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Monday, July 9, 2012

Calorie counting on menus ~ The US experience

The Minister for Health here in Ireland wants to introduce calorie counts on menus and has given the industry 6 months to implement the proposal or, if they fail to  do so, legislation will be introduced. All packaged food requires full nutrition labeling, so it would seem quite reasonable to require the food service sector to follow suit. Calorie counts on menus were first introduced into New York in 2008 and, in 2010, the US Congress passed an act which required menu labeling for all restaurants with 20 or more locations. Researchers at the University of North Carolina conducted a systematic review of the impact of this legislation on actual average caloric intake in the US food service sector. A systematic review sets out very clearly, the criteria that a published paper must meet in order to be considered by the reviewers. In this case the studies had to have an experimental or quasi-experimental design comparing a calorie labeled menu with a menu without any caloric data. The review only considered studies with data on either consumption or purchase and, of course, only English language publications.[1]
They identified 164 titles, of which only 32 appeared from the title to meet the entry criteria. Having read the abstracts of these 32, a total of 18 papers were read in full and of these, 7 were included in the review. Two reported reductions in calorie intake with calorie labeling, 3 reported no change, 1 reported an increase and 1 found that of the 11 largest fast food chains, 3 reported a decrease (McDonald’s -44, Au Bon Pain -80 and KFC -59), 1 reported an increase (Subway +133) while 7 reported no change (Burger King, Wendy’s, Popeye’s, Domino’s, Pizza Hut, Papa John’s and Taco Bel)[2].

This might sound like music to the ears of the food service sector but before the rapture begins lets just ask ourselves if the data should surprise us. Research shows that consumers do not rate obesity and overweight as an important risk for them personally but they do see it as a risk to society as a whole. That is explained by the fact that although a consumer may be fat, they are themselves in control of the situation and if and when they decide to lose weight, they can manage that without any doubt. However, they are not convinced that the rest of society has such marvelous self control and hence, weight is a societal issue but not a personal issue. So if they are asked for their opinion on the listing of calories on menus, they will see the value. Now when consumers go out to dine in a cafeteria, fast food outlet or a restaurant, those that are in the mode of counting calories will be able to benefit from menu labeling. Since this is a minority, we should not be surprised that on average, there was no impact of caloric labeling. If the research was to include those who wanted to lose weight, then almost certainly, the outcome would be positive.

One useful and informative paper comes from Tacoma-Pierce County in Washington and was written by those members of the County Health department that set out to promote menu labeling in a program called SmartMenu[3]... This programme targeted locally  owned restaurants, not the food chain restaurants and this was done specifically to see how such local restaurants with less resources than the chains, could cope with the challenge. Of the 600 restaurants contacted, only 24 agreed to participate and of these, only 18 finally posted the data on their menus. By far the biggest barrier was the preparation of the menu items into a standardized format that could be entered into a nutritional analysis software programme. In the words of the authors: “The challenge for locally owned restaurant owners who are not using standardized recipes to participate in this programme cannot be overstated”. The average time from a signed agreement to participate to the posting of the menus was 8 months. The costs for the restaurants ranged from $1,500 to $8,400. Besides the time, complexity and costs issues, other barriers included the perceived business risk of labeling (the “I got fat eating in your restaurant which mislabeled the caloric value of my favourite dish” law suit) and the low perceived demand for such calorie labeling.

As ever, things are not as straight forward as first imagined. That does not mean that we shouldn’t try to label menus if indeed we believe that it will help those who are dieting and who are generally weight conscious. A few further observations can be made. We must also be aware that there are consumers who rate monetary value higher than health aspects when purchasing foods and who in fact might opt for the best value in terms of calories per euro. Based on the experience of Tacoma-Pierce County, someone is going to have to invest in this if it is going to work. If it is the restaurant owners, then guess who’s ultimately going to pay for the service. Then again, when you go out for dinner, cost is not really an issue.  Finally, last night we ate in a delightful Thai restaurant and nobody ate everything served. How many calories were left on the plate?

[1] 1 English is the language of scientific publication and papers published in other languages are always excluded from systematic reviews. To use them would require a full translation with the help of the author to retain accuracy and that is not feasible. Moreover, journals in non-english language have a local focus and are always of  a very low impact factor.
[2] 2 JJ Swartz et al (2011) International Journal of Behavioral Nutrition and Physical Activity 8, 135
[3] 3 JW Britt et al (2011) Health Promotion Practice 12, 18-24

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