Sunday, December 12, 2010

Menu Labeling May be Used as a Tool, Not Alone as a Public Health Intervention for Controlling the Obesity Epidemic – Cheryl Lu


Given the continual rise and worsening severity in the financial costs and associated health outcomes of the obesity epidemic in the United States, numerous legislative efforts have been made to address this national issue. Menu labeling legislation has been defined as a proposed public health intervention for poor diet and obesity by requiring chain restaurants to provide nutritional information about standard menu items at the point of purchase (1,2). Currently, there are more than thirty states and localities across the nation adopting similar laws that legally require calorie posting and availability of nutritional information (3). The passage of the federal law, the Patient Protection and Affordable Health Care Act (H.R. 3590), in March 2010, mandates menu labeling provisions for restaurants and food vendors to disclose calorie information and nutrient contents to consumers in a uniform and consistent format, which will soon be determined by the U.S. Food and Drug Administration (FDA) (3). Following its enactment, numerous professional health organizations have enthusiastically posited their supports, including American Heart Association (AHA) and American Dietetic Association (ADA), despite mixed and inconsistent research findings in the effectiveness of nutrition labeling with changing consumer behaviors.

Several published research reviews and professional articles have listed the rationales for menu labeling. According to the AHA’s position statement for menu labeling, one of the primary factors contributing to obesity and its related adverse health consequences is the increase in the rate of eating out – Americans spent almost half (46%) of their food dollars eating out in 2004, in comparison to 26 percent in 1976 – and foods eaten away from home typically are served in larger serving sizes and are higher in energy density (4). From the ADA’s statement regarding this initiative, “the act of millions of people making healthful choices can impact the health of the nation and improve the food supply by consumer demand” (3). Ultimately, the desired goal is to provide people with more control over their diets and weight status (5) as a means for tackling the national trend of excessive consumption of unhealthful foods in place of a balanced diet. Other important factors include consumers’ preference to know and the legal right to product information.

The purpose of the present paper is of two-fold. In the first part of this paper, a critique that focuses on the major flaws of the menu labeling policy as an intervention for weight gain and obesity is provided, using the currently available behavioral research studies and social and behavioral principles and concepts. It is important to note that by no means is this paper opposing against menu labeling. In fact, it is the consumer’s right to know. The goal of the critique is to provide some analyses that menu labeling alone is not an effective intervention measure to tackle the issue of the rising obesity rate in America. The focus of the second part of this paper is to present a preliminary proposal for an alternative intervention that include menu labeling as a tool for health professionals and the public to achieve a healthy dietary style.

Critique: Menu Labeling Legislation as an Obesity Intervention

Personal responsibility versus the obesogenic environment

The theoretical explanation of using menu labeling as a policy approach to promote more healthful food choices is primarily based on the Health Belief Model (HBM). The HBM is an intrapersonal behavioral model that explains an individual’s behavior from several criteria of perception, including the perception to a specific health problem or threat, the perceived benefit of adopting a health behavior, and the perceived barriers (6,7). Based on this model, the menu labeling policy assumes the consumers will rationally weigh the risks and benefits that are associated with each food order at the point of purchase. And as a result, nutrition information on chain restaurant menu boards will act as a “cue” to healthier dietary behaviors (8). Under these assumptions, the menu labeling approach is seriously flawed in the manner that it fails to address eating behaviors are irrational (and often emotional) in nature and health are often superseded by social, cultural, and environmental factors (3).

The use of menu labeling/HBM approach places the burden of behavioral change on individuals, rather than acting directly on the overall obesogenic environment. New research data have shown associations between some foods and addictive processes in the brain that are likened to substances of abuse (9). Also, a wealth of studies has identified factors such as high-sugar diets in the modern food environment that can compromise our biological and psychological regulatory systems governing eating and weight control (9). These environmental forces render us to become irresponsible individuals when making food and lifestyle choices.

A consequence of addressing obesity as a personal responsibility by implementing menu labeling alone as an intervention approach is the illusion of control by the public. In her original work on illusion of control, Langer defined the concept as “an expectancy of a personal success probability inappropriately higher than the objective probability would warrant” (10). More specifically, the disclosed calorie information and additional nutrient details may create unrealistically controllable behavioral intentions that do not represent or equate to the actual behavioral change. Some of the current research has already demonstrated this phenomenon. From the work by Elbel and colleagues on the post-labeling effect in New York City in 2008, 27.7 percent of their sample who were aware of the calorie labeling reported that the information had influenced their choices and, among them, 88 percent indicated purchasing fewer calories as a result (11). However, the investigators found no evidence that the calorie information actually resulted in the purchase of fewer calories based on survey responses and transaction receipts (11). Although survey-based and focus-group studies have yielded positive results from consumers stating that they are likely to use menu labels in making decisions about what to purchase (12), these studies only measured behavioral intentions rather than justifying for the actual food choices (13). When actual food choices and total calories consumed were considered and measured, no significant differences in the energy composition of meals ordered or eaten were found between control and calorie-labeled menus in adults aged 18 and above (13,14,15). In certain populations, menu labeling resulted in higher calorie content meals (13, 16). For example, the calorie information on the menus was used to choose a more energy-dense meal and hence higher average energy intake in a male study sample (13).

Taken together, menu labeling is an individualistic approach that frames obesity as personal responsibility and imparts the public with an illusion of control over their actual caloric consumption. Menu labeling alone as an intervention approach fails to address the addictive nature of certain fast foods and sugar-sweetened beverages that have generated the current obesogenic food culture in America.

Emphasis on calories instead of healthy dietary behaviors

The menu labeling legislation focuses the quality of food choices on caloric content, rather than the overall nutrient quality and other healthy dietary behaviors. A major implication of this is the possibility to deliver false nutritional knowledge and beliefs to the public. According to the framing theory, the way that an object is presented can directly influence an individual’s perception toward it (17). A good example of a falsely frame food item is high-fructose corn syrup, the “high-fructose” portion of its name has misled many people to believe that the sweetener is composed mainly of fructose, which contributes to many adverse health consequences related to obesity, despite the fact that it contains about the same amount of glucose and fructose as table sugar (18). Similarly, the use of calorie labeling on chain restaurant menu boards may falsely frame low-calorie foods as better or healthier choices than foods that are higher in calories but may be more nutrient-dense. Another framing bias that menu labeling may create is to associate foods of equal calories to be of equal nutritional value, i.e. the importance of calories from different forms of foods are equal. For example, 300 calories from a beverage may be framed to be as good as 300 calories from a turkey breast sandwich made with whole-wheat toasts (3). And this is exactly what McDonald’s has done in this menu labeling frenzy to reframe itself as a responsible restaurant establishment serving high quality, nutritious food products. In its rebuttal statement regarding childhood obesity, Corporate Vice-President Catherine Adams emphasized their efforts in nutrition labeling since the early 1990’s and the many types of menu items that offer one serving of fruits and vegetables (19). An example within this list is Minute Maid orange juice (19) – although a small serving size of the orange juice contains approximately the same amount of energy (150 kilocalories) as in two medium-sized oranges, the nutritional values of a fruit and its juices are very different. Obviously, menu labeling may become an advertisement tool for fast-food restaurants to frame their products as reasonably healthy based on caloric values, instead of nutrient density.

Though Becker originally developed the labeling theory in 1963 to explain deviance as the creation of social groups via linguistic labels and stereotyping that can lead to self-fulfilling deviant behaviors (20), the theory may be utilized here to explain the relationship between food and society. For example, in the aforementioned study where males were found to order higher energy meals from calorie-labeled menus, labeling theory explains this phenomenon based on the stereotypes that have generally been assigned to men in our society (13) – the male stereotypes are often associated with strength and power, which are qualities that require higher energy input from foods.

Research studies have demonstrated that, to a large degree, consumer selections in restaurants are driven by taste and price rather than the rational consideration about calories (3). Festinger’s theory of cognitive dissonance published in 1962 can be applied in cases where there are multiple conflicting factors affecting a consumer’s ordering behavior. The cognitive dissonance theory describes the tendency of people to seek consistency among conflicting cognitions or beliefs by either making a behavioral change or eliminating the dissonance (21). This phenomenon can occur when consumers need to decide between price and caloric content of their orders. The public is generally very well aware of the cheap pricing rates and the value pricing strategy at chain fast-food restaurants. Therefore, consumers may opt for the larger serving sizes to best economize the monetary value of their food dollars (13). Other factors of consideration may include, but not limited to, taste, convenience, and social pressure.

Focus on the single-meal outcome versus the long-term effect

An inevitable consequence to menu labeling intervention, when public education regarding calories and healthy dietary behaviors has not been fully implemented and utilization of the information is regarded as a personal responsibility, is the emphasis on single-meal (or immediate) outcome rather than the long-term effect for behavioral change. It is important to

note that the legislation do not apply to all restaurants, but only approximately 10% of all restaurants (based on the definition of chain restaurants outlined in the menu labeling mandate in New York City, NY) (11). Weight gain or obesity is the result of a chronic imbalance of too much energy intake that is not compensated by an equal amount of energy expenditure in the form of physical activities. Our daily energy intake is the sum of every eating decision throughout a day. Therefore, one must realize that the obesity epidemic can be controlled only if healthy lifestyle behaviors, including both components of diet and physical activity, can be maintained on a long-term basis.

At present, there has been only one behavioral research performed that investigated the effect of menu labeling beyond one single meal. Roberto et al (15) examined the caloric intake during and after a study dinner, i.e. during and after the exposure to calorie labeling on menus. The experiment found individuals in the calorie labeling condition consumed more calories after the study dinner than those using the control (no calorie labeling) menu. The authors explained this behavior as a compensatory effect from the earlier reduction in ordering during the study meal. Interestingly, when participants were provided with a one-sentence reminder that the daily caloric recommendation for healthy adults is 2000 calories, a significant reduction in calories ordered and consumed following the study dinner was observed, suggesting an education requirement with calorie interpretation. Another important finding from this and other similar studies is the null result of ordering behaviors for desserts and sugar-sweetened beverages. This finding is of great implication because it further indicates the failure of menu labeling to reduce the consumption of these unhealthy foods despite that they are highly calorie-dense and sugar-sweetened beverages have been linked to overweight and obesity in epidemiological studies.

An Alternative Approach: Using Menu Labeling as a Tool in a Multi-Faceted Intervention

Given the great numbers of social factors and physiological complexities associated with the issue of obesity, interventions that utilize just a single mode of action are unlikely to induce changes in the many behaviors that are either the causes or the results of being overweight or obese. Multiple sources within the academia have proposed the use of a multi-faceted approach to address the epidemic by targeting and promoting various health behaviors (3,9,11,13) such as healthy dietary behavior and development of exercise habits.

When the goal behavior for change involves a long-term maintenance component, the associated factors of social norm must be considered to ensure the maximum rate of change. The American eating culture has changed dramatically since the Second World War. Today, 45 percent of American adults agree that restaurants are an essential part of their lifestyle, according a report by the National Restaurant Association (12). And the social norms that have been associated with eating at fast-food restaurants are better taste, cheaper price, convenience, and fun – all of which are generally considered with greater importance than people’s interests in nutrition and health at the time of purchase (3,8,11,13,14). These factors represent points of intervention when designing a comprehensive intervention.

Collective responsibility & Re-setting the optimal default

It is clear that a collective responsibility involving the general public, school system, government, and the food industry is necessary to efficiently change our current obesogenic environment. An important concept that was brought up by Brownell and colleagues is optimal default. Optimal default is defined as an economic construction that uses the “default” conditions to make profound effects on environment (9). Resetting some of the defaults in our current food environment through policy making may bring up an amplifying effect of positive change. An example policy point can be mandating chain restaurants to serve at least a serving of fruit or vegetable with each entrée or value-meal sold. By making a fruit or vegetable a default of sale in restaurants, consumers can be exposed to greater availabilities of these nutrient-dense foods and the 5-A-Day campaign may be further promoted. Another point of policy intervention is to mandate the elimination of value pricing in chain fast-food restaurants along with imposition of higher taxes on calorie-dense, low-nutrient foods such as snacks and sugary beverages. By setting unhealthy food products at high default prices, the association of fast foods as cheap eats may be addressed. Also, the tax profits may be used to offset the financial costs of obesity and its related adverse health outcomes such as diabetes and cardiovascular diseases.

To address the possible psychological reactance that is often associated with the processes of legislative policy making, especially involving tax increases, promotional campaigns like Truth that utilize marketing strategies may be adopted to promote anti-fast-food behaviors. The Truth anti-smoking campaign employed strategies that involved their target audience (i.e. youth involvement), created role brand for youth, and used a tone that reflected youth’s view about tobacco (22). Similar strategies can be used for anti-fast-food campaigns targeted at children and adolescents by making it the “truth” that obesity threatens the health status of 44.3 million American adults in the U.S. (8) – a very sad fact. It is important to create public awareness that a collective responsibility is critical in making the necessary changes of our environment.

Reframing food/eating behaviors as positive and fun

Because eating out at restaurants has become a widely accepted and practiced social norm in American adults (12), the impacts associated with this increasing trend of dining out must be addressed. National survey data has shown people consume almost twice as many calories at restaurants than at home, with higher saturated fat and less fiber and calcium (14). The two major consequences associated with this new norm of dietary behavior are adult and childhood obesity. One of the reasons to why obesity tends to run in families is the positive correlation between calories ordered/consumed by parents and for child (14).

Public health interventions utilizing framing theory may be used to reframe home cooking as a positive and fun activity. The points of approach should include both children and parents. To target children, the approach is to introduce a favorable attitude toward cooking and food preparation by oneself through allowing explorations with raw foods and ingredients and ultimately developing a positive relationship with healthful foods. A good example with this approach is Sesame Workshop’s Food For Thought that supports food security of young children in low-income families (23). The use of Sesame cartoon characters, including Elmo and Cookie Monster, for promotion can function as an effective intervention based on the concept of liking (24). To target the adults or parents, the point of intervention may start with the family core value by utilizing the theory of Maslow’s hierarchy of needs (25). An advertising campaign may be created that combines “family” as the core value with advertising theory (24). This campaign can offer improvements in family relationship and cohesiveness as the main “promise” that is supported with a story of an ordinary family having a fun time while home cooking with the all family members. Finally, framing theory may be helpful in the reframing of home cooking as an activity that is as convenient and easy as eating out at restaurants.

Educational resources

The current food labeling system has caused major confusions and misconceptions in the general public (3). According to an International Food Information Council Foundation (IFIC) focus-group study, participants almost universally believed that the disclosed serving size information is inaccurate and unintuitive; and there is great misunderstanding associated with interpreting the Daily Value of product composition on food labels (26). Given the mistrust and misconception that have been regarded with food labels, educational programs and resources from credible sources must be provided to the public to generate accurate nutritional knowledge and beliefs.

The role of menu labeling in a comprehensive approach to obesity intervention should be minor. The goal is to use menu labeling as a tool, but not to overwhelm people with the mathematics and should by no means create healthy eating as a mathematical event. For example, the calorie labeling on menu boards may be used as a guide to identify foods that are energy-dense, but are of low nutritive values. To do this, a nutritional education program that conveys healthy eating behaviors by educating basic nutritional knowledge must be provided to support the understanding and interpretation of nutritional information on menus.

A significant component of a healthy lifestyle includes regular behaviors of physical activity. To complete the multi-faceted approach, physical activity requirements must be addressed in our intervention. However, the factors (such as the safety of neighborhoods and accessibility to exercise equipment) that are involved in determining physical activity behaviors are quite different to healthy dietary behaviors. Other comprehensive approach utilizing the appropriate social and behavioral instruments and theories should be explored to target this issue specifically.

It is important to note that educational resources are not provided unaccompanied with other components of this multi-faceted intervention. The delivery of these information should consider and take into account the relevant social norms, while present the educational materials in the appropriate context.

Concluding Remarks

Policy makers must realize that the problem with obesity is not a simple equation comprising of one variable of excessive caloric intake. Rather, the problem is multi-faceted and hence a comprehensive approach is necessary to effectively and accurately treat the root causes. Personal responsibility alone does not lead to efficient and effective behavioral changes given that external cues and internal emotions often override our rational thoughts when making decisions about food consumption (3). The menu labeling policy should not be used alone as a way to address uncontrolled weight gain, rather it is meant to be used as a tool in an intervention that is designed to be inclusive regarding the major factors related to obesity. This is because when counting calories is not the primary concern for ordering, menu labeling has a very limited effect on weight control. The proposed multi-faceted intervention approaches the obesity issue from several directions, using several different social behavioral concepts and theories. For the outlook, more research should be carried out to investigate and explore other possible effects, both beneficial and adverse, of the menu labeling legislation after its national implementation in the near future.


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