Calorie labelling on the high streetBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d4502 (Published 26 July 2011) Cite this as: BMJ 2011;343:d4502
In the linked cross sectional surveys (doi: 10.1136/bmj.d4464), Dumanovsky and colleagues assess the effect of a menu labelling regulation on calories (1 kcal=4.18 kJ) per purchase at fast food chains in New York City.1
The need to find new approaches to stimulate dietary change is self evident. More than 60% of adults are overweight, and diet related ill health is estimated to account for 10% of morbidity and mortality in the United Kingdom.2 Years of traditional information based health promotion have heightened awareness of the elements of a healthy diet, with 87% of consumers claiming that healthy eating is important to them.3 Nevertheless, changes in eating habits have been slow, and much remains to be done.4 The challenge is to find and test innovative approaches to drive dietary change within populations.
Front of pack nutritional labelling on products in the supermarket is now widespread in the UK, but with an estimated 20-25% of calories consumed away from home, it is logical that labelling should extend beyond supermarket purchases. Dumanovsky and colleagues report on the New York experience of the mandatory provision of calorie information on menus and menu boards in chain restaurants.1 It is the latest in a series of diverse studies that began with simple analogue experiments of food choice in an experimental laboratory context, whereby participants were asked to make food choices with and without nutritional information.
The recent policy introduced in New York City has provided opportunities for researchers to study the effect of menu labelling in a real life setting. Dumanovsky and colleagues’ observational study, which is the most extensive to date, assessed food purchases on the basis of till receipts from lunchtime customers across a large and random sample of outlets before and after the introduction of menu labelling. The study found no significant difference in calories purchased before and after introduction of the regulation. However, in the 15% of customers who reported using information on calorie content, purchases contained fewer calories (106 kcal) after the regulation was introduced.
Although the study estimates the likely effect on the energy content of purchases at the population level, it leaves many questions unanswered. Taste, price, and prevailing social norms are all important influences on consumer food choices, and it is difficult to isolate the effects of menu labelling from the wider contextual characteristics of the environments in which food choices are made.
Previous evidence of the effect on the calorie content of purchases has been equivocal and elicits strong opinions.5 Few would disagree that more effort is needed to raise awareness of the importance of energy intake to successful weight control, and labelling itself will contribute to a growing “calorie consciousness,” which may yield sustained benefits. What happens beyond the restaurant is a matter of speculation. There is the potential for compensatory behaviours, but it is equally plausible that lessons learnt on the high street about the relative energy content of different items can inform food choices elsewhere.
High street chains in England are about to embark on a similar, although voluntary, scheme as part of the government’s public health responsibility deal. Companies committing to the out of home labelling pledge will display calorie information clearly and prominently (in a size and font similar to the price), at point of choice (usually menu boards in quick service restaurants, or shelf edges in coffee and sandwich shops), and across all standardised items available for 30 days or more each year. To date, 32 companies—covering more than 5000 high street outlets and representing 14% of the total number of meals served outside the home—have signed the deal. This is an overtly pro-choice intervention that empowers consumers when making food choices. In the voluntary context in which it is being enacted in England, it gives businesses autonomy too, and consumers will be able to choose whether to receive such information by their choice of where to eat. Consumer response will be a key part in driving change among businesses not yet engaged in the responsibility deal. It may also act as a barometer of the public appetite for further action to make healthier choices easier.
But knowledge alone may be insufficient to induce sustained changes in dietary habits. There is growing recognition that automatic behaviours may be a more dominant influence on eating habits than reflective processes.6 The experience of salt reduction has shown that industry action using a “health by stealth” approach has delivered measurable improvements in diet.7 Anecdotal reports suggest that menu labelling can drive wider changes on the part of business, including reformulation, portion control, or changing the default option such as substituting reduced fat for full fat milk or mayonnaise. These “supply side” measures may yield bigger health gains than changes in “demand side” behaviour mediated by cognitive processes, and they might avoid the risk of increasing health inequalities that can arise from knowledge based interventions.
Calorie labelling will help consumers make an informed choice about what they eat, but sustained improvements in the nation’s diet will require a transformation of the food supply too.
Cite this as: BMJ 2011;343:d4502
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; SAJ is the independent chair of the Public Health Responsibility Deal Food Network.
Provenance and peer review: Commissioned; not externally peer reviewed.