Americans remain very overweight.  According to the CDC, about 38% were obese in 2014, meaning that they had a body mass index of at least 30, compared to 32% of Americans just a decade ago.  This is in spite of massive efforts to try and get people in the United States to eat more healthfully.  Policy makers continued to believe that this is a problem of information dissemination.  One obvious solution, therefore, is to give people calorie counts of what they're eating in restaurants.  Recent mandates have directed that by the end of next year, calorie labeling will be required on all menus in chain restaurants in the United States.  It is assumed that once Americans know what they are eating, they will eat less, or at least more health-consciously.  But will they?  New data exist.  That's the topic of this week's Healthcare Triage.  

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Menu labeling efforts already exist.  By looking at how they have worked or failed to, we can begin to predict how this widespread regulation might function.  To the research!

A study published recently in Health Affairs examined differences in calorie counts of items offered in restaurants that had already voluntarily begun to post information versus restaurants that had not.  Researchers looked at data from 66 of the largest chains and found that the average per item calories was 139 lower in restaurants that already posted their nutritional information.  

This doesn't mean that calorie counting forces restaurants to reduce the calories they offer, though.  It could just as easily mean that restaurants with lower calorie offerings are voluntarily eager to let you know.  A better understanding of how initiatives might change behavior should come from prospective trials.  Those, too, have been conducted, in the same issue of Health Affairs.

Another study examined how Walmart's Healthier Food initiative changed how people purchased foods.  One of the methods used was adding a front-of-package labeling system, which indicated items that met pre-determined nutritional criteria.  They also offered price reductions on some healthier items.

Over the years of the study, there were significant decreases seen in the caloric content of purchases, but most of the changes happened before the introduction of the program.  The conclusions of the researchers were that retail-based initiatives might not be enough to change behavior.  In other words, calorie labeling might not work.  

Another study was also on point.  In New York City, menu label mandates began in 2008.  After their initial posting, people reported that they saw and used calorie counts more often than people did in restaurants without labels.  However, every year after that, fewer and fewer people reported noticing them or considering them.  Over time, they started to ignore the labels.  More significantly, at no time did the labels lead to a reduction in the calories of what consumers ordered, even if they noticed them.  Knowing how many calories they were ordering didn't change their behavior.

The problem here is that while all of these studies are being packaged as new, we've known about much of this for years, and I've even talked about it on Healthcare Triage before.  The New York City program was studied after it first went into effect.  A 2012 publication in the American Journal of Public Health noted that the results of menu labeling seemed to lead to an increase in calorie intake, due to purchases of higher calorie entrees, not a decrease.

No one should be surprised three years later that this program still doesn't work.  A menu labeling program in Seattle whose impact was investigated in a study published in the American Journal of Preventive Medicine in 2011 led to, and I'm quoting, "Increased nutrition information awareness, but no decrease in calories bought by parents or children."  

A systematic review published earlier this year reviewed all of the existing studies looking at menu labeling and the medical literature through October 2013.  They found a lot of variation in how they fared, and many of the studies didn't occur in real world environments, but the six controlled studies that took place in restaurant settings showed that overall, menu labeling did not produce any significant changes in what people ordered.  The USDA's nutrition evidence library concluded that, and I'm quoting, "Limited and inconsistent evidence exists to support an association between menu calorie labels and food selection or consumption," and you gotta remember that the labels are only as good as the individual cooks.  

In a 2011 student published in JAMA, researchers went to restaurants with menu labeling, bought food, and then took it to the lab to measure its actual calorie content.  They found that while menus were, on average, pretty accurate, substantial variation existed.  About 20% of foods purchased had at least 100 more calories than what was reported.  This discrepancy continued to exist when they repeated the purchases and measurements at a later date.  Worse, the food items with the lowest reported calories or the "healthiest" were the most likely to be off.

For those who argue that there's no harm to labeling menus with calories, I'd point you to my Economist colleagues.  Requiring changes to menus does have a financial cost.  It could impact businesses in ways we might not predict.  Regulations have effects, and in this case, there could be harms we're not measuring. 

Menu labeling also may be taking our eye off the ball.  By offering us a purported solution, it may stop us from trying other things that might work better.  Previous work in health affairs showed that training servers just to ask if consumers might like to downsize three starchy sides induced up to a third of them to order and eat 200 fewer calories per meal.  More recent work in the journal showed that changing the prevalence, prominence, and default nature of healthy options on children's menus led to sustained changes in what people ordered.

We can help people make healthier choices in restaurants.  Menu labeling might be the method of policymakers' choice, but it might not be the proper prescription. 

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