Menu Labeling Laws in the Fight Against Obesity: Beneficial as Part of a Larger Campaign---Corcoran Downey

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 7^th 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.

References

1.     Leading Causes of Death. Centers for Disease Control and Prevention. Online. Available at: http://www.cdc.gov/nchs/fastats/lcod.htm. Updated January 11, 2013. Accessed on December 3, 2013.

2.     Adult Obesity Facts. Centers for Disease Control and Prevention. Online. Available at: http://www.cdc.gov/obesity/data/adult.html. Updated August 16, 2013. Accessed on December 3, 2013.

3.     Nestle, M. Health Care Reform in Action – Calorie Labeling Goes National. New England Journal of Medicine. 2010; 362: 2343-2345. Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1003814. Accessed on December 3, 2013.

4.     Dumanovsky T, Huang CY, Bassett MT, Silver LD.  Consumer Awareness of Fast-Food Calorie Information in New York City After Implementation of a Menu Labeling Regulation. American Journal of Public Health. December 2010; 100 (12): 2520-2525. Available at: http://ajph.aphapublications.org.ezproxy.bu.edu/doi/full/10.2105/AJPH.2010.191908. Accessed on December 3, 2013.

5.     Elbel B, Kersh R, Brescoll VL, Dixon LB. 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-w1121. Available at http://content.healthaffairs.org/content/28/6/w1110.long#sec-14. Accessed on December 3, 2013.

6.     Elbel B, Gyamfi J, Kersh R. Child and adolescent fast-food choice and the influence of calorie labeling: a natural experiment. International Journal of Obesity. 2011; 35: 493-500. Available at: http://web.ebscohost.com.ezproxy.bu.edu/ehost/pdfviewer/pdfviewer?sid=7b4d3ad7-f4ab-40c9-914b-799044e84270%40sessionmgr114&vid=2&hid=121. Accessed on December 3, 2013.

7.     Health Belief Model. Jones and Bartlett Publishers. Online. Available at http://www.jblearning.com/samples/0763743836/chapter%204.pdf Accessed December 3, 2013.

8.     Clarke VA, Lovegrove H, Williams A, Machperson M. Unrealistic optimism and the Health Belief Model. Journal of Behavioral Medicine. 2000; 23(4): 367-376. Available at http://download.springer.com.ezproxy.bu.edu/static/pdf/663/art%253A10.1023%252FA%253A1005500917875.pdf?auth66=1386435496_1c4e7c8d6fc8e98e718e913a3a74b86a&ext=.pdf. Accessed on December 3, 2013.

9.     Stein K. A national approach to restaurant menu labeling: The Patient Protection and Affordable Health Care Act, Section 4205. Journal of the American Dietetic Association. 2011; 111(5): s19-s27. Available at http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S0002822311002677. Accessed on December 3, 2013.

10. Scheibehenne B, Miesler L, Todd PM. Fast and frugal food choices: Uncovering individual decision heuristics. Appetite. 2007; 49(3): 578-589. Available at http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S019566630700267X. Accessed on December 3, 2013.

11. Hartocollis A. Calorie postings don’t change habits, study finds. The New York Times. Available at: http://www.nytimes.com/2009/10/06/nyregion/06calories.html?_r=0. Published October 6, 2009. Accessed on December 3, 2013.

12. Bronwell KD, Kersh R, Ludwig DS, Post RC, Puhl RM, Schwartz MB, Willett WC. Personal responsibility and obesity: A constructive approach to a controversial issue. Health Affairs. 2010; 29(3): 379-387. Available at: http://content.healthaffairs.org/content/29/3/379.long. Accessed on December 3, 2013.

13. Nutbean D. Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21^st century. Health Promotion International. 2000; 15(3): 259-267. Available at http://heapro.oxfordjournals.org/content/15/3/259.full. Accessed on December 3, 2013.

14. Nutbeam, D. The evolving concept of health literacy. Social Science & Medicine. 2008; 67(12): 2072-2078. Available at http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S0277953608004577. Accessed on December 3, 2013.

15. Elbel B. Consumer estimation of recommended and actual calories at fast food restaurants. Obesity. 2011; 19: 1971-1979. Available at http://onlinelibrary.wiley.com.ezproxy.bu.edu/store/10.1038/oby.2011.214/asset/oby.2011.214.pdf?v=1&t=houg1i35&s=db820fe1d559736ffc117e98765fddb511cc06bb&systemMessage=Wiley+Online+Library+will+be+disrupted+on+7+December+from+10%3A00-15%3A00+GMT+%2805%3A00-10%3A00+EST%29+for+essential+maintenance. Accessed on December 3, 2013.

16. Krukowski RA, Harvey-Berino J, Kolodinsky J, Narsana RT, DeSisto TP. Consumers may not use or understand calorie labeling in restaurants. Journal of the American Dietetic Association. 2006; 106(6): 917-920. Available at: http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S000282230600304X. Accessed on December 3, 2013.

17. Frewer L, van Dijk H, Fischer A. Chapter 3: Consumer perceptions of the risk and benefits associated with food hazards. Risk Communication and Public Health. Oxford University Press; 2010:42-43. Available at:http://books.google.com/books?id=PBH3bxSqdy0C&pg=PA43&lpg=PA43&dq=how+to+reduce+for+optimistic+bias+in+a+public+health+intervention&source=bl&ots=mjMoE8KwBA&sig=7_BsQysZhEnmbwxFjMiTMFGRMtM&hl=en&sa=X&ei=4uqhUsvGOPLNsQSe84DQAQ&ved=0CGIQ6AEwBQ#v=onepage&q=how%20to%20reduce%20for%20optimistic%20bias%20in%20a%20public%20health%20intervention&f=false. Accessed on December 3, 2013.

18. Rieseberg AL. Reducing health optimistic bias using photographs of people. Cornell University. 2005. Available at: http://www.ilr.cornell.edu/smithers/docs/riesenberg.pdf. Accessed on December 3, 2013.

19. Poston WSC, Forey JP. Obesity is an environmental issue. Atherosclerosis. 1999; 146(2): 201-209. Available at: http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S0021915099002580. Accessed on December 6, 2013.

20. Hill JO. Understanding and addressing the epidemic of obesity: An energy balance perspective. Endocrine Reviews. 2006; 27(7): 750-761. Available at: http://edrv.endojournals.org.ezproxy.bu.edu/content/27/7/750.full. Accessed on December 6, 2013.

21. Roberto CA, Larsen PD, Agnew H, Balik J, Bronwell KD. Evaluating the Impact of Menu Labeling on Food Choices and Intake. American Journal Of Public Health. 2010; 100(2): 312-318. Available at http://web.ebscohost.com.ezproxy.bu.edu/ehost/detail?sid=faa97e37-7458-4cb7-a6bc-d76730957f9e%40sessionmgr198&vid=2&hid=121&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#db=pbh&AN=47521828. Accessed on December 3, 2013.

22. Melnick M. Nutrition information on Menus: Is there a better way? The Huffington Post. Available at http://www.huffingtonpost.com/2013/05/22/calorie-counts-menu-label-nutrition_n_3247864.html. Published May 22, 2013. Accessed on December 6, 2013.