You go out to dinner, have a nice meal with friends, but later that night, things just don't feel right. Was it something you ate?

If you're lucky, you might spend an uncomfortable evening making trips to the bathroom. If you're not, you could end up in the ER.

Each year, about one in six Americans (48 million people) gets sick from foodborne diseases, according to the Centers for Disease Control and Prevention. About 128,000 are hospitalized and more than 3,000 die — all because of what they ate.

When you go out to eat, you probably don't give food safety much thought. You assume that what's happening behind the scenes is sanitary and meeting local health code standards.

If the restaurant didn't get glowing reviews on its health inspection, it would be shut down, right?

The health inspection 'rule book'

The U.S. Food and Drug Administration (FDA) publishes the Food Code, a model of basic food safety standards that's updated every four years.

The document is hundreds of pages long and includes specifics about nearly every imaginable element of food storage, handling, preparation and service, as well as employee hygiene and health and management practices. (Here's the pdf of the most recent edition.)

But the Food Code isn't mandatory and even when adopted, compliance is voluntary.

"The Food Code can be very impactful if in fact people follow it," says Bill Marler, a well-known food safety attorney, national expert on food safety and the publisher of Food Safety News. "Setting the Food Code aside for a second, each jurisdiction deals with restaurant safety differently."

A health inspection is just a snapshot in time, but each snapshot isn't always indicative of a restaurant's chances of causing an outbreak, says Marler.

"You can have a bad inspection and never poison anybody or you can have a great inspection and be poisoning people," he says. "For the most part, inspections are primarily used as sort of a methodology of getting people to meet some minimum standards."

Marler has litigated high-profile food safety cases all over the country and he's "seen it all."

"I think the one thing that I've sort of taken away generally is that food inspectors see themselves as educators and not policemen or policewomen," he says. "They're not there to catch problems, but to educate and get you to fix problems."

What to look for in a health report

Registered public health sanitarian Roy Costa has worked for more than three decades in the food safety field. He's an inspector, auditor and professor, runs a consulting firm and a food safety blog, and has developed food safety management systems. When inspectors walk into a restaurant, Costa says, they have a checklist of things they want to see.

"What they do is try to rate what they're seeing at the time to the checklist," Costa says. "There's a little bit of observational bias in there. What one inspector thinks is in compliance, another inspector may not agree with."

Although there are all sorts of things an inspector might notice, Costa says, there are five major violations that have been linked over the past 20 years to the majority of serious foodborne illness outbreaks:

  • Improper temperature of food
  • Poor personal hygiene of employees
  • Cross-contamination
  • Improper cooking
  • Raw, ready-to-eat contaminated food

"If you try to analyze a routine inspection report, those are the kind of things you want to pull out — not necessarily that the floor was dirty or they saw a fly or the dumpster was open," Costa says.

Finding a restaurant's ratings

window with health report of NYC pizza place New York City requires restaurants to post inspection grades where they can easily be seen by people passing by. (Photo: La Piazza Pizzeria/flickr)

If want to check out a restaurant's ratings before you dine out, it's not always easy. The rules vary about how to publicize that information.

"Some have a sign on the door. Some have online inspection reports. Some work with Yelp or crowdsourcing sites. Some give the information directly to newspapers on a weekly basis. Some don’t say anything and consumers are left to their own devices," Marler says. "There's very, very little consistency from jurisdiction to jurisdiction."

When restaurants in certain areas — such as New York City and parts of California — were required to post their inspection grades outside so people could see them as they passed by, there was a drop in reports of foodborne illness, Costa says. The restaurants became compliant when they had to become transparent.

Restaurants are not always required to post their ratings, and those inspection results can come in many forms, says Harlan Stueven, M.D., an emergency physician and poison toxicologist specialist.

"There are close to two dozen different grading systems," Stueven says. "Some have color placards, some give grades, some scores, some emojis, some list the number of violations. Really? You expect the public to understand all that?"

As an emergency physician for almost 30 years, Stueven says he has often treated patients who were extremely ill with foodborne illnesses. Intrigued by the topic, he took additional training in toxicology and began writing and lecturing on the topic.

"The more I learned about the problems in the existing system, the more I learned about the improvements that need to be done," he says.

He points out, for example, that during inspections, 28 percent of restaurants in a municipality in Illinois would get an "A" grade, while in another municipality in California, 99 percent would get an "A."

"We've all been to school and we've all seen how teachers vary in their grading," Stueven says. "I can only assume variability in how health inspectors also enforce the laws. I think that is also an issue that needs to be addressed. It has to be done by a person and that person will impose his own variability on the process."

Stueven created DiningGrades.com, a website that lets people search for ratings for nearby restaurants.

"We have tried really hard to take the hugely disparate data that is available and make it a tool that is useful to the public so they can dine with confidence."

The serious problems

If you ever worry about getting sick while eating out, you probably are most concerned about catching a case of food poisoning. In his litigation career, Marler has seen frightening cases like a 19-year-old woman who was left brain damaged and paralyzed after eating a burger contaminated with E. coli or a mother of six who remained in the hospital for more than two years with multi-organ shutdown, also from E. coli.

"In any given outbreak, there are a wide variety of sicknesses," Marler says.

Of the 31 known pathogens (microbes, bacteria and viruses) that cause foodborne illnesses in the U.S., norovirus has caused the most illnesses; salmonella, norovirus, Campylobacter and T. gondii have caused the most hospitalizations; and salmonella, T. gondii, L . monocytogenes and norovirus have caused the most deaths, according to the CDC.

Advice from the experts

fresh sprouts in a bowl Many food safety experts say they avoid sprouts in restaurants because of the chance they can carry foodborne illnesses. (Photo: grafvision/Shutterstock)

These industry watchers spend so much time studying, litigating or reporting on foodborne illnesses and restaurant health inspections, you'd think they'd never set foot in a dining establishment for a meal, but not so. When they eat out, they simply limit what they order (and admit they might not always offer the most appetizing small talk.)

"When I go out to dinner, I have certain things I don't eat that I might eat at home. I'm a much more defensive eater when I go out to dinner," says attorney Marler, who won't order a salad or sprouts and makes sure his steak is well done.

"It's always an interesting conversation when someone says 'You're paranoid,' and I say, 'You have no idea what I've seen'."

Costa rattles off a few foods to avoid: raw oysters, raw sprouts, Caesar salad or hollandaise sauce made with raw eggs, sushi and ceviche.

In addition, he says, the most dangerous foods are those that are prepared in bulk ahead of time that just sit there waiting to be served, like lasagna, meatloaf or stew.

"That is where the temperature and handling is conducive to bacteria growth," Costa says. "If you're consuming something that was cooked immediately before serving, that's the safest product you can buy, as long as it's properly cooked. You don't want to eat undercooked animal protein of any kind."

Emergency physician Stueven says there are some places and dishes he has learned to avoid. He typically stays away from ground meat, for example, and makes sure fish is appropriately cooked.

"If you increase your awareness and just kind of pay attention, you'll pick up on things that will make you a bit more cautious in your choices," Stueven says. "There are a lot of great restaurants out there doing a lot of great services. I've looked at hundreds of thousands of ratings at various chains and private, small mom-and-pop restaurants and I'm proud to say the overwhelming majority of them are doing a very, very good job."

Mary Jo DiLonardo writes about everything from health to parenting — and anything that helps explain why her dog does what he does.