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Review of Literature on the rise of Obesity

Obesity is on the rise both in the US and internationally. In the US, many factors have contributed to the rise in obesity including dining outside of the home and the food choices consumers make. The rise of meal consumption outside of the home and the rise in the obesity have lead many state and local governments, including California, to enact menu labeling laws which require chain restaurants to post nutrition information which include calorie and nutrient information. Data has shown that consumers are not able to accurately estimate calorie and nutrient content of foods and legislators hope that providing nutrition information in chain restaurants will aid consumers in making better food choices. A number of studies have been conducted on the effectiveness of menu labeling. While many of these studies have shown positive results, more research must be conducted in order to address methodological weaknesses of previous studies and to determine if the way current legislation is written is effective in battling the public health problem of obesity as well as the other diseases related to diet such as diabetes and heart disease.

The National Health and Nutrition Examination Survey (NHANES) has collected data on obesity trends in the US since 1976. Data has shown a continuous increase in the prevalence of obesity. Specific time periods have shown a slower or stable growth though there is still a continuous increase. The last survey conducted between 2007 and 2008 consisted of 5,555 adult men and women aged 20 years or older. These results were compared with the data from 1999 through 2006. Overweight was defined as a body mass index (BMI) of 25.0 to 29.9 and obesity was defined as a BMI of 30.0 or higher. The survey found that 33.8% of Americans were obese (32.2% men, 35.5% women) and the corresponding prevalence of both overweight and obese Americans was 68.0%. The results for the 2007-2008 data were at the same rate over the past ten years; however, is still increasing. 1

Increased caloric intake greatly contributes to the alarming increase in obesity. According to the CDC, two-thirds of Americans are overweight or obese. Obesity leads to an increased risk chronic diseases consisting of diabetes, heart disease, stroke, some cancers, and other health problems. The increase in portion sizes has played a large role in the obese population. The increase in obesity and portion sizes are both at a parallel increase. A majority of food facilities have greatly exceed the original serving when they first open.2 In 2006, there was a study done to examine how accurate consumers could estimate their nutrient content of a typical restaurant meal. On average, consumer significantly underestimated the calories and fat.3

Over the past twenty years, there has been a significant increase in the number of meals eaten at a food facility rather than in the home, causing an estimated one-third of the daily caloric amount to be consumed at that meal and almost one-half of the food dollars being spent on food purchased at restaurants or food facilities.4 Out-of-home meal consumption has been on the rise since the 1970s.5 One survey determined about 37% of adults and 42% of children ate fast food.5 In the year 2000, about 41% of the population ate at least three or more commercially prepared foods per week.6 It has been estimated that by the year 2020 food expenditures will increase by 26% and 28% of U.S. of that food expense will be away from home.5 These studies as a whole have shown that Americans continue to eat out more frequently. The USDA Agricultural Research Service stated that out-of-home consumption resulted in an increased intake of energy with 25% intake of calories and fat from fast food, due to increased portion sizes over the years.7 In an effort to curb the impact of out-of-home meal consumption on the rising prevalence of obesity, local governments and states such as California have decided to pass legislation to mandate menu labeling at chain restaurants.

Senate Bill 1420 was passed in California with the intent to provide better access to nutrition information or calorie content to those who consume foods sold at food facilities. This will provide consumers with the information they need to understand the nutritional value on the foods available and assist in helping people pick healthier foods with lower calorie content. Menu labeling will also help those with chronic diseases such as diabetes and heart disease better manage their diets when eating outside of the home.

The bill requires all “chain” restaurants (those with 20 or more locations) within the state of California to provide consumers with nutritional information for all standard food items sold at that facility. The nutritional information will include calorie content, grams of carbohydrates and saturated fat, and milligrams of sodium. A sit-down food facility shall supply nutritional information either in a brochure on the table, on the menu next to the standard food items, in a menu insert, or in a table tent located on the table. “Quick service” restaurants (facilities that do not offer a sit-down area) must disclose the information within a brochure that is made available at the point of sale. Restaurants that offer a drive-thru and uses a menu board to present the standard food items, there must be a notice displayed that states, “NUTRITION INFORAMATION AVAILABLE UPON REQUEST.”2

After January 1, 2011, the bill will require each food facility in California that meets the specific criteria for supply the nutrient analysis for standard food item, as specified and any violation of these provisions is punishable as a misdemeanor. SB 1420 in California was passed after similar laws were passed in other states and cities. As a result of the national focus on health care reform, there is now a push to create a national menu labeling law creating federal guidelines for labeling. 2

In light of the health of our society, in regard to obesity, some state have required restaurants to include nutrition information. One finding shows that posting calories right next to the menu item “could have a sizable salutary impact on the obesity epidemic, even with only modest changes in consumer behavior”.8 Another article states that consumers look at nutrition labels and decreases choices on less-healthful items, where restaurants are not required to supply nutrition information.9 Although states have noticed, the federal government has started to see this health epidemic.10 On the federal level, some politicians are pushing to have nutrition information provided in all states. However, there is a concern among this and that is preemption. Where the federal government may conflict with state powers. Despite this, the federal government is pushing towards to help the public health by providing that there is a federal law that requires all states to have nutrition information posted to combat obesity in the U.S.A.

Studies suggest that consumers greatly underestimate calories and nutrients when assessing menu items. A study by Burton et al used a survey to determine if consumers would be able to accurately estimate the calories, fat, saturated fat, and sodium content of different restaurant food items. The food items were placed in three categories: more healthful, less healthful, and extremely unhealthful depending on their calorie and nutrient content. When participants estimated calories, the less healthful items were thought to have higher calories than more healthful items. The calorie level of less healthful items were underestimated by an average of 642 calories and the extremely unhealthful item (cheese fries with ranch dressing) was underestimated by 2000 calories. Conversely, more healthy items were only underestimated by 42 calories.11

Several studies have explored whether menu labeling affects consumer food choice. A review of six studies by Harnack and French revealed conflicting results and methodological problems. Harnack and French only included studies that used a restaurant or cafeteria setting and excluded studies that only looked at specific menu items (i.e. low calorie menu items). Of the studies reviewed, only four of the studies found significant results supporting the hypothesis that calorie labeling on restaurant and cafeteria menus affected food choice. The same four studies however evaluated calorie labeling at a worksite or school cafeteria which created a methodological issue because the same data could not be applied to a restaurant setting. Two of the studies that Harnack and French reviewed did examine calorie labeling in a restaurant setting however these studies measured intended rather than actual food choice. Other methodological weaknesses of the studies were the use of quasi-experimental designs and the possibility that other factors may have had a cofounding effect.12 These methodological issues weakened the study results and exemplify the need for well-designed restaurant based studies which take confounding factors into consideration.

The purpose of this current study is to address the methodological shortcomings of past studies and examine consumer awareness of menu labeling and its impact on food choice in a restaurant setting. It is important to determine if Californians are aware of menu labeling requirements and if they are using menu labeling to make healthier food choices. As the push for a national menu labeling law is greater than ever, it is important to determine if current legislation has had an impact.

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