Published 18 November 2008, doi:10.1136/bmj.a2229
Cite this as: BMJ 2008;337:a2229

Feature

Public health

The fattening truth about restaurant food

¹ Savoie, France

Head to head, doi:10.1136/bmj.a1761,doi: 10.1136/bmj.a1750

Going out to eat is often a disaster for the waistline. Karen McColl reports on US efforts to make diners more aware of what they are eating

Customers going into restaurant chains like Burger King or Starbucks in New York can now take calories into account when they choose what to eat. Since May, chain restaurants in the city have been required to include calorie contents on menu boards, menus, and item tags. The law applies to restaurant chains with more than 15 branches nationally.

Similar menu labelling, or "calorie posting," laws came into force in September in San Francisco and Santa Clara County in California, and the requirement will soon apply to the whole state. Arnold Schwarzenegger has now approved an amended version of a menu labelling bill that he vetoed last year, making California the first state to pass a menu labelling law. Around 20 cities and states across the US are considering menu labelling legislation. But the restaurant industry is fighting all the way.

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"It’s just the most astonishing thing I’ve ever seen," says Marion Nestle from New York University. Professor Nestle is an academic nutritionist with decades of experience advising on nutrition issues. Yet, since calories have been posted on menus in New York she has been surprised. "For someone like me who thinks that they know about these things, I’m stunned by the number of calories in fast foods. I had no idea." As examples, she cites a blueberry and pomegranate smoothie that provides 1180 kcal (4.9 MJ) and a pizza for one person with more than 2000 kcal (8.3 MJ).

Professor Nestle is not the only nutrition expert to have difficulty assessing the nutritional content of fast food. The Food Commission recently asked 66 nutrition experts at an international obesity conference whether they could tell from the menu description which food was likely to contain most energy or fat. None of the experts answered all five questions correctly, and only a quarter answered more than two questions correctly.¹

Given that nutrition experts have difficulty choosing the healthiest options, what hope for the rest of the population? Research shows that consumers, like nutrition experts, have difficulty assessing the calorie content of fast food items and that people tend to underestimate energy content.^{1 2 3}

It is because people find it difficult to estimate calories that these laws are being introduced as part of an effort to tackle obesity, which now affects a third of US adults.⁴ Another key factor is the importance of eating out in the overall diet. Americans consume around one third of their calories outside the home, and nearly three quarters of all restaurant visits are to fast food or other chain restaurants.⁵ A survey of over 7000 fast food customers by New York’s health department found that a third (34%) of respondents purchased 1000 kilocalories or more at lunchtime.⁶ Research also shows that when calorie information is given people tend to choose high calorie items less often.^{6 7} We also know that consumers—both in the US and the UK—strongly favour having more accessible nutrition information when they eat out.^{1 8 9}

"We’re confident that this law will have two positive effects," says Tom Frieden, New York’s health commissioner. "The first is to encourage restaurants to offer healthier options, and the second will be to encourage some customers to make healthier choices." Dr Frieden estimates that the legislation could result in 150 000 fewer New Yorkers being obese and 30 000 fewer cases of diabetes in the city over the next five years.¹⁰

Improved visibility

Although many fast food chains already make nutrition information available, few customers see this information. At the time of the New York survey only Subway provided information at the point of purchase. Among customers of other outlets, just 4% reported seeing calorie information.⁶ Some nutrition information is available on company websites. Calculations based on figures from McDonald’s, which now also provides nutrition information on the back of tray liners, show that its nutrition information website receives one hit for every 25 000 meals sold.¹⁰ Where restaurants provide nutrition information leaflets on site, public health advocates argue that this information is overly complex and is not readily accessible when consumers order their food.⁹

The key concept behind the menu labelling rules is to provide information in places where people will see it when they are choosing what to order. That means on menu boards and menus. Fast food restaurants describe the menu board as their most important means of communicating with customers, and this is one of the reasons that they have been resisting the legislation so strongly.¹⁰

Although it is still too early to evaluate the impact of the new law, newspaper and blogs have been full of reports quoting shocked customers.^{11 12 13 14} Dr Frieden says that preliminary feedback suggests consumers are becoming more aware of calories, and some outlets are also starting to change what is on offer. There are reports of leading chains highlighting lower calorie options on the menus and introducing healthier options.

"What you hear essentially is sticker shock about the number of [kilo]calories in some common items—whether it’s a 600 calorie cup of coffee, a 1200 calorie salad, a 1400 calorie breakfast, or a 2700 calorie appetiser," Dr Frieden says.

Professor Nestle agrees that some New Yorkers are in shock, but is concerned that the numbers mean little to people who do not know that a typical adult needs only around 2000 kilocalories a day. "It’s a good thing, but it needs to be accompanied by a very clear know your number message so that you know that you should be aiming to consume somewhere in the 2000 range every day," she said. The California legislation does require restaurants to include information explaining recommended intakes in nutrition leaflets. In October the New York Health Department launched an advertising campaign to get the message across that most adults need no more than 2000 kilocalories a day to maintain a healthy weight. Dr Frieden also points out that even if you don’t know how many calories you should be consuming in a day, you can still use the calorie information to compare items and make healthier choices.

Industry response

The restaurant industry has been vigorously opposing the menu labelling legislation. The New York State Restaurant Association has challenged the legislation in court, arguing that the regulation overlaps with federal law and violates their members’ free speech by compelling them to deliver a government message about the importance of calories. The court rejected both arguments in April.¹⁵ The association has appealed, and the appeal court’s decision is expected any day now. In the meantime, restaurants have to comply with the legislation.

In Seattle (King County), industry lobbying and pressure from the state legislature obtained a compromise that allows calories to be posted on signs next to menu boards or on eye level signs at the point of ordering instead of menu boards.¹⁶

As well as using the legal systems to get menu labelling revoked, the restaurant industry is lobbying for legislation to ban such laws being passed in the first place. Ohio and Georgia have recently passed state measures that prohibit any local authorities from introducing menu labelling legislation. There are signs that some restaurant chains now accept that these rules are here to stay. Yum brands, which owns the Pizza Hut and KFC chains, announced on 1 October that it will introduce calorie counts on menu boards in its 20 000 US outlets by 2011.

In the UK, the Food Standards Agency is taking a different approach. "We think that information is important and we’d like to see more restaurants, pubs, and cafés providing information, but it is only one part of the picture. We are also encouraging changes to the food that is available," explains senior policy officer Mark Browne. The agency is working with fast food restaurants, pubs, and popular family restaurants to increase the range of healthier options available, to reduce the fat, sugar, and salt content of existing popular dishes, and to provide nutrition information.

Like the agency’s work to reduce salt in processed food, this work is based on a voluntary approach. Mr Browne says that early discussions with companies have been very encouraging and he is confident that British consumers will soon see more nutrition information when they eat out.

Public health campaigners agree that menu labelling can be only one element of the public health response to obesity, but they are less optimistic that a voluntary approach will work this time. "It seems very unlikely that a voluntary approach would have a big impact. You wouldn’t get the same disclosure on menu boards as you do when you have mandatory legislation," says Anna Glayzer, spokesperson for the Food Commission, which called for government action when the nutrition expert survey was published.¹⁷

Professor Nestle is surprised that the agency is not pushing a compulsory approach. Dr Frieden agrees. "Given how hard restaurants fought this in court, I think it extremely unlikely that they would do it voluntarily in a meaningful way. And the fact that they fought it so hard does suggest that they do think it’s going to change customers’ food choices."

Cite this as: BMJ 2008;337:a2229

Head to head, doi:10.1136/bmj.a1761,doi: 10.1136/bmj.a1750

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Competing interests: None declared.

References

1. Food Commission. Which fast food meals are healthiest? Anyone’s guess! The Food Magazine 2008;Aug:82.
2. Burton S, Creyer EH, Kees J, Huggins K. Attacking the obesity epidemic: the potential health benefits of providing nutrition information in restaurants. Am J Public Health 2006;96:1669-75.[Abstract/Free Full Text]
3. Center for Science in the Public Interest. New poll shows calories hard for New Yorkers to guess. 80 percent want nutrition info on chain restaurant menus statewide. Press release, 11 Jun 2008. www.cspinet.org/new/200806111.html.
4. US Centers for Disease Control and Prevention. Overweight and obesity. 2008, www.cdc.gov/nccdphp/dnpa/obesity/trend/index.htm.
5. Berman M, Lavizzo-Mourey R. Obesity prevention in the information age: caloric information at the point of purchase. JAMA 2008;300:433-5.[Free Full Text]
6. Basset MT, Dumanovsky T, Huang C, Silver LD, Young C, Nonas C, et al. Purchasing behavior and calorie information at fast-food chains in New York City, 2007. Am J Public Health 2008;98:1457-9.[Abstract/Free Full Text]
7. Burton S, Creyer EH, Kees J, Huggins K. Attacking the obesity epidemic: the potential health benefits of providing nutrition information in restaurants. Am J Public Health 2006;96:1669-75.[Abstract/Free Full Text]
8. Food Standards Agency. Consumers give their views on eating out. 22 June 2008. www.food.gov.uk/news/newsarchive/2008/jun/eatout.
9. Center for Science in the Public Interest. Anyone’s guess: the need for nutrition labelling at fast-food and other chain restaurants. 2003. www.cspinet.org/menulabeling/resources.html.
10. New York City Department of Health and Mental Hygiene. Calorie-posting legal timeline. DOHMH Commissioner Frieden declaration February 2008. www.nyc.gov/html/doh/html/cdp/cdp_pan-calorieupdate.shtml.
11. Barron J. Premature sticker shock for the weight conscious. New York Times 2008 Apr 22. www.nytimes.com/2008/04/22/nyregion/22calorie.html.
12. DiGregoria A. Calorie counting in Times Square. Village Voice. http://blogs.villagevoice.com/forkintheroad/archives/2008/04/calorie_countin.php.
13. Bruni F. The bran or the sausage? You’d be surprised. New York Times 2008 Apr 22. http://dinersjournal.blogs.nytimes.com/2008/04/22/the-bran-or-the-sausageyoud-be-surprised.
14. Grub Street. Food blogs are already having sport with calorie listings. http://nymag.com/daily/food/2008/04/food_blogs_already_having_spor_1.html.
15. New York City Department of Health and Mental Hygiene. Calorie-posting legal timeline. Court decision 16 April 2008. www.nyc.gov/html/doh/html/cdp/cdp_pan-calorieupdate.shtml.
16. King County, Washington. Menu labelling in King county. www.metrokc.gov/health/healthyeating/menu/
17. Food Commission. Don’t keep us guessing: campaigners call for more information on fast food menus. Press release, 11 Aug 2008. www.foodcomm.org.uk/press_08_Aug_menus.htm.

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