It is happening!

It has been eight years, but the National Restaurant Menu Labeling Law (part of the Patient Protection and Affordable Care Act) will be in effect on Monday. Restaurant chains with over 20 locations will be required to post the calorie content of their standard offering on menu boards and print menus. The goal is to raise awareness of the amount of calories in the items we choose - and to do so before we make that choice. This law has the potential to change our behavior as consumers as well as the behavior of those providing us with food and beverages. Will the calories available to purchase decline? Will we purchase AND consumer fewer calories? If the answers are yes, will the country's obesity rate plateau or decline? I sure hope so - but that's a lot of ifs. 

Meanwhile, the recommended changes to the Nutrition Facts Panel have been delayed to 2020 - here we go again. The main change on those labels is an emphasis on total calories and added sugar and a de-emphasis on total fat. 

On a personal note, sorry I don't post much anymore, but my students require a substantial amount of my time!

How The 2016 Federal Budget impacts nutrition, dietary advice and calorie labeling

If you are confused about what foods to eat and which constitute a healthy routine diet, you are not alone. In fact, this year has been extraordinary for its confusion and contention surrounding nutrition science and dietary guidelines. In fact, the experts - nutrition and public health – do not agree. The controversy was simmering even before the release of the 2015 Dietary Guidelines Advisory Committee Report, an update to the Guidelines I meticulously explained and passionately promoted 5 years ago – before I joined the rank of researcher (i.e., became a more critical reviewer).

Did the uproar over the Committee’s recommendations make its way into your daily news briefs? If so, you’ll know that the contention was strongest around the recommendation to lower meat intake, not just for health, but for the planet – for sustainability.

After the report was released, a non-scientist, nutrition journalist published a scathing article on the recommendations, which led to a crusade by the Center for Science in the Public Interest and a point by point response letter signed by over 100 experts, researchers and scholars (myself included) that was posted just about a week ago.

There is not just dissent on the recommendations, which include less salt, less saturated fat, less sugar, but also on the scientific evidence used and the scientific process itself. So much so, that the recently passed Omnibus Appropriations Bill 2016, delays the release of the guidelines! Read for yourself (selected text from the Congressional directives):

Congress continues to be concerned about the quality of scientific evidence and extraneous factors that were included in the 2015 Dietary Guidelines Advisory Committee's Scientific Report.

To ensure the guidelines adhere to the nutritional and dietary scope of the law and are based upon sound science, bill language has been included clearly stating that the final guidelines cannot be released or implemented unless they are based upon significant scientific agreement and adhere to the statutory mandate.

Questions have been raised about the scientific integrity of the process in developing the dietary guidelines and whether balanced nutritional information is reaching the public. The entire process used to formulate and establish the guidelines needs to be reviewed before future guidelines are issued. It is imperative that the guidelines be based upon strong, balanced science and focus on providing consumers with dietary and nutritional information that will assist them in eating a healthy and balanced diet. At a minimum, the process should include: full transparency, a lack of bias, and the inclusion and consideration of all of the latest available research and scientific evidence, even that which challenges current dietary recommendations.

The agreement (the Budget) provides $1,000,000 to review the dietary guideline process.

And that’s not all! The Omnibus Appropriations Bill takes aim at school nutrition and calorie labeling as well. The federal government by enactment of this bill, further delays calorie postings for grocery stores and ‘similar retail establishments,’ which I am assuming are the bowling alleys, movie theatres and convenience stores. My colleagues tell me that the FDA had already made those postponements and the Budget Bill just makes it a mandate. I might have been too focused on vending – which was already set for 2016 – to have noticed. What I am thinking is 1) this calorie labeling is never gonna happen and 2) if the federal law is not in place, state and local laws can’t be pre-empted, thus they can remain more restrictive… good for Philadelphia.

With regard to the school lunch program, schools can have more time to figure out how to increase the whole grain content of meals – though 95% of schools haven’t suggested that they need more time, so this is dumb. Also, the rule to lower the sodium content to a new lower goal has been halted pending scientific evidence that it is necessary to do so for health.

Here are a couple of links re the budget that was just passed.

Summary

Pretty much the whole thing

USDA-FDA specific budget language

The delay is NOT the demise of menu labeling

The FDA has granted restaurants and similar retail establishments a delay in posting calorie amounts  -  how that delay actually came about and why, warrants some clarification.

The National Restaurant Industry, like the National Automatic Merchandising Association for vending machines, supports calorie disclosures on menus and menu boards as mandated for large (20 or more) chain restaurants. Large chain restaurants are probably ready to roll with the disclosures - several cities and at least 1 state already have calorie (+) disclosure laws in place (though they are preempted by the federal law). It is not likely that restaurants need or even want the delay, after all, the industry(through its trade group) supported the federal law; a nationwide, preemptive law is good for them.

What is really going on is that the 'similar retail establishments,' ones that sell ready to eat food as a major part of their enterprise, for example, grocery stores, movie theatres, bowling alleys, convenience stores, tried to get out of the mandate. Once they realized the law did indeed apply to them, they asked for and received more time to get their act together.

I do not see the delay as a bad thing and I do not read it as the demise of the legislation. Too many big players AND consumers want calorie displays across the many places where food choices are made. 

Including the similar retail establishments (and vending machines) in the law makes it 1) fair to the sellers of the food - why should some have to disclose and other not? and 2) easier - possible - for us to monitor our calorie intake if we so choose. Whether we will choose to do it or understand how to do it, is a separate discussion.

Researchers and proponents of the law do not know if calorie disclosure by itself is going to change the behavior of people most in need of changing their behavior (i.e., people who exceed their average daily calorie needs), but it makes it possible and before we can do anything else (e.g., tell people how many calories, from which types of foods, are too many), we have to put the information out there. The early positive change that I, and many others envision, is that the retailers are going to reformulate recipes or reduce serving sizes in order to 'present' calorie counts that are more reasonable. Hey, there is a thought, maybe one of the things that 'similar retail establishments' will do with their extra year is reduce calories  - say in that bucket of popcorn!

Anyway, I am not disheartened and as a researcher, I hope to take advantage of the extra time to conceptualize some new evaluation studies!

Building a low calorie meal at Chipotle

Until the menu labeling that is mandated by law and regulated by the FDA blankets the US, there is still the option of using online nutrition information available for most large chain restaurants.  I expect the information to remain available on line after the law is implemented, which is great for planning ahead.  Information on site can help you make a healthy choice at an unfamiliar restaurant you.

I recently got the notion that I should have a meal in mind in case I ended up at Chipotle.  There is one near my office.  I tried several combinations on the interactive web menu and watched the total calorie count go up or down, a little or a lot, depending on the choices that I made.  You can explore the menu this way too, just click here.

I did not add any of the meats when I was exploring, but I did add the Sofritas (a soy product/meat substitute); I think I saw an add for the Sofritas and that might be why I started thinking about Chipotle.  I did toy with tortillas and dressings.

Here is a snap shot of my "meal."  I specifically included the vinaigrette on this salad so you could see how it impacted the calorie total - 270 calories just in the dressing!  The salad has almost 500 calories with the dressing, which of course I don't need because I have the tomato salsa.  In other words, if I were placing an order, I would use the salsa for the dressing, not the vinaigrette.

Next are examples where I chose a burrito (a tortilla w/300 calories!) and a taco (a crispy shell w/ 210 calories).

Final Rule Part II Vending Machines

In my last post, I detailed some information related to menu labeling for restaurants and businesses that sell foods for immediate consumption (businesses like movie theatres and bowling alleys).

The FDA published a separate Final Rule to explain the requirements of nutrition labeling for the vending site. There are similarities to the restaurant regulations, but some differences exist.

The nutrition information to be disclosed at the point of sale (i.e., available before the snack is selected from the machine) is calorie content for the entire package.  The information can be placed on the machine, in the machine or on a sign near the machine. It can even be displayed electronically, as long as it is seen before money is spent.  Just like in menu labeling, no state or local law can preempt the federal law for covered vending operators  (i.e., those who own 20 or more vending machines), but the vending rule specifically says that vending operators MAY PROVIDE ADDITIONAL NUTRITIONAL INFO.  To be clear, the state cannot require them to do so, but they are allowed to do so. To put this in perspective, recall the last blog post. In Philadelphia, certain restaurants are required to post calorie and sodium information on the menu, but if those restaurants are covered by the federal law, they can no longer be made to post anything other than calories.  If a vending owner covered by the federal law himself chose to disclose more than calories, for example added sugar grams, for the contents of his machine, he or she could do so.  I don't know, maybe it isn't different than the restaurant rule.  I don't recall reading anything in the restaurant rule about voluntary disclosure, but I am pretty certain if Apple Bees, for example, decided to post sodium content on the menu in their restaurants, they could legally do so.

The Final Rule for vending does not require the qualifying statement regarding 2000 calories a day (but this is information the rule calls 'additional information' that can be added by the vendor as long as any info or statements are accurate.  Vending companies have 2 years, instead of 1, to post their information.

I have talked about package labeling and the need for revisions in the past.  For the most part (90%), vending machine snacks have nutrition information on them (unlike restaurant foods or movie popcorn); the problem is that the customer cannot see the information when the snack is in the machine.  The Final Rule for vending states that a vendor is exempt or a snack machine is exempt, if the customer can easily see and read the Nutrition Facts Panel before they select and purchase the snack.  In addition, if snack packages change and the calorie information - for the entire package - can be clearly seen in a front of pack label, the machine will be exempt.

I am not sure how this could impact the Institute of Medicine's Front of Pack labeling recommendations and the FDAs delay in implementing them.  On the one hand, vending companies and their professional organization, the National Automated Merchandising Association might lobby congress to get FOP labels mandated, in which case, snacks would come prelabeled and the vending companies wouldn't have to do anything.  On the other hand, the Grocery Manufacturers Association might push back -hard -against a front of pack law based on the IOM recommendations, because the IOM recommends a rating system - in other words, the snack could be rated as POOR.  I am for this type of labeling, as you know.  Here is one past post in reference.

I don't generally purchase snacks from vending machines, but I look forward to the implementation of this law. I'd much rather have information available if I needed it than be forced to make a decision without it.

See the rule in the Federal Register 

Federal Nutrition Labeling - Exemption from Preemption?

YES!  I know that the FDA released the final rule for the national restaurant menu and vending machine nutrition (i.e., calorie) labeling law.  I haven't blogged about it yet because I was a little busy and I was trying to find out more, if I could, about the preemption piece.  To be clear, the final rule does a lot of what public health advocates, such as myself, hoped it would do and importantly, it includes movie theaters and prepared foods at grocery and convenience stores. Many reporters and bloggers have been talking about the final rule, and I hope that my post offers a little more than the usual fare (pun intended).

The FDA has a good Q and A page where you can learn more about which places will have calorie info available for you.  Click here to see and search the Q and A.  I went to the website myself to see if I could find out about bowling alleys, which I consider a caloric cesspool; and I found this beautiful paragraph

Establishments such as restaurants that are quick service and/or sit-down, food take-out facilities, pizza delivery establishments, food facilities in entertainment venues (e.g., movie theaters, bowling alleys), cafeterias, coffee shops, superstores, grocery and convenience stores, are covered if they meet the criteria listed above. 

Now there are two important qualifiers to the rule and as I've learned from some friends in King Co Washington and Philadelphia PA; its not as simple as it first seems.  I also spoke - through email - to a legal counsel at Perkins Coie LLP in Colorado.

1) The rules only apply to businesses with 20 or more establishments (re the 'criteria listed above' comment in the FDA paragraph I quoted). So YES to McDonalds and AppleBees and no to that quaint family owned bistro by your house. Yes to the AMF bowling alley with more than 300 lanes in the USA, no to the vending company with 10 machines. [I cannot wait to see the menu boards at bowling alleys (maybe my sister will send me a picture!).  I suddenly feel compelled to research how calorie laws affect the eating habits of bowlers!]

2) As the NRA hoped, the final rule does preempt the 15 or so existing state and local menu labeling laws (there are no vending laws to preempt). On the face of it, preemption means that no state or local law can be different from the national law. The national law says the menu boards, food tags and print menus must list total calories for each item - next to the item and in font the same size as the font listing the price; establishments also have to provide a statement regarding the standard 2000 calories a day contextual statement, and provide additional nutritional information in print, upon request. (Frequent readers of my blog know I think the contextual statement should say many people need closer to 1500/1800 calories a day, but it doesn't).

These 2 things (businesses included and preemption) play into each other in a way you might not expect, and in a way I didn't really see until someone pointed it out to me.  First, it is believed that a restaurant under the jurisdiction of the federal law, like AppleBees, cannot be made to display anything more than calorie content. Two local laws that I am aware of, one in King Co Washington and the other in Philadelphia PA, mandate that restaurants of certain size, also display fat grams and sodium mg on their print menus. It is possible that the federal law has a floor preemption instead of a ceiling.  IN other words, the law could mean that restaurants have to have calorie info but state and local laws could require more.  Most people (including two lawyers) have assured me that the preemption is a ceiling and states/localities can't require more than calorie disclosure. States and localities who want to force restaurants, by law, to disclose other nutrient information can petition the FDA for an exemption from preemption (great phrase!).  Stay tuned for more on King Co and Philadelphia's laws.  I will say that Philadelphia has a strong health related case for forcing the disclosure of sodium, and they know it.

But here is the clever part(and I am not sure who bested who on this one, the FDA or the National Restaurant Association).  States and localities can require establishments that are not under the FDA rule (i.e., local, small chains) to comply with a more involved law - and establishments that are not under the FDA's jurisdiction can OPT IN to the FDA rule.  Restaurants (or vending companies for that matter) that operate less than 20 establishments can make themselves fall under the FDA law.  If they opt in, then they cannot be targeted by state and local law.  SO, the new rule actually encourages restaurants to get on board because it can protect them from having to disclose, on their menu and menu board, more information. That sort of thing was exactly what the Restaurant Association was trying to shield their members from - having to comply with a patchwork of laws.


*** BTW making a company tell its customers what is in the products it sells is NOT an infringement on liberty!  Watch out for that kind of fear mongering spin - consumers have always had a right to know the contents of their purchases.

Nutrition Labels: Calories and Sugar

I am a little disappointed in the scientific rigor of the two studies I mention below, especially because they address two issues of importance to me - and you; restaurant menu and food package labeling. The study designs/methods make it hard, no impossible, to make causal inferences.  We can't say x caused y, in either study - but to be fair, the second study was only meant to describe peoples perceptions.  Unfortunately, the people surveyed are not representative of the larger US population.

The first study (from the University of Glasgow in Scotland) compared the average weight gain of two different groups of college students - during two different years.  The first group may or may not have eaten at the cafeteria when no calorie labels were present and the second group may or may not have eaten at the cafeteria when calorie labels were present.  The first group gained 8 pounds during 36 weeks (perhaps a semester) and the second group gained 4 pounds during the 36 weeks they were assessed.  There is absolutely no way to say that the calorie labels were responsible for the weight gain differences - none.  And I am 100% pro labeling. However, during the second year when calorie labels were on the menus, the customers did purchase less calories than when the labels were not on the menus - during this one time period.  That is important.

The second study - a very small, internet survey- strove to answer the question of whether or not Americans would be confused by the addition of an added sugar declaration on the Nutrition Facts Panel (the panel on the back of packaged foods).  The rationale for this study was the assertion by anti- added sugar labeling folks that consumers would not find the additional nutrition information helpful - on the contrary, naysayers say - added sugar information will confuse the public.

The assertion that more information is bad really gets under my skin, because again, I am pro labeling.  However, there is evidence from studies on nutrition information that suggests we cannot apply available nutrition information in the context of our personal, daily needs.  That is why the IOM and others have recommended more intuitive labels, ones that highlight a few nutrients of concern, like salt, sugar and overall calories- in color coded front of the package schemas.

But the FDA is considering changes to the Nutrition Facts Panel(NFP) on the back, including an added sugar declaration - read more here.  Ted Kyle and his colleague surveyed a small group of internet users, a couple hundred, and asked them if the added sugar section of the NFP was helpful or confusing.  The survey respondents looked at a make believe label before answering the question.  Most of the people who participated said that the additional information was helpful.  I think this is probably right, however, the survey doesn't really tell us anything about what people will do when the labels actually contain this information, we need a different kind of study for that.

You can read a popular press write up about the Glasgow study here, and an over view of the added sugar survey results can be found here.  The ConscienHealth blog written/maintained by Ted Kyle focuses on more rigorous studies than the added sugar survey  and is one of my favorites.

Has Menu Labeling Had an Impact on TV Ads?

   There is a lot of opinion and a little bit of science for and against the (conspicuously absent) national menu labeling law.  In case you have forgotten - it has been 4 years - the law requires restaurant chains with 20 or more outlets to post calorie information for all standard items at the point of decision making/purchase (i.e., the menu board or menu).  If you have not been following the issue with me, let me state up front that I am a proponent of nutrition disclosures, especially calorie amounts, at all places where food and beverages are sold.  I believe that the information helps certain consumers and harms none.

   What I take away from the many research studies (Krieger & Saelens, 2013; Liu, 2013; Sinclair, Cooper, & Mansfield, 2014; Wei & Miao, 2013) that have tested local laws (and field/lab experiments) is: 1) for some people, the information is helpful and leads them to choose lower calorie options, while others either don’t see the information, don’t know what to do with it (when calorie disclosures come within a context, the information is more meaningful), or see it and actually choose higher calorie meals, and 2) some researchers are assessing whether menu labeling has an impact on weight or BMI, which is a long term goal and not necessarily the primary goal of calorie disclosures.

   What is of greater and more immediate interest to me is 1) whether or not consumer attitudes about and understanding of calories change after the introduction of calorie information and 2) whether or not the items available to purchase become lower in calories.  If you are interested in a good over view of calorie content in major restaurant items circa 2010, see this article by Wu (Wu & Sturm, 2013).

    On that last note - do restaurant owners change their behavior - I have something promising to report.  I have seen at least 3 TV commercials from different restaurants that post the calorie content, out loud, in a caption or both.  For example, McDonald’s states that its egg McMuffin has 300 calories in this TV ad, and Dunkin Donuts promotes a less than 300 calorie breakfast flat bread here.  I am pretty sure that I have seen a Taco Bell ad showing calorie content as well.  This is something new and though I don’t have evidence to back my assertion, it is possible that the state and local laws, along with the national labeling expectations and all this talk about calories, is leading consumers to expect the information and companies to provide it - and in so doing, the restaurant owners realize that they might need to offer lower calorie options.  YES, there are still plenty of ridiculous offerings, see the CSPI Xtreme Eating 2014, but that doesn’t negate the positive.

    Block and Roberto (Block & Roberto, 2014) encourage us to look for myriad positive outcomes of menu labeling as we continue to study the impact of such laws, I think they are right, and I add these commercials to the examples they provided in their recent publication (free on line).

Block, J. P., & Roberto, C. A. (2014). Potential Benefits of Calorie Labeling in Restaurants. JAMA.

Krieger, J. W., & Saelens, B. E. (2013). Impact of menu labeling on consumer behavior: A 2008-2012 update. Minneapolis, MN.

Liu, J. (2013). Menu labeling and food choice: A systematic review of the literature concerning the effects of menu labeling on consumer food choices.

Sinclair, S. E., Cooper, M., & Mansfield, E. D. (2014). The Influence of Menu Labeling on Calories Selected or Consumed: A Systematic Review and Meta-Analysis. Journal of the Academy of Nutrition and Dietetics.

Wei, W., & Miao, L. (2013). Effects of calorie information disclosure on consumers’ food choices at restaurants. International Journal of Hospitality Management, 33(0), 106-117. doi: 10.1016/j.ijhm.2012.06.008

Wu, H. W., & Sturm, R. (2013). What's on the menu? A review of the energy and nutritional content of US chain restaurant menus. Public health nutrition, 16(01), 87-96.

Nutrition Labels: Chaos, Confusion and Coercion

As it turns out, the FDA didn't publish those final rules for menu labeling last month and the IOM didn't persuade the government to mandate new front of pack labels for packaged foods. Instead, there is a mix match of existing individual state and city menu labeling laws and states continue to send more bills on labeling to their legislatures.  Even the US Congress has a new restaurant menu labeling bill, which is attempting to rewrite the current law (the one not yet implemented or enforced).  In the new bill, lobbyists for convenience stores, entertainment venues and grocery retailers are trying to get their constituents or companies excluded from mandatory labeling.  I disagree with the entertainment venue exclusion, or any exclusion for an establishment selling foods without a label, e.g., a steam table at a grocery store or 7-Eleven.

With regard to packaged foods, I expected that the recommended update to the nutrition facts label would see years of delay, but I did not expect that a group would form to scare us into believing that being told the amount of calories and sugar in our food was a threat to our independence!  Seriously.  The group is called Keep Food Legal, because apparently full disclosure on the ingredients in the products we purchase is somehow paternalistic and threatens our individual liberties.

BTW, in more sugar news, the World Health Organization has updated its stance on limiting sugar intake (to reduce obesity and oral disease); they recommend no more than 5% of total daily calories from added sugar.  This is a little less than is recommended by the American Heart Association.  If you missed the blogpost where I introduced the sugar concerns generated from recent research, you can read it here.

Lastly, the Grocery Manufacturers Association is going full steam ahead with its Facts Up Front labels (and spending lots of money to do it).  The problem with industry front of pack labels and the individual city and state menu laws is that they are not standardized across products or states and do not necessarily have the information that is most important to us (e.g., some list total carbohydrates instead of grams of added sugar).  

That being said, I am starting to warm up to the industry sponsored front of pack food labels because I think they are the best we're going to get for a while. And the Facts Up Front labels list sugar grams and calories, which matter.  

That's my update on labels. The next blog will be about sedentary activity and why you and I should avoid it.

If you want more info on the food industry and labeling, I recommend a ConscienHealth blog post - access it here.

The other effect of a national restaurant menu labeling law

You have probably read news stories suggesting that calorie information on restaurant menus and menu boards does not work.  It does appear that state or city nutrition menu labeling laws have not had a big impact on the average amount of calories customers purchase.  However, I have noted several research studies that are exceptions to these findings and I continue to believe that providing nutrition information at the point of decision making is a good idea.  The labeling can help reduce the over consumption of calories that occurs when people eat out.  I also believe, based on the research of others (see e.g., Ellison), that using a traffic light presentation (i.e., green, amber or red based on calorie amount) will enhance the effectiveness of menu labeling.  

For the most recent scientific review of menu labeling please click here.

Today I want to mention progress on another hoped for outcome related to menu labeling - changing the amount of calories in meals restaurants offer. The FDA still hasn't issued the final rule on how restaurants are to present the information, but in expectation, it would seem, restaurants are promoting special menus that offer lower than 'usual' calorie amounts.  (Recall the studies I have cited in past posts which showed the average chain restaurant meal having over 900 calories.)

In my anecdotal review (i.e., I have not systematically studied restaurant menus before and after the legislation was passed, or as the final rule approaches, or controlled for the fact that it is the first of the year), I found at least 9 major chain restaurants (e.g., Apple Bees, Outback, Macaroni Grill, Subway, McAlisters, Long John Silvers, IHOP, TGIF) who are promoting entrees with 500 to 600 calories or less.  Subway is advertising breakfast options at 200 or less.

One of the distal (or immediate) outcomes of a menu labeling law is that it heightens peoples awareness of calories and makes calories seem more important. I believe that menu labeling IS effective for these outcomes. The restaurant industry is aware of this and that is why menu labeling laws also work to change what is available - in other words, law can change the environment. Law can have a greater impact on population health than interventions aimed at individuals.  I am confident that once the labeling rule is published and restaurants nationwide fulfill their obligations to post calorie information, we will begin to see a change in the amount of calories purchased and in the future, perhaps, a reduction in the prevalence of diseases associated with being over fat.

Future Self-Control

    I am 100% in favor of mandatory nutrition information at the point of purchase for ready to eat foods at all places where they can be purchased (e.g., restaurant, vending machine, movie theater, bowling alley).  I believe that an interpretive system, like the multiple traffic light (red for high in a nutrient, amber for moderate and green for low), is crucial, but I understand that nutrition labeling as a means to change behavior will always be less effective than other strategies, like zoning laws and taxes.
    The provision of nutrition information, even with a color code or star rating system, leaves individuals free to make an informed choice.  Unfortunately, choosing food isn't the same as choosing a dishwasher (which also comes with content info and a rating system).  
   There are many things that influence a food choice.  One of my favorite theories or frames which addresses these nuances is behavioral economics.  
READ THIS GREAT ARTICLE, by Liu, Wisdom, Roberto, and Liu (2013).  
  The reason I think the traffic light labels are crucial is two fold.  First, most people do not have awareness of dietary guidelines or the nutrition knowledge that allows them to determine if a food is high or low in items that are best limited (e.g., saturated fat, sugar, salt, calories).  Second, many people are present biased in their (food) decision making. In other words, the desire for the taste or the happy memory associated with a certain food, is first and foremost in a present biased persons mind.  The needs of  'here and now' trump any consequences (weight gain, ill health) that might occur sometime in the future.
   There is another factor (noted in the article I linked earlier) that I wanted to share.  I think you will go "oh my gosh, that is so true!" just like I did.  This is the belief or confidence we have in the self-control of our future selves.  For example, on a certain day of the week, you know that you should skip dessert.  You are full and can't afford the extra calories.  But it is someone's birthday so you just have to have some, and you'll do better next time or the next day.  Then someone brings cookies to the office and you really shouldn't have any, but everyone else is having them, and they really taste good, so you eat the cookies and promise yourself that tomorrow you will have dinner with out bread.  Oh, but tomorrow comes and the waitress served bread so you have to eat it, right? etc.....

What foods are healthy and how can you tell from a menu?

To see the summary abstract of the study I refer to in this blog post, please click here.
The lead author is Lillian Sonnenberg.

   The purpose of this particular post is to share the results of another menu labeling study that used the Multiple Traffic Light (MTL) system to help customers identify "healthier" items.  I have a concern and a point to make regarding overall menu labeling, the federal legislation and why my point probably won't make a difference, but first.. a digression.
   Notice that in the above paragraph I put the word healthier in quotation marks.  I did this because in the research publication the authors assessed purchasing of items deemed healthier if they met criteria to be labeled as green. Two of the 5 criteria for a green label were low calorie (e.g., 500 or less for an entree) and low in saturated fat (i.e., < 2 grams).  The researchers also surveyed the customers before and after they introduced the labels.  The foods sold before and after the introduction of the labels were the same and the researchers knew if a person bought a green labeled food even during the time when no labels were posted.  When the researchers asked customers to answer a few questions after their purchase, the researchers also took their receipts.  Therefore, the researchers could match the survey answers with the items purchased.  A funny thing.. even customers who said that they always or almost always choose 'healthy' items were buying foods that were most often red (or unhealthy).  After the labels were placed, the 'healthy' eaters did only slightly better at purchasing green labeled foods.
   The researchers point out that customers do not seem to know what determines a foods healthiness.  I am not at all surprised and to be fair, isn't 'healthy' subjective and likely to change with every news headline?  Instead, I think that the researchers could have defined healthy in their question. They might have asked how often the customer chose foods low in calories or low in saturated fat (but even here a person must possess some nutrition knowledge to know what constitutes low, which is why MTL labels are effective - green = low).  The researchers failed to mention another likelihood for why people who said they chose healthy items did not in fact buy them. It is possible that they said it because it was the socially correct answer, not because it was what they actually do.
   Ok, now my main point.  Since the Affordable Care Act was passed with a National Restaurant Association supported nutrition menu labeling law included, new research has indicated that calorie disclosure alone (as per the law) is not sufficient to change selections.  Instead, menus using the MTL as the Sonnenberg et al study and many others have found, are more effective.  The law should be amended to incorporate these new findings, but it won't be  - nor will it be overturned - even if the ACA is.  I make both assertions for the same reason.  The National Restaurant Association is in large part responsible for the passing of the law - which in many ways is great.  It probably would not have happened without their endorsing it.  They will make sure that the law stays in place because it prevents states and cities from requiring restaurants to do anything different - it mandates a nationally standardized format that a restaurant chain can implement across its regions.  One law - one format.  And the format won't change (even if it isn't effective, or maybe for that very reason)  because if the MTL was used, the menus would be covered in RED and that would be bad for business.  (I think it would force restaurants to revise their recipes - in a good way-, but I just don't see this getting any industry support)
 

Do calorie recommendations make a difference in calories purchased?

   I want to mention a few things from the study I cite below.  Here is the most important one. A conclusion statement in the summary is misleading.  The statement, "Posting calorie benchmarks had no direct impact..." implies that the benchmarks were posted on the menu or menu board, but they were not. The study did not assess the effect of posting daily or per meal calorie recommendations (i.e., the benchmarks) ON A MENU.  It tested the effect of handing someone a piece of paper with this information on it as they walked into a restaurant.  That is a huge difference.  The researchers do not try to say otherwise.  It is just the one sentence that is wrong.  Unfortunately, a lot of people will not read the study to find out the difference.  In addition, it is that conclusion that most of the popular press headlines are touting.

   This was not a study on whether or not menu labeling works.  The study tested the effect of telling someone how many calories they might need in a day and the effect of telling them how many calories they might need in a meal.  In other words, would  people given either piece of information purchase a lower amount of calories than people not given any information.  (This was tested in a situation where calories were listed on menus and in a situation where calories were not listed on menus. That condition did not make a difference.)

    The slips of paper they handed the customers did not seem to help.  But I caution you not to conclude that the information isn't helpful.  There is a big difference in a menu board disclosure and a piece of paper someone hands you.  Still, it fuels my argument for something more powerful and less mathy... traffic light labeling. 

   There was something else I found interesting in this study.  The researchers asked the customers how many calories a doctor or nutritionist would recommend that they consume in a day.   Both men and women substantially UNDER estimated their own caloric needs, by 200 or 300 calories.. and YET, they ordered enough to far exceed their own estimated daily number.

E.g.,  a person who thought they needed 1100 calories for a whole day ordered 900 calories for their lunch.  Again, too much math.  Too much thinking at the point of purchase when other factors, like taste, cost, time, etc are more important.  (isn't it crazy that people think they need 1300 to 1600 hundred calories when our packages refer to a 2000 calorie diet AND people tend to actually consume 2000 or more a day  - more than most people need)

   STILL, the menu item calorie information should be available to every one every where.  Consumers have the right to know what they are eating. However, the best chance for changing the number of calories purchased may come when the restaurants start revising their recipes and the calories AVAILABLE to us become fewer.  Traffic light labels and lower calorie meals.. that's the ticket :)

 (Also, note - the people in this study were all eating at McDonalds.. there might be something about McDonalds customers that is different than other restaurant customers)

Article cited:

Downs, J. S., Wisdom, J., Wansink, B., & Loewenstein, G. (2013). Supplementing menu labeling with calorie recommendations to test for facilitation effects. American Journal of Public Health, e1-e6. doi: 10.2105/AJPH.2013.301218

Summary

See how the type of nutrition label impacts your understanding.

I have spoken of front of pack nutrition labels many times and provided examples of different systems.  A system can be one that appoints stars for meeting a certain criteria, or one that uses a symbol to denote healthiness, or my favorite, one that uses a multiple traffic light.  The multiple traffic light system shows whether the product is low, medium or high in amount of each nutrient most people should limit (i.e., sugar, salt, sat fat and calories).
The most important thing about a front of pack label is that it be standardized across all products, manufacturers and restaurants (if it goes to menu labeling).  Imagine how confusing it would be (and is now in the US) if each company decided what information, if any, to put on the front of a package.  
When it comes to making health and weight related dietary choices the most important disclosures are these: calories, sodium, sugar, and probably saturated fat. We need to be able to see the amount of these nutrients at a glance across items as we shop.  The traffic light system goes one better.  If the traffic light is used, a consumer does not have to do math or know the number of grams or milligrams that are recommended for any one nutrient in a daily diet.  The consumer just has to know that green is better (GO) and red should be limited or avoided (STOP).  In essence, a consumer can aim for mostly green and yellow.
The UK has begun its voluntary traffic light labeling program in grocery stores and it seems to be doing well.
When researchers and public health professionals were making the case for front of pack labels, they put together an on line quiz to test consumers understanding of nutrition labels.  It is still available, here.  I took it and suggest you do as well.  

How menu labeling can help you detect good food gone bad

Last night I ate dinner out with a dear friend at a local Applebee's.

   This particular Applebee's had calorie information for a few items on its print menu.  It had comprehensive nutrition information on its website.  You can see that information here.  I accessed (and assessed) the information prior to my visit, but I could have seen it from my smartphone while at the table.  Not everyone can do either of those two things.
  While dining, I told my friend that I saw some items on the menu that had over 2000 calories.  This was in reference to the research articles I talked about here, which showed the average restaurant meal has over 1000 calories, more than half a days worth for many of us.
   She asked me which items, but I could not remember at the time.  I looked again today and it was the appetizer sample and two dishes with riblets.
   My friend and I both ordered the blackened tilapia meal which had a very reasonable 410 calories (as opposed to the fish and chips which had 1690!).  My meal had less than 410 calories because I asked the chef not to use butter and I replaced the potatoes with steamed broccoli (great service from the wait person and manager, Winston Salem, NC).  My friend and I ate similar volumes of food but I had fewer calories (I make these choices because I like to eat many times a day).  
   The tilapia looked like a good choice and it was a good choice. I can't say the same for the grilled chicken salad which had 1290 calories.  There was also this great find on the children's menu.  The item was titled 'Kids Celery Side with Dressing."  In case you didn't know, 3 whole cups of chopped celery has less than 50 calories.  This 'low calorie' vegetable side item had 220 calories - I am guessing that about 200 of those calories were from the dressing.  To be fair, the celery - even with this dressing - had half the calories of the kids french fries.
    Speaking of kids meals, remember this post regarding the nutrition in children's meals at certain restaurants.  Applebee's did make it to the low end of the upper half of the list with 4 to 8 % of its children meals meeting expert nutrition standards.  It paled in comparison to Subway and even Red Lobster and IHOP.

Oh and btw - I just started a twitter feed so if you want to follow me there you can. I expect I will mostly tweet photos of volumetric meals and maybe an occasional research update, esp related to diet quality and public health policy.  @DeirdreDingman

Menu labeling proceeds without the FDA

    I have noticed that my blog gets the most views when I stick with calorie and menu labeling stories. (don't worry I only see the absolute number of viewers not WHO is viewing the blog.. that's not my department  ha ha)
   Good news.  Two more restaurants have decided to go ahead with menu labeling for all their stores, not just in states or cities where it is already the law.  I don't blame them. Even as the government drags it feet - new estimated date is 2014, the demand from customers is there.
    The two stores in the news are Taco Bell and Starbucks.  I just have a few comments and then I think you should click this link to a great USA Today interactive.  It lets you guess the calories in some of the 2 restaurants meals and beverages.
   My first comments are about Starbucks. The company has now decided to label the items in its pastry cases as well as the beverages.  They have been labeling the beverages for some time. After NYC passed a menu labeling in 2008, researchers conducted a study to compare the amount of calories purchased by Starbucks customers before and after the law and in locations without a law (like Boston at the time).  The law did seem to have the intended effect. The amount of calories purchased did go down after the menu labeling was introduced.  However, when the researchers looked more closely, they found that the customers were buying less food calories, not less beverage calories.  You will see in the USA Today 'game' that the beverages are a substantial source of the calories.
   Now about Taco Bell.  They are also going to post calories on their menus but with great fan fare.....also announced that they would include the amount of protein (in grams) each item contains. REALLY?  Because we don't get enough protein?  The only rationale I see for this is that they want to distract the customer from the fact that most of the items have ridiculous amounts of calories.
   Trust me - Americans as a group are not protein deficient.  What we don't get enough of is vitamins, nutrients, antioxidants and fiber from complex carbohydrates like those in whole grains, fruits and vegetables.  Do I think they should list the amount of carbs in an item - lord gosh NO... That is more confusing than the protein label. (sugar and starches are also carbs).  
   Best ideas for all of us is

•  choose the lower calorie option that has more vegetable than meat and cheese, 
• watch out for too much fat (which you will be doing if you choose the lower calories),
•  choose fruit over potatoes, etc.  
• And try not to drink your calories - unless its a (as in one) glass of beer or wine, maybe.

Here is the citation for the study I mentioned.
Bollinger, Bryan, Phillip Leslie, and Alan Sorensen. Calorie posting in chain restaurants. No. w15648. National Bureau of Economic Research, 2010.

And here is the link again if you waited.  

Does Information Make It Easy?

   This past Monday, the Huffington Post ran an article on menu labeling that was written by two former USDA secretaries.  They were writing in support of the mandate found in the Affordable Care Act that requires restaurant chains and similar establishments to post the calorie contents of their items on menus and menu board.  
   The secretaries, Dan Glickman and Ann Veneman were specifically speaking to the debate over similar establishments, and as I have suggested here, they urged the FDA to include movie theaters in the mandate.  They also called for supermarket inclusion and alluded to sports arenas, but did not mention bowling alleys.  They appeared to be in support of having all of the venues included because they spoke of consumers being able to compare items no matter where they were choosing them.  They said that the regulations should be "inclusive."  They also said, and here is where I disagree, that having information available at all locations will make the healthy choice the easy choice.
    Though it is necessary to have information to make an informed choice and information is necessary to make one that meets your values, having it does not make the healthy choice easy.  Why not? Because information is only one factor that goes into food decisions and if survey research is correct, it is not the number one or even number two factor in this choice.  Along side those lower calorie items (on that menu) are the cheaper ones and the more palatable ones(high sat fat and sugar).  In order for the healthy choice to truly be easy, we have to do something about the unhealthy choice.  We have to find a way to make it LESS desirable.  (raise the price or limit the advertising for instance)

Decision Making Models

For one of my classes this past week, I read some research articles on school vouchers and school choice.  Within this framework, there was a discussion about the use of information.  Here it was using information to decide where to send a child to school.  This goes beyond choosing to move into a good school district, because not everyone has the power to do that.  Voucher programs are one way that parents who cannot live near a school that they like can still have some options.
    When voucher programs are available the decision making model assumes that parents will use information about the schools in the program to choose one that meets their personal values and educational expectations or preferences.  For example, a parent may be interested in student teacher ratio, the size of a class, the size of  a school, the cost (tuition not covered by the voucher), the location, the academic history, the percent of students who graduate, the level of education of the teachers.. and so on and so forth.  A parent may even prioritize their list of preferences. In addition, what a parent feels is a quality of a good school, say student teacher ratio, is not likely to change from day to day or within present company, or when they are feeling blue.  It is  a time consistent and rational preference or value.
    The research on school vouchers tends to show that just having a choice increases a parent's satisfaction with their child's school.  Choice is important.  Research also shows that children of motivated parents do better (regardless of school or choice).  But important for me, research also shows that a lot of the information needed to make a decision is not available, or is not readily available.  This leaves less assertive, familiar or formidable parents unable to go about getting the information.  Heck, they might not even know what makes a school a good school because their educational experience was itself limited.  They lack criteria to judge or select/  
  In reading all of this, my mind went constantly to decision making at the point sale and food. (I have no children, the school voucher issue is not my battle!).  Many people do not know what information is the most important (calories, sugar, fat, sodium, etc) needed to make a decision nor where to find that information.  People who have determined that low calorie, healthier foods are their preference, may still change their mind according to circumstance.  Food decisions are quite often irrational and not time consistent.
   This is more reason for menu labeling that is simple and in your face.  Restaurant and similar establishments (ones that sell FOOD) should provide calorie info, (and I think sat fat and sugar info), put those numbers in a circle that is green, yellow or red and remind people that what they eat today can effect their health tomorrow.