Monday, December 13, 2010

When Information Isn’t Enough: A Critique of Nutrition Labeling in Fast Food Restaurants Based on the Health Belief Model – Meredith Wallace

Today, Americans spend over $400 billion each year on food outside of the home (1). Approximately 32% of total daily calories are from food consumed away from home (2), accounting for over half of an individual’s total food spending (3). Data consistently highlight the negative health impacts of frequent fast food consumption, including weight gain (3). In the face of the obesity epidemic in the United States, combined with increasing prevalence of heart disease and diabetes, recent efforts have focused on providing information to consumers to encourage better nutrition choices. The Health Care Reform Act passed in 2010 requires chain restaurants with 20 or more establishments post calorie counts on menus or in close proximity to the point-of-purchase (4). Although providing caloric information is an important first step in improving the dietary decisions and long-term health of our nation, it is not sufficient to accomplish this goal as providing information alone will not produce the desired behavior change.
Though packaged foods have been required to include a nutrition facts panel (NFP) since the Nutrition Labeling and Education Act (NELA) was passed in 1990 and effective in 1994 (2), restaurants and fast food chains were previously exempted from these requirements (5). The underlying rationale for requiring publication of nutrition facts was “to help consumers choose more healthful foods by providing them access to consistent, standardized, and credible nutrition information” in an effort to empower them to make better diet decisions (2). Ultimately, long-term health benefits, including reduced incidence of heart disease and cancer, were anticipated from improved diets (5). Given the increasing proportion of meals eaten outside the home (6), the current legislation expands this intervention beyond packaged food, hoping to combat the increasing prevalence of obesity by improving consumer knowledge of nutrition of fast food menu items (4; 6; 7).
Given the reliance on the Health Belief Model, several fundamental flaws preclude the success of this intervention. The belief that providing information will alone translate into the desired behavior change, a key element of the Health Belief Model, is an inherently flawed approach given the reliance on the movement from intention to behavior. Additionally, the assumption of rational behavior further undermines the success of this effort. Finally, by identifying “healthy” and “unhealthy” menu options, consumers are reminded of the risk and dietary implications associated with a high-calorie diet, increasing perceived severity and potentially reinforcing the consumption of unhealthy foods.
Failure to Translate Information into Action
Consumers significantly underestimate the calories in food consumed outside of the home and generally have poor nutritional understanding (6). Caloric estimations are particularly inaccurate for high-calorie foods, and one study found 99% of individuals underestimated the calories contained in extremely high calorie items (6). Given the lack of knowledge of nutritional content of food, providing caloric information on restaurant menu items is intended to allow the consumer to contextualize the impact of dietary decisions given their daily nutritional requirements. In fact, the provision in the Health Reform Act also requires information on the suggested daily value in addition to the calorie information for each item (4). A key piece of the cost-benefit analysis performed by the FDA when considering implementing menu labeling requirements was the hypothesized improvements in health due to changes in ordering behavior (2). This evidence points to the explicit assumption that providing information would change behavior of restaurant customers.
To review, the Health Belief Model (HBM) incorporates perceived susceptibility and perceived severity of the undesirable health outcome with perceived benefits of adopting a recommended behavior and perceived barriers to doing that behavior, resulting in the intention to change behavior and ultimate adoption of the recommended behavior (8). A key piece of this model is the cue to action which ultimately motivates the likelihood of taking the preventative action (8). Even when perceived susceptibility and perceived severity of a given outcome are low, the model indicates that a strong cue to action can inspire the desired behavior (8). Furthermore, the model assumes that the intention to adopt the recommended behavior translates to action (8).
As the nutrition labeling requirement is designed, providing caloric information in the context of daily requirements provides the cue to action by calling attention to the nutrition of each menu item. According to the HBM, this should directly increase the perceived threat of a high-calorie diet and associated health outcomes, which leads to an increased likelihood of changing ordering behavior.
However, the fundamental flaw of the HBM is the assumed translation of intention to behavior. Individuals patronizing fast food restaurants likely do not have the desire for a healthy diet, and ordering decisions may form the basis of restaurant selection thus be difficult to change at the point-of-purchase (3). As one fast food executive noted, “people may go where healthier foods are advertised, but they usually wind up eating the same old stuff” (11). Changing ordering behaviors requires an individual desire to improve eating behavior, which is not necessarily instilled by merely providing calorie information (6). Furthermore, success of menu labeling requires availability of alternative options that are more nutritious, equally tasteful and of comparable price (6). As such, simply providing nutrition information is not a sufficiently intense cue to action to inspire a behavior change among these individuals.
Several studies have highlighted the weakness in translating intention to behavior, as proposed in the HBM. Based on customer behavior data in New York City, where menu labeling was instituted in 2008, almost 28% of consumers noticed labels, but no change in ordering behavior (in terms of caloric content) was observed (4). While there was a significant increase in customer-reported awareness of calorie information, from 24% pre-enforcement of labeling requirements to 64% post-enforcement, only 27% of individuals who saw the calorie information reported using this information when ordering (7). Outside of the restaurant context, both objective knowledge of the healthy characteristics of consuming fish and desire in a healthy diet had an insignificant, though weakly positive, influence on actual fish consumption (9). Thus, neither dietary knowledge nor intention translated to a positive behavior change (9). These data exemplify the fallacy of the HBM that knowledge translates to an intention to change behavior, thus exposing a significant flaw in the foundation of the intervention that seeks to change behavior by providing calorie information.
Irrationality of Behavior
In addition to assuming individuals will be inspired to change their dietary behavior based on the simple cue to action of knowing caloric content of menu choices, the nutrition labeling policy also assumes that individuals will make a rational decision based on the information available. Following the tenants of the HBM, it is assumed that individuals will select less caloric foods that are better for their health when provided with nutritional information. Even the federal judge that upheld the regulation requiring restaurants in New York City to label menu items cited the rational decision making process of consumers in his opinion, “It seems reasonable to expect that some consumers will use the information [provided on menu boards] to select lower-calorie meals”, thus helping to lower the prevalence of obesity (10).
However, the HBM has frequently been critiqued for the assumption of rational behavior (11). Specifically, in a proposal to expand the HBM, Burns directly addresses the assumption that individuals often act irrationally, based on emotions, thereby missing or ignoring cues for action (11).
Data in the literature is mixed regarding the impact of availability of calorie information on consumption, though few studies have shown conclusive evidence of improved health behaviors resulting from increased nutrition awareness (12). One study found that providing nutrition label did not improve decision making in terms of caloric intake or sodium (2) indicating consumers do not make rational decisions regarding nutrition. Furthermore, some data indicate there is no support for a reduction in total fat, saturated fat or cholesterol intake when nutrition information is available (2). When pricing was held constant, males consumed an average of 200 additional calories when nutrition information was provided compared to when only price information was available (12). Furthermore, the study found similar caloric consumption across the four conditions designed to determine the impact of both value pricing and availability of caloric information (12).
The ability to make a rational decision also relies on the availability of healthy alternatives that are equal appealing in terms of taste and cost. However, market research indicates that as long as unhealthy foods are available, they will be selected over healthy alternatives (13). This is largely driven by the fact that food choice in the United States is influenced most by taste and cost rather than dietary considerations (14; 13). As such, evidence demonstrates that even when presented with the information to improve their diet individuals do not make rational nutritional decisions, further undermining the success of menu labeling efforts.
Continued Poor Diet Choices Resulting from Increased Perceived Severity
Information provided at the point-of-purchase regarding the proportion of recommended daily value a menu item contains is designed to convey the direct dietary impact of that decision. Drawing attention to the caloric content of restaurant menu items thereby increases the perceived severity influence in the HBM construct by highlighting the significant dietary impact of these food choices. Perceived severity is partially dependent on knowledge (8), thus the nutritional labeling intervention is designed to provide information necessary to increase the perceived risks of consuming high-calorie menu items on nutrition and recommended daily intake.
However, focusing on nutritional value of food indulgences, like restaurants and fast food establishments, may also cause demotivation and fail to result in a behavior change, resulting in a “backlash” (15). As discussed in class, data indicates there is a reverse influence where increased perceived severity promotes negative behavior (promotes rebellious behavior) rather than the desired outcome. As mentioned previously, providing calorie information resulted in increased calorie consumption among males compared to when nutritional information was not available (12). Rather than reducing calorie intake through nutritional awareness, the information resulted in increased consumption, demonstrating the negative impact of increasing perceived severity within the HBM construct.
Similar to the desire to reinstate freedom due a perceived threat, as described by the Theory of Psychological Reactance (17; 16), it is likely that labeling menu items with calorie information is perceived as a forceful instruction on how to make dietary decisions. Under the tenants of this theory, perceived threats to freedom, such as being instructed to order healthier items, instills psychological reactance and motivates the individual to reestablish their freedom (16). Given the data on increased calorie consumption following awareness of nutrition information, the negative impact of increasing perceived severity on the likelihood of action observed in the HBM may operate through a similar mechanism as the desire to reestablish freedom explained by reactance theory. As one 10th grade male stated during market research, “overall it is really hard to tell American teenagers what to do… [i]f you tell them to do one thing, they’ll do the other” (13).
The strong desire for freedom thus supersedes willingness to use nutrition information provided at fast food restaurants by increasing the perceived severity of high-calorie menu selections, resulting in continued consumption of unhealthy foods. Thus, the intent of providing information to consumers backfires, propagating high-calorie diets among fast food consumers.

A Comprehensive Solution
To support improved nutritional choices by consumers when eating away from the home, a comprehensive, multi-faceted program to improve nutritional awareness and convey benefits of a healthy lifestyle is required. As discussed, a single, point-of-purchase intervention of providing caloric information is not sufficient to produce the desired improvement in our nation’s health. Diet change involves multiple decisions and trade-offs with delayed results of weight loss (18), and the HBM is poor at predicting long-term decisions, thus it is critical to expand the focus of the intervention to include broad health-related benefits of healthy nutrition behavior (9).
Rather relying on the assumption of the HBM that intention and likelihood of adoption a behavior translates into action, leveraging Advertising Theory to draw on the emotions of consumers is a more direct approach to inspiring behavior change. The main tenant of Advertising Theory is to make a promise to the consumer, with larger promises being most effective in motivating behavior (19). Drawing on core values important to individuals, regardless of their accuracy or relevance to the desired outcome (improved health), provides the foundation of a successful advertising campaign (19).
For example, a media campaign in support of menu labeling could draw on core values such as time with family, improved longevity and desire for control by providing evidence and images of families enjoying “healthy” menu items in a fast food restaurant. Emotional cues, such as imagery, music and storyline, would effectively inspire individuals to select healthier menu options given the promised benefits. Furthermore, emphasizing the ability to control one’s health through diet choice would empower individuals and appeal to an important core value. Similar to the Gardasil commercials which emphasize control and the promise of a healthy, carefree life without the concern of HPV or cervical cancer (20), ability to control one’s diet and future health can be promoted through this campaign. Exposure to this information prior to visiting a fast food restaurant would likely reduce the preconceived notion of order preference (3), as discussed earlier.
This approach also employs the Law of Small numbers, which leverages the tendency of individuals to underestimate the implications of a small sample size (21). After observing examples of individuals who improved their health following diet modifications, consumers would be more likely to believe they too would benefit from healthier menu choices. Similar to the Subway commercials highlighting the transformation of Jared and others influenced by his diet (22), a commercial might tell the story of a middle-aged man who lost weight and reversed his type 2 diabetes diagnosis following a switch from a daily Big Mac value meal to a grilled chicken sandwich or salad from the same fast food restaurant. This story would demonstrate the ability to enjoy fast food while improving health and long-term outcomes. This approach would complement the other aspects of the campaign, including continued availability of nutrition information at point-of-purchase. By addressing core values and providing concrete illustrations of the benefits of healthier menu selections when at fast food restaurants, this addition to the campaign would directly address the flaw in the current intervention of simply providing caloric information to consumers and assuming behavior will change.
As highlighted previously, behavior is not always rational. Given that menu labeling has yet to produce significant behavior changes regarding nutritional choices in food consumed away from the home, there is an opportunity to leverage the irrationality of human behavior as public health tool. When making decisions, individuals rely on relativity to compare available options (23). As discussed by Dan Ariely, whether selecting between newspaper subscription options, homes or partners, we compare the relative options available when making our decisions (23). Translating this idea to menu options at a fast food restaurant, a single cheeseburger may be relatively more “healthy” than the double cheeseburger, but both may represent over half of one’s required daily caloric intake when combined with the traditional side dishes and beverage selection. Furthermore, when a “decoy” is presented, or an option that is similar but slightly inferior to one of the other options, people tend to focus on the more similar options and select the one that is superior (23). Returning to fast food menu options, proposals have been made to offer combinations which include healthier side dishes, such as fruit or salad and bottled water, as a healthier alternative to traditional value meals (18). Consistent with the decoy model, providing a slightly healthier option could entice individuals to make small changes in ordering behavior as compared to the other menu options. For example, comparing a salad compared to a value meal with fries and soda might be difficult for a consumer given the inherent differences of the options. However adding the new alternative of a value meal with salad and bottled water, which is relatively similar to the original value meal option, will make the new, somewhat healthier option seem the most attractive. By leveraging the theory of relativity, the desired behavior change is accomplished.
Additional research indicates the order in which menu items are presented impacts the ultimate selection of customers (18). When healthier items are presented first consumers are better able to identify and ultimately select these options (18), perhaps because seeing these items first sets the frame of expectations for the appropriate caloric intake for the meal. Rather than labeling items as “healthy”, which one fast food executive noted “scares people away” (24), simply altering the order in which information is presented might result in a positive behavior change. As such, working with restaurants to reconfigure menus to leverage the predictable irrationality of individuals could result in more nutritious ordering.
Finally, addressing the focus on perceived severity of ordering high-calorie menu items and resulting continuation of negative diet behavior, it is important to consider tools to decrease psychological reactance and promote self-efficacy. Rather than focusing solely on the negative aspects of fast food (calories), individuals should be empowered to make small, manageable changes to improve their diet, thereby increasing self-efficacy of the ability to change one’s diet and improve health in the long-term.
To minimize reactance, the method in which the campaign proposed above is implemented is critical. One key lever to reducing perceived psychological reactance is increasing the similarity of the perceived message source with the target audience (25). As such, the individual featured in the media campaign that illustrates the promise of improved health through small changes in fast food menu selections should be representative of the “typical” fast food customer. Data demonstrate that the more similar the source to the recipient of the message, the more likely the recipient is to accept the message, even if it is inconsistent with their initial beliefs (25). As such, leveraging segmentation data would increase the impact of this campaign, given the varying demographics, values and attitudes of groups within the population (26). A second method to reduce reactance is obscuring the source of the message. As discussed in class, the appearance that there is no source of the message reduces reactance as it is less authoritative and has less of an impact on the perceived threat of freedom. The personal, emotion-based campaign embodies this concept as there would be no apparent source of the campaign. Rather, the personal stories of success would provide the motivation to improve dietary decisions of consumers.
While menu labeling can be part of the solution, a comprehensive and systematic campaign incorporating multiple approaches is required to reverse the obesity epidemic in the United States (18). Despite the fundamental flaws in the existing menu labeling initiative passed as part of the 2010 Health Reform Act, opportunities exist to refine and expand the approach to improve awareness and understanding of more healthful nutritional options when eating away from the home. Specifically, a campaign that leverages a range of social behavioral theories for effective social communication, such as Advertising Theory, irrationality of behavior and psychological reactance, evolves the current approach by considering the emotional-basis of behavior. Initiating and sustaining healthy eating behavior is difficult, thus relying on a single approach of providing information and assuming the desired outcome will result is not an effective solution.

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