Decreasing Obesity or Increasing Guilt? A Critique of the Labeling of Menus with Calories – Francine L Maloney

Introduction

On March 23, 2010 President Obama signed Public Law 111-148, previously known as the Health Reform Bill, into act. Among the 904 pages, there are new laws regarding health insurance among Americans, taxes on tanning salons and tax rebates for small business owners; all of which received vast media attention. But about half-way through the document one will stumble upon “Section 4205. Nutrition Labeling of Standard Menu Items in Chain Restaurants,” a part of which states, a “retail food establishment that is part of a chain with 20 or more locations…shall disclose in a clear and conspicuous manner …the number of calories contained on the standard menu item” (1).

In the past 30 years, the prevalence of obesity in the United States has increased substantially, from 23% to 31%, most of which has been attributed to a decrease in exercise and an increase in calorie consumption (2). In 1990, while obesity was still on the rise, the Food and Drug Administration (FDA) required nutrition labels be placed on food products (3). It would take another 14 years before the FDA’s Obesity Working Group would recommend providing nutritional information at the point of sale in restaurants (3).

Since 2004, restaurants across the United States, most notably fast food chains, have been mandated to have nutritional information available to customers. As customers have noticed, and the media has reported on, these brochures are not always in the most obvious of locations. Some chain restaurants have tried to curb this problem by putting in kiosks, which their customers can easily step up to while waiting for their table, look through the menu of available items and find the full list of nutritional information. While this may solve the problems of misplaced brochures and small print, it also creates a host of new issues. For example, the Unos Chicago Grill Restaurant does not list all menu items in their kiosks, and those that are offered are often in multiple serving sizes – potentially misleading some customers into thinking their pasta dish has 640 calories when there are really two servings and 1280 calories (excluding the calories from the breadstick that is served with the dish) (4).

The current passage of this public law will attempt to use the social expectations theory of public health. The social expectations theory works on the foundation of taking the thought, or individual, out of the decision making process and changing the drive of behaviors by law (5). There are numerous laws in the United States that use the social expectations theory effectively, such as prohibiting drinking and driving. Once driving under the influence was no longer an option under new laws, the social expectation was to have a designated driver whenever drinking was going to take place. The thought process of whether or not to drink and drive was eliminated and it was replaced with a new expectation (5).

Although social expectation theory is often effective at changing social norms, especially when linked to policy changes, there is clear evidence that groups of individuals will break the social norm. Just as teenagers often do not wear seatbelts, while the majority of society abides by the social expectation of wearing one; I believe there will be classes of individuals who will not follow the expectations of how the new menu labeling will affect food choices.

Critique Argument 1: Lack of Information

Under the new law, only calorie information needs to displayed on the menu, along with an anchor of the daily caloric needs for most individuals (presumably 2,000 kcal/day) (1). Unfortunately, providing only caloric information is not representative of whether or not the food is good for you. A calorie is the amount of energy needed to raise 1 liter of water 1 degree Celsius from 14.5°C to 15.5°C at 1 atmosphere, but that does not tell the average person whether they should order the small or medium fries; and neither does showing them only calorie information and omitting the other nutritional contents (3).

In 1990, the Nutrition Labeling and Education Act put into effect food labeling on all products, which had to include serving size, the number of servings in the container, calories per serving, total amount of fat, saturated fat, cholesterol, sodium, total carbohydrates, sugars, total protein, and dietary fiber (6). Except for a few small changes this is the same information we see on food labels today, and this is the information in which people are used to assessing before making a decision based on nutritional information.

Beyond the gross lack in all nutritional information, studies have shown that various individuals use different pieces of information before deciding upon what to eat. These factors include, individual characteristics (e.g. age, gender, education), situational, behavioral and attitudinal characteristics (e.g. income, working status, special diet status, diet-health awareness, organic buyers, type of household, meal planners, area of residence), nutrition knowledge, motivation, attitude toward nutrition, and product nutrition factors (e.g. price, nutrition, taste) (7). An example of how ones age and use of nutritional label use was summarized by Drichoutis et al, stating “specifically, as age increases so is the likelihood of using information about fat content, cholesterol content, and health benefits” (7).

By only providing caloric information the customer is left in the dark about how the nutrition is divided among the food. Exactly how many calories from fat or whether the meal is largely protein or carbohydrate based cannot be told from calorie information alone. If the goal is for the public to make an educated decision regarding their food intake, we must give them all the information to make those decisions.

Critique Argument 2: Downstream problem-solving for an upstream problem

Menu labeling is an attempt to solve the obesity epidemic by scratching at the surface of a problem in which its roots are not only deeply planted but difficult to understand. Changing a person’s eating behavior has been notoriously difficult (8). In addition, physical activity level, understanding genetic factors, and the psychological influence are all important factors in trying to combat the obesity epidemic.

As soon as an individual looks to lose weight they are advised to cut their intake, mostly through the use of calorie counting. Mann et al conducted a review of studies that looked at the long-term outcomes of calorie-restricting diets to assess whether dieting is an effective treatment for obesity (8). While one might expect individuals to lose a substantial amount of weight on calorie-restricting diets, the evidence shows otherwise. The studies indicated that one third to two thirds of dieters regain more weight than they lost on their diets. In addition, these studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change (8). While one of the goals of menu labeling is to make individuals more aware of the calories, and therefore choose the lower-calorie option, may seem like a reasonable solution to cutting a person’s caloric intake – studies do not support this as an effective way of decreasing obesity.

On the other hand, let’s give menu labeling the benefit of the doubt and say that it will help some individuals make “better” choices. Maybe they will choose the 800 calorie meal over the 1,100 calorie option. While some might view that a step in the right direction it would only be addressing one issue. The United States Department of Agriculture recommends every individual has “physical activity [that] should be moderate or vigorous and add up to at least 30 minutes a day” (8). Menu labeling does not even address lack of physical activity as part of the trend in obesity. While one campaign cannot be expected to address every problem, the combination of exercise and healthy food choices may be effective at helping individuals at sustaining weight loss –some studies have shown the best outcomes have come from exercise alone (8).

Finally, displaying caloric information will not help to understand or solve the genetic and psychological drives that individuals have when making food choices. Over the past two decades research has focused on the nature versus nurture debate of obesity; and while it is hard to distinguish completely it has been estimated that the “heritability of body mass index would be in the range of 40 to 70%” by studying a sample monozygotic twins raised together and a sample raised apart (10). Our genes are not the only thing that plays a role in our food choices; our mood is likely to have a large impact as well. As all individual’s have experienced, when we are tired, happy, frustrated, sad, or overwhelmed the food choices we make tend to change. The psychological impact on our decisions cannot be ignored nor can it be minimized. When a person feels rushed and tired, they reach for something that is comforting – as “dietary indulgence is often cited as a consumer’s self-control problem” (7).

Critique Argument 3: Optimistic Bias – Underestimating Risk and Overestimating Labeling

Despite the overwhelming belief that humans are rational beings, all evidence points to the fact that we are repeatedly make irrational decisions (11). One of the most classic forms of irrationality is through the optimistic bias. This theory shows that individuals tend to underestimate risks that apply to them (12). While any one person may understand perfectly well the entire risk, there is an irrational process that overrides their risk.

The most classic example of the optimistic bias is from cigarette smokers. When a group of smokers were asked what percentage of smokers they thought will eventually develop lung cancer, the result was an astounding 43% (the true answer is between 5-10%). But when then asked if they think they are at increased risk of developing heart disease and having a heart attack, 29% did not recognize that they were at an increased risk of disease (12). This universal human phenomenon leaves individuals believing that for every good outcome their own chances are higher than average, while for every bad outcome their own chances are less than average – otherwise known as “it will never happen to me” thinking.

As stated previously, the 1990 legislation of the National Labeling and Education Act (NLEA) required food disclosure of the nutritional content of foods and a standardized labeling on all packages (6). By 1994 the legislation was mandated and all companies had nutritional labels on their products. The theory behind the legislation is similar to today - if individuals are provided with the nutritional information of their food, then they will make better, healthier, food choices.

However, even though nutritional labeling is theorized to allow consumers to make healthier food choices, obesity is still rising and cannot solely be attributed to restaurants (7). While trying to provide more information and give more autonomy to an individual might seem helpful, it might be hurtful. “Ironically, remedy messages boomerang on people they are intended to help most because some consumers appear less risk averse when remedies are available.” (7). Additional studies did not detect any changes in consumers’ search for nutritional information or their recall of this information in the pre- and post- NLEA period (7). While other researchers found “consumers preferences and purchasing patterns within the prepared frozen meals category did not change significantly after implementation on NLEA” (7), which may be more indicative of the behaviors of individuals food preferences in restaurants.

But NLEA went into effect over 15 years ago and discrimination towards the obese has only increased. Some may argue that as a society we will be empowered to make better food choices, we have learned more about nutrition, the media has inundated us with enough guilt that we are ready to make choices that are healthier – at least this is in part what New York City thought in 2008 when it became the first US jurisdiction to mandated calorie labeling on menus of restaurants with 15 or more locations nationwide (13).

It is important to recognize some of the similarities between the calorie labeling in New York City and the national implementation to be mandated, as well as provide some of the rationale provided by New York City’s push for calorie labeling. As stated, New York City mandates all restaurants with 15 or more locations nationwide must take part, for these chains account for a disproportionate share of meals served and “have standardized sources, menus, recipes, and portion sizes, facilitating reasonable accurate calorie labeling” (14). The food items to be covered include all items for which there is a name and a price, or a name on an item tag to highlight the effect of portion size. The only information required for display are calories, for “calories amount is the single most important value in public health” and “calories generally correlate with carbohydrates, fat, and sodium” (14) . A final issue, one not yet addressed by the national mandate, is items with multiple servings (such as a whole pizza or bucket of chicken). For this, calories must be calculated for the item as served, for the posting the entire calorie amount provides full disclosure for people who will consume the item alone (14).

Since only 2 years have passed since the mandate of calorie labeling on fast-food and sit down restaurants in New York City, few studies have examined the effects on purchasing behaviors among the public. Elbel et al conducted their study over a 2-week period in July 2008, capturing both pre- and post- calorie labeling data. Using a city in New Jersey as a control site, the researchers found that “27.7 percent who saw calorie labeling in New York said the information influenced their choices. However, [they] did not detect a change in calories purchased after the introduction of calorie labeling” (13). In fact, the raw data shows that the average number of calories purchased in the New York as 825 pre-implementation with an increase of 21 calories to 846 post-implementation. The control group (Newark, NJ) had an average number of calories purchased as 823 pre-implementation and 826 post-implementation (13). Just as smokers who know the overall risk of smoking but do not believe they themselves are at increased risk; these individuals looked at the calorie information and thought it affected their choice but in reality they were still choosing a meal with equivalent calories prior to implementation – the optimistic bias was in full effect.

Proposed Intervention:

While the flaws of the menu labeling initiative are apparent, the law has yet to be mandated or presented to the public and there are more interventions that can accompany the law that may help it to succeed.

I suggest that if we are to label menus we must first educate the public about nutrition labels through a mass campaign with the help of clinicians. Additionally, if we are to only use calorie information as part of restaurant labeling, individuals must understand how fat, carbohydrates, protein and sodium influence calories. Secondly, I propose in conjunction with the menu labeling, restaurants be mandated to change either the preparation style or serving size of a single dish that exceeds any daily value on a nutrition label. By enforcing such a rule, the government would be taking an upstream approach at solving the obesity epidemic while also helping to eliminate any guilt or shame people may feel when making food choices. Finally, advertisements must use individual stories with people the public can relate to showing how to incorporate restaurant meals into everyday living. The public should not be made to feel shamed or vilified for choosing to eat in restaurants nor should they feel obligated to only choose the lowest calorie option. Instead, a model of incorporating all types of food, even high-calorie, into a diet should be shown in an appropriate manner.

Defense of Intervention 1: Education

Nutritional food labeling has only been implemented in the United states for 20 years, mandated for 16, and in many respects can still be viewed as in its infancy stages of education and public awareness. As the first generation to receive a full education using the food guide pyramid and learning how to interpret a nutrition label from kindergarten through high school, it is easy to understand why the obesity epidemic is still on the rise. Unlike other labeling initiatives (e.g. tobacco label warnings), nutritional labels are meant to provide the consumer with information that must be processed, understood, and comprehended in order to make a decision. If we expect consumers to make choices based on nutrition labels we need to educate them how to properly interpret labels.

Despite being the in age of ever growing technology and wide internet availability, I believe that easy to comprehend paper brochures explaining nutrition labels should be made available to the public. While most individuals have access to the internet, whether it is at home, work, or even their phone, the paper brochure could be strategically offered in more appropriate locations, such as hospitals and physician offices. Through the use of a brochure, an individual would have the opportunity to self teach key concept of nutrition labels, as well as ask medical professionals about more advanced concepts, such as percent daily values (which vary based on an individual’s need and physical activity level).

A study done by Cohen et al. used the primary care physicians as a vehicle to increase their effect on their patients who smoke (15). By randomizing both physicians and patients (regardless of whether they wanted to quit) into groups with various levels of physician education, physician reminders for smoking cessation counseling, and nicotine gum availability to patients, the study was able to show physicians in the intervention group not only spent significantly more time counseling their patients about smoking but the success rates of quitting were also statistically significant between group (15).

Just as the smoking intervention helped increase quitting success rates, a nutrition labeling brochure can only increase the knowledge base for individuals on how to use this tool effectively. While it may be necessary for the physician to be reminded to ask about the brochure, the prompt may help to open the lines of communication and really allow for the clinician to see the level of understanding their patient has regarding nutritional labels.

Defense of Intervention 2: Upstream Actions

Mandating calorie labeling is a downstream action, relying on customers to make educated decisions on which foods to eat based on calorie information alone. There are numerous steps that could be taken before calorie labeling goes into effect in order to help the public, or even eliminate the need for calorie labeling.

One of the main pushes behind labeling calories comes from the high calorie food items found in some restaurant’s items. By labeling the menu we are choosing to guilt the customers into making what society deems the more appropriate, lower calorie, choices. But what if items that contain over the entire daily need of calories, fat, carbohydrates, etc were prohibited from being sold?

It has already been stated that the positive forces of menu labeling may be its indirect effect on restaurant preparation of items, specifically those that contain the highest calories. “The New York City Health Department’s more systematic evaluation, as yet unpublished, suggests that calorie reductions of about 10% have been common” (3). This force has also been the primary push from many politicians behind menu labeling. Therefore, if this is our goal, why not address the issue directly instead of hoping it will indirectly happen through a separate policy.

I would propose in addition to menu labeling, restaurants must also be enforced to change the preparation style or decrease the serving size of any dish that is over the daily requirement based on a 2,000 kcal/day diet. For example, the Beef Ribs offered at the Cheesecake Factory contain 2,310 calories per dish (not including sides) (16). By enforcing such a policy individual customers would not be put in a situation in which guilt and shame could be induced for wanting to order an item off a menu, instead the restaurants would be held responsible for healthfulness of their food choices.

Defense of Intervention 3: Personal Stories

The use of personal stories have been used effectively in both media advertising to sell products and in public health as a means to reduce the influence of an individual’s optimistic bias. As stated previously, the optimistic bias is the theory that people tend to underestimate risks that apply to them. While they may try to understand perfectly well the entire risk, there is an irrational process that overrides their ability to access their risk (12).

One of the effective public health campaigns to reduce the number of tobacco smokers was by telling the store of Pam Laffin. The Massachusetts Department of Public Health began airing commercials featuring a 31 year old female, her two young children and the effects smoking had on their lives. The campaign focused on the life of Pam’s disease, children’s lives, and personal grips with death (17). It allowed the viewing audience to see exactly how one individual can be affected by smoking, instead of using blanket warnings, hate campaigns against the tobacco industry, or healthy actors telling an audience they should not smoke. This was something people could relate to. Biener et al conducted a study regarding Pam Laffin’s commercial advertisements to promote smoking cessation. A portion of his results found that when a group of recent quitters were asked “did television commercials about tobacco contribute to quitting?” those who answered in the affirmative reported the influence of television (29%) than nicotine replacement therapy (18%), professional consultation (13%), or self materials (5%) (18).

Just as the Pam Laffin commercials had a tremendous impact on the choices people made about smoking cigarettes, I believe using a personal story to promote healthy eating can have a positive impact on society. I would propose to use an individual that multiple demographics can relate to, such as a working mom/dad, college student, or man/woman that works long hours and does not typically have time to prepare meals. The main purpose of the commercials would be to provide examples to the pubic of how they can incorporate restaurant meals into their eating habits, possibly even daily, in an effective way while still promoting balanced meals.

It is important that these messages do not come across as shaming individuals for choosing to eat in restaurants or fast-food establishments. Society must learn that all foods can be eaten, including the higher calorie options at restaurants, when they are balanced with overall nutritional needs. So much of the focus in today’s public campaigning is to strive to eat balanced, ideal meals at every single meal time. Unfortunately, this is not always realistic with either individual’s schedules or food cravings. If the advertisement can show relatable consumers making reasonable meal choices (not just the lowest calorie option), I believe the public would be influenced in a positive light to understand more realistic options for consuming a more rounded diet.

In the end I believe the labeling of menus with calorie information can be an effective tool for providing individuals with a sense of autonomy over their meal choices if implemented appropriately. The danger of invoking shame and guilt onto individuals is real and one that we all need to be aware of. Living in a society that idolizes thinness is difficult enough; we cannot be having more people feel shamed for not choosing the lowest calorie item.

References:

1. The Patient Protection and Affordable Care Act, 455 §§ 148-4205-4206 (2010). Print. http://www.washingtonwatch.com/bills/show/111_PL_111-148.html

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4. Unos Chicago Grill Restaurant. Nutrition Information: Rattlesnake Pasta. Boston, MA: Pizzeria Uno Corporation. http://www.unos.com/kiosk/nutritionUnos.html

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11.Ariely D. Predictably Irrational. New York, NY: HarperCollins Publishers, 2009.

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13. Elbel B, Kersh R, Brescoll V, Dixon B. Calorie Labeling and Food Choices: A First Look At The Effects On Low-Income People In New York City. Health Affairs 2009;28(6):w1110-21.

14. Farley T, Caffarelli A, Bassett M, Silver L, Frieden T. New York’s Fight Over Calorie Labeling. Health Affairs 2009;28(6):w1098-w1109.

15.Cohen S, Stookey G, Katz B, Drook C, Smith D. Encouraging Primary Care Physicians To Help Smokers Quit: A Randomized, Controlled Trial. Annals of Internal Medicine 1989;110(8):648-52.

16. NutriSoft. Cheesecake Factory: Nutrition. NutriSoft, LLC. http://www.cheesecakefactorynutrition.com/restaurant-nutrition-chart.php?rid=58

17. YouTube. Pam Laffin – Difference. San Bruno, CA: YouTube, LLC. http://www.youtube.com/watch?v=F3D3NnLXYNg&feature=related

18. Biener L, Taylor TM. The continuing importance of emotion in tobacco control media campaigns: a response to Hastings and MacFayden. Tob Control 2002;11:75-7.