The following was a paper I wrote on restaurant labeling. Interestingly enough, 1277 people voted on DietDetective.com and more than 85% said that  restaurants SHOULD be required to put nutritional information on menus. Take a look at this report and let me know your thoughts.

Currently as many as 65 percent of Americans are either overweight or obese. Obesity is associated with increased risk for cardiovascular disease, diabetes, certain forms of cancer, depression, discrimination and weight-related bias, and various other physical, psychological, and social morbidities.

The cause of obesity for each individual may be due to a combination of several factors including individual behaviors, environmental factors, and genetics. There have been a multitude of suggestions and research to create a more ecological approach in combating the obesity epidemic. One specific recommendation is to provide point-of-sale nutrition information at food-away-from-home establishments.

In 1970 American’s spent 26% of their food dollars on meals away from the home, today, however, almost half (47.5 percent) is spent on foods outside the home. Foods from restaurants and other food service establishments are generally high in calories and saturated fat and low in fiber and nutrients such as calcium as compared to home-prepared foods. Studies also link eating out to higher calorie consumption, overweight, and obesity in both adults and children.

Nutrition labeling in the food-away-from-home market is considered an important element in helping consumers to make more informed decisions. One proposed legislation is the Menu Education and Labeling Act, which would require point-of-sale information at all fast food restaurants and chains with 20 or more establishments.    Looking at lessons learned from nutrition labeling on food packaging can offer insight into the potential effectiveness of nutrition labeling at food-away-from-home. While nutritional information on food packaging has helped consumers make better dietary choices, it has yet to positively impact the obesity crisis. However, the FDA’s Obesity Working Group reports suggests that having point-of-purchase nutritional information would have a positive impact, from an ecological perspective, on healthier eating and potentially reduce the risk factors that cause obesity.

 Additionally, consumers should have the ability to make informed decisions regarding their eating behavior, and a calorie budget should be as important as a financial budget (i.e., menus have price information). 

 Introduction

Currently as many as 65 percent of Americans are either overweight or obese.^[1] Obesity is associated with increased risk for cardiovascular disease, diabetes, certain forms of cancer, depression, discrimination and weight-related bias, and various other physical, psychological, and social morbidities. ^[2]  The average increase in annual medical spending associated with obesity is 37.4 percent ($732) and ranges from 26.1 percent ($125) for out-of-pocket to 36.8 per-cent ($1,486) for Medicare and 39.1 percent ($864) for Medicaid.[3]  Combined, they account for 9.1 percent of total annual U.S. medical expenditures in 1998 and may have been as high as $78.5 billion ($92.6 billion in 2002 dollars). [4]

Although genetics contributes to obesity, both weight loss and weight gains are directly related to caloric intake and expenditure. Weight gain results if more calories are consumed than are used, and weight loss results if more calories are used than consumed. Individual behaviors of sedentary lifestyle and poor eating choices are related to environmental and behavioral issues, which significantly influence child and adolescent obesity.[5]

Causes of Obesity

Weight loss and weight gain are both directly related to calorie intake and expenditure (energy imbalance), however many different factors contribute to an individual becoming overweight or obese. [6]  The cause of energy imbalance for each individual may be due to a combination of several factors including individual behaviors, environmental factors, and genetics.[7] 

However many of the interventions target individual behaviors and evidence suggests that, “these approaches that depend on individuals making lifestyle changes have been ineffective in preventing the epidemic. An alternative model views obesity as an epidemiological disease with food(s) and other environmental agents acting on the host to produce disease.”[8]^,[9] 

Ecological Approach

There have been a multitude of suggestions and research to create a more ecological approach in combating the obesity epidemic, including policies similar to that of tobacco prevention programs. [10]^,[11]  The following are some of the suggestions to reduce the risk factors associated with obesity: banning advertising of unhealthy food towards children, taxes on foods or beverages with minimal nutritional value[12] (e.g. fast food), increasing the availability of nutritious groceries in socioeconomically disadvantaged areas, insurance coverage for obesity prevention and treatment, physical education or physical activity in schools,[13] financial incentives to manufacturers and food outlets to sell smaller portion sizes,[14]  improving the built environment (parks, playground, safe streets, fewer elevators, etc…)[15] and finally including nutrition labeling in the food-away-from-home market.[16]^,[17]

Restaurants Patterns and Obesity  

In 1970 American’s spent 26% of their food dollars on meals away from the home,[18] today, however, almost half (47.5 percent) is spent on foods outside the home. [19] “Food-away from-home expenditures as a share of total food spending have risen steadily over the last several decades while the share of food-at-home expenditures has fallen” [20] Americans who consume a “poor” quality diet based on the Healthy Eating Index tend to consume a greater proportion of their daily calories away from home than those with a “good” quality diet [21]

Foods from restaurants and other food service establishments are generally high in calories and saturated fat and low in fiber and nutrients such as calcium as compared to home-prepared foods. Studies also link eating out to higher calorie consumption, overweight, and obesity in both adults and children.[22] In addition, it is not uncommon for restaurant entrees to contain one half to an entire day’s worth of calories (1100 to 2350 cal). [23] Plus restaurants often serve larger portions, increasing the likelihood of diners   consuming more calories than they would at home. [24]   Frequent consumption of restaurant food has been associated with increase in body fatness in adults.[25]  Research has shown that adolescent girls who eat quick-service food twice a week or more are likely to increase their relative BMI over time.[26]

One potential move towards an ecological approach that could reduce the risk factors associated with obesity is nutrition labeling in food-away-from-home. While nutrition labeling is currently required on most processed foods, nutrition information is required for restaurant food only if a nutrient content or health claim is made for a menu item[27]

The Nutrition Labeling and Education Act (NLEA) explicitly exempts restaurants from most food labeling requirements. [28]  Restaurants, unlike the manufacturers of packaged foods, are not required by the NLEA to provide nutrition information for a menu item or meal unless a nutrient content claim or a health claim is made for such item or meal. When such a claim is made, the restaurant need only provide information on the amount of the nutrient that is the basis of the claim. Thus, for example, if a restaurant claims that a particular menu item is "low in fat" (i.e., makes a nutrient content claim with regard to fat) then this requirement is satisfied by adding: "low fat - provides fewer than 3 grams fat per serving" (i.e., the basis of the "low fat" claim). The restaurant may provide information about the nutrient for which the claim is made in various ways, including in brochures. In other words, restaurants need not provide such information on the menu or menu board. [29]

Because consumers are less likely to be aware of the ingredients and nutrient content of away-from home food than of foods prepared at home, public health advocates have called for mandatory nutrition labeling for major sources of these foods, such as fast-food and chain restaurants.[30]

Menu Education and Labeling Act

In the Obesity Working Group’s report to the Food and Drug Administration, one of their recommendations to combat obesity incorporated assistance from the restaurant industry (including both quick service and other types of restaurants.[31]  And one the proposed policy initiatives from this report was a the voluntary use of point-of-sale nutrition information in restaurants and other away-from-home sources of food to display nutrition information like that on the familiar “Nutrition Facts” panel found on most packaged foods sold in stores. [32]^,[33]

Thus the introduction of The Menu Education Labeling Act (MEAL),  proposed legislation in both the House of Representatives[34] and the Senate[35], which would extend nutrition labeling beyond packaged foods that you find at your local supermarket to include foods at fast-food and other chain restaurants. This act would require fast-food and chain restaurants (companies with 20 or more restaurants under the same trade name) to list calories, saturated plus trans fats, and sodium on printed menus and calories on menu boards.

The following comments from the bills sponsor Connecticut’s Congresswoman DeLauro on the floor of the House of Representatives create a compelling argument for the Menu Education and Labeling Act:

[I]t would give consumers [MEAL] the necessary nutritional information to make healthy choices for themselves. You might think that Americans do not want to be bothered with additional information they supposedly already know, but the evidence suggests otherwise. Not only do three-quarters of American adults report using the food labels on a regular basis that they find on packaged foods in the grocery stores, but 48 percent say the nutrition information on those labels has caused them to change their minds about what they buy   Giving people the information that they need to make informed decisions about what they eat is the kind of approach that this body should be taking today in addressing obesity. [36] 

The Menu Education and Labeling Act is not likely to be passed in the near future considering the current political environment of anti-government regulation; nevertheless proposed legislation heightens the awareness of the issues, and paves the way for future programs and or laws to be implemented.[37] 

Another potential source of menu labeling policy could come from the states—they could pass their own version requiring nutrition information in restaurants. And while no state has yet to do that, there are currently eight states that are considering passing legislation requiring restaurants to take affirmative actions placing nutritional information on menus. Those states include the District of Columbia, Massachusetts, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, and Vermont.  Most of these bills are still in committee. [38]     

Restaurant Industry Opposition

The restaurant industry has been an outspoken component to these potential mandatory labeling requirements citing increased costs. Those costs include: labeling costs, chemical analysis needed to determine the nutrient content of offerings, and reformulation costs (e.g., revising menu boards, printing collateral, and updating web sites). [39] The industry, through its lobbying group, the National Restaurant Association attacked the Menu Education and Labeling Act with the following statement:

As a result of the many choices that appear on our nation's restaurant menus, and people's desire to customize their order, there can be no feasible, one-size-fits-all application of menu labeling legislation. For example, a consumer buying a sandwich with 5 items or toppings (such as bread, meat, cheese, lettuce, tomato) can order it 120 ways. Someone presented with 15 items for a sub or sandwich can order it 1.3 trillion ways – making accurate nutrition labeling virtually unattainable for restaurants.

Furthermore, with the diversity of restaurant formats and ordering mechanisms, it is unlikely consumers would be able to experience the same continuity that they are accustomed to with the pre-packaged labeling program, creating even more uncertainty in an already confusing system.[40]

The statement by the restaurant industry may sound logical; however, many restaurants have provided nutritional information (e.g., Denny’s, Subway, Bob Evans). In fact, for years as a health journalist I attempted to get information from Starbucks, and similar claims were made by corporate management, and now, four years later, Starbucks has this information available on their website and in store brochures, [41] so nutrition information is possible to provide.

Does Nutrition Labeling on Food Packages Work?         

While there have been no formal studies done regarding the placing of nutrition information on food-away-from-home, looking at the lessons learned from the Food and Drug Administration’s Nutrition Labeling and Education Act of 1990 (NLEA), can shed some light on the topic. [42]   

The NLEA, required nutrition labeling for most foods (except meat and poultry),[43]^,[44] and are designed to promote and protect public health by providing nutrition information so that consumers can make informed dietary choices[45]  

Research has demonstrated that nutrition labeling helps reduce certain risk factors associated with disease including lower intakes of total fat, saturated fat and cholesterol. [46]^{,[47],[48],[49]}

Additionally, studies have shown that reading the nutrition label is associated with knowledge about general nutrition and fat, perceived importance of following specific dietary practices (e.g., avoiding too much fat and eating a variety of foods), and of maintaining a desirable weight. [50] It’s also been shown to be helpful for the socioeconomically disadvantaged, where minority label readers had higher fruit and vegetable consumption and lower fat intakes. [51] 

In a review published in the journal Public Health Nutrition, the authors looked at one hundred and three research papers that focused on food nutrition labeling and concluded that consumer understanding or use of nutrition labeling literature showed that “reported use of nutrition labels is high but more objective measures suggest that actual use of nutrition labelling during food purchase may be much lower.”[52]  The authors also found that the label might be difficult to use: “Most appear able to retrieve simple information and make simple calculations and comparisons between products using numerical information, but their ability to interpret the nutrition label accurately reduces as the complexity of the task increases.”[53] 

Another important point is that nutrition label reading is not just for those attempting to control weight. Patients also use the nutrition label to make better choice when attempting to eat diets lower in fat, and increase fruit, vegetable and fiber consumption, those with high blood pressure to reduce sodium intake, and those with high cholesterol were more likely than those with normal or low cholesterol to look for saturated fat and cholesterol on the label. [54]  Also, those with food allergies (e.g., peanuts, milk, eggs, gluten) use labels to determine the safety of the food before consumption.[55]

There has also been some criticism of the food label.  Some say the food label is difficult to read and[56] 70% of adults still want labels to be easier to understand.[57] Other research has shown a lack of effectiveness, where a combination of both education and labeling in supermarkets failed to reduce fat intake. No significant effects were found for the educational intervention, alone or with the labeling, on total fat intake and the psychosocial determinants of eating less fat.[58] Also, it’s important to recognize that those who need to be reading the label most (e.g., those who are at increased risk for heart disease, reviewing labels for saturated fat and cholesterol) oftentimes don’t. [59] However, “consumer education can provide educational messages to motivate and to teach label use.” [60] 

Others argue that even with the food label introduction, the country’s obesity rate has increased significantly.[61] The report and recommendations of the FDA’s Obesity Working Group, found that while there is evidence of an impact of dietary change (e.g., low fat diet), there is little evidence indicating the effects the food label on reducing obesity in this country. [62]  

Nevertheless, while there some restaurants do provide nutrition information in the form of posters, placemats or menu icons, or on the Internet; the Obesity Working Group believes that a point-of-sale remedy would be the most helpful to consumers and could potentially positively impact obesity. [63]^,[64]   The following is a summary of the recommendations of the Obesity Working Group’s report to the FDA regarding the restaurant industry: [65]

Short-term

Long-term

Again, while these recommendations are a good starting point, often times without regulation there fails to be action (smoking, seat belts).

Would Menu Labeling Work?

Currently, most fast food establishments offer nutritional information menus online and some on brochures or posters inside the restaurant. However, many of the socioeconomically disadvantaged, those that tend to be more obese, [66]  don’t have internet access, and thus don’t have access to the site or the guidelines. [67]^,[68]   

And again, the recommendations of the Obesity Working Group were to try and encourage point-of-sale nutritional information. [69] Would having food information at the point of sale help reduce risk factors that lead to obesity? In one study with US Military personnel, participants were exposed to calorie, fat and cholesterol information on 3 x 5 cards along with colored posters promoting healthier choices. The researchers found no relationship between point-of-purchase nutritional information and healthier eating. [70] 

However, there are studies that have had success in increasing healthier food choices by using point-of-purchase collateral. For instances, researchers were able to increase healthful snack selection in a college foodservice setting. [71]  And Seymour et al, completed a review of point-of-purchase interventions, and found: “Overall, simply providing information in the restaurant setting appears to be associated with increased purchase of targeted items....”[72]  It should be noted that when taking into consideration any point of sales intervention, that taste and cost are the most important components of food choice, and not nutrition concerns.[73]  This is important for researchers and policy makers when attempting to create interventions, because just having calorie information without directing consumers to healthier and tastier choices, which are low in price, the intervention might not be helpful.

Another argument in favor of point-of-purchase menu nutritional information becomes apparent in the following study conducted at Cornell University. Researchers intercepted 300 people as they finished their lunches at McDonald's or Subway. They were asked to estimate calories consumed. Customers at McDonald's consumed about 710 calories and estimated 670 calories each whereas those who ate Subway ate 560 calories but estimated 335. Here individuals assumed they had a larger “calorie budget” because foods were promoted as “healthier” and no point-of-sale nutritional information was provided. [74]  If individuals eat more of the food choice because it is perceived as healthy, it could counteract the intended benefits.[75]

Conclusions

Offering nutritional information at the point-of-purchase could be an element in an ecological approach to dealing with obesity crisis, and the risk factors associated (e.g. cardiovascular disease, diabetes). However, the current bill, the Meal Education Labeling Act, could be considered too high an aspiration given the current political climate. And while consumers, might be inconvenienced by having to search for nutrition information on a web site, brochure, poster or even on the packaging of the actual food (By mid-2006 nutrition information will now be displayed on the majority of McDonald’s product packaging using an easy-to-understand icon and bar chart format)[76]  at least it is a start.

Yet, nutrition information is still not readily available for many family style and casual dining restaurants (e.g., Olive Garden, Red Lobster, Outback). In fact, a study appearing in the American Journal of Preventive Medicine found that while the number of restaurants providing nutrition information has increased over the last 10 years, making informed and healthful food choices is still hindered by the lack of nutrition information at many restaurants (only 44 percent of the largest chain restaurants in the country provide nutrition information for the majority of their menu items). [77] 

There is evidence to suggest that it is possible to promote healthy eating as a business in spite of the restaurant industry’s negative few of providing nutritional information. [78] For instance, Subway, which not only offers nutritional information at the point of purchase, but actually promotes healthy eating on all of their establishments, and created their healthy offerings as branding for the company.[79] Subway has become the top franchisers in the country, with as many as 20,740 North American locations—surpassing even McDonalds. [80]^,[81]

Some make the argument that markets will determine what should and shouldn’t be done, and the government has no place to regulate restaurants—consumers will decide if they want healthy or unhealthy food. And this may be the case. For instance, Burger King recently made the corporate decision to move away from “healthier” foods. The reason: the market doesn’t exist among its customer base.[82] The introduction of Burger King’s Enormous Omelet Sandwich, which packs a staggering 740 calories, and the 1,410-calorie “Monster Thickburger" from Hardee’s are two examples of this apparent trend that the fast-food industry is changing their attitudes in spite of success like Subway.[83]

However, if it’s free markets that should prevail, shouldn’t the consumer have the opportunity to make an informed decision about their eating behavior? Isn’t an individual’s calorie budget as important as his or her financial budget? If so, then why are prices next to every single menu item and not calories?  Menu labeling could have a minor impact in an overall program to combat obesity, but it’s unlikely to provide significant improvement to the current epidemic. 

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