Restaurant Menu Labeling Tackling One Environmental Factor Contributing to the Obesity Epidemic Jennifer Jabri, PhD Student Walden University PUBH 8165-1: Environmental Health Instructor: Dr. Rebecca Heick Spring, 2010 My name is Jennifer Jabri and I am a Public Health PhD student at Walden University with a concentration in community health promotion and education. Thank you for taking the time to learn more about the need for restaurant menu labeling and the possible impact on the obesity epidemic. This presentation is targeted to owners of smaller restaurants with less than 20 locations, and to the general public who eat about half of their meals outside of the home.

Why do we need Menu Labeling? Restaurants tend to serve larger portions of higher fat, higher calorie foods. Americans eat half of their meals “prepared and consumed elsewhere” (p. 292).1 Most people, including nutritionists, underestimate the number of calories in restaurant meals.2 1. Mikkelsen, L., Erickson, C.S., & Nestle, M. (2007). Creating healthy food environments and preventing chronic disease. In L. Cohen, V. Chavez, & S. Chehimi (Eds). Prevention is Primary: Strategies for Community Well-Being. (p. 287-311). San Francisco, CA: Jossey-Bass. 2. Rudd Center for Food Policy & Obesity. (2008). Menu labeling in chain restaurants: Opportunities for public policy. Retrieved from: http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabelingReport2008.pdf American’s buy nearly half of our meals “prepared and consumed elsewhere” (Mikkelsen, Ericksen, & Nestle, 2007, p. 292). Restaurants tend to serve larger portions of higher fat and higher calorie foods. That is a significant number of meals consumed without knowing the calorie content, fat grams, sodium content, or other nutritional information.

Larger Portions Portion sizes have nearly doubled in the last 20 years. Calories/serving 20 years ago compared to today1: Fries: from 210 to 610 cals Cheeseburger: from 333 to 590 cals Spaghetti: from 500 up to 1025 cals Bagel: from140 to 350 cals 1. National Heart, Lung and Blood Institute. (n.d.). Obesity (OEI) slide sets. Retrieved from: http://hp2010.nhlbihin.net/oei_ss/menu.htm#sl2 educatgioninitiative . One contributing factor to the obesity epidemic is the fact that we are eating larger portions than we did 20 years ago, which means that we are ingesting many more calories, which contributes to weight gain. These are just a few examples to illustrate the changes in portion size and the resulting caloric increases. We have come to think of these new, larger portion sizes as normal.

People Eat More at Restaurants When eating out of the home, both children and adults tend to eat larger portions, consuming more calories.1,2,3 One study found that a third of 7318 restaurant patrons consumed at least 1,000 calories or more for lunch.4 1. Binkley, U.K., Eales, J., Jekanowski, M. (2000). The relation between dietary change and rising U.S. obesity. International Journal of Obesity; 24:1032-1039. 2.Paeratakul, S., Perdinand, D., Champagne, C., Ryan, D., & Bray, G. (2003). Fast-food consumption among U.S. adults and children: Dietary and nutrient intake profile. Journal of the American Dietetic Association; 103(10):1332-1338. 3.Zoumans-Morse, C., Rock, C., Sobo, E., Neuhouser, M. (2001). Children’s patterns of macronutrient intake and associations with restaurants and home eating. Journal of the American Dietetic Association; 101(8):923-925. 4.Bassett, M.T. (2008). Purchasing behavior and calorie information at fast-food chains in New York City, 2007. American Journal of Public Health; 98(8):1-3. If we are eating half of our meals outside of the home, then half of our meals tend to be larger than what we would serve ourselves at home. It is recommended that an adult eat around 2,000 calories a day. In one study, a third of the customers at a minimum of 1,000 calories, so at least half of the day’s recommended calories were obtained from one meal. So, it is easy to see how one could overeat and gain weight.

We require nutritional labeling on our packaged foods, so why not for restaurant meals? In fact, three-fourths of Americans use food labels to help them make food choices.1 Many surveys have found that the majority of Americans support the addition of nutritional information to menus and menu boards. 2 1. Rudd Center for Food Policy & Obesity. (2008). Menu labeling in chain restaurants : Opportunities for public policy. Retrieved from: http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabelingReport2008.pdf 2, Rudd Center for Food Policy & Obesity. (2008). Menu labeling in chain restaurants : Opportunities for public policy. Retrieved from: http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabelingReport2008.pdf Packaged foods are required to have nutritional labeling. Our restaurant menus should also have some nutritional information available to the consumer in order for them to make informed decisions regarding their food choices. Surveys have found that most Americans support this.

Epidemic of Overweight and Obesity Eating out at restaurants is contributing to the epidemic of overweight and obesity in the U.S. Less than one-third of Americans are at a healthy weight1 Dramatic increase in extreme obesity 1, 2 1. Flegal, K.M., Carroll, M.D., Ogden, C.L., Curtin, L.R. (2010). Prevalence and trends in obesity among US adults, 1999-2008. JAMA; 303(3):235-241. Retrieved from: http://jama.ama-assn.org/cgi/content/full/2009.2014; http://jama.ama-assn.org/cgi/content/full/303/3/235/JOC90148T3 2. Hensrud, D.D., & Klein, S. (2006). Extreme obesity: A new medical crisis in the United States. Mayo Clinic Proceedings; 81 (Suppl. 10):S5-10. Over 68% of Americans are overweight or obese (Flegal, Carroll, Ogden & Curtin, 2010), which means that less than one-third of Americans are at a healthy weight. In 2007-2008, it was estimated that 5.7 percent of Americans aged 20 years or older were extremely obese with a BMI greater than 40 (Flegal et al., 2010). This equates to approximately 17,597,343 million extremely obese Americans (from the current population) up from 11.5 million in 2002 (Hensrud & Klein, 2006). According to Hensrud & Klein (2006), the prevalence of extreme obesity has been increasing twice as fast as obesity in general” (p. S6).

Changes in the Prevalence of Obesity 1986-20081 1. Centers for Disease Control (CDC). (2009). U.S. obesity trends: Trends by state 1985-2008. Retrieved from: http://www.cdc.gov/obesity/data/trends.html#State The Centers for Disease Control created these maps to illustrate the dramatic changes in the levels of obesity over the time period of 1986-2008. As of 2008, the state of Colorado was the only state with an obesity prevalence less than 20 percent. In 1986, there were no states that had obesity levels above 14 percent, and now every state except Colorado has an obesity prevalence above 20 percent of the population, with a handful of states even having prevalence rates above 30 percent. This does not include all of the overweight people!

Research on Menu Labeling In a study to evaluate whether having nutrition labels on menus would affect the food choices of study participants, researchers found that those who had menus without nutrition information ate several hundred calories more than participants who received menus with nutrition information. 1 1. Roberto, C.A., Larsen, P.D., Agnew, H., Baik, J., & Brownell, K.D. (2010). Evaluating the impact of menu labeling on food choices. American Journal of Public Health; 100(2): 312-318. There have been many studies that have found that consumers make healthier choices when they are informed consumers by having nutritional information available to them to aid their decision making. In one particular study, those who had menus without nutritional information at several hundred calories more than participants who received menus with nutrition information.

Research on Menu Labeling Only about half of chain restaurants offer nutritional information . Not always accessible as is oftentimes located in a non-visible area, or the patrons must ask for it.1,2 If it is not visible, many people will not think to look for it.1,2 In an observational study, it was reported that, “Only 6 (0.1%) of 4311 patrons accessed on-premises nutrition information before purchasing food. This very small percentage suggests that such information should be more prominently displayed, such as on restaurant menu boards, to help customers make informed decisions” (p. 820).3 1. Silver, L. & Bassett, M.T. (2008). Food safety for the 21st century. JAMA; 300:957-959. 2. Rudd Center for Food Policy & Obesity. (2008). Menu labeling in chain restaurants : Opportunities for public policy. Retrieved from: http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabelingReport2008.pdf 3. Roberto, C.A., Agnew H., & Brownell, K.D. (2009). An observational study of consumers’ accessing of nutrition information in chain restaurants. American Journal of Public Health; 99(5):820-821 . Some industry representatives argue that many restaurants do make nutritional data available, but the fact is, only about half of chain restaurants offer nutritional information and it is oftentimes not accessible as is located in a non-visible area, or the patrons must ask for it (1,2). If it is not visible, many people will not think to look for it (1,2). In an observational study, they reported that, “Only 6 (0.1%) of 4311 patrons accessed on-premises nutrition information before purchasing food. This very small percentage suggests that such information should be more prominently displayed, such as on restaurant menu boards, to help customers make informed decisions” (p. 820) (3).

What Nutritional Information would be included on the Menu/Menu Boards? Standard food items on the menu, not for specially ordered dishes, or for specials that are on the menu for a brief period of time.1 The number of calories “clearly associated with each standard menu item.”2 A statement regarding recommended daily caloric intake limits for adults. 2 Written nutritional information available to patrons. 2 1. Rudd Center for Food Policy & Obesity. (2008). Menu labeling in chain restaurants : Opportunities for public policy. Retrieved from: http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabelingReport2008.pdf 2. Buckberg, J.R., & Chestler, A.L. (2010). Congress passes menu labeling in health care reform. Retrieved from: http://www.lexology.com/library/detail.aspx?g=eeff77b9-f95f-485b-a827-2ada0d6132bc Menu labeling would be required for standard food items on the menu, not for specially ordered dishes, or for specials that are on the menu for a brief period of time. It would include the number of calories “clearly associated with each standard menu item”, a statement regarding recommended daily caloric intake limits for adults, and have written nutritional information available to patrons.

What about the Costs? “Many chain restaurants already analyze the nutritional contents of their menus. Changing menu boards is a one-time cost” (p. 7).1 1. Rudd Center for Food Policy & Obesity. (2008). Menu labeling in chain restaurants : Opportunities for public policy. Retrieved from: http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabelingReport2008.pdf “Many chain restaurants already analyze the nutritional contents of their menus. Changing menu boards is a one-time cost” (p. 7).

How Can Federal Menu Labeling Legislation Benefit the Restaurants? It would make them subject to federal regulations rather than different local, county, or state regulations, which is important for chain restaurants with locations across the country.1 1. National Restaurant Association. (2010). National Restaurant Association says nutrition information provision is win for consumers and restaurants. Retrieved from: http://www.restaurant.org/pressroom/pressrelease/?ID=1910 Menu labeling requirements would be standardized between locations because it would make them subject to federal regulations rather than different local, county, or state regulations, which is important for chain restaurants with locations across the country.

How Would Menu Labeling Make a Difference in the Obesity Epidemic? It will help people to be informed decision makers regarding their food choices, as they will know the nutritional count of what they are eating. This may influence them to choose healthier options to control the fat and calories they consume. 1, 2 This may be a form of primary prevention of overweight and obesity. It may also cause restaurants to offer healthier options and alter some of their recipes. 1. Khan, L.L., Sobush, K., Keener, D., Goodman, K., Lowry, A., Kakietek, J., et al. (2009). Recommended community strategies and measurements to prevent obesity in the United States. MMWR;58(RR-7):1-32. Retrieved from: http://www.cdc.gov/mmwr/pdf/rr/rr5807.pdf 2. Rudd Center for Food Policy & Obesity. (2008). Menu labeling in chain restaurants : Opportunities for public policy. Retrieved from: http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabelingReport2008.pdf Nutritional labeling on restaurant menus will help people know exactly what they are eating and hopefully influence them to choose healthier options to control the fat and calories they consume. This may be a form of primary prevention of overweight and obesity. It may also cause restaurants to offer healthier options and alter some of their recipes.

A Grassroots Movement There have been menu labeling laws passed in numerous cities, counties, and states throughout the U.S. with various rules and regulations regarding the requirements for menu labeling.1. 1. Robert Wood Johnson Foundation. (2009). Menu labeling: Does providing nutrition information at the point of purchase affect consumer behavior? Retrieved from: http://www.healthyeatingresearch.org/images/stories/her_research_briefs/her_menu_labeling_brief_06_29_09_final.pdf There have been many menu labeling laws passed in various locations around the country, from city and county level, to the state level. However, these laws vary.

Current Legislation In March 2010, the healthcare reform bill (H.R. 2590) was signed into law in order to amend the Federal Food, Drug, and Cosmetics act (Section 4205), which had menu labeling requirements for chain restaurants with 20 or more locations.1 Small businesses are exempt from this. The National Restaurant Association supported this bill.2, 3 , 4 Buckberg, J.R., & Chestler, A.L. (2010). Congress passes menu labeling in health care reform. Retrieved from: http://www.lexology.com/library/detail.aspx?g=eeff77b9- f95f-485b-a827-2ada0d6132bc Center for Science in the Public Interest. (2010). Health reform to deliver calorie counts to chain restaurant menus nationwide. Retrieved from: http://cspinet.org/new/201003211.html National Restaurant Association. (2010). National Restaurant Association says nutrition information provision is win for consumers and restaurants. Retrieved from: http://www.restaurant.org/pressroom/pressrelease/?ID=1910 Robert Wood Johnson Foundation. (2010). Restaurant industry backs menu-labeling legislation. Retrieved from: http://www.rwjf.org/publichealth/digest.jsp?id=11101 In March 2010, President Obama signed into law the new healthcare reform bill (H.R. 2590) to amend the Federal Food, Drug, and Cosmetics act (Section 4205), which had menu labeling requirements for chain restaurants with 20 or more locations.1 Small businesses are exempt from this. The National Restaurant Association supported this bill because it benefits consumers in making informed food choices and it benefits the restaurants by protecting them from lawsuits.

What About Smaller Restaurants? They should consider posting the calorie content of standard menu items. Customers will come to expect this information after being accustomed to obtaining it from chain restaurants. However, it can also benefit smaller restaurants as they can voluntarily opt in and would then be subject to these federal standards rather than being subject to varying requirements set by different communities, or states. While smaller restaurants are exempt from these requirements, it is beneficial for them to opt in and adopt the practice of the larger restaurants, which would require them to follow federal standards. At the least, calorie contents should be posted on nutritional menu labeling. Once menu labeling becomes mainstream, then customers will begin to expect this nutritional information to be available.

Conclusion Menu labeling requirements can benefit both the restaurants and consumers. Smaller restaurants should also post caloric information on their menus. It is one step toward combating the epidemic of overweight and obesity in the U.S. Following federal menu labeling laws can protect small restaurant owners from lawsuits, and it benefits consumers as it is a step towards a healthier and less obese America. Thank you for your time.

References Bassett, M.T. (2008). Purchasing behavior and calorie information at fast-food chains in New York City, 2007. American Journal of Public Health; 98(8):1-3. Binkley, U.K., Eales, J., Jekanowski, M. (2000). The relation between dietary change and rising U.S. obesity. International Journal of Obesity; 24:1032-1039. Buckberg, J.R., & Chestler, A.L. (2010). Congress passes menu labeling in health care reform. Retrieved from: http://www.lexology.com/library/detail.aspx?g=eeff77b9-f95f-485b-a827-2ada0d6132bc Centers for Disease Control (CDC). (2009). U.S. obesity trends: Trends by state 1985-2008. Retrieved from: http://www.cdc.gov/obesity/data/trends.html#State Center for Science in the Public Interest. (2010). Health reform to deliver calorie counts to chain restaurant menus nationwide. Retrieved from: http://cspinet.org/new/201003211.html Flegal, K.M., Carroll, M.D., Ogden, C.L., Curtin, L.R. (2010). Prevalence and trends in obesity among US adults, 1999- 2008. JAMA; 303(3):235-241. Retrieved from: http://jama.ama-assn.org/cgi/content/full/2009.2014; http://jama.ama- assn.org/cgi/content/full/303/3/235/JOC90148T3 Hensrud, D.D., & Klein, S. (2006). Extreme obesity: A new medical crisis in the United States. Mayo Clinic Proceedings; 81 (Suppl. 10):S5-10. Khan, L.L., Sobush, K., Keener, D., Goodman, K., Lowry, A., Kakietek, J., et al. (2009). Recommended community strategies and measurements to prevent obesity in the United States. MMWR;58(RR-7):1-32. Retrieved from: http://www.cdc.gov/mmwr/pdf/rr/rr5807.pdf Mikkelsen, L., Erickson, C.S., & Nestle, M. (2007). Creating healthy food environments and preventing chronic disease. In L. Cohen, V. Chavez, & S. Chehimi (Eds). Prevention is Primary: Strategies for Community Well-Being. (p. 287- 311). San Francisco, CA: Jossey-Bass. .

References National Heart, Lung and Blood Institute. (n.d.). Obesity (OEI) slide sets. Retrieved from: http://hp2010.nhlbihin.net/oei_ss/menu.htm#sl2 educatgioninitiative National Restaurant Association. (2010). National Restaurant Association says nutrition information provision is win for consumers and restaurants. Retrieved from: http://www.restaurant.org/pressroom/pressrelease/?ID=1910 Paeratakul, S., Perdinand, D., Champagne, C., Ryan, D., & Bray, G. (2003). Fast-food consumption among U.S. adults and children: Dietary and nutrient intake profile. Journal of the American Dietetic Association; 103(10):1332-1338 Robert Wood Johnson Foundation. (2010). Restaurant industry backs menu-labeling legislation. Retrieved from: http://www.rwjf.org/publichealth/digest.jsp?id=11101 Roberto, C.A., Agnew H., & Brownell, K.D. (2009). An observational study of consumers’ accessing of nutrition information in chain restaurants. American Journal of Public Health; 99(5):820-821 . Roberto, C.A., Larsen, P.D., Agnew, H., Baik, J., & Brownell, K.D. (2010). Evaluating the impact of menu labeling on food choices. American Journal of Public Health; 100(2): 312-318. Rudd Center for Food Policy & Obesity. (2008). Menu labeling in chain restaurants : Opportunities for public policy. Retrieved from: http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabelingReport2008.pdf Silver, L. & Bassett, M.T. (2008). Food safety for the 21st century. JAMA; 300:957-959. Zoumans-Morse, C., Rock, C., Sobo, E., Neuhouser, M. (2001). Children’s patterns of macronutrient intake and associations with restaurants and home eating. Journal of the American Dietetic Association; 101(8):923-925.

Recommended Reading Robert Wood Johnson Foundation. (2009). Menu labeling: Does providing nutrition information at the point of purchase affect consumer behavior? Retrieved from: http://www.healthyeatingresearch.org/images/stories/her_research_briefs/her_menu _labeling_brief_06_29_09_final.pdf Rudd Center for Food Policy and Obesity. Retrieved from: http://www.yaleruddcenter.org/news.aspx?id=35 Legal Issues With Menu Label Laws: Pomeranz, J.L. (2009). Compelled speech under the commercial speech doctrine: The case of menu label laws. Journal of Health Care Law and Policy; 12:159-194. Retrieved from: http://www.yaleruddcenter.org/resources/upload/docs/what/law/CompelledSpeec h_MenuLabelLaws.pdf Public Health Law Center. (2010). Menu labeling legislation. Retrieved from: http://www.publichealthlawcenter.org/topics/healthy-eating/menu-labeling- legislation