severity of concussions was similar for wearers and nonwearers.” (p. 229). In science, if a difference is not statistically significant, there is no real difference between the two groups. In fact, the authors later go on to state the following: “Similarly, research to date indicates that the wearing of mouthguards does not reduce the incidence of concussion in rugby.” (p. 232-233).

It should not come as a surprise to anyone keeping up with the research literature on this topic that there is no conclusive evidence that mouthguards prevent concussions since McCrory addressed this very topic in 2001. In that paper, McCrory noted that, “The ability of mouthguards to protect against head and spinal injuries in sport falls into the realm of ‘neuromythology’ rather than hard science.” McCrory shows how two often cited papers have been used to perpetuate this myth.
The first paper often cited was by Stenger et al. in 1964. In this study, the authors reported their observations of a season of Notre Dame University football. They anecdotally reported one case in which they felt that mouthguard use abolished the symptoms of repeat concussion. The case includes the implausible claim that the patient could not recall a game or scrimmage dating back to highschool in which he had not either partly or completely lost consciousness. Despite this claim of losing consciousness every game and scrimmage, the patient made his way onto a Division I football team as an All-American. In the Stenger paper, there were 10 cases of concussion during the entire season, which did not provide enough data to perform statistical analysis of a protective effect. In addition, all of their data was speculative. The most the authors could do was speculate that mouthguards may reduce concussions since mouthguards alter the position of the mandible.

The second paper often cited is by Hickey et al. (1967). This study did not even examine living people, but instead used mouthguards fitted to cadavers (also known as dead people). The author showed that mouthguards could reduce forces applied to the head after a blow to the jaw. This was then used by later authors as evidence that mouthguards reduce concussion risk in living people, although Hickey et al. never made such a claim. The problem is that this is obviously a huge generalization which does not provide any direct proof of reduced concussion risk in living humans. In addition, the degree to which a cadaver’s skull responds to trauma is different from how the skull of a living human would respond.

In 1998, a review by Chalmers (1998) stated, “Moreover, there is evidence that mouthguards are effective in protecting against concussion and injuries to the cervical spine.” (p. 339). He cites numerous studies as evidence to support his statement. These studies are Clegg (1969), Fricker (1983), Kerr (1986), Jagger and Milward (1995), Johnsen and Winters (1991), Powers et al. (1984), Stenger at al. (1964), and Chapman (1985). Let us examine these studies one by one.

CHAPMAN (1985a): The author states that “The use of mouthguards should be encouraged in all contact sports as the most important value of the mouthguard is the concussion saving effect following impact to the mandible. This fact alone should make the wearing of mouthguards compulsory in all contact sports.” (p. 27). The problem is that no references are listed to support the claim. However, earlier in the article, the authors reference the Hickey et al. study (see above for discussion) as support for wearing a mouthguard in sports.

CLEGG (1969): Regarding mouthguards, the author states, ”It reduces the incidence of concussion caused by blows from under the chin.” (p. 341). No references were cited by Clegg to support the statement.

FRICKER (1983): Not a single mention of concussion or brain injury is made in the article.

JAGGER (1995): The author states that, “The increased separation between the head of the glenoid fossa that occurs at the increased vertical dimension should also decrease the transmission of force from the mandible to the cranial base and thus reduce the risk of concussion.” (p. 31). The reference was Chapman (1985b). Chapman (1985b) stated: “Thus, standard mouthguards protect against orofacial injuries (dental injuries, intraoral and circumoral lacerations and jaw fractures) and concussion.” (p. 25). The references cited were Clegg (1969; see above), Davis and Knott (1984) and Chapman (1985c). Davis and Knott (1984) is a dental article with no mention of concussion. Chapman (1985c) states that mouthguards result in reduced injury to facial regions and “…a reduction in the concussion force from a blow to the mandible.” (p. 34). The references were Clegg (1969; see above), Upson (1982) and Davies et al. (1977).  The articles by Davies and Upson (1982) make no mention of mouthguards reducing concussions.

JOHNSEN & WINTERS (1991): The authors state that, “The use of mouthguards reduces the likelihood of concusssions, cerebral hemorrhage, unconsciousness (“knock-out“), or other serious central nervous system injuries and even death.“ (p. 658). Three references were cited, a) Hickey et al. (see above), b) Stenger et al. (see above), and c) Godwin et al. (1968). The reference to Godwin is odd because it is a dental article that does not contain a single mention of concussions or any other type of central nervous system problem.

KERR (1986): The author states that mouthguards “…prevents fractures, dislocations, and concussions.” (p. 417). The author references Hickey et al. (see above) and Cathcart (1959). Note that the reference in the text is to Cathcart (1959) yet the biography lists Cathcart (1952) and that the actual reference is really from 1951. The Cathcart article does not make a single mention of concussions.

POWERS ET AL. (1984): The authors state that, “The mouth protector reduces forces that may cause concussions, neck injuries, and jaw fractures.” (p.84).  The reference? You guessed it. Hickey et al. yet again (see above).  A few sentences later the authors state: “According to some observers, an additional benefit was a reduction in the number of concussions and neck injuries occurring among football players.” (p. 84). The reference was Stenger et al. (see above) and News of Dentistry (1972).  The News of Dentistry reference discussed the 1971 University of Connecticut football program. It stated that no players wearing a mouthguard suffered a concussion but two players who wore a mouthguard did not. This was what was offered as support for “key protection” when the reality is that the numbers are too small to make any sweeping generalizations about a protective effect.

STENGER ET AL. (1964): See above.

Conclusions

As this article has demonstrated, there is no strong scientific evidence that mouthguards prevent or reduce concussive injuries. Despite this, a myth continues to exist in the media, among coaches, the public, and some health care providers that mouthguards prevent or reduce concussions. As was detailed above, this belief owes its historical roots to the citation of articles that do not support the claim. Many of the cited articles contain no mention of concussions or refer back to two articles from the 1960s based on one living person and one dead person. This article highlights the need for statements to be based on evidence and for people to check the sources of information and critically analyze them before believing a particular claim. Mouthguards do play a role in reducing dental and oral-facial injuries and are recommended by many physicians for this express purpose.

References

Barbic et al. (2005). Comparison of Mouth Guard Designs and Concussion
Prevention in Contact Sports. A Multicenter Randomized Controlled Trial. Clin J Sport Med, 15, 294-298.

Blignaut et al. (1987). Injuries Sustained in Rugby by Wearers and Non-Wearers of Mouthguards. Brit.J.Sports Med., 21, 5-7.

Cathcart, J. (1951). Mouth protectors for contact sports. Dental Digest, 57, 346-348.

Chalmers, D. (1998). Mouthguards Protection for the Mouth in Rugby Union. Sports Med, 25, 339-349.

Chapman PJ. (1985a). Concussion in contact sports and importance of mouthguards in protection. Aust J Sci Med Sport, 17, 23-7.

Chapman (1985b). The bimaxillary mouthguard. Increased protection against orofacial and head injuries in sport. Australian Journal of Science and Medicine in Sport, 17, 25-28.

Chapman (1985c). Orofacial injuries and the use of mouthguards by the 1984 Great Britain Rugby League Touring Team. British Journal of Sports Medicine, 19, 34-36.

Clegg JH (1969). Mouth protection for the rugby football player. Br Dent J,127, 341-3.

Davies et al. (1977). The prevalence of dental injuries in rugby players and their attitudes to mouthguards. British Journal of Sports Medicine, 11, 72-4.

Davis and Knott (1984). Dental trauma in Australia. Australian Dental Journal, 29, 217-21.

Fricker JP. (1983) Mouthguards. Aust J Sports Med Exerc Sci, 15, 22-3.

Garon et al. (1986). Mouth protectors and oral trauma: a study of adolescent football players. J Am Dent Assoc, 74, 112, 663-665.

Godwin, W. (1968). Stress transmitted through mouth protectors. J Am Dent Assoc. 77, 1316-20.

Hickey J. et al (1967). The relation of mouth protectors to cranial pressure and deformation. J Am Dent Assoc, 74, 735–40.

Jagger RJ, Milward PJ.(1995). The bimaxillary mouthguard. Br Dent J., 178, 31-2

Johnsen DC and Winters JE. (1991). Prevention of intraoral trauma in sports. Dent Clin North Am, 35, 657-66

Kemp et al. (2008). The Epidemiology of Head Injuries in English Professional Rugby Union. Clin J Sport Med ,18, 227-234.

Kerr IJ. (1986). Mouthguards for the prevention of injuries in contact sports. Sports Med, 3: 415-27.

Knapik et al (2007). Mouthguards in Sport Activities History, Physical Properties and Injury Prevention Effectiveness. Sports Med, 37, 117-144.

Labella et al (2002). Effect of mouthguards on dental injuries and concussions in college basketball. Med Sci Sports Exerc., 34, 41-4.

Marshall et al. (2005). Evaluation of protective equipment for prevention of injuries in rugby union. International Journal of Epidemiology, 34, 113–118.

McCrory (2001). Do mouthguards prevent concussion? Br J Sports Med, 35:81–82.

Mihalik et al. (2007). Effectiveness of mouthguards in reducing neurognitive deficits following sports-related cerebral concussion. Dental Traumatology, 23, 14-20.

News of Dentistry (1972). Fitted mouthguards afford key protection, Journal of the American Dental Association, 84, 531..

Powers et al. (1984). Mouth protectors and sports team dentists. Bureau of Health Education and Audiovisual Services, Council on Dental Materials, Instruments, and Equipment. J Am Dent Assoc, 109, 84-7.

Stenger et al. 91964) Mouthguards: protection against shock to head, neck and teeth. J Am Dent Assoc, 69: 273-81.

Takeda et al. (2007). Can mouthguards prevent mandibular bone fractures and concussions? A laboratory model with an artificial skull model. Dental Traumatology, 21, 134-140.

Upson, N. (1982).  Dental injuries and the attitudes of rugby players to mouthguards. British Journal of Sports Medicine, 16, 241-44.

Wisniewski et al. (2004). Incidence of cerebral concussions associated with type of mouthguard used in college football. Dental Traumatology, 20, 143-49. 

Fast Food Wars: Uno Chicago Grill

Uno Chicago Grill (formerly known as Pizzeria Uno) is the fifth and last pizza restaurant to be subjected to analysis in the Fast Food Wars. I decided to enter them into the competition because it is a place where many people across the U.S. go for pizza, despite the fact that they do not deliver. Of all the pizza restaurants that will be analyzed in the Great Pizza Battle, Uno Chicago Grill is the one that most typifies a standard sit-in dining restaurant with a broad menu. To keep the analyses fair and on the same level with the traditional pizza chains reviewed, the analyses listed below are limited to all pizzas (deep dish and thin crust pizza), appetizers, and deserts.
As a reminder, the analyses conducted below are based on a formula I created called the UHI (UnHealthy Index). The UHI is calculated by taking the six most common nutritional concerns that people have (total calories, saturated fat, trans fats, cholesterol, sodium, and carbohydrates), adding them together, and dividing by six. Higher UHI scores reflect unhealthier foods and scores closer to zero (i.e., water) reflect healthier foods.

First, a word about pizza serving sizes at Uno Chicago Grill, which can be confusing if you examine the nutritional menu. The serving sizes for deep dish pizzas state Ind: 3 or Reg: 6. “Ind” means individual and “Reg” means regular. An individual pizza is 7 inches and a regular pizza is 10 inches. Each is sliced into 6 pieces. Thus, the serving size for an individual pizza is 2 slices and for a general pizza is 1 slice. For thin crust pizzas, the serving size is two slices.

UNHEALTHIEST FOODS OVERALL:

First, let’s start with the five foods on the Uno Chicago Grill menu with the highest UHI scores. The unhealthiest food you can purchase at Uno Chicago Grill in the above categories is the...

1. Chicago Classic Deep Dish Pizza. This is a pizza that contains sausage and pork. Each serving has 770 calories, 18 grams of saturated fat, 0 grams of trans fat, 75 mg of cholesterol, 1640 mg of salt, and 40 grams of carbohydrates. Total UHI score: 423.83

2. Numero Uno Deep Dish Pizza. This pizza contains sausage, pepperoni, pork, and brick. Total calories: = 640, saturated fat = 12 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 1200 mg, carbohydrates = 41 grams. Total UHI = 323.

3. Lobster BLT Thin Crust Pizza. Total calories = 510, saturated fat = 10 grams, trans fat = 0 grams, cholesterol = 85 grams, sodium = 1160 mg, carbohydrates = 33 grams. Total UHI = 299.66.

4. Prima Pepperoni Deep Dish Pizza. Total calories = 610, saturated fat = 12 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 1040 mg, carbohydrates = 39 grams. Total UHI = 290.16.

5. The Chi Town Tasting Plate. Contains buffalo wings, avocado egg roll, chicken thumbs, crispy cheese dippers, and French fries. Total calories = 470, saturated fat = 6 grams, trans fat = 0 grams, cholesterol = 85 grams, sodium = 1030 mg, carbohydrates = 28 grams. Total UHI = 269.83. Serving size = 5.

WORST ITEMS BY NUTRITIONAL CATEGORY:

Highest calories: 770 (Chicago Classic Deep Dish Pizza)

Highest saturated fat: 18 grams (Chicago Classic Deep Dish Pizza; Uno Deep Dish Sundae [serving size = 2]; Banana’s Foster [serving size = 1; Mega Sized Deep Dish Sundae [serving size = 5])

Highest trans fat: 0.5 grams (Cheeseburger Deep Dish Pizza). All other items analyzed in the above categories have no reported trans fat.

Highest cholesterol: 145 mg (Bread Pudding with caramel sauce, serving size = 2)

Highest sodium: 1640 mg (Chicago Classic Deep Dish Pizza)

Highest carbohydrates: 96 grams (Mini White Chocolate Chunk Deep Dish Sundae, serving size = 1)

UNHEALTHIEST APPETIZERS:

1. The Chi Town Tasting Plate. Contains buffalo wings, avocado egg roll, chicken thumbs, crispy cheese dippers, and French fries. Total calories = 470, saturated fat = 6 grams, trans fat = 0 grams, cholesterol = 85 grams, sodium = 1030 mg, carbohydrates = 28 grams. Total UHI = 269.83. Serving size = 5.

2. Three Way Buffalo Wings. Total calories = 430, saturated fat = 8 grams, trans fat = 0 grams, cholesterol = 135 grams, sodium = 970 mg, carbohydrates = 3 grams. Total UHI = 257.66. Serving size = 3.

3. Three Way Buffalo Bites. Total calories = 320, saturated fat = 2 grams, trans fat = 0 grams, cholesterol = 60 grams, sodium = 1070 mg, carbohydrates = 20 grams. Total UHI = 245.33 Serving size = 3.

4. Muchos Nachos. Total calories = 460, saturated fat = 8 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 810 mg, carbohydrates = 54 grams. Total UHI = 229.5. Serving size = 3.

5. Buffalo Chicken Quesadillas. Total calories = 350, saturated fat = 8 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 890 mg, carbohydrates = 36 grams. Total UHI = 220.66. Serving size = 3.
   
UNHEALTHIEST DESSERTS:

1. Mini White Chocolate Chunk Deep Dish Sundae. Total calories = 660, saturated fat = 14 grams, trans fat = 0 grams, cholesterol = 80 grams, sodium = 390 mg, carbohydrates = 96 grams. Total UHI = 206.67. Serving size = 1.

2. Uno Deep Dish Sundae. Total calories = 700, saturated fat = 18 grams, trans fat = 0 grams, cholesterol = 70 grams, sodium = 310 mg, carbohydrates = 95 grams. Total UHI = 198.83 Serving size = 2.

3. Mega Sized Deep Dish Sundae. Total calories = 700, saturated fat = 18 grams, trans fat = 0 grams, cholesterol = 70 grams, sodium = 310 mg, carbohydrates = 95 grams. Total UHI = 198.83 Serving size = 4.

4. Bananas Foster. Total calories = 640, saturated fat = 18 grams, trans fat = 0 grams, cholesterol = 90 grams, sodium = 260 mg, carbohydrates = 82 grams. Total UHI = 181.66. Serving size = 1.

5. Bread Pudding with Caramel Sauce. Total calories = 450, saturated fat = 16 grams, trans fat = 0 grams, cholesterol = 145 grams, sodium = 330 mg, carbohydrates = 46 grams. Total UHI = 164.5. Serving size = 2.

KIDS MENU:

If you are going to get pizza from the Kids menu, the most unhealthy items is the Kids Pepperoni Pizza (UHI: 250.33) and the Kids Deep Dish Pepperoni Pizza (UHI: 249.83). The healthiest pizza on the kids menu is the Kids Cheese Pizza with a UHI of 219.83. The Kids Deep Dish Pizza comes in a close second with a UHI of 219.67.

SAUCES:

Uno Chicago Grill has eight sauces to choose from. The unhealthiest sauce is the Asian sauce, with a UHI of 139. This is because the sodium level is 710. The 2nd unhealthiest sauce is the Buffalo Garlic (UHI = 96.3) and the 3rd unhealthiest is the Buffalo Wing (UHI 88.83). The other sauces are relatively equivalent with UHIs in the 40s to 60s range. The healthiest sauce is the tamarind cashew sauce, which has a UHI of 41.66and is the only sauce with a UHI in the 40s. The serving size for the tamarind cashew sauce is 57 grams and the other sauces have a serving size of 43 grams.

HEALTHIEST FOODS OVERALL: (excluding sauces)

1. The healthiest item you can purchase at Uno Chicago Grill in the pizza, appetizers, or desert section is the

house made guacamole. It has only 235 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 230 mg of salt, and 32 grams of carbohydrates. Total UHI: 82.25. Serving size = 2.

2. Mini Bananas Foster. This dessert has 350 calories, 9 grams of saturated fat, 0 grams of trans fat, 45 mg of cholesterol, 140 mg of salt, and 46 grams of carbohydrates. Total UHI: 98.33. Serving size = 1.

3. Mini All American Apple Crumble. This dessert has 320 calories, 8 grams of saturated fat, 0 grams of trans fat, 50 mg of cholesterol, 250 mg of salt, and 44 grams of carbohydrates. Total UHI: 112. Serving size = 1.

4. Mini Hot Chocolate Brownie Sundae. This dessert has 370 calories, 8 grams of saturated fat, 0 grams of trans fat, 60 mg of cholesterol, 190 mg of salt, and 54 grams of carbohydrates. Total UHI: 113.66. Serving size = 1.

5. Avocado Egg Rolls. Each egg roll has 270 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 25 mg of cholesterol, 350 mg of salt, and 38 grams of carbohydrates. Total UHI: 114.08. Serving size = 2.

HEALTHIEST PIZZAS OVERALL:

Now that you have a sense of which appetizers and desserts to steer towards, let’s move to the pizzas. The healthiest pizzas on the menu are all in the thin crust domain. According to the Chicago Uno restaurant I called, these pizzas are about 9 inches. For these pizzas, the serving size is two out of six slices. Rankings are as follows:

1. Thin Crust Roasted Eggplant Spinach & Feta . Total calories = 290, saturated fat = 3.5 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 560 mg, carbohydrates = 38 grams. Total UHI = 151.08.

2.Thin Crust Cheese & Tomato . Total calories = 280, saturated fat = 5 grams, trans fat = 0 grams, cholesterol = 20 grams, sodium = 590 mg, carbohydrates = 33 grams. Total UHI = 154.66.

3. Thin Crust BBQ Chicken Multigrain. Total calories = 330, saturated fat = 4.5 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 550 mg, carbohydrates = 39 grams. Total UHI = 160.58.

4. Thin Crust BBQ Chicken. Total calories = 340, saturated fat = 5 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 660 mg, carbohydrates = 39 grams. Total UHI = 180.66.

5. Thin Crust Gluten Free Veggie. Total calories = 320, saturated fat = 4.5 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 710 mg, carbohydrates = 43 grams. Total UHI = 182.08.

Note: Soft drinks were not subject to analysis.

From the Uno Chicago Grill website:

All nutritional information is derived from a computer analysis of recipes with the help of "Genesis R&D SQL", nutrition and labeling software, from ESHA Research in Salem, Oregon and data from our suppliers. The nutrition information provided is based on standard recipes that may vary based on portion size, regional and seasonal differences in products or substitution of ingredients. This information is not to be used by individuals with special dietary needs in lieu of professional medical advice. The nutritional information is subject to change.

Fast Food Wars: Pizza Hut

Pizza Hut is the fourth pizza restaurant to be subjected to analysis in the Fast Food Wars because it was recently ranked as the pizza chain with the most stores by Pizza Magazine. In fact, I was surprised to learn that in 2008, Pizza Hut had almost twice as many stores (14,759) than Domino’s Pizza (8,641). According to the Pizza Hut Wikipedia entry, they have approximately 34,000 restaurants, delivery/carry-out locations, and kiosks in 100 countries.

As a reminder, the analyses conducted below are based on a formula I created called the UHI (UnHealthy Index). The UHI is calculated by taking the six most common nutritional concerns that people have (total calories, saturated fat, trans fats, cholesterol, sodium, and carbohydrates), adding them together, and dividing by six. Higher UHI scores reflect unhealthier foods and scores closer to zero (i.e., water) reflect healthier foods.

UNHEALTHIEST FOODS OVERALL:

First, let’s start with the five foods on the Pizza Hut menu with the highest UHI scores. By far, the absolute unhealthiest food you can purchase at Pizza Hut is the...

1. 9" Personal PANormous™ Pizza Meat Lover’s version. It contains pepperoni, beef topping, mild sausage, ham, Italian sausage, bacon bits and mozzarella cheese. The serving size for analysis is the entire pie, which is appropriate because it is a personal pizza. This bad boy has 1470 calories, 30 grams of saturated fat, 1.5 grams of trans fat, 175 mg of cholesterol, a whopping 3670 mg of salt (!), and 123 grams of carbohydrates. Total UHI score: 911.58.

The remaining unhealthiest foods at Pizza Hut are also all members of the 9" Personal PANormous™ Pizza, so this is really something you want to veer away from. Here are the stats.

2. 9" Personal PANormous™ Pizza Spicy Italian version: Total calories: = 1220, saturated fat = 22 grams, trans fat = 1.5 grams, cholesterol = 115 grams, sodium = 3150 mg, carbohydrates =126 grams. Total UHI = 772.42.

3. 9" Personal PANormous™ Pizza Triple Meat Italian version: Total calories = 1280, saturated fat = 23 grams, trans fat = 1 gram, cholesterol = 135 grams, sodium = 3070 mg, carbohydrates = 123 grams. Total UHI = 772.

4. 9" Personal PANormous™ Pizza Supreme version: Total calories = 1270, saturated fat = 24 grams, trans fat = 1.5 grams, cholesterol = 130 grams, sodium = 2920 mg, carbohydrates = 125 grams. Total UHI = 745.08.

5. 9" Personal PANormous™ Pizza Dan’s Original version: Total calories = 1270, saturated fat = 23 grams, trans fat = 1 grams, cholesterol = 125 grams, sodium = 2810 mg, carbohydrates =124 grams. Total UHI = 725.5.

No other Pizza Hut menu item had a UHI in the 700 range.

UNHEALTHIEST ITEMS BY NUTRITIONAL CATEGORY:

Highest calories: 1470 (9" Personal PANormous™ Pizza Meat Lover’s version)

Highest saturated fat: 30 grams (9" Personal PANormous™ Pizza Meat Lover’s version)

Highest trans fat: 2 grams (Fried Cheese sticks, 4 pieces)

Highest cholesterol: 175 mg (9" Personal PANormous™ Pizza Meat Lover’s version)

Highest sodium: 3670 mg (9" Personal PANormous™ Pizza Meat Lover’s version)

Highest carbohydrates: 129 grams (9" Personal PANormous™ Pizza Meat Lover’s version)

UNHEALTHIEST APPETIZERS AND SIDE ITEMS (includes chicken wings and stuffed pizza rollers):

1. The unhealthiest appetizer or side item you can purchase at Pizza Hut are the cheese sticks (4 pieces). It contains 380 calories, 9 grams of saturated fat, 2 grams of trans fat, 40 mg of cholesterol, 1020 mg of salt, and 29 grams of carbohydrates. Total UHI score: 246.6.

The remaining unhealthiest appetizer of side items you can purchase at Pizza Hut are all in the Crispy Bone In Wings section. The following information is for every two chicken wings you eat.

2. Crispy Bone In Wings Buffalo Mild version: Total calories = 230, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 1040 mg, carbohydrates = 16 grams. Total UHI = 222.33.

3. Crispy Bone In Wings Buffalo Burnin Hot version: Total calories = 230, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 1020 mg, carbohydrates = 16 grams. Total UHI = 219.

4. Crispy Bone In Wings Buffalo Medium version: Total calories = 230, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 45 grams, sodium = 1010 mg, carbohydrates = 16 grams. Total UHI = 217.3.
   

5. Crispy Bone In Wings Spicy BBQ version: Total calories = 240, saturated fat = 2.5 grams, trans fat = 0 grams, cholesterol = 50 grams, sodium = 950 mg, carbohydrates = 19 grams. Total UHI = 210.25

DESSERTS:

Pizza Hut essentially has two desserts to choose from: Cinnamon Sticks (2 pieces) or HERSHEY'S® Chocolate Dunkers® (2 pieces). If you had to choose, the healthiest choice is the Cinnamon Sticks, which has a UHI of 66.25. The Chocolate Dunkers have a UHI of 73.3. If you add the 2 oz white icing for the cinnamon sticks or the 1.5 oz of HERSHEY'S® Chocolate Sauce®, you are adding 36 and a half UHI points for each.

HEALTHIEST FOODS OVERALL:

1. The healthiest item you can purchase at Pizza Hut (excluding beverages, dipping sauces, and small desert glazes) would be 2 pieces of Cinnamon sticks. It has only 170 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 200 mg of salt, and 26 grams of carbohydrates. Total UHI: 66.25.

2. Assuming you’re fast food hunger will not be satisfied by two cinnamon sticks, then you can move up to the second healthiest item which is the healthiest appetizer on the menu: the Traditional Wings All American version. Every two wings have only 80 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 40 mg of cholesterol, 290 mg of salt, and 0 grams of carbohydrates. Total UHI: 68.58.

3. HERSHEY'S® Chocolate Dunkers® (2 pieces). Every two pieces have 200 calories, 4 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 210 mg of salt, and 26 grams of carbohydrates. Total UHI: 73.3.

4. The apple pie side item. Every two pies have 330 calories, 5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 190 mg of salt, and 40 grams of carbohydrates. Total UHI: 94.16.

5. “BUT I CAME HERE FOR PIZZA!” you proclaim. Well, you’re in luck. The fifth healthiest item on the menu is a slice of the 12” Fit 'n Delicious® Pizza (Green Pepper, Red Onion & Diced Red Tomato version): Each slice has 150 calories, 1.5 grams of saturated fat, 0 grams of trans fat, 10 mg of cholesterol, 400 mg of salt, and 24 grams of carbohydrates. Total UHI: 97.58.

HEALTHIEST PIZZAS OVERALL:

1. As noted above, the healthiest pizza at Pizza Hut is the 12” Fit 'n Delicious® Pizza(Green Pepper, Red Onion & Diced Red Tomato version) with a UHI of 97.58.

2. One slice of the 9” Pizza Mia Pizza, cheese only. Each slice has 200 calories, 4 grams of saturated fat, 0 grams of trans fat, 15 mg of cholesterol, 490 mg of salt, and 24 grams of carbohydrates. Total UHI score: 122.16.

The remaining most healthiest pizzas are all from the 12" Fit 'n Delicious® Pizza, so it is nice to see that it objectively lives up to its advertised name. Serving size is 1 slice.

3. 12" Fit 'n Delicious® Pizza, Chicken, Red Onion, & Green Pepper version (one slice): Total calories = 180, saturated fat = 2 grams, trans fat = 0 grams, cholesterol = 20 grams, sodium = 510 mg, carbohydrates = 23 grams. Total UHI = 122.5.

4. 12" Fit 'n Delicious® Pizza, Ham, Red Onion, & Mushroom (one slice): Total calories = 160, saturated fat = 1.5 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 550 mg, carbohydrates = 23 grams. Total UHI = 124.9.

5. 12" Fit 'n Delicious® Pizza, Ham, Pineapple, & Diced Red Tomato version (one slice): Total calories = 160, saturated fat = 1.5 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 550 mg, carbohydrates = 24 grams. Total UHI = 125.08.

Note: Soft drinks were not subject to analysis.

From the Pizza Hut website: Nutritional values not applicable to Pizza Hut products in Hawaii. Substitutions of ingredients may alter nutritional values. Menu items and hours of availability may vary at participating locations. Although this data is based on standard portion product guidelines, variations can be expected due to seasonal influences, minor differences in product assembly per restaurant and other factors. Some menu items may not be available at all Pizza Hut restaurants, and certain locations may at times offer buffet items, test products, limited-time offerings or other regional menu choices not listed here. Product data is based on current formulations as of date of posting. If you have any questions about Pizza Hut and nutrition or are particularly sensitive to specific ingredients or foods, please contact us at 1-800-948-8488.

Fast Food Wars: Papa John's

Papa John’s is the third pizza restaurant to be subjected to analysis in the Fast Food Wars. According to the Papa John’s Wikipedia entry, Papa John’s is the third largest take-out and delivery pizza restaurant chain in the U.S. behind Pizza Hut and Domino's Pizza. Internationally, there are over 3,300 Papa John's establishments, including over 2,600 in the U.S. and more than 500 in over 30 other countries

As a reminder, the analyses conducted below are based on a formula I created called the UHI (UnHealthy Index). The UHI is calculated by taking the six most common nutritional concerns that people have (total calories, saturated fat, trans fats, cholesterol, sodium, and carbohydrates), adding them together, and dividing by six. Higher UHI scores reflect unhealthier foods and scores closer to zero (i.e., water) reflect healthier foods.

For the pizza analysis, keep in mind that Papa John’s makes pies in an original crust version and a thin crust version. The thin crust version only comes in one size (14”) whereas the original crust version comes in sizes of 8”, 10”, 12”, 14”, and 16. In general, the higher larger the pizza, the larger the UHI will be. All specialty pizzas advertised on the Papa John’s website were analyzed for both original crust and thin crust. All pizza analyses below were performed based on a serving size being equal to ONE SLICE.

UNHEALTHIEST FOODS OVERALL:

First, let’s start with the five foods on the Papa John’s menu with the highest UHI scores. By far, the absolute unhealthiest food you can purchase at Papa John’s is the...

1. 16” The Meats Pizza, original crust. It contains pepperoni, sausage, beef, hickory-smoked bacon, and ham. One slice of this bad boy has 400 calories, 8 grams of saturated fat, 0 grams of trans fat, 40 mg of cholesterol, 1100 mg of salt, and 40 grams of carbohydrates. Total UHI score: 264.47.

2. 16” Hawaiin BBQ Chicken, original crust. This pizza is covered in barbeque sauce, grilled all-white chicken, hickory-smoked bacon and fresh-sliced onions, then topped with sweet pineapple .Total calories: = 370, saturated fat = 5 grams, trans fat = 0 grams, cholesterol = 35 grams, sodium = 1080 mg, carbohydrates = 49 grams. Total UHI = 256.5.

3. 16” BBQ chicken and Bacon, original crust. Tangy barbeque sauce and piled high with grilled all-white chicken, hickory-smoked bacon and fresh-sliced onions. Total calories: = 371, saturated fat = 5 grams, trans fat = 0 grams, cholesterol = 35 grams, sodium = 1080 mg, carbohydrates = 48 grams. Total UHI = 256.3.

4. 16" Spicy Italian, original crust. Pepperoni and a double portion of spicy Italian sausage. Total calories = 400, saturated fat = 8 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 1040 mg, carbohydrates = 41 grams. Total UHI = 254.8.

5. 14" The Meats, original crust. Total calories = 370, saturated fat = 7 grams, trans fat = 0 grams, cholesterol = 40 grams, sodium = 1050 mg, carbohydrates = 38 grams. Total UHI = 251. This means that you can buy any of the 16” pizzas except those mentioned above and the choice will be healthier than ordering a 14” The Meats Pizza.

UNHEALTHIEST ITEMS BY NUTRITIONAL CATEGORY:

Highest calories: 580 (Cinnamon Sweetsticks; 4 pieces). Fresh, hand-tossed dough topped with sweet cinnamon spread, drizzled with white icing and then oven-baked

Highest saturated fat: 8 grams (14” The Meats original crust, 14” Spicy Italian original crust, and 14” The Meats thin crust)

Highest trans fat: NONE. Papa John’s reports using no trans fats in any of their food products. Good job!

Highest cholesterol: 50 g (BBQ wings, Buffalo wings, honey chipotle wings). Serving size is every two wings.

Highest sodium: 1100 mg (14” The Meats original crust)

Highest carbohydrates: 98 grams (Cinnamon Sweetsticks, 4 sticks).

UNHEALTHIEST APPETIZERS AND SIDE ITEMS:

1. The unhealthiest appetizer or side item you can purchase at Papa John's are the

cheese sticks. Every 4 pieces contain 370 calories, 7 grams of saturated fat, 0 grams of trans fat, 35 mg of cholesterol, 860 mg of salt, and 41 grams of carbohydrates. Total UHI score: 218.83.

2. BBQ wings: Total calories = 170, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 50 grams, sodium = 1070 mg, carbohydrates = 3 grams. Total UHI = 216. Serving size: 2 wings.

3. Garlic Parmesan Breadsticks: Total calories = 340, saturated fat = 1.5 grams, trans fat = 0 grams, cholesterol = 0 grams, sodium = 720 mg, carbohydrates = 54 grams. Total UHI = 185.92. Serving size: 2 sticks.

4. Buffalo Wings: Total calories = 190, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 50 grams, sodium = 760 mg, carbohydrates = 6 grams. Total UHI = 168.16. Serving size: 2 wings.

5. Breadsticks: Total calories = 290, saturated fat = 0.5 grams, trans fat = 0 grams, cholesterol = 0 grams, sodium = 540 mg, carbohydrates = 54 grams. Total UHI = 147.42. Serving size: 2 sticks.

Note: Papa John’s only has 6 side items and appetizers. This leaves the chickenstrips as the healthiest side item/appetizer. Total calories = 130, saturated fat = 0.5 grams, trans fat = 0 grams, cholesterol = 25 grams, sodium = 430 mg, carbohydrates = 10 grams. Total UHI = 99.25. Serving size: 2 strips.
   
DESSERTS:

Papa John’s has three desserts to choose from. The unhealthiest are the Cinnamon Sweetsticks with a UHI of 237.08. In the middle is the Cinnapie with a UHI of 199.33. The healthiest desert is the apple pie with a UHI of 182.08. Serving size for each of these desserts is 4 sticks.

DIPPING SAUCES:

Papa John’s has 8 dipping sauces to choose from. By far the most unhealthiest dipping sauce is the Buffalo sauce, with a UHI of 174.5. This is because it has 1030 mg of sodium! None of the other sauces even come close, with the 2nd highest UHI coming from the garlic sauce (77.1). The healthiest dipping sauce is the cheese sauce, with a UHI of 34.5. The second healthiest is the pizza sauce with a UHI of 42.17.

HEALTHIEST FOODS OVERALL:

1. The healthiest item you can purchase at Papa John's (excluding beverages and dipping sauces) is the

10” Garden Fresh pizza. The pizza contains fresh-sliced onions, green peppers, gourmet baby portabella mushrooms, ripe black olives and juicy, and fresh-sliced Roma tomatoes. Each slice has only 140 calories, 2 grams of saturated fat, 0 grams of trans fat, 10 mg of cholesterol, 350 mg of salt, and 20 grams of carbohydrates. Total UHI: 87.

Note: In general, analyses show that 10”pizzas have a higher UHI than 8” pizzas. Other exceptions are the 10” cheese pizza (UHI: 110) and the 8” cheese pizza (112) as well as the 10” spicy Italian (UHI: 150) and the 8” spicy Italian (UHI: 153).

2. Two chicken strips. Total calories = 130, saturated fat = 0.5 grams, trans fat = 0 grams, cholesterol = 25 grams, sodium = 430 mg, carbohydrates = 10 grams. Total UHI = 99.25. Serving size: 2 strips.

3. 8” Garden Fresh pizza. Every slice has 180 calories, 2 grams of saturated fat, 0 grams of trans fat, 10 mg of cholesterol, 440 mg of salt, and 26 grams of carbohydrates. Total UHI: 110.

4. 8” Spinach Alfredo pizza. This pizza has a rich and creamy blend of spinach and garlic Parmesan Alfredo sauce. Every slice 190 calories, 4 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 420 mg of salt, and 24 grams of carbohydrates. Total UHI: 110.

5. 10” Cheese pizza. Each slice has 180 calories, 2.5 grams of saturated fat, 0 grams of trans fat, 15 mg of cholesterol, 440 mg of salt, and 25 grams of carbohydrates. Total UHI: 110.

Note: Soft drinks were not subject to analysis.

From the Papa John’s website:

Menu items may vary by restaurant.

The nutrient value of our products may vary based on the local supplier, region of the country, season of the year, and/or slight variations in product assembly. Nutritional data is derived from information provided by Papa John's suppliers and from testing conducted in accredited laboratories.

For additional nutritional facts regarding Papa John's menu items, call 888-404-7537 and select option 1.

Fast Food Wars: Little Caesers

Little Caesers is the 2nd pizza restaurant to be subjected to analysis in the Fast Food Wars. According to the Little Caesers Wikipedia entry, Little Caeser’s is the third largest carry-out pizza restaurant chain in the U.S. Currently, there are around 2,000 locations, down from a peak of around 5,000 in the 1990s.

As a reminder, the analyses conducted below are based on a formula I created called the UHI (UnHealthy Index). The UHI is calculated by taking the six most common nutritional concerns that people have (total calories, saturated fat, trans fats, cholesterol, sodium, and carbohydrates), adding them together, and dividing by six. Higher UHI scores reflect unhealthier foods and scores closer to zero (i.e., water) reflect healthier foods.

Only the items advertised on the Little Caeser’s website were analyzed. All pizza analyses below were performed based on a serving size being equal to one slice.

UNHEALTHIEST FOODS OVERALL:

First, let’s start with the five foods on the Little Caeser’s menu with the highest UHI  scores. By far, the absolute unhealthiest food you can purchase at Little Caesers is the…

1. Three Meat Treat Pizza. It contains pepperoni, Italian sausage, and bacon. One slice of this bad boy has 350 calories, 8 grams of saturated fat, 0 grams of trans fat, 40 mg of cholesterol, 730 mg of salt, and 30 grams of carbohydrates. Total UHI score: 193.

2. Buffalo Dipping Sauce, one container. Total calories: = 140, saturated fat = 2 grams, trans fat = 0 grams, cholesterol = 0 grams, sodium = 940 mg, carbohydrates = 4 grams. Total UHI = 181.

3. Baby Pan! Pan!, Pepperoni, one pan. Total calories: = 360, saturated fat = 7 grams, trans fat = 0 grams, cholesterol = 35 grams, sodium = 610 mg, carbohydrates = 33 grams. Total UHI = 174.167.

4. Deep Dish Pizza, Pepperoni, one slice.Total calories = 360, saturated fat = 6 grams, trans fat = 0 grams, cholesterol = 30 grams, sodium = 610 mg, carbohydrates = 38 grams. Total UHI = 174.

5. Ultimate Supreme Pizza, one slice: It contains pepperoni, onion, Italian sausage, mushroom, and green pepper. Total calories = 310, saturated fat = 6 grams, trans fat = 0 grams, cholesterol = 30 grams, sodium = 640 mg, carbohydrates = 31 grams. Total UHI = 169.5.

UNHEALTHIEST ITEMS BY NUTRITIONAL CATEGORY:

Highest calories: 380 (Buttery garlic dip, 1 container).

Highest saturated fat: 9 grams (Buttery garlic dip, 1 container)

Highest trans fat: NONE. Little Caeser’s reports using no trans fats in any of their food products. Good job!

Highest cholesterol: 40 g (Three Meat Treat Pizza). Serving size: one slice

Highest sodium: 840 mg (Buffalo dip, 1 container)

Highest carbohydrates: 38 grams (Deep Dish Pizza, pepperoni and Deep Dish Pizza, just cheese). Serving size: one slice.

UNHEALTHIEST APPETIZERS AND SIDE ITEMS:

Keep in mind that Little Caesers only has 8 appetizers and side items, so the items listed towards the bottom can also be seen as some of their healthier items as well.

The unhealthiest appetizer or side item you can purchase at Little Caeser’s are the

1. Caeser’s wings (hot). Each wing contains 60 calories, 1 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 430 mg of salt, and 1 gram of carbohydrates. Total UHI score: 85.3.

2. Pepperoni cheese bread, 16-piece order. : Total calories = 160, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 280 mg, carbohydrates = 16 grams. Total UHI = 79. Serving size: one piece.

2. Pepperoni cheese bread, 10-piece order. : Total calories = 150, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 15 grams, sodium = 280 mg, carbohydrates = 13 grams. Total UHI = 76.83. Serving size: one piece.

4. Italian cheese bread: Total calories = 130, saturated fat = 2.5 grams, trans fat = 0 grams, cholesterol = 10 grams, sodium = 230 mg, carbohydrates = 13 grams. Total UHI = 64.25. Serving size: one piece.
   
5. Caeser’s wings, mild: Total calories = 60, saturated fat = 1 grams, trans fat = 0 grams, cholesterol = 20 grams, sodium = 290 mg, carbohydrates = 1 gram. Total UHI = 62. Serving size: one wing.

DIPPING SAUCES:

Little Caeser’s has 6 dips to choose from and one sauce (Crazy Sauce). By far the most unhealthiest dipping sauce is the Buffalo sauce, with a UHI of 181. This is because it has 940 mg of sodium in each small container! The 2nd highest UHI in this category comes from the buttery garlic dip (134.83). The healthiest dip sauce is the ranch, with a UHI of 108.67. However, if you want something much healthier to dip in, go with the Crazy Sauce, which has a UHI of only 52.5.

HEALTHIEST FOODS OVERALL:

1. The healthiest item you can purchase at Little Caesers (excluding beverages, dips, and sauces), is the Caeser’s wings, oven roasted. Each wing has only 50 calories, 1 gram of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 150 mg of salt, and 10 grams of carbohydrates. Total UHI: 36.83.

2. Crazy bread. Each piece has only 100 calories, 0.5 grams of saturated fat, 0 grams of trans fat, 15 mg of cholesterol, 380 mg of salt, and 3 grams of carbohydrates. Total UHI: 44.25. My personal favorite.

3. Caeser’s wings barbecue. Every wing has 70 calories, 1 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 220 mg of salt, and 3 grams of carbohydrates. Total UHI: 52.33.

4. Caeser’s wings, mild, one wing. Total calories = 60, saturated fat = 1 grams, trans fat = 0 grams, cholesterol = 20 grams, sodium = 290 mg, carbohydrates = 1 gram. Total UHI = 62.

5. Italian cheese bread, one piece. Total calories = 130, saturated fat = 2.5 grams, trans fat = 0 grams, cholesterol = 10 grams, sodium = 230 mg, carbohydrates = 13 grams. Total UHI = 64.25.

HEALTHIEST PIZZA OVERALL:

1. The healthiest pizza you can purchase at Little Caesers is the

14" Round HOT-N-READY Pizza, Just Cheese. Each slice has only 240 calories, 4.5 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 410 mg of salt, and 30 grams of carbohydrates. Total UHI: 117.42.

2. Vegetarian pizza. This pizza contains mushroom, black olives, tomatoes, onion, and green pepper. Each slice has 270 calories, 4.5 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 530 mg of salt, and 32 grams of carbohydrates. Total UHI: 142.75.

3. 14" Round HOT-N-READY Pizza, Pepperoni. Every slice has 280 calories, 5 grams of saturated fat, 0 grams of trans fat, 25 mg of cholesterol, 520 mg of salt, and 30 grams of carbohydrates. Total UHI: 143.33.

4. Deep dish, pizza, just cheese, one slice. Total calories = 320, saturated fat = 5 grams, trans fat = 0 grams, cholesterol = 25 grams, sodium = 490 mg, carbohydrates = 38 gram. Total UHI = 146.33.

5. Hula Hawaiin, pineapple and ham, one slice. Total calories = 270, saturated fat = 4.5 grams, trans fat = 0 grams, cholesterol = 25 grams, sodium = 600 mg, carbohydrates = 33 grams. Total UHI = 155.42.

Note: Soft drinks were not subject to analysis. From the Little Caesers website:

Nutritional and ingredient information is based on Little Caesars standard U.S. product formulation. While the ingredient information is based on standard product formulations, variations may occur depending on the particular supplier, product assembly per restaurant, regional, and other factors. Further, product formulations may change periodically. Calculations were performed on Genesis® R&D SQL Software, by ESHA Research, PO Box 13028, Salem, OR 97309 USA.

Fast Food Wars: Domino's Pizza

Domino’s Pizza is the first pizza restaurant to be subjected to analysis the Fast Food Wars. According to the Domino’s Pizza Wikipedia entry, Domino’s Pizza is the second-largest pizza chain in the United States. Domino's currently has nearly 9,000 corporate and franchised stores in 60 international market and all 50 U.S. states.

A few words about how the Domino's Pizza analyses were conducted. It was initially confusing to how to find all of the nutritional information for some specific Domino's Pizza items. This is because their nutritional pdf only provides ranges for the nutritional informational of foods on various categories rather than tell you the values for each item.

To find the nutritional information for each specific item, you need to click on their Cal-O-Meter, select an item, and then click View Details to the upper right. Since Dominos has 4 different pizza crusts and 4 different sizes with so many different toppings, there are almost an infinite amount of possible pizza creations. To simplify matters, results are presented for large pizzas only because this size applies to all crusts (not all sizes do) and because it is the standard size that people order.

As a reminder, the analyses conducted below are based on a formula I created called the UHI (UnHealthy Index). The UHI is calculated by taking the six most common nutritional concerns that people have (total calories, saturated fat, trans fats, cholesterol, sodium, and carbohydrates), adding them together, and dividing by six. Higher UHI scores reflect unhealthier foods and scores closer to zero (i.e., water) reflect healthier foods.

UNHEALTHIEST FOODS OVERALL:

First, let’s start with the five foods on the Domino's menu with the highest UHI scores. The unhealthiest food you can purchase there in the above nutritional categories are all in the oven baked sandwich category (serving size = 1 sandwich). These include:

1. The Italian Sandwich: It contains Pepperoni, Salami, & Ham topped with Banana Peppers, Green Peppers, Onions, & Premium Provolone Cheese. This bad boy has 820 calories, 20 grams of saturated fat, 1 grams of trans fat, 130 mg of cholesterol, 2700 mg of salt, and 70 grams of carbohydrates. Total UHI score: 623.5.

2. Buffalo Chicken with Blue Cheese: Total calories: = 830, saturated fat = 16 grams, trans fat = 1 grams, cholesterol = 115 grams, sodium = 2690 mg, carbohydrates =74 grams. Total UHI = 621.

3. Chicken Bacon Ranch: Total calories = 870, saturated fat = 16 grams, trans fat = 1 gram, cholesterol = 125 grams, sodium = 2380 mg, carbohydrates = 72 grams. Total UHI = 577.3.

4. Italian Sausage and Peppers: Total calories = 860, saturated fat = 21 grams, trans fat = 1 grams, cholesterol = 125 grams, sodium = 2260 mg, carbohydrates = 74 grams. Total UHI = 556.8.

5. Sweet and Spicy Chicken Habernero: Total calories = 800, saturated fat = 17 grams, trans fat = 1 grams, cholesterol = 125 grams, sodium = 2170 mg, carbohydrates =83 grams. Total UHI = 532.6.

HEALTHIEST FOODS OVERALL:

The five healthiest items you can purchase at Dominos Pizza (excluding beverages, dipping sauces, and salad dressing) are as follows:

1. Garden Fresh Salad. Each half-bowl has only 70 calories, 2.5 grams of saturated fat, 0 grams of trans fat, 10 mg of cholesterol, 80 mg of salt, and 5 grams of carbohydrates. Total UHI score: 27.92. Serving size = half-bowl.

2. Cinna Stix. For each stick, the total UHI is 36.44.

3. Breadsticks. For each stick, the total UHI is 36.5.

4. Cheesy Bread. For each stick, the total UHI is 46.4.

5. Grilled Chicken Sandwich. The total UHI is 67.75 for each half a bowl.

UNHEALTHIEST ITEMS BY NUTRITIONAL CATEGORY:

Highest calories: 870 (Chicken Bacon Ranch oven baked sandwich)

Highest saturated fat: 21 grams (Italian Sausage and Peppers oven baked sandwich; a bowl of the Mac-N-Cheese Pasta in a Dish)

Highest trans fat: 1.5 grams (Mac-N-Cheese Pasta in a Dish)

Highest cholesterol: 130 mg (Italian Sandwich oven baked pizza)

Highest sodium: 2700 mg (Italian Sandwich oven baked pizza)

Highest carbohydrates: 83 grams (Sweet and Spicy Chicken Habernero)

UNHEALTHIEST LEGENDS AND FEAST PIZZAS:

Keep in mind that these values are for ONE SLICE of a large pizza, so if you eat more than one slice you need to adjust the numbers accordingly. All four crusts were analyzed.

1. Fiery Hawaiin (hot sauce) Legends pizza, Brooklyn style: It contains sliced ham, smoked bacon, juicy pineapple, roasted red peppers, jalapeños, hot sauce, provolone cheese and mozzarella cheese. Each slice has 370 calories, 8.5 grams of saturated fat, 0 grams of trans fat, 55 mg of cholesterol, 1280 mg of salt, and 31 grams of carbohydrates. Total UHI score: 290.75.

2. MeatZZa Feast Pizza, Brooklyn style: Pepperoni, ham, savory Italian sausage and beef topped with an extra layer of cheese. Total calories = 390, saturated fat = 10 grams, trans fat = 0 grams, cholesterol = 65 grams, sodium = 1240 mg, carbohydrates = 30 grams. Total UHI = 289.17.

3. ExtravaganZZa Feast Pizza, Brooklyn style: It has loads of pepperoni, ham, savory Italian sausage, beef, onions, green peppers, mushrooms and black olives with extra cheese. Total calories: = 400, saturated fat = 10 grams, trans fat = 0 grams, cholesterol = 60 grams, sodium = 1220 mg, carbohydrates = 31 grams. Total UHI = 286.83.

4. California Chicken Bacon Ranch Legends Pizza, Brooklyn style: Total calories = 490, saturated fat = 11.5 grams, trans fat = 0.5 grams, cholesterol = 75 grams, sodium = 1100 mg, carbohydrates = 28 grams. Total UHI = 284.17.
   

5. Fiery Hawaiin (hot sauce) Legends pizza, Deep dish style: Total calories = 400, saturated fat = 7 grams, trans fat = 0 grams, cholesterol = 35 grams, sodium = 1190 mg, carbohydrates = 40 grams. Total UHI = 278.67.

HEALTHIEST LEGENDS AND FEAST PIZZAS:

Keep in mind that these values are for ONE SLICE of a large pizza, so if you eat more than one slice you need to adjust the numbers accordingly. All four types of crusts were analyzed.

1. Philly Cheese Steak Legends pizza, Thin crust: It contains roasted red peppers, spinach, onions, mushrooms, tomatoes and black olives with feta and provolone cheeses. Each slice has 230 calories, 5.5 grams of saturated fat, 0 grams of trans fat, 30 mg of cholesterol, 450 mg of salt, and 20 grams of carbohydrates. Total UHI score: 122.58.

2. Philly Cheese Steak Legends pizza, Thin crust: Total calories = 230, saturated fat = 6.5 grams, trans fat = 0 grams, cholesterol = 35 grams, sodium = 470 mg, carbohydrates = 18 grams. Total UHI = 126.58.

3. Memphis BBQ Chicken Legends Pizza, Thin crust: Total calories: = 250, saturated fat = 5.5 grams, trans fat = 0 grams, cholesterol = 35 grams, sodium = 470 mg, carbohydrates = 23 grams. Total UHI = 130.58.

4. Deluxe Feast Pizza, Thin crust: It contains pepperoni, savory Italian sausage, green peppers, mushrooms, onions and cheese. Total calories = 250, saturated fat = 5.5 grams, trans fat = 0 grams, cholesterol = 30 grams, sodium = 550 mg, carbohydrates = 21 grams. Total UHI = 142.75.

5. Honolulu Hawaiin Legends pizza, Thin crust: Sliced ham, bacon, pineapple and roasted red peppers with provolone cheese on a parmesan crust. Total calories = 260, saturated fat = 5.5 grams, trans fat = 0 grams, cholesterol = 35 grams, sodium = 600 mg, carbohydrates = 22 grams. Total UHI = 153.75.

UNHEALTHIEST SINGLE PIZZA TOPPINGS (calculated for an entire large pizza):

1. Anchovies: 110 calories, 0 grams of saturated fat, 0 grams of trans fat, 45 mg of cholesterol, 3310 mg of salt, and 63 grams of carbohydrates. Total UHI score: 588.

2. Bacon: Total calories = 470, saturated fat = 13 grams, trans fat = 0 grams, cholesterol = 110 grams, sodium = 1770 mg, carbohydrates = 9 grams. Total UHI = 395.3.

3. American Cheese: Total calories: = 360, saturated fat = 19 grams, trans fat = 1 grams, cholesterol = 90 grams, sodium = 1780 mg, carbohydrates = 3 grams. Total UHI = 375.5.

4. Italian Sausage: Total calories =500, saturated fat = 16 grams, trans fat = 0 grams, cholesterol = 80 grams, sodium = 1470 mg, carbohydrates = 13 grams. Total UHI = 346.5.

5. Green Olives: Total calories = 150, saturated fat = 3 grams, trans fat = 0 grams, cholesterol = 0 grams, sodium = 1870 mg, carbohydrates = 3 grams. Total UHI = 337.67.

HEALTHIEST SINGLE PIZZA TOPPINGS (calculated for an entire large pizza):

1. Green Pepper: 15 calories, 0 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 0 mg of salt, and 4 grams of carbohydrates. Total UHI score: 3.16.

2. Green Chile Pepper: Total calories = 15, saturated fat = 0 grams, trans fat = 0 grams, cholesterol = 0 grams, sodium = 0 mg, carbohydrates = 4 grams. Total UHI = 5.7.

3. Spinach: Total calories: = 15, saturated fat = 0 grams, trans fat = 0 grams, cholesterol = 0 grams, sodium = 45 mg, carbohydrates = 2 grams. Total UHI = 1.7.

4. Garlic. Total calories = 50, saturated fat = 0 grams, trans fat = 0 grams, cholesterol = 0 grams, sodium = 5 mg, carbohydrates = 12 grams. Total UHI = 11.16.

5. Mushrooms: Total calories = 30, saturated fat = 0 grams, trans fat = 0 grams, cholesterol = 0 grams, sodium = 35 mg, carbohydrates = 3 grams. Total UHI = 11.3.

UNHEALTHIEST APPETIZER OR SIDE ITEM (includes bread, chicken wings, and salads):

Hot Buffalo Wings (serving size = 2 wings). Every two wings contains 200 calories, 3.5 grams of saturated fat, 0 grams of trans fat, 50 mg of cholesterol, 690 mg of salt, and 2 grams of carbohydrates. Total UHI score: 157.58.

HEALTHIEST APPETIZER OR SIDE ITEM (includes bread, chicken wings, and salads):

Buffalo Chicken Kickers (serving size = 2 wings). Every two wings contains 100 calories, 1 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 280 mg of salt, and 7 grams of carbohydrates. Total UHI score: 68.

UNHEALTHIEST DIPPING CUPS:

Dominos has 8 dipping cups to choose from, one of which is a sweet icing dessert cup, which is covered in the dessert section below.

The choice of dipping cups really comes down to sodium levels. The unhealthiest dipping cups (serving size = 1 package) are:

1. Hot sauce. 150 calories, 0.5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, a whopping 1480 mg of salt, and 3 grams of carbohydrates. Total UHI: 272.25.

2. Parmesan Peppercorn. 310 calories, 5 grams of saturated fat, 0 5 grams of trans fat, 15 mg of cholesterol, 510 mg of salt, and 3 grams of carbohydrates. Total UHI: 140.58.

3. Italian. 220 calories, 3.5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, a whopping 460 mg of salt, and 1 gram of carbohydrates. Total UHI: 114.08

4. Blue cheese. 240 calories, 4.5 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, a whopping 310 mg of salt, and 2 grams of carbohydrates. Total UHI: 96.08.

HEALTHIEST DIPPING CUPS:

The healthiest dipping cups (serving size = 1 package) are:

1. Marinara sauce. 25 calories, 0 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, a whopping 270 mg of salt, and 5 grams of carbohydrates. Total UHI: 50.

2. Garlic. 250 calories, 5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 160 mg of salt, and 0 grams of carbohydrates. Total UHI: 69.17.

3. Ranch. 200 calories, 3 grams of saturated fat, 0 grams of trans fat, 10 mg of cholesterol, 340 mg of salt, and 2 grams of carbohydrates. Total UHI: 92.5

4. Blue cheese. 240 calories, 4.5 grams of saturated fat, 0 grams of trans fat, 20 mg of cholesterol, 310 mg of salt, and 2 grams of carbohydrates. Total UHI: 96.03.

SALADS:

Dominos has two salads to choose from: the Garden Fresh and the Grilled Chicken Caesar. Serving size is a half a bowl. The healthiest choice is the Garden Fresh with a UHI of 27.92. The Grilled Chicken Caeser salad had a UHI of 67.75. The difference is mostly due to higher sodium content (290 for the Grilled Chicken Caser and 80 for the Garden Fresh). Incidentally, each package of croutons has a UHI of 40.17.

SALADS DRESSINGS:

Dominos has 5 salad dressings to choose from. These are ordered from unhealthiest to healthiest as follows:

1. Light Italian. 20 calories, 0 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 770 mg of salt, and 3 grams of carbohydrates. Total UHI: 132.17.

2. Creamy Caeser. 210 calories, 3.5 grams of saturated fat, 0 grams of trans fat, 10 mg of cholesterol, 520 mg of salt, and 0 grams of carbohydrates. Total UHI: 123.92.

3. Blue cheese. 230 calories, 4.5 grams of saturated fat, 0.5 grams of trans fat, 25 mg of cholesterol, 440 mg of salt, and 2 grams of carbohydrates. Total UHI: 117

4. Buttermilk ranch. 230 calories, 3.5 grams of saturated fat, 0 grams of trans fat, 10 mg of cholesterol, 390 mg of salt, and 2 grams of carbohydrates. Total UHI: 105.92.

4. Golden Italian. 210 calories, 3.5 grams of saturated fat, 0 grams of trans fat, 0 mg of cholesterol, 360 mg of salt, and 2 grams of carbohydrates. Total UHI: 95.92.

DESSERTS:

Dominos only has two desserts to choose from: Cina Stix or Chocolate Lava crunch cakes. If you had to choose, the healthiest choice is the Cina Stix Sticks. Each stick has a UHI of 36.44. By contrast, each chocolate lava crunch cake has a UHI of 107. The sweet icing dipping cup has a UHI of51.25 due to each cup having 250 calories, 57 carbohydrates, and 0.5 grams of saturated fat. There are no trans fats, cholesterol, or sodium in the sweet icing. Note: Soft drinks were not subject to analysis.

From the Dominos website:

The pizza products listed in this publication, when made with approved Domino’s Pizza ingredients, will provide the nutritional composition as indicated. Information may vary slightly depending on location and supplier. The availability of optional toppings may vary by store. The nutrition information is generated by the industry standard Genesis R&D Nutritional software. The ingredient listings are provided by ingredient manufacturers. Domino’s Pizza LLC, its franchisees and employees do not assume responsibility for a particular sensitivity or allergy to any food provided in our stores. This guide includes only standard menu items. For nutritional information on special menu product offers, visit www.dominos.com.

Fast Food Wars: The Prelude

There are a few basic things I believe about fast food. First, it usually tastes great. Second, it’s very convenient. Those two aspects are precisely what make fast food so appealing in our busy lives despite the constant messages we receive about how unhealthy much of it is. The appeal of the taste and convenience often outweighs the guilty feeling that many people feel have after eating fast food. However, that guilt is reduced and sometimes absent altogether when people do not realize exactly how much fat, sodium, cholesterol, etc., that they are consuming. Don’t get me wrong…I love a fast food bacon cheeseburger with French fries, a few slices of pepperoni pizza, or a vanilla milkshake once in a while. So I’m not about to tell people never to eat fast food. However, based on personal experience, I believe that people would eat less of it or at least make better selections if they had the nutritional information handy.

Well the nutritional information is handy, you say. Technically, that’s true. You can go to the company’s website and view the nutritional chart but how many people are really going to do that when they make an impulse decision to pull through a drive thru on the way home from work? Not many. You can look in the restaurant for the nutritional information but it is not always displayed prominently and is not a viable option for someone going through a drive thru. In addition, even if you do look at the nutritional chart, there is usually so much information crammed into it that it is difficult to make sense out of it all when you have people breathing down your neck or tailgating you to make a selection because everyone is starving.

What we really needed is some type of guide that people can use and have readily available to make quick snap decisions about fast food selection at various restaurants. If you search the internet or flip thru magazines at the grocery store, you will find many articles entitled “Top 10 Worst Fast Foods” or some such thing. The articles usually list 10 fast foods to avoid and provide an option about something else to eat instead. I usually have a few problems with these articles. The first is that they all seem to come to different conclusions on which fast foods to avoid and do not tell the reader exactly how the foods were selected and ranked. Second, I can’t tell which restaurants were or were not included in the analyses. This is where MedFriendly enters the picture.

Being a scientist at heart, I thought it would be interesting to create a quick and easy formula and reference for people searching for ways to make better fast food selections. I wanted the public to know how I developed the formula so it can be reproduced by anyone and to let everyone know which restaurants were subjected to analysis. In creating the formula, I decided to take the six most common nutritional concerns that people have (total calories, saturated fat, trans fats, cholesterol, sodium, and carbohydrates), add them together and divide by six. This yields an average score that I have termed the “UnHealthy Index” or the UHI. Higher UHI scores reflect unhealthier foods.

I did not use total fat in the equation because not all fat is bad for you. For example, cashews are high in fat but mostly in monosaturated fats, which is good for the body. Thus, I decided to stick with the two types of fat that are the worst for you: saturated fat and trans fat.
   
In deciding where to start with these analyses, I decided to start with my favorite food of all: pizza. Pizza does not tend to be analyzed in the articles I have previously reviewed. Although I tend to buy from local mom and pop pizza vendors, sometimes I will call or visit the occasional pizza chain. As best as I can ascertain, there are really four mega pizza chains: Pizza Hut, Domino’s Pizza, Papa Johns Pizza, and my favorite (Little Caesars). Then, there is Sbarro’s Italian Eatery, where it always feels like I’m spending one hundred dollars for a slice of pizza at the mall. So I decided to look at Sbarro's too but unfortunately their website and stores do not provide nutritional information at the time this article was written. In fact, they've been telling me for a year now that they would have the nutritional information up soon and it is still not there. Read into that what you will. And lastly there is Pizzeria Uno. Although they don’t deliver, it’s a popular pizza destination and worthy of analysis.

Each pizza restaurant will be subjected to objective nutritional analysis and a handy reference with the results will be provided for you. When all restaurants have been analyzed, a final comparison between all of the above restaurants will ensue. It is this that I have deemed the Great Pizza Battle and it is the opening salvo to the Fast Food Wars, only on MedFriendly.com. Come back Sunday  for the first analysis....Domino's Pizza.

MedFriendly Unveils New Useful Medical Links Section

As part of the massive MedFriendly redesign project, one of the sections that received a complete overhaul from top to bottom was the Useful Medical Links section. Each and every link was checked, inactive links were removed and updated, and new links added as well. Link descriptions were refined and a brand new design makes the pages much easier to navigate. If you have seen the Useful Medical Links section in the past, I invite you to check out the new version. If you have not seen it before, please check it out, and if you like it, please pass it on.

The Debut of the New MedFriendly Home Page

It is with great pleasure that I reveal the NEW MedFriendly Homepage. Now, you will see a fresh, crisp, and professional looking web design that will greatly enhance readability, page loading speed, and your overall use of the site. All linked areas from the new page will bring you to pages that also have the same new design. Links that used to be on those pages to other terms have been disabled and will gradually be replaced with active links once the entries for those links have been reformatted with the new design. Each day, older terms will be replaced with the new format. New terms will continue to be added as well.

Some things to note on the new homepage: Now, there is no longer a separate page for the top 10 list as they are listed on the bottom right of the page. To bring more people to this blog, the top right of the home page will have a link to the most recent blog entry. This will allow for better integration between MedFriendly.com and the MedFriendly Blog and will provide the home page with dynamic content. The most commonly used links are listed on the top left of the page and other links are located in the "Other MedFriendly Features" section. Nice new buttons for the MedFriendly Facebook and Twitter account are included.

Special thanks to those of you who provided feedback on the new site design, especially my wife who provided critical input that helped shape the look of the site.

Merry Christmas & Happy Holidays from MedFriendly.com

Just a quick note to wish all of the MedFriendly Blog and MedFriendly.com readers a very happy, healthy,  and joyous holiday season. 

New MedFriendly Measurements Section Is Up

Another phase of the MedFriendly Redesign project is complete. If you have used the MedFriendly Measurements section in the past, check out the new crisp design for the pages and embedded tables. Here you will find handy tables useful for converting Celsius to Fahrenheit for body temperatures. There is also a greatly expanded Celsius to Fahrenheit conversion table and a Fahrenheit to Celsius conversion table. Psychologists will enjoy the updated standard score to percentile conversion chart. If there are other tables you would like to see, let me know. Very shortly, the new MedFriendly homepage will debut. Stay tuned.

Why New York State Needs to Ammend the Concussion Management and Awareness Act

In September 2011, New York Governor Andrew Cuomo signed into law the Concussion Management and Awareness Act (sponsored by Senator Hannon and Assemblywoman Nolan), mandating that students can only return to play following a concussion after they are symptom-free for 24 hours and cleared by a physician. The intention of the law was to improve patient safety. However, the exclusion of one the most qualified types of health care providers (clinical neuropsychologists) from performing such evaluations can lead to patient harm by returning students too early (resulting in further neurological harm) or keeping them out of sports much longer than necessary (resulting in psychological harm). 

Neuropsychologists specialize in objectively assessing the relationship between brain functioning, thinking, emotions, and behavior – all of which can be affected in the early phase of concussion recovery. This is done through a series of specialized tests, records review, interview, behavioral observations, and application of statistical knowledge. Neuropsychologists also have much more time to spend with their patients than physicians due to the nature of the evaluation.

Neuropsycholgists have been instrumental in developing published return to play safety protocols and have routinely made return to play decisions prior to the passage of this legislation. Neuropsychologists developed the most popular computerized cognitive assessment programs that are used to make return to play decisions, have played a leading role in researching concussion for the past 25 years, and have published textbooks on the topic. A neuropsychologist from New York (Dr. Thomas Kay) was the senior contributor of the American Congress of Rehabilitation Medicine’s operational definition of concussion. Nearly all major college and professional sports organizations include neuropsychologists in their concussion management program and most states that have passed similar legislation allow neuropsychologists make return to play decisions.

Concerns were expressed to the sponsors of this bill and the Governor’s office about the exclusion of neuropsychologists before its passage. Neuropsychologists were assured that neuropsychologists would still be able to play a role in these assessments that would be used by physicians. However, some school districts are only allowing return to play decision to be made from a specific list of physicians (e.g., pulmonologists, orthopedists, pediatricians) who do the entire assessment without any input from a neuropsychologist. If the child’s own pediatrician is not on the official list of providers, he/she may not be allowed to provide clearance to return to play.

Due to this potential safety issue and the new restriction upon a psychologist’s scope of practice, we urge parents and concerned citizens to contact Senator Hannon, Assemblywoman Nolan, Governor Cuomo, and their local representatives to tell them that you strongly support allowing psychologists to be included in a bill that allows them to make return to play decisions following concussion. as an update to this article, please see How New York Fumbled the Ball on Concussion Management.

New MedFriendly Redesign Sneak Peak Is Up

As previously noted, MedFriendly is currently undergoing a major site redesign. The difference is like night and day. The site will have a much more professional look to it, pages will load faster, will be indexed even higher in search engine results, and the overall user experience will be greatly enhanced. For a sneak preview, you can click on the new Advertising page. If you click the white text links on the top left of the page, you will be see some of the other new pages as well, all with the same new design (except for the Blog and Message Board of course).

All newly created pages will have this new design. The main MedFriendly home page is still being redesigned and will hopefully be up within a week. Please feel free to let me know how you like the new look if you have not done so already.

Guest Blog Entry: A Comparison Of The US And UK Head And Brain Injury Compensation Law

The following provides an overview of the US and UK legal systems regarding head and brain injuries compensation, when said injuries are sustained through road traffic accidents. The aim is to provide an interesting comparison, as well as an insight into what you can expect to encounter when seeking compensation.

Both legal systems work on a fault based principle. In the US there are federal laws to abide by, and state laws, which differ from state to state. This is where cases can become more complicated, as motor insurance is not compulsory in all states. For this reason some claimants will have a harder time acquiring justice and compensation. Also dependent on state laws, is the recovery of level of damages. Awards, which are compensation for pain, suffering and loss of amenity, are determined by a jury, in contrast to the UK, where awards are made by a judge. In the US awards are distributed using a top down system. They can be distributed as a lump sum or structured settlement, thereby creating an annual income. In the UK a bottom up system is in place, meaning the annual income is established by determining the claimants financial need based on injuries, past and present medical costs, and rehabilitation costs, and then meeting this need. 

The countries’ systems also vary when handling legal costs. In America, the legal costs are commonly dealt with under a contingency fee. There are no initial costs for the claimant and their family, as the attorney can take a percentage of the compensation, once the case is concluded. This percentage is agreed upon by attorney and claimant at the beginning of the case, and is dependent on the risk involved in said case. 

In comparison the general idea behind the UK’s compensation system of all personal injuries, including head injury, and following traumatic brain injury, is to provide the claimant with enough compensation so that they are in the same position they were prior to the road traffic accident. To note, when referring to the UK law in this article, what is meant is the law in England and Wales, since Scotland and Northern Ireland have different compensation laws. The process works as follows: Expert evidence is acquired from experts within medical and non- medical fields. The award is again based on pain, suffering and loss of amenity, by assessed through referencing guidelines, previous, similar cases, which are concluded, and the personal circumstances of the claimant. When discussing financial losses, these are defined as past and future loss of earnings, medical expenses, treatment, equipment need, and accommodation. For a brain injured claimant, the largest section of an award is the cost of their future care, be it at home or in a different setting, i.e. a rehabilitation unit. Rehabilitation has a strong focus within the UK’s compensation process, and is based on encouraging both claimant and defendant to work together and asses the injured individual’s rehabilitation needs. 

Another difference to some states of US, are laws on motor insurance. In the UK motor insurance is compulsory, and there is also the Motor Insurers Bureau, which compensates victims of uninsured or untraced drivers. 

As in the US awards are given as sums of money, or periodical payments providing guaranteed for life annual payments based on the individual’s needs and covering both care and case management costs. In general, legal costs are fully recoverable from the defendant, and a brain injured individual will receive 100% of their compensation, if their claim is successful. 

Neither of the presented legal systems are perfect, and neither are wrong. We can learn from each other’s laws. It is also good to be aware of different countries’ laws, in case of sustaining head and brain injuries through a road traffic accident, when abroad. Here, it is equally vital to find an attorney with knowhow of jurisdictional and applicable law rules. You will require specialist advice to ascertain if you can bring your claim in the country of your choice and if there is a choice of jurisdiction which is the most appropriate venue for your claim. It may be that attorneys from both companies are required to work together to ensure the best outcome for you.

When seeking compensation for head and brain injury in either country, it is important to find an attorney with experience and expertise within head and brain injury cases. It’s best to research attorneys and to meet the one you are considering, to be sure you both get on with each other and can imagine working together as a team.   

Today's guest blog entry was written by Pannone.

Where the Republican Candidates Stand on Health Care

As I was watching the Republican Presidential Debate last night, I thought I would take a closer look at the candidate's websites to find more details about where they stood on healthcare. No matter what your view is on the Patient Protection Affordable Care Act is (also known as Obamacare), the United States Supreme Court will be hearing Constitutional challenges to it, probably in March 2012. Thus, it is going to be a very important issue throughout the election. Of the six candidates, what I found interesting is that two of them have no information about what they would do to fix the healthcare system. A person by person breakdown is listed below, along with links to the sections of their websites discussing healthcare or their stands on various issues. The list is provided in alphabetical order.

1. NEWT GINGRICH: Gingrich lists 13 main ways he would improve healthcare, which include various specifics. This includes use of tax credits, purchase of insurance across state lines (to improve competition), expanding choices in Medicare, customizing state Medicaid systems, establishing a high risk people to cover the sickest uninsured citizens, preventing insurers from cancelling insurance on people who are very sick or giving them discriminatory rates, extending health savings accounts, rewarding the best healthcare provided at the lowest cost, taking steps to reduce healthcare fraud (e.g., electronic medical records), medical tort reform, reforming the FDA,  helping people find information on price and quality of healthcare, and investing in medical research.

2. MITT ROMNEY: Romney lists six main ways he would improve healthcare, which alos contain various specifics. He states that would begin his Presidency by granting an executive order to states to opt out of Obamacare, ask Congress to repeal Obamacare, and emphasizing reforms at the state level. The second area Romney cites involves focusing on the states by block granting funds for Medicaid patients and the uninsured. He also promotes a tax deduction to allow people to purchase their own health insurance. His fourth main idea is reforming federal regulations such as allowing people to purchase insurance across state lines. His fifth idea is medical tort reform. Lastly, he promotes the use of health savings accounts.

3. RON PAUL: He pledges to repeal Obamacare (although you need Congressional support for that), allow purchase of insurance across sate lines, provide tax credits and deductions for all medical expenses, exempt terminally ill patients from the employee portion of the payroll tax, provide payroll deductions for close family members of terminally ill patients, medical tort reform, preventing Medicare & Medicaid funds for being used for other purposes, allow all Americans to open health savings accounts, promoting alternative medicines and supplements, and preventing a national database of personal health information.

4. MICHELE BACHMANN: She states that she will repeal Obamacare, stabilizing Medicare for future generations,promoting medical innovation and personal choice, promoting competition in the healthcare market, and empowering health care providers to make decisions about the shape and form of your health insurance.

5. JOHN HUNTSMAN: While his website contains sections on jobs and the economy, national security, foreign policy, energy security, and financial regulatory reform, there is no section on healthcare.

6. RICK SANTORUM: While his website contains information on defending the taxpayer, American exceptionalism, faith and family, Iran, and other topics, there is no section on healthcare.

Interestingly, the two candidates with no clear distinct section on healthcare on their websites are generally running lowest in the polls.

All Brain Injuries are Not the Same: Part 2

Today’s blog entry is part 2 of yesterday’s blog entry about the reasons why it is important to distinguish mild traumatic brain injuries from moderate to severe traumatic brain injury as opposed to lumping them all together under the term “brain injury”. Further explanations as to how this distinction is important includes:

4. NEUROIMAGING: In moderate to severe TBI, the results of neuroimaging are critical to deciding how to manage the patient. For example, if a bleed is large enough, this might require neurosurgery to remove pressure on the brain. This sometimes requires repeat brain scans in the acute injury phase to monitor the size and effects of an intracranial lesion (e.g., a brain bleed). In MTBI cases, initial neuroimaging results in the ER do not show abnormalities between 90 to 95% of the cases. Thus, after an initial negative brain CT scan, clinical management of the MTBI patient is often based on subjective symptoms (e.g., headache) rather than objective findings.

5. COURSE: In moderate to severe TBI, the recovery course is well-defined and empirical, with the most drastic improvement occurring in the first six months, additional recovery over the next six months, and slower recovery up to 18 to 24 months. In mild TBI, the course of recovery is clear for the vast majority of people which would suggest that most recover within a week to a few months. However, the course of recovery for those who experience persisting symptoms (more than three months) is less clearly understood.

6. OUTCOME: As noted above, outcome is strongly related to acute injury characteristics in moderate to severe TBI cases and it is generally an exception when psychological factors confound outcome (although this certainly can occur). Conversely, in mild traumatic brain injury, outcome is poorly related to acute injury characteristics. Rather, non-injury related factors tend to be the most predictive of outcome. Examples of non-injury factors include litigation/compensation-seeking, psychological distress, pre-injury psychiatric history, post-injury stressors, substance abuse, and various other psychosocial issues.

7. DISABILIY: In moderate to severe TBI, disability (a form of outcome) is more clearly attributed to injury severity, the functional neuroanatomy of the injury, and resulting impairments. In mild TBI, there is a less clear association between the clinical presentation of the patient and the degree to which neurological and psychological factors play a role.

These examples show that one cannot speak of traumatic brain injury as if it has the same meaning across the severity spectrum. The media and health care providers are strongly encouraged to clearly distinguish between mild and moderate to severe brain injuries when discussing this topic with patients and the public.

All Brain Injuries are Not the Same: Part 1

One of the most popular myths in the media and among some health care providers is that traumatic brain injury (TB) can be discussed as a unitary concept. In other words, the topic is discussed as if it is not necessary to make a distinction between a mild and moderate to severe TBI. In fact, it is quite necessary to make the distinction rather than broadly discussing the effects of “brain injury.”

Unfortunately, what often happens is that findings from patients with moderate to severe TBIs are misapplied to those with injuries on the mild end of the spectrum. As Dr. Michael McCrea (2008) writes in his evidence based text, moderate to severe TBI is a completely different animal than mild TBI (also known as concussion). There are many examples, which are nicely summarized in McCrae’s text and the interested reader should read that book for specific references supporting the statements below. Some of these examples are presented and expanded upon below to help better inform the public.

1. USEFULNESS OF SEVERITY GRADING TOOLS: In moderate to severe TBI, there are measures available that are useful for grading the severity of the injury whereas the scales on the mild end of the spectrum are not as helpful. The most commonly used severity index is the score on the Glasgow Coma Scale (Teasdale & Jennett, 1974) which assesses level of consciousness. The scale ranges from 3 to 15 points and provides a way to rate patients on their eye movements, motor responses, and verbal responses. The TBI classification scheme based on the GCS is as follows: 13-15 (mild), 9-12 (moderate), and 3-8 (severe). While a significant injury and/or alteration in consciousness is required to obtain a GCS score between 3 and 12, the same cannot be said for the mild end of the TBI severity range. For example, consider a person who merely bumps his head into a wall with a minimal degree of force that was not significant enough to cause a brain injury. Assume, however, that the person develops a headache and is concerned that he has a brain injury, causing him/her to go to the ER. When the person goes to the ER, he/she is physically examined and a GCS score of 15 is assigned because there were no abnormalities with eye movements, motor responses, or verbal responses. According to the criteria above, a GCS score of 15 is equated with a mild TBI. Clearly, however, this example shows a GCS score of 15 does not always equate to brain injury.

2. ACUTE INJURY CHARACTERISTICS: In moderate to severe TBIs, the acute injury characteristics are the strongest predictors of outcome. In mild TBIs, there is only a limited correlation between acute injury characteristics and outcome. For example, in mild TBI, a brief and transient loss of consciousness is not strongly predictive of outcome. Conversely, loss of consciousness in a severe TBI patient, which could last for weeks and beyond, is strongly correlated with outcome. One of the problems is that acute injury characteristics are not as clearly documented in MTBI cases because of a lack of witnesses and the transient nature of the event. For example, a mild TBI patient may lose consciousness for a few minutes but if no one was present to witness this, it cannot be confirmed. Conversely, in a moderate to severe TBI case, LOC usually lasts long enough such that paramedics or some other observer would be able to confirm its presence.

3. CRITERIA FOR DIAGNOSIS: The criteria for diagnosing moderate to severe TBI tends to be more consistent throughout the literature compared to mild TBI. The criteria used to diagnose MTBI are largely based on self-reported subjective symptoms (e.g., altered mental status) without collaborating and/or objective data (e.g., witnesses, neuroimaging findings). In moderate to severe TBI, objective data are often sufficient enough (e.g., diffuse bleeds throughout the brain) such that self-report is not required to make the diagnosis.

Come back tomorrow for part 2, in which more distinctions will be provided.

 REFERENCES

McCrea, M. (2008). Mild traumatic brain injury and postconcussion syndrome. The new evidence base for diagnosis and treatment. New York: Oxford University Press.

Teasdale, G, Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet, 2:81–84.

Why Physicians Need to Pay Attention to Malingering And Exaggeration

Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs (APA,1994).

The word “malingering” comes from the French word “malinger” meaning “poor or weakly” as these are the characteristics feigned or exaggerated by the malingerer. Malingering has been documented as far back as in the Bible when David feigned insanity to escape a king he was afraid of. There have many books written about malingering and thousands of research articles written about it.

Malingering and/or exaggeration for external gain are both common in society. For example, last week, 18 people were arrested in New York State for workers compensation fraud. At a minimum, when one adds up how much money the state of New York paid out on fraudulent claims in these cases it comes to at least $243,000. To have pulled this off, it required physicians and other health care professionals to have signed off disability claims forms. While malingering can manifest by verbally feigning or grossly exaggerating symptoms, some people go through much greater lengths to malinger. For example, last week a California psychologist was accused of faking her own rape by splitting her own lip with a pin, scraping her knuckles with sandpaper, having her friend punch her in the face, and wetting her pants to give the appearance she had been knocked unconscious. The motive? To convince her husband to move from the neighborhood.

On 12/11/12, a Virginian woman was charged with fraudulently claiming that she had cancer to raise money from sympathetic supporters for personal reasons. She’s not the first to have done so. Earlier this year, a man was arrested for fraudulently obtaining almost a million dollars in sympathy donations by claiming he had cancer.  

Physicians and other health care professionals should be very concerned about exaggeration and malingering because they are enabling the process if they are not taking reasonable steps to detect it and address it. Many health care providers do not address this topic in their exams or clinical notes for several reasons, included but not limited to, a) not wanting to deal with the “hassle” of identifying the problem, such as confronting someone (which can be uncomfortable) and/or dealing with complaints, b) extreme patient advocacy, c) not wanting to believe that some patients distort their presentations for external reasons due to an overly trusting worldview, and d) concerns that identification of this problem will harm the patient in some way (e.g., loss of benefits).

While false positive identification of malingering and exaggeration is a legitimate concern (of which there are many ways to address this in the scientific literature), not identifying it can harm other patients and society in two main ways. First, malingering and exaggerated presentations rise insurance costs for all citizens because the insurance company has to spent thousands of dollars on services/treatments that need not be provided or at least not to the extent that they were provided. Most importantly, however, patients with more genuine needs have delayed access to health care services because appointments are taken by people who are trying to game the system and/or who do actually need that particular service.

While a public forum is clearly not the appropriate place to discuss malingering and exaggeration detection strategies, healthcare providers need to go to greater lengths to consider and assess response bias in their evaluations or at least refer to someone who will. There are many texts, research articles, conference workshops, and invited speakers that can be used as sources to provide healthcare providers with more information on the topic. A recent article written by myself and some colleagues discusses how to provide feedback about malingering and exaggeration to the patient. An upcoming edited book entitled Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering (Publisher: Springer) by myself and Dr. Shane Bush will address this topic and many others (including techniques that general healthcare providers can use).

Ultimately, you cannot effectively treat patients who do not want to get better and who do not actually have the problem you believe you are treating (or have it but to a much lower extent than they are claiming). This does not mean every patient is treated like a malingerer, but rather, that objective data (which can be obtained via a neuropsychological evaluation) combined with clinical experience and research knowledge should be used to guide clinical decision making as opposed to purely relying on subjective reporting, subjective impressions, and a desire to help. All of this can be done in a respectful, caring, and patient centered way.

Also see: Why Sports Leagues Need to Pay Attention to Malingering.

Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, 4th ed. Washington, DC: American Psychiatric Association; 1994.