Wednesday, June 20, 2012

Eating and Counting at the Same Time – Calorie Charts in Restaurants

Regrettably the rate of obesity has grown significantly in the last 20 years in both adults and children. While some individuals lament the simplistic explanation that most have derived for this outcome, over-consumption of food, instead favoring other explanations like environmental toxins or changes in gut bacteria concentrations; the reality is that the primary reason for an individual being overweight is an imbalance in calorie intake vs. biochemical caloric consumption. Outside influencing factors like toxins and gut bacteria simply influence intake and consumption. One of the explanations for the significant increase in this imbalance is the change in food consumption behavior.1,2 For example it is thought that modern Americans consume approximately 1/3 of their total calories along with approximately ½ of the total money spent on food not at home, but at restaurants.3,4

Even when food is not consumed in the home one still must take measure of its nutritional content. Unfortunately most consumers appear generally unaware of the need to measure calorie content, do not care to count or inaccurately estimate the number of calories they consume when eating out. Part of this problem stems from the fact that few people can accurately estimate the number of calories in a meal by simply looking at it; some surveys have identified that most respondents underestimated the calorie count in various take-out items by nearly ½ with some inaccuracies on single items amounting to 650 calories.5,6 In addition various other studies further demonstrated the inconsistency in consumer knowledge regarding calorie counts and using them to improve decision making as some studies identified different and healthier food choices when exposed to visually presented calorie counts and other studies with similar methodologies, but different people, identified no significant difference in food choice.7-12

It must be noted that the concerns with obesity and out of home eating are only one element behind increasing obesity rates. If one does not track how one eats at home or in non-chain restaurants where calorie counts are typically not available then tracking nutrition when eating at chain restaurants loses most of its purpose. Also people must be committed to using the information which means accepting that they cannot eat whatever they want whenever they want otherwise posting calorie counts will not produce the results that some hope for.

The above points notwithstanding clearly the public needs some assistance because despite what some want to believe the health of general society affects everyone in some context solely due to the interconnectivity of the healthcare system and its limited resources. Therefore, after watching some state governments poke around the edges of regulation, the federal government finally demanded some form of concrete information structure for a calorie information program in section 4205 of the Affordable Care Act passed in 2010. This structure was designed so that ‘chain restaurants’ (restaurants with more than 20 locations) had to provide calorie data and additional nutritional information for basically all food items (menu and self-service), so patrons could make more informed food choices.

Unfortunately there was no generally required format to these calorie postings relying instead upon the FDA to accept recommendations for what type and how mandatory information should be presented. The FDA has proposed five general recommendations: 1) Calories for items are displayed in proximity to food items on the menu board; 2) Menu board contains a statement that written nutritional information is available on request; 3) Menu board contains a succinct statement regarding suggested caloric intake; 4) Menu board contains a statement that puts the calories in context of total requirements; 5) Menu board provides nutrient content for standard menu items that come in different flavors, varieties, or combinations but are listed as a single menu item;12 however, of the five recommendations only the first and last ones have been given any type of guidelines for implementation with the remaining three lacking any type of guidelines. Not surprisingly the three recommendations lacking guidelines are rarely implemented. New guidelines are scheduled to be released sometime in July 2012.

Note that it is estimated that at least ½ of U.S. chain restaurants provided nutrition information publicly either apart from the menu at the restaurant itself or on the company’s website;14 however, it stands to reason that such postings, especially on websites, heavily limits the usefulness of the information due to availability issues when that information is most desired by the consumer.

An improved and firm structure for presenting calorie information is required because a vast majority of postings offered by most restaurants do not provide sufficient information to accurately access the caloric intake of most meal combinations even if the patron is committed to counting calories. There are limited problems presenting calorie information for single static items like black coffee or an egg mcmuffin when there is no ability to change the ingredients; the most glaring problems arise with combination or multi-serving items where the exact ingredients utilized are at the whim of the patron.

There are two chief problems: first due to space limitations on the physical menu calorie counts are actually restricted to ranges due to the different choices associated with a given meal option.13 These calorie postings do not differentiate between the different options instead indicating that the options range between say 500 to 1860 calories. It is almost impossible to expect even active patrons to be able to effectively manage their diets with such a large gap and a lack of more specific information. Second, there is some concern that those ranges are inaccurate, accidentally or purposely lowered on the menu versus actual calorie counts or even information on the restaurant’s own website.13,14 Unfortunately the five options currently being considered by the FDA to present calorie information do not appear to alleviate the problems with combination menu items. The five considered options are: 1) a single average value; 2) a minimum to maximum range; 3) means; 4) medians; 5) hybrid models;13

What is almost insulting about this list of options is that clearly the first four options will do almost nothing to help individuals make informed food selections because of the lack of specificity. The hybrid model does little better due to its complexity because the calorie count posted would depend on the overall range of calories in all of the offered food combinations, but still not good enough.13

The almost silly thing about all of these options is that they seem to exist to avoid inconveniencing or ‘over-burdening’ food establishments. What is the point of applying a food calorie regulation to these establishments if one allows them to skirt along the edge of the requirement. It gives the impression that government is saying to patrons, “well those establishments have some form of calorie count it is not our job to require them to simplify it to the point where you don’t need to do your own intensive research or have a degree in biochemistry to track the amount of calories you are consuming for today’s meal.” The FDA needs to either require transparent simplicity or just not bother at all.

What would transparent simplicity look like? First, the requirement of the calorie posting next to the meal item on the menu itself is understandable in its intent, but as mentioned the limited space significantly reduces specific item combination accuracy. Every ‘chain’ restaurant has available wall space near the ordering area. In this wall space the restaurant should post a large nutritional chart with sufficient sized font (at least 12) providing information on each individual item with outline formatting for each additional option for a given item. Individual ingredient listing will be especially important for ‘construction’ food projects like sub sandwiches, fried chicken and pizzas. An example of this formatting is shown in the below figure (note that the associated numbers are fictional calorie counts)

Looking at the above figure note that the numbers are additive, thus if one orders a medium pizza with onions and olives the total calorie count will 970. The placement of this chart should have its ceiling at six and half feet above the floor allowing for easy viewing for most adults and the items should be listed in alphabetical order to reduce searching time. Also for restaurants that have a lot of combination potential it would also help to provide patrons a quick means of summating the total calorie counts of their meals. To this end the restaurants should supply a calculator tethered to the chart similar to how a bank has pens attached to various writing surfaces. Obviously the calculator does not need to be an expensive scientific model just one that can add, subtract and multiply.

Although there are arguments that it has been politicized due to special interests, a copy of the new FDA food chart should be displayed next to the nutritional information to provide an additional element of context with regard to balanced eating. The calorie chart could then show how each of the major areas in the chart (Grain, Protein, Fruit and Vegetable) is represented in each menu item. Some may argue that this is too much to expect from restaurants, but most menu items in restaurants are static, thus food chart/plate analysis will only need to be conducted once.

However, simply providing the calorie information may not be enough. Some researchers identified interesting self-destructive behavior by some individuals that utilized calorie counts when making food purchases. In certain circumstances the net amount of calories consumed in a day did not significantly change between a group that was exposed to calorie information versus a group that was not exposed to any calorie information.8 There are two possible explanations for this behavior: first, individuals purposely ate less when eating in the restaurant leaving them hungrier later in the day to which their response was to eat more food than those who ordered more food in the restaurant. Second, individuals took a psychological ‘reward’ approach in that because they were ‘good’ and ordered a lower calorie meal at the restaurant there was more leeway to eat more later. Interestingly when patrons were ‘reminded’ that the average person should consume approximately 2000 calories per day this ‘catch-up calorie consumption’ tendency is lessened.8 The reason for this change is not overly clear, but the explanation may be in the next paragraph.

What the above study may identify is that consumers still need a context in which to apply the counted calories. Without floors and ceilings the counts are simply just meaningless numbers. In addition to reminding patrons of the generally acknowledged calorie ceiling, they should also be reminded to actually count calories. A sign near each register asking if the patron is satisfied with the calorie count of their meal with the 2000 calorie per day reminder should be sufficient. It must be understood that restaurants are not responsible for whether or not individuals make healthy food selections; it is simply their responsibility to ensure that patrons are properly informed regarding the nutritional content of their food options and not to favor any food choice over another.

If the above recommendations were accurately followed then patrons should have requisite information to make informed decisions regarding what foods they consume outside of the home. However, there are some other issues that need to be addressed. One important element of addressing calorie count charts, especially for the poor, is monetary efficiency. If a patron can see that one food item costs $2 and has 500 calories and another food item costs $2 and has 300 calories the individual may select the first item because he/she receives more calories for money spent. Also there is some evidence to suggest that providing calorie information could reduce the motivation to tax unhealthy foods.15,16

The potential of calorie counts to shift responsibility on consumers over service providers, thus possibly reducing the probability of applying a tax to unhealthy foods is also a notable consequence. One important issue with regards to changing eating habits is that healthy food is typically more expensive than unhealthy food. Clearly from an economic and health perspective it is important to close, if not reverse, that gap. However, some studies have reported that lowering the costs of healthy foods do not translate into increased purchase, but increasing unhealthy food price does.17,18 Thus policy makers must ensure that creating regulation for posting calorie charts is not the end result of regulation if the obesity problem continues.

In addition accurate calorie information could eliminate a psychological tactics used by some dieters in inherently overestimating calorie counts on high calorie items. The psychology goes that a dieter will see a high calorie food item and assume that based on the ingredients the calorie count has to be x large. If the calorie count is available the dieter may realize that he/she had overestimated the calorie count and justify purchase by presuming overestimation of calories on other food items. However, while it is important to point out these concerns so they can be appropriately addressed none of these above concerns are significant enough to warrant terminating the idea of posting accurate calorie count information in restaurants.

Overall the general idea behind posting calorie counts is sound as long as the regulations surrounding it are genuinely applied. However, one cannot simply presume that the application of this strategy will single-handily end the rise in obesity rates; it is just one element in the fight against societal expansion of obesity.

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2. Kuo, T, et Al. “Menu Labeling as a Potential Strategy for Combating the Obesity Epidemic: A Health Impact Assessment.” Amer. J. Public Health. Sept. 2009. 99(9): 1680-1686.

3. Industry at a glance. National Restaurant Association Web site. Available at: 2009.

4. Keystone center backgrounder—Keystone forum on away-from-home foods: opportunities for prevention weight gain and obesity report. 2006.

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12. Harnack, L and French, S. “Effect of point-of-purchase calorie labeling on restaurant and cafeteria food choices: a review of the literature.” Int J Behav Nutr Phys Act 2008. 5:51.

13. Cohn, E, et Al. “Calorie Postings in Chain Restaurants in a Low-Income Urban Neighborhood: Measuring Practical Utility and Policy Compliance.” Journal of Urban Health. 2012. DOI: 10.1007/s11524-012-9671-0

14. Wootan, M and Osborn, M. “Availability of nutrition information from chain restaurants in the United States.” Am J Prev Med. 2006. 30(3):266–268.

15. Giesen, J, et Al. “Exploring how calorie information and taxes on high-calorie foods influence lunch decisions.” Am J Clin Nutr. 2011. 93:689–94.

16. Epstein, L, et Al. “The influence of taxes and subsidies on energy purchased in an experimental purchasing study.” Psychol Sci. 2010. 21:406–14.

17. Epstein, L, et Al. “Purchases of food in youth. Influence of price and income.” Psychol. Sci. 2006. 17:82–9.

18. Epstein, L, et Al. “Price and maternal obesity influence purchasing of low- and high-energy-dense foods.” Am. J. Clin Nutr. 2007. 86:914–22.

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