Introduction
Obesity, in both
adults and children is a major public health problem in the United States.
Obesity rates continue to rise and obesity related diseases are becoming
leading causes of death; diabetes, a disease related to obesity, is currently
the 7th leading cause of death in the United States1. Obesity
also puts an individual at increased risk heart disease as well as some
cancers, the leading and second leading causes of death respectively1.
The annual health care costs of obesity are an estimated $147 billion dollars2,
making it both a medical and economical burden in the country. Obesity is
defined as having a Body Mass Index, or BMI, of greater than 30 kg/m2.
Currently, about 36% or over a third of adults in the United States are
obese2. Obesity is a serious health problem in our country that
needs to be addressed.
The Health Care
Reform Act included a mandate that restaurants with 20 or more locations
nationwide must post the calorie content of their menu items on the menu boards3
in an effort to decrease obesity rates. However, some states passed laws
regarding menu labeling prior to the passage of the Health Care Law; New York
in 2006, followed by California, Oregon, and Maine by 2009, and along with
various other cities across the country3. The initiation and passage
of these laws were supported by a 2003 report issued by the Center for Science
in the Public Interest which found that people are eating an increasing number
of meals away from the home and that children consume twice as many calories at
restaurants than as at home3. This report was followed by a 2004 FDA
Obesity Working Group report, “Calories Count,” which recommended providing
nutrition information at the point of sale in restaurants as an intervention.
Overall, evidence suggested that calorie counts on menus might have a
beneficial effect; however, there was no conclusive evidence that providing
calorie counts on restaurant menus would lead to a change in the patrons eating
habits and therefore a change in the obesity prevalence rates in the country.
Yet many states, and eventually the national government, pressed forward in
initiating calorie counts in restaurants as an intervention approach for the
growing obesity epidemic.
The laws were put
in to place with the notion that providing calorie counts on menus would lead
people to choose lower calorie options, therefore leading to a decrease in
overall caloric intake, and mitigation of the increasing obesity trend. A study
by Dumanovsky et al in 2010 examined the effect of the labeling law in New
York, specifically looking at consumer awareness of the calorie information4.
The study found that customer awareness of calorie information increased
significantly from 25% to 64%4. This study simply showed that more
customers became aware of the calorie content of the menu items due to the
labeling law but it did not examine the effectiveness in usage of those calorie
counts. A study conducted by Elbel et al, found similar results to the previous
study; 54% of people noticed the calorie counts in New York City after the
labeling law and 27.7% percent of the sample that saw the calorie labeling
indicated that the information influenced their choices5. Of the
people stating that the calorie information influence their menu choice,
approximately 88% indicated that they purchased fewer calories as a result5;
however, no significant differences were found in the number of calories,
saturated fat, sodium, or sugar contained in the purchased menu items5.
This second study showed that while
people were noticing the calorie counts on the menus it was not translating
into a significant change in calorie consumption. Elbel published an additional
study in 2011 examining the effect of the menu labeling on teenager’s food
choices. The study found that 57% of adolescents noticed the calorie count on
menus and that 9% considered that information, however there was no significant
difference in the amount of calorie purchased before and after the
implementation of the labeling law6.
The three studies
presented show that calorie-labeling interventions have been unsuccessful at decreasing
caloric intake and mitigating the rising obesity rates. While these
interventions are an attempt at causing behavior change among the population
there are three major flaws in the execution of the intervention that lead to
its ineffectiveness at reducing the amount of calories consumed by an
individual. This paper will address the three major flaws of the menu labeling
laws as an obesity intervention and provide proposed solutions to the flaws in
order to improve the intervention.
Critique of Menu Labeling Laws
Flaw
1: Assuming Obesity is a Serious Health Risk
The
theoretical basis behind calorie labeling as an intervention to decrease
obesity rates is the Health Belief Model. The Health Belief Model is an
intrapersonal model of behavior that explains an individuals behavior based on
the perceived benefits, susceptibility, severity, and barriers or costs of
adopting a health behavior, along with cues to action and self-efficacy7.
Based on the Health Belief Model, the menu labeling laws assume that
individuals view obesity at a severe health risk with high susceptibility. The
laws assume that this high level of susceptibility and severity, along with the
cue to action, in the form of calories on a menu board, will cause people to
choose a lower calorie meal option. Moreover, the label laws assume that people
care about the health risks of obesity. The fundamental flaws that lead to the
failure of the menu labeling laws begins with theses underlying assumptions
that individuals in the population view obesity as a serious and immediate
health risk.
When
it comes to health, individuals are innately optimistic; people perceive their
health outcomes as being more positive than others in similar circumstances8.
Individuals perceive their personal risk of an adverse event as grossly
underestimated; individuals realize there is a risk of disease, however it
doesn’t apply to them, they are not at risk like the rest of the population. This notion is known as Optimistic
Bias, and has been examined in relation to the Health Belief
Model, finding that unrealistic optimism frequently occurs in relation to the
perceived risk of negative health outcomes8. This theory of Optimistic
Bias shows that individuals are likely to view their personal risk
of obesity and obesity related diseases as less than it actually is. This would
mean that individuals do not necessarily view obesity as a serve health threat
to which they have a high susceptibility. Without the belief that the threat
and susceptibility to a health outcome are high the Health Belief Model is
ineffective in eliciting behavior change; therefore, if individuals do not view
obesity as a severe health outcome to which they are highly susceptible the
health belief model is not an effective basis of an intervention such as menu
labeling. Optimism Bias must be
overcome and individuals must be able to recognize their true risk for obesity
and obesity-related illnesses in order for the menu labeling laws to
effectively elicit behavior change.
Flaw
2: Assuming Eating Behavior is Individualistic and Rational
The
Health Belief Model, as discussed above, is also the basis of a second
fundamental flaw in the menu labeling laws. The model inherently places the
responsibility for change on the behavior with the assumption that behavior is rational
and therefore can be altered; individuals will rationally weigh the perceived
benefits and risks of a behavior prior to making their decision. Based on this
aspect of the Health Belief Model, the menu labeling laws assume that eating
and food choices are a rational decision that can be changed on the individual
level. This is the second fundamental flaw in the policies; the laws do not
address or consider that food choices are often irrational decisions rooted in
emotional and environmental influences. According to Stein, “external cues and
emotional drivers often override rational thought when it comes to food
consumption.”9Daily food choices and decisions are influenced by
cultural, social, situational, physiological, and cognitive aspects10.
The media can also influence an individual’s food choices, about $11 billion is
spent annually on adverting food and beverages9, as can taste:
“Customers buy based on taste and will continue to do so.”9 As Stein
explains, taste and price drive consumer food selections more so than health9.
Price in particular can be a major factor in food choices for low-income
consumers; often the price of an item drives food choices more so than
nutrition. Nutrition is not the top concern for low-income individuals11. Food choices are influenced by many
external factors, which can make them irrational behaviors that occur in the
moment, rather than rational planned decisions that are based on health and
nutrition as the menu labeling law assumes.
The
use of the Health Belief Model also places the burden of changing food choices
on the individual, instead of addressing the current obesogenic environment of
the United States as a whole. As discussed above individual’s food choices are
influenced by external factors, which can make their decisions irrational, but
can also indicate that the root of the problem is not at the individual level,
that it is in fact on a larger societal level. According to Bronwell, “Humans
are highly responsive to even subtle environmental cues, so large shifts in
access, pricing, portions, marketing, and other powerful drivers of eating and
activity will have major effects on weight.”12 Bronwell also
explains that conditions of the modern food environment, such as rising portion
sizes, increasing amount of sugar in food, and increasing calorie consumed
through beverages can lead to disturbances in the balance of hunger, satiety,
and body weight12. Therefore
obesity as a public health problem may be rooted in society rather than the
individual. Bronwell also proposes the notion that food may trigger addictive
processes similar to those triggered by drugs12, which would disrupt
psychological systems and therefore making it difficult to place all of the responsibility
on the individual. The current food environment greatly influences the
individual food decisions, therefore, intervention should aim to address larger
societal and environmental factors rather than only focusing on the individual
as the menu labeling acts do. The menu labeling laws are based on the notion
that food choices are an individual decision; not taking into account the
various societal and environmental factors that may lead to and influence an individual’s
food choice.
The
menu labeling laws frame obesity as a personal responsibility that can be
altered by rational food choices. However, research has shown that obesity is
rooted in many environmental factors, which can influence an individual’s food
choice, making them more irrational than rational. Menu labeling does not look
beyond the individual level to underlying societal and environmental factors,
which is a major flaw of the intervention aiding in the ultimate
ineffectiveness of the intervention as a whole.
Flaw
3: Assumption of Knowledge
A
third flaw of the menu label laws is the sweeping assumption that the
individuals, as well as the population as a whole, have knowledge about obesity,
obesity related diseases, calories, and the relationship between calories and
weight loss or gain. The concept of health literacy explains the effects of a
lack of education on health outcomes. Nutbeam defines health literacy as “the
personal, cognitive and social skills which determine the ability of
individuals to gain access to, understand, and use information to promote and
maintain good health. These include such outcomes as improved knowledge and
understanding of health determinants, and changed attitudes and motivations in
relation to health behavior, as well as improved self-efficacy in relation to
defined tasks”13 Health literacy involves the knowledge, skills, and
confidence to be able to change personal behaviors and improve health14.
The menu labeling laws assume that
consumers have a certain level of health literacy, that they know the amount of
daily calories recommended, that they understand how the calories on the menu
fit into their daily allowance, and that they understand the relationship
between caloric intake and obesity.
In order for the
calorie counts listed on the menus to be effective consumers must have a basic
knowledge of the relationship between calories consumed and weight management,
as well as the amount of calories they need in a day. A study conducted by
Elbel found that about one third of consumers accurately estimate the number of
calories an adult should consume daily, one third also believe that adults
should eat less than 1,500 calories per day, and only 8% believe adults should
consume over 2,500 calories per day15. Elbel also states that racial
and ethic minorities are more likely to overestimate the recommended caloric
intake15. A similar study by Krukowski found that only 67% of the
participants were able to identify the number of calories they should be
consuming, which was a very liberal range of 1,500-2,500 calories per day16.
These studies support the notion that consumers do not have accurate knowledge
regarding the number of calories recommended each day, which is basic knowledge
necessary for interpreting and using the calorie counts listed on menus. Without
knowledge of the recommended calories consumed per day, individuals making have
no reference with which to compare the calorie content of their meals, and
calorie postings on menu boards become futile.
Along with
knowledge of daily calorie recommendations, the menu labeling laws assume that
individuals understand the relationship between calorie intake and weight.
There is an underlying assumption that consumers are aware that to lose weight
they should decrease the number of calories consumed on a daily basis; this
assumption is not always true. Individuals with low health literacy may not
understand that if they choose a menu option with lower calories every day they
will decrease their daily intake, which could lead to a weight loss in the long
term. Without this knowledge the calorie listings on menu boards are not useful
at transferring daily food choices into weight loss and mitigation of the rising
obesity rates. According to Stein, ““But if consumers don't understand how to
use the information, the specifications regarding font, how big the type size
should be, and where in restaurants the information should appear are not
likely to make any kind of impact on healthful eating behaviors.”9
The menu labeling laws are based on the underlying assumption that individuals
have the health literacy to use the calorie counts in the intended way,
however, this is not the case for the entire population, which leads to the
lack of effectiveness of the laws.
Proposed Improvements to Intervention
The
previous discussion of three major flaws of the menu labeling laws have made it
clear that the laws alone are ineffective as a public health intervention for
the mitigation of obesity rates. However, this does not mean that there is not
a place for the menu labeling laws. A few changes, to address the
aforementioned flaws, would help to strengthen the intervention and improve the
effectiveness. Providing calorie counts on menus should be used more as one
aspect of a larger intervention. In improved intervention would include an
advertising campaign to increase awareness of the risk for obesity,
complementary laws to limit the availability of high calorie options in restaurants,
and inclusion of daily calorie requirements and caloric exercise equivalents on
the menu boards. These proposals will address the three discussed flaws and
will build on the menu labeling laws to develop a complete, well-rounded,
intervention for the rising obesity rates in the United States.
Addressing
Flaw 1:
As
explained previously, one major flaw of the menu labeling laws is an underlying
assumption that individuals see obesity as a serious and highly susceptible
health risk. This flaw is fundamentally due to the optimistic bias. The optimistic bias leads people to
underestimate their personal risk, which leads individuals to not see obesity
as a health risk that is going to effect them. Addressing optimistic bias and
the effect it has on the menu labeling law presents a difficulty for the public
health intervention.
Reducing
optimistic bias can be very difficult; studies have shown varied success at
using cognitive approaches to reduce the bias, however an important first step
is to segment consumers whoa re most at risk and start by targeting them17.
One study examined the
effectiveness of using visual images to decrease optimism bias, hypothesizing
that greater similarities between the audience and the person in the photograph
would lead to a stronger decrease in optimistic bias18. This study did not show that the photos
influenced the optimistic bias scores, however a strong interaction effect
existed between the participant gender and the treatment photos18.
While the second study did not have significant results it should not be
completely dismissed, as it is one of very few studies examining methods to
reduce optimistic bias.
Going
off of this study, the proposed addition to the obesity public health campaign
to address optimistic bias would be to add an advertisement portion to the
campaign. Advertisements would feature an individual who is obese and suffers
from an obesity related disease, along with including text that links food
choices to obesity. An example of text that could be featured on an
advertisement may be “Choosing a lower calorie option at each meal may decrease
your chances of becoming diabetic.” Billboards and television advertisements
would primarily be used, along with advertisements on public transportation, as
they are most likely to be seen by a wide variety of people. The advertisements
would use people similar to the demographic of the area in which the billboard
was displayed; they would have to be tailored for the area in which they are
run. For example, a billboard in the Bronx, NY would feature a local individual
who lives in the area. Another aspect of the advertising campaign would be to
target the advertisements into areas that are at high risk for obesity and may
have a high tendency to consume the majority of their food outside the home, such
as low-income neighborhoods. People are more likely to associate with a person
similar to them and more likely to feel an emotional connection to a story
rather than to facts, therefore an advertising campaign for the menu labeling
that focuses on using real people who are obese and have obesity related
conditions may help to reduce optimism bias and therefore increase the
effectiveness of the intervention as a whole.
Addressing
Flaw 2:
The
second major flaw of the menu labeling laws was the underlying assumption that
eating behaviors and food choices are individualistic and rational. Research has established that obesity is
an environmental issue, with high calorie diets, low physical activity, socioeconomic
status, and place of residence being the major factors of the current
obesogenic environment in the United States19. Addressing the
obesogenic environment is necessary in the fight against obesity. According to
Hill, “Our best strategy for reversing the obesity epidemic is to focus on
preventing positive energy balance in the population through small changes in
diet and physical activity that take advantage of our biological systems for
regulating energy balance. Simultaneously, we must address the environment to
make it easier to make better food and physical activity choices.”20
While the menu labeling laws are an attempt at addressing the high calorie diet
aspect of the obesogenic environment, the intervention focuses on the
individual choosing a lower calorie option, not altering the environment
surrounding the food choice.
To
improve the obesity intervention and fix the second flaw of the menu labeling
laws an environmental aspect needs to be enacted. The food environment of the
United States as a whole needs to be addressed, making high-calorie,
low-nutrient food less available for consumption. This is not a simple feat. However, the recent passage of the
Trans-Fat ban is a glimmer of hope when it comes to altering the food
environment of the country. A proposed addition to the menu labeling law that
would focus on the environment and not the individual would be the proposal and
passage of a law, which regulated the caloric content of meals offered in
restaurants. Such a law would set a maximum calorie amount that can be
contained in a lunch meal offered by restaurants and another maximum calorie
content for dinner meals. For instance, lunch meals sold in restaurants cannot
exceed 650 calorie total and a dinner meal cannot exceed 800 calories. It
should be acknowledged that this is an extreme proposal, and a law of this type
would be met with a large amount of resistance, however, it is so drastic that
it would indeed alter the food environment. This law would eliminate the
possibility of people ordering a 1,000-calorie lunch from a fast food joint
because it is no longer an option; changing the environment will make changing
individual behaviors more possible.
Addressing
Flaw 3:
The
final flaw of the menu labeling laws assumed that individuals had the health
literacy to be able to understand the calorie counts on the menu boards and use
that information in the intended way. The best way to address this flaw is to
provide the consumers with the education necessary to understand the calorie
counts. However, identifying the optimal manner in which to provide this
education can be difficult. While an educational hand out or pamphlet would
seem like the natural choice, the consumers would then have to actually take
and read the additional materials, which is highly unlikely, especially in a
fast food restaurant. Therefore, it is important to provide the education
alongside of the listed calorie content. Providing this education along side
the calorie counts must be clear, concise, and simple, not crowding up the menu
board and decreasing the chances that people stop to read it.
A
possible means of providing education surrounding the calorie contents listed
on the menu boards would be to include a statement on the menu that states that
the recommended daily calorie allowance for adults is 2,000 calories. This
statement would have to be on the menu and in the same size font as everything
else, not in a smaller font so that it goes unnoticed by patrons. By providing
this information, that the average adult should consume 2,000 calories per day,
customers can compare the meal they are intending to purchase to the
recommended calorie per day and see how they relate. While this does assume
basic math skills it is better and more effective than providing calorie counts
alone. A study conducted by Roberto et al examined the effects of calorie
labeling on food choices and intake in an adult sample21. The study
used three conditions, one with no calorie labels, one with calorie labels, and
one with calorie labels plus a label stating the recommended daily caloric
intake for an average adult21. The study found that both calorie
label groups ordered fewer calories than those in the non-label group and that
participants in the calorie labels plus recommendation group consumed an
average of 250 fewer calories than those in the other groups21. This
study supports the notion that including information about the recommended
daily caloric intake may improve the effectiveness of the calorie labeling
laws.
Another
possible addition to the menu labeling laws would be to put the calorie of the
meals into a simple activity that all people can understand, such as exercise.
Providing consumers with an idea of what physical activity is the equivalent of
the calories of the food item may make more of an impact on people than
calories alone. While people may not understand calories and the relationship
of calories in food to health, associating calories with a physical activity
can provide this knowledge. For instance, listing the calories in a
cheeseburger followed by how many minutes a person would have to walk to burn
those calories. This method may be
particularly useful in an adolescent population. A study conducted by Bleich
found that “teens were far more likely to choose a low-calorie option if the
drink's caloric value was described in terms of exercise. The exercise labels
reduced calorie purchases by 40 percent.”22 A similar study
conducted in a simulated restaurant scenario found that “study participants
ordered meals with about 200 fewer calories -- regardless of their education
level or how well they tested for mathematical literacy -- if they were
informed of how many miles they would have to walk to burn off the meal.”22
Exercise equivalents seem easier for people to contextualize than just a
caloric number, which would indicate that listing calories along with an
exercise equivalent might help to improve the effectiveness of the menu
labeling laws.
Conclusion
The
calorie labeling laws, initially initiated by New York and eventually added to
the National Health Care law, have not been as effective at mitigating the
rising obesity rates in the United States as professional would have hoped. The
laws are plagued by several flaws, which include underlying assumptions that
individuals view obesity as a serious risk to which they are susceptible, that
food choices are individualistic and rational, and that people have to
knowledge to know what the calorie counts mean. However, these flaws do not mean that the laws are useless
and they should be changed. In fact, calorie labels on menus are useful as part
of a larger, more encompassing campaign against obesity. The laws, along with
additions such as an advertising campaign, the inclusion of education on the
menu boards, and additional laws to address the obesogenic environment would
complement each other and work together to create a more solid public health
campaign designed to decrease the prevalence of obesity in the Unites States.
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