Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Thursday, May 7, 2009

Limitations of Restaurant Nutrition Labeling in Promoting Healthier Choices and a Proposal for Increasing Its Effectiveness – Stacey Kokaram

An increasing number of cities and towns across the US are requiring restaurants to provide nutrition information for their menu items (1, 2). Currently, the Nutrition Labeling and Education Act (NLEA) gives the Food and Drug Administration (FDA) the authority to require and regulate nutrition labeling for most food products regulated by the Agency (3). Over the past years, several pieces of legislation have been introduced in Congress to expand the FDA’s authority to also require nutrition labeling in restaurants (4). A recent observational study published in the American Journal of Public Health, showed that only 0.1% of patrons entering four popular fast-food restaurants referenced in-store available nutritional information (5). The study did not analyze whether the information had an effect on the food choices of these consumers. Nutrition labeling in restaurants would provide information for consumers to make healthier food choices but is only a small component of what is necessary to promote and support healthier eating among consumers.
This paper explores three key limitations that prohibit restaurant nutrition labeling from leading to healthy eating behavior. These limitations include: 1) the amount and accuracy of information posted; 2) the belief that intent to eat healthier will lead to healthy eating behavior; and 3) the lack of access to healthier food alternatives.

Nutrition Labeling Requirements & Accuracy
Many of the current restaurant nutrition labeling regulations require restaurants to post minimal nutritional information. The labeling requirements in King County, Washington require chain restaurants with 15 or more establishments to include total number of calories, grams of saturated fat, grams of carbohydrate, and milligrams of sodium for all standard menu items (2). This amount of information is not adequate in order to promote healthy dietary habits. Additionally, variability in nutritional content of foods requires that additional steps occur in order to make the available information useful to consumers.
The American Dietetic Association (ADA) convened the Task Force on Restaurant and Nutrition Labeling Research to analyze the effects of restaurant nutrition labeling using scientific principles tested through research and to identify gaps in the available research (6). The task force, comprised primarily of public health officials and registered dieticians, raised a key concern about the unintended consequences potentially caused by nutrition labeling. The concern is that by posting minimum caloric information, consumers will make choices based solely on calories and not on other nutritional values. Overall nutrition is particularly important for children and adolescents whose bodies need nutrients and who tend to eat at fast-food restaurants most frequently.
Another concern raised by the ADA’s task force is the accuracy of nutritional analysis programs. The task force reports that nutritional information can vary significantly in packaged foods, which are produced in tightly controlled environments, therefore the probability is high that even greater amounts of variability will occur in restaurant nutrition labeling. Steps should be taken to reduce this variability and this variability information should accompany any labeling initiatives to ensure that the information provided to consumers is accurate. Providing inaccurate information to consumers would counter the intentions of the restaurant nutrition labeling initiative.

Healthy Eating Intent vs. Behavior
Restaurant nutrition labeling initiatives follow the principles of the health belief model (7,8). The principle most affected by these initiatives is the consumer’s perception of the severity of eating unhealthy foods. These initiatives assume that most people know that high calorie foods are bad for them and will avoid eating foods they know are high in calories. Like the health belief model, restaurant nutrition labeling erroneously assumes that because a person intends to eat healthy foods, they will actually eat healthy foods.
The United States Department of Agriculture’s (USDA) Economic Research Service (ERS) conducted a study in which the researchers analyzed consumer food choices based on the consumer’s long-term health objectives and immediate visceral influences, such as hunger and stress (9). The analysis used behavioral economics to develop models to predict the effects of time pressures and hunger and compared these models to results from the 1994-96 Continuing Survey of Food Intake by Individuals and the Diet Health and Knowledge Survey. The results found that those under stress and those who had gone longer without eating were more likely to eat more calories per meal than those who were not under these influences when faced with immediate food choices. These results remained true even for those who had long-term health goals.
Another key limitation of using the health belief model for this initiative is the assumption that people will make rational food choices. Even if a person is presented with accurate nutritional information, knows the severity of eating unhealthy foods and is not under stress, there are still other factors that could lead the person to choose unhealthy foods over healthier options. A study challenging the notion that intention leads to behavior was published in the Journal of Marketing in 2003 (10). This study found that health claims and nutrition information generally had an effect on consumer’s attitudes towards food items but for many, this evaluation did not actually influence the consumer’s actual consumption behavior.
Consumer’s attitudes towards taste of healthy foods can play a significant factor in their decision to choose either the healthy item or the unhealthy item. A study conducted by Horgen and Brownell (11), suggests that consumers may associate the term healthier foods with bad taste. The study looked at the effects of price decreases, health messages and the combination of the two methods on consumer choice of targeted food items. Although the combination of price decreases and health messages produced an increase in sales of the healthy items, the results suggested that the perception of the taste of healthier foods attenuates the effect of price decreases alone in these healthier food choices.

Access to Healthier Alternatives
In a 2006 study of fast-food restaurant patrons, 87.2% indicated that price was an important factor in their food choice while only 57.9% indicated that nutrition was an important factor (12). While cost is a factor in food choices for most people, for some cost is THE deciding factor. Restaurant nutrition labeling may provide consumers with the information to make healthier food choices but the labeling initiative does not go far enough to ensure that those who want to make healthier choices have the resources to follow through with their intention. Even if these individuals know the nutritional information related to the food they’re purchasing, there may not be a cost-effective alternative available for them to purchase. Several studies have been conducted which show that diet-related health outcomes are worse in areas with less access to supermarkets and more access to convenience stores and fast-food restaurants than in areas with large supermarkets (13,14) The populations that live in the areas with less access to large supermarkets in general have a lower socioeconomic status than those who live in areas with accessible grocery stores (15).
An earlier study mentioned in this paper, showed that price decreases on food items had a more significant impact on the purchase of these items than did the inclusion of health messages promoting the items (11). If prices for healthier food options were decreased, this suggests that the likelihood of consumers purchasing these items would increase.
Finally, healthy food options available at restaurants need to increase in order to assure that people have choices in what they can eat. Glanz, et al (16) evaluated the major factors that influence restaurant chains to plan their menus. They found that growing sales and increasing profits were not surprisingly the most important consideration, with health and nutrition much less influential. Several respondents to the survey noted that healthier food options have been offered in order to prevent loss of business from certain health advocacy groups. The study suggested that consumer demand is likely the major factor that will influence major chains to include and keep healthier food options on their menus. Additionally, the researchers suggest that public health and government agencies should work towards increasing chain restaurant perceptions of consumer interest and also incentives for restaurants to offer healthier food options. The availability of healthier food options will help reduce a potential barrier consumer’s face while trying to adopt healthier eating habits.

Restaurant nutrition labeling initiatives have the potential to provide valuable information to some consumers who wish to improve their dietary health. These initiatives facilitate healthy eating among those who already perform healthy eating behaviors but do little to promote healthy eating behaviors among those who do not regularly make healthy food choices. Strategies to expand the benefits of restaurant nutrition labeling to wider audiences must include other components that affect food choice behavior and reduce barriers to healthier food choices.

Counter-Proposal for Intervention
The three limitations of the restaurant nutrition labeling program presented above can be remedied. The remainder of this paper will present a modification to the program which will address these three main limitations. The redesigned restaurant nutrition labeling program should be comprehensive and include multiple public health campaign components rather than simply providing information to the public. A committee at the Institute of Medicine “strongly suggests that interventions need to use multiple approaches (e.g. education, social support, laws, incentives, behavior change programs) and address multiple levels of influence simultaneously (i.e., individuals, families, communities, nations)”(17). The proposed campaign has three key components that improve upon the previous intervention. The first component is for restaurants to provide more complete and accurate nutrition information to the public using a system that allows consumers to easily identify healthier menu items. Secondly, the campaign would use social sciences theories to promote the use of the system to consumers so hey could make healthier food choices. Finally, the campaign would focus on making restaurants that used these labeling systems easier to access for those who would like to make healthy food choices.

Complete and Accurate Information System
The information that restaurants are required to post should take into account nutrients rather than just calorie count and fat content as some restaurants have done (1,2). By providing only calorie count and fat content, people may not be making the healthiest food choices. According to the ADA, posting of calorie and fat information without additional nutrient information could take the focus away from healthy eating and put the focus on calorie counting alone (6).
Comprehensive posting of nutritional information, however, may become burdensome for both the restaurant and the consumer if there are lots of items on a restaurant’s menu. An alternative strategy for condensing prominent displays of nutritional information while still providing complete nutritional information for patrons could be done using two components. The first should be a pamphlet with complete information on all products the restaurant serves. This gives the customer the option of seeking out specific amounts of various nutrients in foods if, for example, they are diabetic and need to watch their sugar intake or if they have high blood pressure and need to limit their sodium intake. The majority of consumers would use the second component which would be a nutritional posting similar to the “DDSMARTTM” menu used by Dunkin’ Donuts (18). This type of menu creates a visual way for consumers to more easily identify foods that are the healthiest on the restaurant’s menu. This menu would allow consumers to see which items are healthiest in the restaurant and would allow them to make smarter food choices without having to analyze the nutrition content of every item served by the restaurant. According to a study by Malhotra (19), consumers have finite ability to absorb and process information given a short amount of time. If given too much information in a short time, consumers can actually make poorer decisions than they would if they didn’t have as much information. This theory supports concise but accurate restaurant labeling which could serve as a compromise to promote healthier food choice and prevent restaurants from being overburdened by extensive menu labeling. Nutritional standards would have to be developed by agency enforcing the restaurant labeling regulation in order for foods to make it on to the “healthy options menu.”

Promoting the Labeling System
Once an acceptable system is established to identify the healthiest items on restaurant menus, the system needs to be marketed to consumers. If a consumer can easily identify a brand to mean healthier food, without having to process lots of information at the point of purchase, then they would be more likely to make a healthier food choice than if they had to process lists of nutritional information (19). Branding theory is based on analyzing a target audience to create a brand that has attributes with which the audience can identify (20). Once this identity and sense of shared attitude is established, consumers will recognize the brand and may become loyal to it (21). The association by consumers of healthier foods with bad taste suggested by the Horgen and Brownell (11) study could be combated by this branding campaign. This type of branding and brand loyalty would make it easier for consumers to choose items from the menu with which they were familiar. The branding would have to include a visually appealing and easily recognizable menu design that consumers could identify once in the restaurant. The simple act of being able to identify healthy choices without sorting through nutritional information will increase the likelihood that people who intend to eat healthy will eat healthy. The simplification of the choice reduces an irrational barrier that prevents people from following up their intent to eat healthy with the actual behavior (19).

Increase Availability of Restaurants With Labeling System
Finally, once the labeling system is in place in the restaurants and is made easily recognizable for consumers through the promotion process, policy makers should ensure that consumers have access to get to these restaurants. The labeling policies in both New York City (1) and King County (2) both had limitations on which type of restaurants had to comply with the labeling law. If an area does not have a high quantity of restaurants that must comply with the regulation, then the labeling system would be virtually useless to the consumers who lived in that area. Policy makers should ensure that the majority of restaurants must comply with the regulation or that the restaurants that do have healthier menus are more accessible within neighborhoods.

Although current restaurant nutrition labeling programs in various cities have good intentions, the programs do not go far enough to ensure that the labeling program itself is effective. By assuming that providing more information will lead consumers to make healthy behavior changes, policy-makers are erroneously designing interventions based on the Health Belief Model (7,8). While having more information may change consumer intentions, their behavior at the point of purchase in these restaurants is what should be addressed in order to truly promote healthier food choices.

1. Board of Health Vote to Require Chain Restaurants to Display Calorie Information in New York City. New York City Department of Health and Mental Hygiene Web site. Available at Accessed on April 5, 2009.
2. Trans fat and nutrition labeling in King County. King County Public Health Web site.
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