1. Promoting Healthy Eating by Listing Caloric Information on Restaurant Menus
Kyle Riding MPH student
Walden University
PUBH
Dr. Howard Rubin
Spring Term, 2010
Good afternoon, my name is Kyle Riding and I am a MPH student at Walden University. I’m hear to talk to you today about including calorie information on restaurant menus throughout the commonwealth. I’d like to start by first thanking everyone here at the Massachusetts Department of Public Health for providing me with the opportunity to present this information.

2. Overview Current Overview of the Obesity Epidemic Causes of Obesity
Negative Health Outcomes Associated with Obesity
Why Include Caloric Information on Menus?
Public Attitudes/Beliefs on Caloric Intake
Current Federal Legislation’s Impact on Restaurant Menus
There are several topics I’d like to discuss during this presentation. I’d like to begin with an overview of where we stand as a nation when it comes to obesity. We have all heard about the ‘obesity epidemic’ and I’d like to explore why it is called an epidemic, what is causing it, and why is this an issue.
From there I’d like to discuss why I am asking you, as the state Department of Health, to issue requirements for restaurants to provide calorie information on their menus. I’d also like to share a study that shows that the public itself is not against indicating nutritional information on menus.
Finally, the recent federal healthcare reform legislation had an impact on this issue. However, it left gaps that still must be addressed to ensure that prevention efforts of this kind are going to be effective.

3. The Obesity Epidemic
The overall obesity prevalence within the United States is greater than 30%.
During the 1980’s and 1990’s prevalence increased at an unprecedented rate.
Obesity rates have stabilized overall
The risk of large increases in obesity occurring again cannot be ruled out.
As public health professionals we are all too aware of the obesity epidemic. One recent study has shown that the prevalence of obesity within the United States is greater than 30%. The fact that 1 in 3 Americans are obese is a troubling statistics that needs to be addressed. It is important to understand how we got to this point Well, what we term as the ‘obesity epidemic’ really began to show itself in the 1980’s and 1990’s when the prevalence increased at drastic rates that have never been seen before.
One positive sign coming out of this study is that obesity rates have stabilized but there is still a slight increase occurring and the risk of another drastic rate increase could easily occur. Considering the weight status of our youth, another rate increase is very possible.
Flegal, K.M., Carroll, M.D., Ogden, C.L., Curtin, L.R. (2010). Prevalence and Trends in Obesity Among US Adults, Journal of the American Medical Association, 303(3),

4. Childhood Obesity
Currently 31.9% of children within the United States between 2-19 years old are overweight or obese
Falls in line with the overall population statistic
This number has tripled over the last 30 years!
Creates the threat of another large increase in overall obesity prevalence
If we are currently having an ‘obesity epidemic’ in this country, than our children our being hit very hard. A recent study by Ogden indicated that 31.9% of children in the United States are overweight or obese.
The First Lady of the United States, Michelle Obama, has taken this issue to heart and has spearheaded a new governmental effort known as ‘Let’s Move’. This group indicates that the rate of obesity amongst our children has tripled over the past 30 years. Massachusetts is not shielded from any of these statistics.
Let’s Move. (2010). Accessed on: 4/15/2010. 
Ogden, C.L., Carroll, M.D., Flegal, K.M. High Body Mass Index for age among US children and adolescents, JAMA, 299(20)

5. Massachusetts Statistics
The Commonwealth has 4th lowest level of overweight among all US states
However, the rate of overweight has increased by 30% over the past decade
In 2002 one out of two adults within the Commonwealth were either overweight or obese!
While we here in the Commonwealth are doing fairly well compared to other states across the nation, we are still doing poorly. Over the past decade we have seen the rate of overweight increase by 30%. An even more startling statistic is that one out of two adults within Massachusetts are overweight or obese. In fact, 62% of men in the state are overweight or obese and 42% of women fall into the same category. Obviously, there is a problem that needs to be addressed and Massachusetts should try to take a leadership role in decreasing the prevalence of obesity.
Bureau of Health Statistics, Research, and Evaluation. (2002). Growing Concerns about Obesity Among Adults in Massachusetts: A Statistical Analysis of BRFSS Data. Mass. Department of Public Health.

6. Defining Overweight and Obesity
The CDC uses BMI as a scale for measuring obesity and overweight status
BMI is derived from a calculation that compares height and weight
Adult Overweight
BMI between 25 and 29.9
Adult Obesity
BMI 30 or above
Childhood Overweight
Having a BMI between the 85th and 95th percentile for the age of the child
Overweight Obesity
Having a BMI over the 95th percentile for the age of the child
At this point, I think it is important to actually take a moment and describe how cases or overweight and obesity are defined. The CDC uses a calculation known as Body Mass Index, or BMI, which compares height to weight. While this is the best classification method we have at this time it has its fair share of flaws. This is because it doesn’t directly measure fat content and doesn’t take into account excess muscle mass and therefore can misclassify individuals as overweight or obese.
CDC. (2009). Obesity and overweight. Accessed on: 4/10/10.

7. What Causes Obesity?
As noted by the CDC the cause of obesity is very well known
The body functions by having a balance between calories taken in and calories exerted
When the balance tips in favor of too many calories taken in weight gain occurs
So now that we know the prevalence of obesity and how it is defined, it is important to understand what causes it. The answer, according to the CDC, is quite straightforward. Our bodies like to be in a steady balance between calories taken in through food and calories exerted through physical activity.
However, like any scale this one can be tipped out of balance. When we put more calories into our bodies than we exert, we gain weight. Unfortunately, this is the way the scale has tipped for many individuals in our society.
CDC. (2009). Obesity and Overweight for Professionals: Causes. Accessed on: 4/10/2010.

8. Negative Health Outcomes
Being overweight or obese carries with it the risk of many negative health outcomes:
type 2 diabetes
hypertension
coronary heart disease
forms of cancer
renal and liver disease
sleep apnea
osteoarthritis
This tipping of the scales in favor of gaining weight is not simply a matter of looks. Many severe negative health outcomes have been associated with being overweight or obese. These include type 2 diabetes, hypertension, heart disease, cancers, renal disease, liver disease, sleep apnea, and osteoarthritis. This places a tremendous strain on individuals and society as a whole since these conditions require the individuals to utilize medical resources.
Gade, W., Gade, J., Collins, M., Schmit, J., & Schupp, N. (2010). Failures of feedback: Rush hour along the obesity highway. Clinical Laboratory Science, 23(1),

9. The Community Environment & Obesity
The community environment has been known to cause obesity
Several things can be done to limit cases of overweight and obesity:
Promote healthier choices
Create Opportunity for physical activities
Encourage the food industry to provide reasonable food and beverage choices
While it is easy to sit back and blame those that are overweight and obese for their condition, there are issues beyond the individual that can lead to being overweight or obese. In its information about obesity, the CDC makes it clear that there are environmental factors that can lead to obesity. They recommend that the community do several things to prevent obesity.
These prevention efforts include promoting healthier food choices, creating opportunities for physical activities, and encouraging the food industry to take action. However, while it is important that we work collaboratively with the food industry to provide healthier food options, we shouldn’t expect the industry to completely change their existing offerings or remodel their menus. Therefore, we need to try and work to educate the public on what the food industry currently offers.
CDC. (2009). Obesity and Overweight for Professionals: Causes. Accessed on: 4/10/2010.

10. Public’s Understanding of Caloric Intake
Consumers are not savvy at understanding their caloric intake
One study found that actual calories was almost two times the amount estimated by participants
Creates an environment that is unsuitable for preventing obesity.
While one may assume that the public is aware of what they are eating, they are not. A study by Burton, Creyer, Kees, and Huggins indicated that the public does not truly understand how many calories they are consuming.
The study asked individuals to estimate how many calories are present in typical restaurant foods. One would hope that that public has an understanding of what they are eating but unfortunately the results indicated that people grossly underestimated the amount of calories they would have consumed. In fact, the calories actually being ingested were almost double of what individuals were guessing. This level of knowledge about actual caloric content creates an environment that is unsuitable for preventing obesity. In fact, the study went on to find that food choices were significantly changed by the actual nutrition information.
Burton, S., Creyer, E.H., Kees, J., Huggins, K. (2006). Attacking the Obesity Epidemic: The Potential Health Benefits of Providing Nutrition Information in Restaurants. American Journal of Public Health, 96(9).

11. Adding Caloric Information to Menus
A recent study looked at the effects of presenting caloric information on menus:
The study had three groups of menus:
Menus with no caloric information
Menus with caloric information
Menus with caloric info and recommended allowances
The groups that used menus with caloric information consumed 14% fewer calories
A study published in the February 2010 edition of the American Journal of Public Health looked into the effectiveness of adding caloric information to restaurant menus. In this study the authors decided to give out three groups of menus. One set of menus would have no caloric info, the next set would include caloric info, and the final group would include caloric intake along with recommended daily allowances.
It was found that the group who had just calorie information presented to them ate less calories than the group who had no calorie information. However, this group returned to poor eating choices at meals after the study. In contrast, the group that had calorie information and recommended allowances presented to them ate fewer calories at the meal involving the labeled menu and subsequent meals after the study. In fact, it was found that this group, on average, consumed 250 less calories than the other group at meals after the study.
The main conclusion drawn from this study was that presenting calorie information was effective at changing food choices for the better. Therefore, there is current evidence supporting preventing obesity through providing more information to consumers.
Roberto, C.A., Larsen, P.D., Agnew, H., Baik, J., Brownell, K.D. (2010). Evaluating the Impact of Menu Labeling on Food Choices and Intake. American Journal of Public Health, 100(2),

12. Children’s Menus
While the previous study shows that food labeling can effect calorie consumption for adults, can the same be true for children?
One study says YES!
The study was conducted on a small sample (n=99)
The group of parents who had calorie information ordered meals with an average of 102 fewer calories.
While educating adults empowers them to make healthier decisions, children depend on their parents to make food choices for them. A study published in the February 2010 issue of Pediatrics indicates that parents do improve their food choices for their children when presented with calorie information.
In this study two sets of McDonald’s menus were created. One included calorie information while the other did not. Parents of 3-6 year olds were given the menus and were asked to choose meals for themselves and their children. The group that was presented with menus that had calorie information ordered meals for their children that, on average, contained 102 fewer calories. This study was the first to indicate that children would benefit from menus being labeled with nutritional information. However, with all the data supporting labeling menus, it is important that the public be willing to accept the presence of caloric information on their menus.
Tandon, P.S., Wright, J., Zhou, C., Rogers, C.B., Christakis, D.A. (2010). Nutrition MenuLabeling May Lead to Lower-CalorieRestaurant Meal Choices for Children. Pediatric, 125(2),

13. Public Perception
Will including this information on all restaurant menus be acceptable to the public?
One study set up several focus groups across 4 U.S. cities
Results indicated
Individuals were interested in having info available to them (even if they wouldn’t use it)
Food serving sizes should represent a true portion size
Symbolic icons indicating healthy food options would be welcome
Asking the question about what the public thinks is a valid one. One study found that individuals were willing to have this information on their menus.
In the article, the results of 4 focus groups that discussed this issue were analyzed. It was shown that individuals would be interested in having caloric information available to them but they may not always utilize them. This makes sense since sometimes individuals just need to eat without regard for consequence. However, they are still accepting of the idea. The groups also believed that the serving sizes should represent a true portion of the food they are eating instead of some smaller amount. This way, the number of calories being eaten is actually represented by the number given. Finally, individuals wouldn’t mind having some sort of symbol or icon that indicates healthy food choices so that their eyes can easily gravitate towards better options.
So with data indicating the effectiveness of including caloric information and the public being willing to accept such labeling, the government should be taking action.
Lando, A.M., Labiner-Wolfe, J. (2007). Helping Consumers Make More Healthful Food Choices:
Consumer Views on Modifying Food Labels and
Providing Point-of-Purchase Nutrition Information at
Quick-service Restaurants. J Nutr Educ Behav, 39,

14. New Federal Regulations
Within the recent healthcare reform legislation there was a provision for labeling menus with calorie information
This part of the legislation only affects large chains and does not affect any other types of restaurants
At the Federal level the government is trying to make menu labeling the norm. As noted in a recent article of the New York Times the newly enacted healthcare reform legislation requires large chains to label their menus with caloric information. However, this creates a major gap since smaller chains and single restaurants are not covered.
Rosenbloom, S. (2010). Calorie Data to Be Posted at Most Chains. The New York Times, March 23, 2010.

15. Why are the New Federal Regulations Not Enough?
Targeting large chain restaurants will allow consumers to make healthier decisions at many fast food chains
However, one recent study indicates that fast food chains are not always the worst option
The federal legislation may not provide enough coverage
While covering only the larger chains may seem like enough since it targets the fast food chain restaurants, one study points out that targeting these types of restaurants is not enough. The fast food restaurants are often made out to be the bad guy and rightfully so. However, the local restaurants may be as unhealthy as the large chains. The new legislation would not cover these types of restaurants equally.
Serrano and Jedda found that this concept is not without merit. In their study they found that children’s fast food meals were healthier than non-fast food restaurant meals. Fast food children’s meals actually had smaller portions, less calories, and less fat than children’s meals at non-fast food restaurants.
This study indicates that the gap left by the new Federal Legislation needs to be filled by the Commonwealth.
Serrano, E.L., Jedda, V.B. (2009). Comparison of Fast-Food and Non-Fast-Food Children’s
Menu Items. Journal of Nutrition Education and Behavior, 41(2),

16. What would it look like??
The menu information would not be a drastic change. It would simply be an insert anywhere along the menu description that shows how many calories there are in the food item that would be served.

17. Conclusion
The country and the state of Massachusetts are in the midst of an obesity epidemic
Caloric imbalance is the cause of weight gain
An environment that doesn’t provide information about caloric content of food can lead to obesity
The Commonwealth should have all restaurants include caloric information onto their menus
The addition of this information is effective, supported by the public, and must occur across all types of restaurants
I’d like to conclude this presentation with a review of the important points. The United States and Massachusetts are suffering from an obesity epidemic. Caloric imbalance, or an increased amount of calories eaten without a concurrent increase in exertion, leads to increased weight and obesity. This imbalance is not solely an issue that lies with the individual, the community environment also is to blame. An environment that doesn’t educate people about their food choices hinders people from making health choices. The Commonwealth should have all restaurants include caloric information on their menus. This concept is supported by studies that indicate including this information is effective and supported by the public. Finally, this must occur across all restaurants and not just fast food chains that are the most obvious suspects.
I’d like to thank you all for your time and welcome any questions at this time.

18. References
Bureau of Health Statistics, Research, and Evaluation. (2002). Growing Concerns about Obesity Among Adults in Massachusetts: A Statistical Analysis of BRFSS Data. Mass. Department of Public Health.
Burton, S., Creyer, E.H., Kees, J., Huggins, K. (2006). Attacking the Obesity Epidemic: The Potential Health Benefits of Providing Nutrition Information in Restaurants. American Journal of Public Health, 96(9).
CDC. (2009). Obesity and overweight. Accessed on: 4/10/10.
CDC. (2009). Obesity and Overweight for Professionals: Causes Accessed on: 4/10/2010.
Flegal, K.M., Carroll, M.D., Ogden, C.L., Curtin, L.R. (2010). Prevalence and Trends in Obesity Among US Adults, Journal of the American Medical Association, 303(3),
Gade, W., Gade, J., Collins, M., Schmit, J., & Schupp, N. (2010). Failures of feedback: Rush hour along the obesity highway. Clinical Laboratory Science, 23(1),
Lando, A.M., Labiner-Wolfe, J. (2007). Helping Consumers Make More Healthful Food Choices:
Consumer Views on Modifying Food Labels and
Providing Point-of-Purchase Nutrition Information at
Quick-service Restaurants. J Nutr Educ Behav, 39,
Let’s Move. (2010). Accessed on: 4/15/2010. 
Ogden, C.L., Carroll, M.D., Flegal, K.M. High Body Mass Index for age among US children and adolescents, JAMA, 299(20)
Roberto, C.A., Larsen, P.D., Agnew, H., Baik, J., Brownell, K.D. (2010). Evaluating the Impact of Menu Labeling on Food Choices and Intake. American Journal of Public Health, 100(2),
Rosenbloom, S. (2010). Calorie Data to Be Posted at Most Chains. The New York Times, March 23, 2010.
Serrano, E.L., Jedda, V.B. (2009). Comparison of Fast-Food and Non-Fast-Food Children’s Menu Items. Journal of Nutrition Education and Behavior, 41(2),
Tandon, P.S., Wright, J., Zhou, C., Rogers, C.B., Christakis, D.A. (2010). Nutrition MenuLabeling May Lead to Lower-CalorieRestaurant Meal Choices for Children. Pediatric, 125(2),