Within the past two decades the prevalence of obesity in the United States has risen dramatically, enough to classify the occurrence as an epidemic.5 Obesity is attributed to 300,000 annual deaths and is associated with a long list of health effects including type 2-diabetes, hypertension, and impaired quality of life.4 Current estimates of America’s obese population include 68% of adults and 32% of children, but the factors causing this dramatic increase are not fully understood.1 However, part of this rise can be attributed to an increasing trend in the amount of calories consumed outside of the home in restaurants. Between 1978 and 1996, food consumed outside the home has jumped from 18% to 32% of total daily calorie intake, showing that Americans are making food prepared outside the home part of their regular diet more than ever before.6 This food is also typically higher in total calories and saturated fat.6 Changes in the external environment involving food supply and accessibility, eating habits, and economic status may be factors leading to the increase in food consumed away from home and the shaping of America’s waistline. One policy proposal, at the intersection of healthcare and law, is to lower the prevalence of obesity is to institute a law requiring calorie labels on restaurant menus in the hopes of reducing overall caloric intake and improving nutrition. As a fourth year medical student, I strongly support displaying calorie counts for food items on menus ubiquitously to reduce the prevalence of obesity and improve health outcomes across the country.
Over the last decade, many state and local governments have taken action on the issue of obesity by mandating calorie labels on menus. Beginning with New York City in 2006, at least 21 states and localities introduced menu labeling legislation by the start of the 2007-2008 legislative sessions.12, 17 By the end of 2008, the whole state of California followed suit as did many other districts across the country.21 Generally, this legislation targets fast food restaurants with 15 or more locations and a certain annual income.21
Since the early 1990s the federal government has pushed legislation on reducing obesity to the forefront of health policy issues. In 1994, the Nutrition Labeling and Education Act (NLEA) was enacted by the U.S. Food and Drug Administration to require nutrition labeling on packaged foods.1 The label was required to include information for nutrients, fat, calories, and sugars compared to the amount recommended for daily intake. Explaining how to correctly read nutrition labels and account for proper portioning is a difficultly for many of the patients I have counseled on weight loss. Thus, there are some barriers to obesity reduction, perhaps in those people who need it the most.
Unfortunately, NLEA exempted restaurants from having to provide their customers with calorie information, unless they were openly promoting the nutritional value of their products. In March, 2010, a broadening of federal policy occurred when the Obama Administration enacted its comprehensive Health Care Reform Act, which, among other things, reversed the calorie listing exemption for restaurants.1 Section 4205 of the Patient Protection and Affordable Care Act of 2010 mandated the calorie labeling of foods sold in restaurant chains with more than 20 outlets.1 It specifically addressed restaurants, similar establishments, and vending machines.
Supporters of calorie menu labeling legislation include many health-related organizations and health professionals. The American Dietetic Association (ADA), the world’s largest group of food and nutrition professionals, supports the legislation, claiming “people need scientifically valid and understandable nutrition information to make healthful choices in all venues, including restaurants… Over time, the act of millions of people making healthful choices can impact the health of the nation and improve the food supply by consumer demand.”22 The American Heart Association, (AHA) Institute for America’s Health, and Obesity Action Coalition hold a similar view.22 The AHA believes that to combat obesity, consumers must make healthier food choices and that “ to do so in restaurants… requires that consumers have accurate, sufficient information provided in a usable format at the point of service.”13 The primary opponent of menu labeling is the restaurant industry led by the Restaurant Association.14 Restaurant owners feel that menu labels “would create yet one more hurdle to businesses already struggling with a difficult regulatory environment.”15 They also feel that labeling would limit menu options to only choices that had been analyzed, doing away with fresh daily specials.15 The industry also cites studies indicating that “calorie posting increases demand for some restaurants and lowers it for others,” making unhealthy restaurants particularly concerned.3
An ex-parte study conducted on the federal Nutrition Labeling and Education Act, enacted in 1994, concluded that small changes in the public’s diet from reading nutritional labels may generate significant public health benefits. 24 Consumers want nutritional information and evidence has shown that they are unable to accurately estimate the calorie content of restaurant foods without it. 14 Findings by lab-based studies have been showing that putting calorie content on menus impacts consumers by reducing their caloric intake. People given menus with calorie labels decreased their calorie intake compared to those without the calorie labeled menus, especially when a daily recommended calorie chart was added to the menu according to one study.16 Another study focused on calorie posting in food chains and determined that with the calorie postings, the average calories per transaction fall by 6%, but that the reduction was mostly in food choices and not drink choices.3 These findings support the idea that calorie labels should be added to food chain menus to increase healthy food consumption.
One possible alternative is a multipronged approach that would involve cooperation from law, industry, and healthcare.2 The prongs would include more obesity education in the medical school curriculum, more nutritional education for the public, and promotion of physical activity.2 In medical school, we are only now learning new techniques like motivational interviewing to help inspire patients to take control of their health and weight. I have also noticed some physicians writing exercise prescriptions to help their patients’ loose weight, though this is controversial. Some alternatives can be extreme forms of menu labeling, such as warning labels on products extremely high in calories.20 Another more promising alternative is a sin tax on soda and sweetened drinks or junk food.11 This would help consumers limit their consumption of unhealthy foods or drinks through a punitive tax, and the money generated from the tax could be used fight obesity epidemic by funding physical fitness, nutrition education, or another alternative.11
Numerous studies offer similar conclusions about calorie intake reduction with the posting of calories on menus, but there are some discrepancies concerning how much of an impact it has. However, it is clear that by providing consumers with the information about the number of calories and about the nutrition in the foods they are eating, that they are more likely to make healthier well-informed food selections. Studies performed on the effectiveness of the NLEA have shown that the policy generated public health benefits and studies on the effect on menu labeling have also shown that consumers are more likely to pick healthier food options with the menu labeling policy.
Despite these costs, the benefits to consumers are plentiful. Greater quality of life and productivity are associated with healthier lifestyles. One study indicated that “menu labeling is an important first attempt to alter food environments on a large scale and could ultimately prove to be both beneficial to health and cost effective.” 5 Another study concluded that even if calorie postings only yielded a “modest decrease in body weight” the benefits outweigh the costs.3 Another, after applying the decrease in calorie intake to the average weight gain of Americans, found that calorie label postings there would be a beneficial impact.7 Since it would be spread over millions of consumers, the impact would be very large even if everyone contributed only a small amount to reducing their overall calorie intake, thus effectively combating obesity.7 Lastly, some revenue could be generated from fines on restaurants that are not complying.
Both negative and positive externalities are possible outcomes of implementing calorie counts on menus important, which I have insight on being in the health profession. Negative externalities include children becoming obsessed with calorie counting or other neurotic rules around food intake.10, 19Another behavioral concern is an increase in eating disorders or poor self-image, especially in children.19 On the other hand one study measuring the impact of menu labeling laws on minority low income households in New York City found that 25% of people were noticing the calorie content, but not changing their purchases. 5 This may be attributed to people of varying demographics and socioeconomic statuses valuing calorie content per dollar and valuing meals of higher calories as a better deal.10 One positive externality would be restaurants altering their menus to carry healthier food choices in the long run due to higher demand for low calorie foods.1 Implementation problems include maintaining accurate labeling changes, especially where food is not standardized, such as in up-scale restaurants, daily specials, or the use of substitute ingredients. Employee training, monitoring and careful policy enforcement are also additional implementation challenges.15
Placing calorie information on menus would reduce the calorie intake among consumers and make it easier to make healthier food choices. This effect has been observed by multiple studies. The costs to restaurants are minimal compared to the benefits that even small changes in calorie intake could have on fighting obesity. From analysis of the current legislation, a trend toward healthier eating would continue if the policy was extended to include all restaurants – not simply larger fast food chains. As a medical professional on the frontlines of the obesity epidemic – it is clear that these laws do not go far enough and the practice of law on this issue needs to become a more prominent force in America today.
- Arsenault, J. E. (2010). Can Nutrition Labeling Affect Obesity? Choices: The Magazine of Food, Farm & Resource Issues, 25(3), 27-30. Retrieved from EBSCOhost.
- Blackburn, G. & Walker, A. (July 2005). Science-Based Solutions to Obesity: What Are the Roles of Academia, Government, Industry, and Health Care? American Journal of Clinical Nutrition, 82 (1), 207S-210S.
- Bollinger, B., Phillip, L., & Sorensen, A. (2011). “Calorie Posting in Chain Restaurants.” American Economic Journal: Economic Policy, 3(1): 91–128.
- Dixon, J. (2010). The effect of obesity on health outcomes. Molecular and Cellular Endocrinology, 316 (2), 104-108.
- Elbel, B., Kersh, R., Brescoll, V., & Dixon, L. (2009). Calorie Labeling and Food Choices: A First Look at the Effects on Low-Income People in New York City. Health Affairs:Web Exclusives: Online Articles From 28(6), W1110-W1121.
- Guthrie, J.F., Lin, B-H., Frazao, E. (2002). Role of food prepared away from home in the American diet, 1977-78 versus 1994-96: Changes and consequences. Journal of Nutrition Education and Behavior, 34(3), 140-150.
- Kuo, T., Jarosz, C. J., Simon, P., & Fielding, J. (2009). Menu Labeling as a Potential Strategy for Combating the Obesity Epidemic: A Health Impact Assessment. American Journal of Public Health, 99(9), 1680-1686. Retrieved from EBSCOhost.
- Layton, Lyndsey. “FDA Proposal Would Require Chain Restaurants to Display Calorie Information – The Washington Post.” The Washington Post: National, World & D.C. Area News and Headlines – The Washington Post. 2011. Web. 23 Sept. 2016. <http://www.washingtonpost.com/politics/fda-proposal-would-require-chain-restaurants-to-display-calorie-information/2011/04/01/AFOxCkHC_story.html>.
- Lazarus, David. “Junk Food Tax | Tax Junk Food: Fight Obesity One Penny at a Time – Los Angeles Times.” Featured Articles From The Los Angeles Times. LA Times, 25 Dec. 2016. Web. 25 Sept. 2016. <http://articles.latimes.com/2011/feb/25/business/la-fi- lazarus-20110225>.
- Loewenstein, G. (2011). Confronting Reality: Pitfalls of Calorie Posting. American Journal of Clinical Nutrition, 93(4), 679. Retrieved Dec 23, 2016, from Highwire Press.
- Lazarus, David. “Junk Food Tax | Tax Junk Food: Fight Obesity One Penny at a Time – Los Angeles Times.” Featured Articles From The Los Angeles Times. LA Times, 25 Feb. 2016. Web. 25 Dec. 2016. <http://articles.latimes.com/2011/feb/25/business/la-fi- lazarus-20110225>.
- “Menu Labeling.” Center for Science in the Public Interest. Web. 23 Dec. 2016. <http://www.cspinet.org/menulabeling/>.
- “Policy Position Statement on Menu Labeling.” American Heart Association. Web. 23 Dec. 2016. <http://www.heart.org/idc/groups/heart- public/@wcm/@adv/documents/downloadable/ucm_301652.pdf>.
- Pomeranz, J. L., & Brownell, K. D. (2008). Legal and Public Health Considerations Affecting the Success, Reach, and Impact of Menu-Labeling Laws. American Journal of Public Health, 98(9), 1578-1583.
- “Restaurant Association.” Menu Labeling Opposition Facts. 2008. Web. 23 Sept. 2011. <http://www.ramw.org/Hospitality-News/Hot-Topics/Menu-Labeling-Opposition-Facts.html>.
- Roberto, C., Larsen, P., Agnew, H., Baik, J., & Brownell, K. (2010). Evaluating the Impact of Menu Labeling on Food Choices and Intake. American Journal of Public Health, 100(2), 312-8.
- Rutkow, L., Vernick, J. S., Hodge, J. G., & Teret, S. P. (2008). Preemption and the Obesity Epidemic: State and Local Menu Labeling Laws and the Nutrition Labeling and Education Act. Journal of Law, Medicine & Ethics, 36(4), 772-789.
- Sallis, J. F., & Glanz, K. (2009). Physical Activity and Food Environments: Solutions to the Obesity Epidemic. Milbank Quarterly, 87(1), 123-154.
- Schwartz, M., & Henderson, K. (2009). Does Obesity Prevention Cause Eating Disorders?. Journal of the American Academy of Child & Adolescent Psychiatry, 48(8), 784-786.
- Seiders, K., & Petty, R. D. (2004). Obesity and the Role of Food Marketing: A Policy Analysis of Issues and Remedies. Journal of Public Policy & Marketing, 23(2), 153-169. Retrieved from EBSCOhost.
- State and Local Menu Nutrition Labeling Legislation Summary. 2011. Web. 23 Sept. 2016. <http://www.collenlaw.com/services/FINAL_Menu_Labeling_Laws_Chart.>.
- Stein, K. (September 2010. A National Approach to Restaurant Menu Labeling: The Patient Protection and Affordable Health Care Act, Section 4205. Journal of the American Dietetic Association, 110(9), 1280-1289.
- Yang, Y., & Nichols, L. M. (2011). Obesity and Health System Reform: Private vs. Public Responsibility. Journal of Law, Medicine & Ethics, 39(3), 380-386.
- Zarkin, G., Dean, N., Mauskopf, J., & Williams, R. (1993). Potential Health Benefits of Nutrition Label Changes. American Journal of Public Health, 83(5), 717-724. Retrieved December 11, 2016, from ABI/INFORM Global.
- “2011MayFranchiseReportMenuLabelingPage2.htm.” Baker Botts L.L.P. 23 Sept. 2016.<http://www.bakerbotts.com/file_upload/2011MayFranchiseReportMenuLabelingPage 2. htm>.