Shortcomings of Restaurant Menu-Labeling Laws: Consumers Desire Information but Do Not Act Upon It- Sarah Kenney

It goes without saying that obesity is a large public health problem in the United States, no pun intended. Obesity levels have doubled since 1960, with approximately two-thirds of American adults currently classified as overweight or obese (1). This rise in obesity rates has been linked to an array of chronic diseases and to mortality and morbidity. While the contributing factors to obesity are multifactorial, the most obvious correlation is the link between weight gain due to increased calorie intake. Between 1970 and 2000, caloric intake increased on average by 168 calories per day and 335 calories per day for men and women, respectively (1).

In the same time span that we have seen obesity on the rise, there has also been a steady increase in the frequency that Americans eat meals outside the home. Americans eat out twice as often as they did in 1970, and the average person consumes about one-third of their caloric needs outside the home (2). Between 1997 and 2007, restaurant sales increased from about $323 billion to $537 billion, a 66% increase (3). These sales represent about half of Americans’ food budgets.

It is believed that food purchased outside the home is partially responsible for the increased intake and poor diets seen in most Americans. This food is typically higher in calories and of poor nutritional quality (ex. high in saturated fat and low in fiber). Additionally, it is served in large portions, which encourages over-consumption (4). Eating fast food has been independently associated with not only weight gain, but also insulin resistance and type 2 diabetes (3). The typical adult eats restaurant food an average of 5.8 times per week (5). On average, adults consume about 205 calories more on days when they eat fast food (6). Given these two statistics, an adult will take in an additional 1189 calories per week just from eating outside the home. Over the course of one year, this represents an 18-pound weight gain, if not countered with reduced caloric intake during other meals and/or exercise.

Due to these alarming statistics and the unlikelihood that restaurant patronage will decline given the “fast-paced” lifestyle most Americans lead, the government has taken action to aid people in making informed decisions when eating out, with the goal being that when provided with nutrition information, people will choose a healthier alternative. Action has been taken on the local, state and federal level over the last five years. Most recently, in March 2010, the Restaurant Nutrition Menu Labeling Requirement, Section 4205 of the Patient Protection and Affordable Care Act, was signed into law and requires restaurants with more than 20 locations to post calorie information for all food items sold, with additional nutrition information available upon request (7). Restaurants had previously been exempt from the 1990 Nutrition Labeling and Education Act, which required nutrition labels on food products (5). The new law will be implemented over the course of the next two years, as the U.S. Food and Drug Administration (FDA) must determine specific regulations and then allow time for owners to make the changes in order to be in compliance with the law (8).

While we wait for the gradual implementation and data collection in order to determine the efficacy of the law, we can look to similar interventions previously implemented at the state and local level, most notably in New York City, to predict the national level results. In July 2008 New York City became the first U.S. jurisdiction to implement a law requiring the posting of nutrition information in restaurants that had fifteen or more locations (9). While the intervention has good intentions, it has thus far proven unsuccessful due to fundamental flaws in design, specifically regarding underlying assumptions made regarding human behavior. Three main problems with the intervention are: 1) it assumes people behave rationally and that intention leads to behavior; 2) it assumes it understands what people want; and 3) it assumes people can contextualize calorie information.

Intention Does Not Equal Behavior

The Health Belief Model is based on the assumption that people behave rationally (10). The theory further states that when there is a balance between the perceived benefits of an action and the perceived barriers to that action, an intention to perform that action is created. The restaurant menu-labeling law is based on the assumption that, when presented with calorie information for a variety of items, customers will use this information to choose a “healthier” option, one that is lower in calories than their typical order. The perceived benefit of choosing a healthier menu option is an improvement in health. The barriers to choosing a healthier option are low, as the information is clearly available. Reducing the barriers to the action helps to balance it with the benefits. But, one of the flaws in the Health Belief Model is that it states that intention leads to behavior, which is not always true (10). The restaurant menu-labeling law follows this incorrect assumption, with research to support the fallacy of the theory.

Multiple national polls have reported that the majority of the population (between 67-83%) support menu labeling and 89% of New Yorkers were also supportive of the new policy (5). Additionally, a poll of low-income and minority individuals, who are at a higher risk for lifestyle-related diseases, such as obesity and type 2 diabetes, found that the majority (93%) thought calorie information was important while 86% believed restaurants should be required to post calorie information (11). While the general population is receptive and supportive of the changes, indicating they are aware of the perceived benefits of healthy eating, when presented with the desired data at the point-of-purchase, customers are not making better choices. One study found no significant difference in the calorie content of meals ordered and eaten between one group given calorie information on the menu and a control group (12). This same study found that intake was similar between subjects who reported noticing calorie information and those who did not, demonstrating that while people state they want to know calorie information; it does not affect their menu choices (12). Another study reported 71% of participants noticing nutrition information, but only 20% of these choosing a lower calorie option as a result (13). These results are similar to two additional studies, both showing that only about 27% of patrons use the information when making decisions (6, 9). These studies show that while intention is present (people wanting the information posted), this rarely leads to behavior change (choosing a lower calorie option). This is not to come as a surprise, as a 2007 study of focus groups found that the majority of participants wanted the information made available to them, but admitted that they would not always consider it when deciding what to order (14).

Understanding What Drives People

The key to successfully marketing a campaign, whether it be for a product or a public health intervention, is knowing what your target audience wants and creating the promotion around that desire; this is the basis of Marketing Theory (15). We know that people support posting calorie information, but it is assumed that people desire this information because they want to use it to make better food choices to improve their health (i.e., lower calorie options). While this may be the driving force for some people (approximately 20%), the evidence shows that some individuals use this information in other ways. For example, the subpopulation of males in a 2008 study seemed to use the calorie information to choose a higher caloric meal (12). Researchers explained this as a desire by men for an energy dense meal. Labeling could also be used by low-income populations to identify the calorically dense, “value” items on the menu (16). Often fast-food is seen as a cheap source of calories, as opposed to high-cost, low-calorie fresh fruits and vegetables. In this case, an individual would be in favor of labeling, but for the opposite reason researcher intend it to be used for.

The labeling campaign also makes the assumption that calories are the most important measure to customers when trying to identify a healthy meal option. To identify the overall health value of a food item, other nutritional components must be identified, such as total fat, saturated fat, sodium, fiber, etc. To the 8% of the American population with diabetes, they would argue that total carbohydrate should be posted on the menu (17). 30% of the population has hypertension and may want to see sodium levels (18). A study randomized participants to receive menus with either no nutrition information (control), just calories, or a menu with calories, fat and sodium levels. Results showed that there was not a decrease in the ordering of the chef’s salad option when just given calorie information. But, when provided with fat and sodium levels there was a significant decrease in order compared to both the control and the calorie-only menu, indicating that consumers use more than just calories to make diet decisions (5). The law requires other nutrition information to be available in writing if requested, but there has been no research to show that, when given an option of what is posted, the public prefers calories to other nutritional markers.

Lastly, research shows that although people support these measures, taste is most important in ordering, not nutrition. Two studies had participants rank the importance of a variety of factors in purchasing foods and in both, taste ranked first, with convenience, price, cravings and family preference following, and nutrition ranking lowest (12, 13).

Putting Calories in Context

Providing calorie information for menu items is only useful if the individual understands what that means to them. Energy needs differ for everyone based on age, gender, height, weight, activity level and illness. While it is unreasonable to advise that each person know their exact caloric needs, it is necessary that individuals have a general understanding of acceptable calorie ranges for weight maintenance in adults. Without this knowledge, telling someone that a sandwich has 625 calories, for example, is practically useless. They can only compare it to other menu items, not to daily calorie requirements. The labeling law does not take this potential lack of knowledge into account, thus decreasing the potential effectiveness of the information.

Research has shown that people, even nutritionists, underestimate the calories in meals eaten outside of the home (5). One study found that 90% of consumers underestimated calorie content of items by an average of 600 calories (50% less than the actual content) (3). A baseline study was conducted in New York City prior to the implementation of the labeling law to measure mean caloric intake at lunchtime. The average calories for a lunchtime order were 827 calories, and one-third of purchases exceeded 1,000 calories (1). Standard energy needs for most healthy adults is about 2,000 calories per day. If this is divided between three meals, with no snacking in between, meals should average about 670 calories. With standard orders well above this level and assuming most people snack between meals, it is not surprising people gain weight if they regularly eat out.

When menu-labeling is implemented, customers notice the calories and a significant portion of them indicate that they use the information in making their decisions. But, studies show that while these people believe they are making better choices, calories ordered and eaten do not differ from before labeling. A survey in New York City looking at the effectiveness of menu-labeling at McDonald’s showed that 82% of patrons reported that labeling impacted their choices, but there was no difference found in calories ordered compared to menus with and without labeling (5). In a study that measured calories ordered before and after implementation of the law in New York City, 88% of participants reported they purchased fewer calories in response to the labeling, but calories ordered were actually 21 calories higher after the law was implemented (9). In subgroup analysis in the same study, some groups showed non-significant increases for groups who indicated labeling was important to them (9). These results support the argument that without putting calorie information into context, choices are not altered.

An experiment in menu labeling found that the labeling only affected amount of food consumed when paired with information stating that 2,000 calories was the recommended daily value (9). Participants in a separate study indicated that they preferred a menu that provided suggested calories per meal instead of calories per day included with the labeling (19).

Creating Effective Restaurant Menu-Labeling Laws

Again, the proponents of the labeling laws have good intentions, and the intervention is not completely without merit, but there is room for improvements.

In order to make the nutrition information posted more valuable to consumers, the information must be put into a useful context. There are a few possible ways this could be done. First, the FDA could mandate that restaurants post a statement saying that typical daily caloric needs are 2,000 calories. An alternative to this is to post a statement stating how many calories should be in an average meal, as was preferred by study participants (19). The possible issue with this is that not everyone divides his or her calories the same way throughout the day. Some people might choose three “square” meals, while others might eat five to six small meals throughout the day. It may not be difficult to post both versions in the same sentence, which would cater to different preferences (i.e. “The average American should consume 2,000 calories/day, or between 600-700 calories in each of three meals per day.”). Another way of indicating the nutritional value of menu items without providing calories is to use an icon system. Focus groups indicated that using a symbol to identify healthier choices could be helpful (14). This would be beneficial to patrons who have an aversion to calorie counting or who lack the knowledge necessary to contextualize the calorie amounts. It would also make identifying healthy options quick and easy, compared to trying to complete a cost-benefit analysis on menu items (calories vs. cost vs. cravings).

Proponents of the law need to address the underlying wants and desires of people who eat outside the home. By going back and completing this market research, they might discover that the driving force for most people is not calorie levels. Customers who have specialized diet needs and require additional nutrition information may not feel comfortable asking for this information or may not have access to the Internet to complete the research needed before eating out. In order to satisfy customers who desire nutrition information outside of calorie amounts, restaurants can again, use a symbol system to identify foods that meet certain requirements (low sodium, low saturated fat, etc.)

For the campaign to be successful, it is important that the final menu choice is always perceived to belong to the customer. To this end, the campaign should not “preach” to customers about choosing healthier options, as this will lead to reactance, and customers will choose the higher calorie options. The promotion would be better off having an advertising campaign that used a Registered Dietician to explain that all options can fit into a healthful diet. This can be done by understanding your calorie needs and how to adjust your intake when you choose your favorite, high calorie restaurant foods, and by explaining that lower calorie options exist, if you choose not to indulge at that meal. Advertising Theory can be used to sell the promise of such ideals as better health, increased energy, happiness, and attractiveness that come with choosing the healthy options.

Conclusion

With the passing of the recent health care bill, restaurant menu-labeling will soon be a reality in everyone’s life. As the FDA begins to draft its mandates for implementation of the national law, they should look to the research that has come from other trials and studies. While the evidence supporting the effectiveness of these laws is mixed at best, the research provides a starting point and indicates that small changes in delivery can lead to significant improvements in efficacy. By conducting market research and listening to the desires of the consumer, it is possible to make this intervention a successful tool in the campaign to fight obesity and chronic disease.

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