May 19, 2018

Will Posting Nutritional Information on Menus Prod Diners to Make Healthier Choices?

Some studies say no effect.  Others say a very small effect. The article comes from a major medical journal so the authors  conclude in favour of providing the dietary information.  But that is more an expression of political correctness than anything else.  A conclusion that the doubtful benefits don't justify the costs would also be warranted.

Note that the authors are also politically correct in demonizing salt (sodium). That is very poorly informed from a medical viewpoint.  There is now much evidence that salt is helpful rather than harmful. See here, here and here


On May 7, all US chain restaurants with 20 or more locations—and that includes coffee shops, bakeries, and movie theaters that sell food—had to start posting the calorie content of their menu items.

The rationale behind the US Food and Drug Administration (FDA) mandate, set forth in the Affordable Care Act in 2010, was that it might make customers think twice about ordering a meal that contained more calories than they should consume in an entire day. But whether posting calorie counts will help trim the proportion of US adults and children who are overweight or obese remains to be seen.

“About half of consumers’ annual food dollars are spent on, and a third of total calories come from, foods prepared outside the home,” according to the FDA’s final rule on menu nutrition labeling, published in December 2014 (implementation of the rule has been postponed twice from its original date of December 1, 2015). “Research indicates that many people do not know, or underestimate, the calorie and nutrient content of these foods.”

US consumers have had nearly a quarter of a century to familiarize themselves with nutrition labeling on packaged foods, required by the FDA since 1994. Mandating the posting of calories in restaurants “is a really good start to be more consistent with the way we have labeling on packaged foods in grocery stores,” said Heather Eicher-Miller, PhD, an assistant professor of nutrition science at Purdue University.

A number of jurisdictions already require chain restaurants to post calories, beginning in 2008 with New York City. In addition, some nationwide chains, such as Krispy Kreme and Subway, already post calories.

Evidence Is Thin

Evidence that providing calorie counts on restaurant foods spurs customers to ditch fettuccine alfredo for filet of sole is pretty thin. Even if diners do opt for the lower-calorie items, it’s not known whether they’ll compensate by eating more than they normally would at their next meal.

Eicher-Miller coauthored a meta-analysis in 2017 that concluded that menu labeling in restaurants did not result in a change in quantity or quality of calories consumed by US adults. “But that doesn’t mean it can’t be helpful or important,” she said, explaining that only time and further research will tell whether the FDA’s mandate might eventually have the desired effect.

A recent Cochrane Review found that adding calorie information to menus in restaurants, coffee shops, and cafeterias could reduce calories purchased by about 8%, or by about 50 calories out of a 600-calorie meal. And there was no evidence that posting calories caused unintended harm by increasing the number of calories purchased or consumed.

The authors’ conclusion was not a ringing endorsement of menu nutritional labeling though, due to a dearth of high-quality studies. “We tentatively suggest that nutritional labeling on menus in restaurants could be used as part of a wider set of measures to tackle obesity,” they wrote. “Additional high-quality research in real-world settings is needed to enable more certain conclusions.”

Higher-quality studies are needed to answer 2 key questions, said Theresa Marteau, PhD, director of the Behavior and Health Research Unit at the University of Cambridge Institute of Public Health in the United Kingdom and a coauthor of the Cochrane Review. How should nutrition labeling on menus be designed to optimize the impact on purchasing and consumption, particularly for those in lower socioeconomic groups who might be more likely to benefit? And how effective are menu nutrition labels alongside other efforts to promote healthier diets, such as availability of healthier options and smaller portion sizes?

While these questions have yet to be answered, Marteau said, “we believe that there is sufficient evidence of effectiveness for the FDA to proceed with required nutritional labeling on menus and for the UK, and other jurisdictions, to move toward mandating this.”

Nutritional Illiteracy

One reason the research so far has failed to find much of an effect from posting calories is because relatively few consumers use the information, said Punam Ohri-Vachaspati, PhD, RD, a professor of nutrition at the School of Nutrition and Health Promotion at Arizona State University. At restaurants, Ohri-Vachaspati said, “we are all impulsive eaters, and we are all used to making impulsive decisions.”

In a study published in 2015, Ohri-Vachaspati and her coauthors found that 60% of people interviewed outside of McDonald’s restaurants said they had noticed nutritional information on the menu boards, but only 16% of them said they had considered it when deciding what to order. Higher income and having a bachelor’s degree or higher were independently associated with a greater likelihood of noticing as well as using the menu calorie labels.

Simply slapping calorie totals on a menu isn’t enough, Ohri-Vachaspati said. Diners need to understand what calories mean in the context of their daily diet. The FDA is requiring that menus must say “2000 calories a day is used for general nutrition advice, but calorie needs vary.” However, not everyone grasps what that means, Ohri-Vachaspati said.

“I think that the average American consumer does not understand what calories are” or how many they should consume in a day, said Sara Bleich, PhD, professor of public health policy at the Harvard T. H. Chan School of Public Health. “It’s unfortunate that it’s just calories that are being reported.”

Beyond Calories

Besides posting total calories on menus or menu boards, restaurants must have available “on the premises” printed information about 10 other nutrients in their dishes, including grams of fat, carbohydrate, protein, and fiber and milligrams of cholesterol and sodium, according to the FDA.

Whether customers will actually use that information is another matter. “People generally do not ask for nutrition information beyond what’s printed on the menu,” said Karen Byrd, PhD, MBA, a registered dietitian and professor of nutrition, dietetics, and food management at Murray State University in Kentucky.

A recent study by Byrd and Eicher-Miller and coauthors suggests that it might be more useful to post sodium content on menus instead of calories, especially considering that US adults get approximately a third of their total daily sodium intake from restaurant foods.

Many US adults consume more than the recommended daily limit of 2300 mg of sodium, according to a recent study in JAMA led by Centers for Disease Control and Prevention (CDC) researchers. They estimated that the average daily sodium intake of US adults was 3608 mg.

In her study, Byrd examined whether sodium warnings required on chain restaurant menus in New York City since 2015 had any effect. The restaurants are supposed to place a triangular icon with a salt shaker in the middle next to menu items that have 2300 mg of sodium or more.

“Based on my research, that’s not effective,” possibly because only 17% of all menu items contained at least 2300 mg of sodium, making it easy for consumers to overlook the icon, said Byrd, who conducted the study while on the Purdue faculty.

However, posting the number of milligrams of sodium next to each item on the menu did make a difference, although it depended on whether people perceived relatively healthier foods as tasty. Those who liked to eat healthy food selected meals with lower sodium content, Byrd found. On the other hand, 1 in 5 participants in her study said they thought lower-sodium foods weren’t tasty, so posting the sodium content drove them to order higher-sodium menu items.

In contrast, posting calories made no difference in the calorie content of the meals ordered, even among participants who thought healthy foods were tasty, Byrd’s study found.

Restaurants’ Role

Even participants in Byrd’s study who opted for lower-sodium menu items were unable to reduce their sodium intake at one meal to below 2300 mg, the maximum recommended daily intake, because so many dishes came close to or exceeded that level.

“Additional action by the restaurant industry to reduce the sodium content of restaurant foods, as proposed by the FDA, may be necessary to make a significant public health impact,” she and her coauthors wrote.

The problem is that simply eliminating salt added in the preparation of food or at the table might not meaningfully alter sodium intake in the population because it remains high in commercially processed foods, Joachim Ix, MD, MAS, and Cheryl Anderson, PhD, MPH, MS, both of the University of California, San Diego, wrote in an editorial accompanying the CDC study in JAMA. “Because of this, strategies to reduce sodium intake should focus at the population level first and should include the industries that supply processed foods, beverages, and menu items,” Ix and Anderson wrote.

Recent research by Bleich suggests that large US restaurant chains are moving in that direction by cutting calories and sodium in their new menu items.

In one study, she and her coauthors found that the calorie-adjusted sodium content in newly introduced menu items in the 66 top-earning restaurant chains declined by 104 mg from 2012 to 2016. “However,” they wrote, “sodium content of core and new menu items remains high, and reductions are inconsistent across menu categories and restaurant types.”

In another study, Bleich and her coauthors found that items dropped from the chains’ menus during that period contained 71 more calories than the items that remained on the menu. “I think that’s probably a reflection of shifting consumer demands,” Bleich said.

Diners’ behavior is resistant to change, but eliminating higher-calorie menu items might have a “significant and positive impact on population health,” she and her coauthors wrote.

“The overarching point is it’s an overall good trend,” she said of the lowering of sodium and calories in restaurants, although “we want to keep an eye on some red flags.” For example, Bleich said, to cut calories, restaurant chains are often replacing healthy fats with sugar, which could leave customers less sated.

The mandated posting of calories in restaurants will likely motivate them to reformulate more dishes, Bleich predicted. “You don’t want to be known as the restaurant that has the highest-calorie appetizer.”

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