Monday, May 20, 2013

Calorie Labels on Menus: Why this Public Health Approach Fails In Low-Income Neighborhoods--Alina Rossini

More than one-third of adults in the United States are obese (35.7%), meaning their Body Mass Index (BMI) exceeds 30 (1). Within the American population, non-Hispanic blacks have the highest age-adjusted rates of obesity (49.5%) compared with all Hispanics (39.1%) and non-Hispanic whites (34.4%) (1). Americans who live in the most poverty-dense counties are those who are most likely to be obese (poverty/obesity) (1). Obesity is related to other non-communicative diseases that include heart disease, stroke, type-II diabetes, and certain types of cancer, all of which are some of the leading causes of preventable death (1). Medical costs associated with obesity were estimated to be around $147 billion, and obese people pay an average of $1,429 more than their non-obese counterparts (1). The Surgeon General issued a warning of an ‘obesity epidemic’ in 2001, and years later, New York City and Philadelphia have required that fast food chains include caloric information of standard menu items (2). However, it was not until the Patient Protection and Affordable Care Act of 2010 that there were national laws enacted to target the epidemic.
As part of the Patient Protection and Affordable Care Act of 2010, all chain restaurants with 20 or more locations must include calorie information on all their menus (3). Among other policy approaches, menu labeling has been proposed to address the growing rate of obesity in the United States, and the focus has primarily been on food consumed outside of the home. Eating meals away from home comprises 30% of daily caloric intake and 50% of yearly food expenditure (3). This trend is alarming because food consumed outside of the home is more likely to be higher in calories, fat, and sodium than foods prepared in the home (3) There have also been links between high rates of obesity and frequent consumption of food outside of the home (3). However, calorie labeling is an ineffective tool in combatting obesity, especially in low-income settings. According to an analysis done by researchers from New York University in 2009, only half of the fast-food consumers from low-income communities in New York City noticed calorie labeling. Consequently, only 28% of those who noticed the labels changed their order (4). Low-income and minority communities were chosen for the study due to the higher rates of obesity and the higher presence of fast-food restaurants in these neighborhoods (4). Calorie labeling in low-income environments is unsuccessful, as demonstrated by this study and others like it. While there are various reasons why this public health approach is limited, this study will focus on three major flaws and develop solutions for each.

 Literacy rates undercut the success of calorie labeling

Health literacy is a major flaw of the calorie labeling initiative, because not all Americans can properly read nutrition facts. In order to understand labels, individuals must first know how many daily calories are recommended for adults (5). In a study done in 2010 by New York University researchers, only one-third of fast food customers in low-income areas could accurately identify the number of calories an adult should consume each day as between 1500 to 2500. (6). Without knowing the recommended daily caloric intake, calorie labeling in fast-food restaurants becomes meaningless, because consumers are unable to relate calorie labels of individual items to the number of calories needed per day. Consumers do not have a caloric reference point in order to understand if a food item is high or low in calories. The study also concluded that racial and ethnic minorities of low-income communities were most likely to overestimate the suggested number of calories needed each day (6).
In addition to being unaware of how many calories are recommended each day, many consumers are also unaware of serving size (5). The number of calories in each serving and serving size are two critical pieces of information that are essential for weight control (5). According to a health study, 33% of people do not regularly read caloric information and only 5% looked at serving size (5). This suggests that people are unable to properly read food labels, because sometimes interpreting these labels requires mathematics to determine the total caloric amount. The study also concluded that people with less healthful diets are less likely to look at calorie labels and have less interest in doing so (5).
Low health literacy poses a significant barrier to the successful adoption of calorie labeling on menus, because it lowers the perceived risk of chronic diseases associated with a poor diet, such as obesity (7). Without a basic understanding of the consequences associated with an unhealthful diet, consumers are unaware of what constitutes a healthy diet and what does not. If consumers are unable to determine what is healthy, they are also unable to determine what would be the benefit of choosing healthier fast food options. They are also less likely to use calorie-labeled menus in their decision-making process (7). By not penetrating the consumers’ decision-making process, people who frequent fast food establishments will not be encouraged to change their eating behaviors (7). Ultimately, without labeling menus in a way that is understood to all consumers, no matter their education level, calorie labeling will continually fail in low-income areas.

Food Labels: Where are they in placed in fast-food restaurants?

Calorie labeling on menus is expensive for restaurants, so the Obama administration targeted restaurants that had 20 or more locations because they could better absorb the costs (5). However, extensive calorie labels on menus is still widely unavailable (9). Many restaurants choose to put the most comprehensive calorie listings online, and many fast food restaurants offer pamphlets that are not always available at point of purchase (10). In a study that examined the availability of calorie information in McDonald’s restaurants in Washington DC, only 59% provided in-store information for the majority of items on the menu (10). In 62% of the restaurants, it was necessary to ask two or more employees in order to obtain the calorie information (10). In majority of the McDonald’s visited, the information was available on tray liners (43%), pamphlets (43%), posters (5%), or one-page charts (10%) (10). Consumers see tray liners only after they purchase food, and food items often conceal or sully the information, yielding it illegible. Pamphlets are only available at the register where people may feel pressured to order quickly, and therefore not use it (10). Also, if people want more in-depth nutrition facts, that information is only available online (9). Even at the largest fast-food chain in the country, 40% of McDonalds outlets did not provide nutrition information for the majority of the items on the menu (10).
Consumers consider asking employees or searching for online caloric menus as a burden, and the majority of fast-food consumers do not perceive a benefit in searching for the information (9). The Behavioral Economics Model can explain the inaction of consumers (11) As explained by economics, behavior is the result of benefits and costs. Benefits are interpreted as reinforcers and people who frequent fast food restaurants more often obtain more reinforcing value from food than those who do not (11) Consequently, the cost of searching for caloric information outweighs the immediate desire for fast food; the convenience and craving is more important to consumers than caloric information or health (11). The absence of point of purchase nutrition information in majority of fast-food restaurants creates barriers in accessing the calorie facts, and the burden in searching for it is too high for majority of consumers. 

Barriers to obtaining healthful foods
The final major flaw of this public health intervention can be explained with the social ecological model. The social ecological model explains that interventions that solely focus on behavior change on the individual level often neglect the social and environmental context in which those behaviors occur (12). This clarifies why calorie labeling is ineffective. The intervention fails to recognize that there are few alternative healthy options available in fast food restaurants, convenience stores, and small grocery stores since they rarely have fresh produce or low-fat dairy items (13). This is especially true in low socioeconomic neighborhoods, where smaller grocery stores, convenient stores, and fast food restaurants like KFC and McDonald’s are abundant compared to higher quality grocery stores, Starbucks and Chipotle that are commonly found in middle- to high-socioeconomic communities (13). While calorie labeling aims to help consumers choose more healthful options, the intervention fails to understand that there are few, healthy alternatives in low-income communities because of the specific fast-food environment (13). Unless the intervention addresses the barrier in accessing more healthful foods, calorie labeling will continually fail in these communities

Defining a Better Intervention

Calorie labeling on menus as a public health approach to combat obesity will fail in low-income neighborhoods across the country if low health literacy rates, availability of nutrition information, or the low access to healthier options is not addressed. These three major flaws undercut the successful adoption of calorie labeling in quick serve food locations.
This study proposes a three-pronged intervention to specifically target the three main flaws. This new design improves calorie-labeling techniques by using color to represent the level of healthfulness of menu options, allows for customization of standard menu items for fewer calorie and low-fat alternatives, and finally proposes effective measures to support community partnerships to transform the physical and social environment as demonstrated in Chelsea, Massachusetts. This strategy focuses on the three critical weaknesses of calorie labeling as a public health intervention. By adopting this innovated design, calorie labeling will find more success in low-income communities. 

Numbers or Colors?

The past failure of calorie labeling efforts highlights that the general health knowledge of a population greatly impacts the efficacy of this public health approach. While calorie labeling may sway people in choosing a more healthful option, the approach cannot be expected to change a population’s eating behaviors if the majority of consumers do not know how many calories are needed each day. For this reason, calorie labeling needs to be reformatted.
Presenting caloric information by using colors may increase menu-labeling effectiveness, according to a study by Yale University researchers (14). After calorie-labeling formats were compared, investigators found that using colors to represent healthfulness of food items led to the fewest calories ordered by participants on average (14). This suggests that using green, yellow, and red to designate healthfulness leads to more informed decisions by consumers (14).
Green, yellow, and red are universal colors that represent good, moderate, and poor (14).  When applied to menus, the colors are interpreted as an item that is healthy, moderately healthy, or not very healthy. Little outside health knowledge is needed to understand the labels, since the colors have meaningful significance across many cultures (14). Therefore, the labels’ health meanings can be interpreted without having to read words. Language barriers in non-English speaking populations, primarily in Latino communities, limit access to healthy food options. Thus, the color system will be useful in areas where there are non-English speakers or illiterate community members. Color-coordinated calorie menus will allow all consumers, regardless of language ability, to successfully interpret the healthfulness of a menu item.
It is also important to educate consumers on health issues, such as the recommended daily caloric intake. To address this issue, menus should have informative prompts that read, “The health guidelines for Americas suggest consuming about 2,000 calories per day” (6). This prompt will provide consumers with a reference point, giving them a context in which they can better interpret the number of calories in menu items. (6).
Providing this background information is essential for informative decision-making, and will help successfully implement calorie labeling in low-income communities. Also, reformatting calorie labeling into a colored-coordinated system will allow all consumers to easily interpret healthfulness without having to understand English or to know basic health knowledge.

Small Changes

As discussed previously, calorie labeling is not always readily available in fast-food restaurants. Convenience and desire for food are always preferred over health, or in this case, searching for the caloric information (9). Point of purchase information is crucial to decision making, because if the caloric information is not readily accessible, consumers will not search for it, and it will not be taken into consideration when ordering (10). Instead of making consumers find and read labels, fast food restaurants can customize standard menu items to offer healthier options at the register.
Customization can take many forms on fast-food menus. For example, consumers can have the option of grilled meat instead of fried, using less bread, adding vegetables, removing all or some cheese, ordering low-fat salad dressing, or asking for sauce on the side. By asking consumers if they would like any of these options at the register, they are informed of these healthier options without having to consult pamphlets or search online. These small changes do not tell people to choose different options all together, but they make consumers’ favorite menu items healthier.
According to the incorrect assumption of the health belief model, consumers will completely change their fast-food orders once they learn that a high calorie diet gravely threatens their health. This theory, however, does not take into the account the high value of convenience and desire of food in comparison to health. In other words, consumers will not modify their eating habits for health reasons, as that is not a reason compelling enough to prompt change. Customization, therefore, will allow consumers to order the foods they love with the additional option to decrease their overall caloric intake.

Community Partnerships

Without considering the social environment of low-income communities, calorie labeling will continually fail. Policy changes need to be implemented that make healthier fast food alternatives easier to find. As the Social Ecological Model suggests, it is unrealistic to expect people to modify their behaviors when their physical and social environments do not support the change (12). Instead, the environment needs to become a part of the transformation. To incentivize change, community partnerships can be created to encourage local food marts to carry more produce and low-fat dairy products by offering a tax credit for those who do (15).
An intervention like this was implemented in Chelsea, Massachusetts in 2010 called ‘Healthy Chelsea’ (16). Just northeast of Boston, this city has declared itself a safe-haven for undocumented immigrants and is made up of 44.1% foreign-born non-citizens (17). Moreover, 62.1% of people living in Chelsea are of Hispanic or Latino decent and 67.8% of residents speak little to no English (17). Only 14.5% of the residents have a college degree or higher (17). The health initiative includes 56 individuals representing local government, state government, community organizations, healthcare providers, and businesses (16). These organizations collect health and behavioral data in Chelsea and use that information to assess the social and environmental factors influencing Chelsea’s high obesity prevalence (16). Through this assessment, the initiative implements and supports more healthful behaviors that are conducive to the diverse cultural and ethnic background of the residents (16). The initiative has increased the volume of fresh produce sold at local markets, given tax credits to participating locations, and has provided healthy marketing materials around the city (16). There has been a close partnership between the city’s Planning and Development Department to support infrastructure changes such as park renovations and installations (16). The initiative also pioneered the passage of Chelsea’s trans fat free regulation (16).
Community partnerships and organizations are essential to changing the social and physical environment to encourage the adoption of new behaviors at the population level, as demonstrated with the ‘Healthy Chelsea’ initiative (15). A tax incentive will provide affordable, low-calorie options in low-income neighborhoods where those alternatives are scarce. This will give residents the ability to choose more healthful foods when they are food shopping or dining out with their family, ultimately encouraging people to make healthier food choices.

While calorie labeling was developed with meaningful intentions, it is not a universally effective approach. It fails to address low health literacy rates, the value of convenience over health, and the impact of the physical and social environment on decision-making. By neglecting these issues, calorie labeling will continually fail in low-income communities. This paper recommended a better intervention, designed to consider these three major flaws. These major critiques demonstrate how social theories were not properly applied, and the intervention uses these same social theories to strengthen calorie labeling in low-income communities. The improved approach involves reformatting calorie labeling by using colors to represent the level of healthfulness of food items, allows for customization of standard menu items for fewer calorie and low-fat options, and finally proposes effective strategies to promote community partnerships to transform the physical and social environment as demonstrated in Chelsea. This three-pronged approach focuses on the major flaws of the intervention and encourages healthier decision-making in low socioeconomic communities. Making these types of changes is essential to combat obesity, and as this paper suggests, the calorie labeling approach will not be successful unless it is tailored to the specific needs of the target population.

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14. Liu, Peggy J., Christina A. Roberto, Linda J. Liu, and Kelly D. Brownell. "A Test of Different Menu Labeling Presentations." Appetite 59 (2012): 770-77

15. "Helping Grassroots Advocacy Efforts Take Root." Journal of the American Dietetic Association 111.3 (211): 356-58.

16. "Massachusetts General Hospital." Healthy Chelsea.

17. "Chelsea QuickFacts from the US Census Bureau." Chelsea QuickFacts from the US Census Bureau.

1 comment:

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