Menu Labeling Provision of Patient Protection and Affordable Care Act 2010: A Deeply Thought One or Another Disappointment of an Obesity Intervention? – Ece Koprulu
Over the past several decades, the meal patterns of adults in the United States have changed immensely (1). The food culture changed so much, that it became cheap, easy, appealing, and socially acceptable to consume empty calories from fast foods, junk foods and beverages. Moreover, restaurant revenues in the United States grew from $43 billion in 1970 to $558 billion today, which can be explained by the increase in the proportion of total food expenditures spent on food away from home: from 34% in 1974 to about 50% in 2004 (2,3). Unfortunately, the food offered at restaurants and other away from home eating locations tend to be higher in their calorie and fat content, as well as their portion sizes, and lower in nutrients, such as calcium and fiber, when compared to foods eaten from home (4,5). As a result of these factors accompanied by other individual and environmental factors, obesity has become a national health threat and thus, a major public health challenge leading to many other diseases and conditions such as cancer, type 2 diabetes, stroke, and death. Many health campaigns have been promoted over the past years to get Americans more physically active and eat healthier; however, it seems that obesity rates have yet to show any change. In fact, none of the States met the Nation’s Healthy People 2010 goal of lowering obesity prevalence to 15%, and the most recent National Health and Nutrition Examination Survey (NHANES) shows that currently 35.7% of U.S adults and 17% of youth are obese (6,7).
Given the severity of the problem in the nation, it is crucial to create effective public health interventions. One recent intervention towards this growing issue is the menu labeling provision as part of the Patient Protection and Affordable Care Act. The law, passed by the Congress in March 2010, requires chain restaurants with at least 20 outlets to post calories on menus, menu boards (including drive-thru windows) and food display tags, with additional information (fat, saturated fat, carbohydrates, sodium, protein, and fiber) available in writing upon consumer request (8). New York City restaurants were the first to use caloric information of foods on their menus, even prior to the passage of the law. California, Oregon, Philadelphia, King County in Washington State, and others now also require such information in restaurant menus (9). Posting calorie counts works on the principle that giving people the right nutritional information will help them make healthier food decisions, since most diners are not aware of the calories they consume when they eat at a restaurant. At a first glance, it seems like an effective intervention that can help the society to be more conscious of what they are eating. However, it seems that the feasibility of such intervention in low-income neighborhoods, a setting in which access to healthy food is known to be limited, has not been thought (10). This paper hence will analyze the reasons why this intervention was another failure and the psychological concepts behind its ineffectiveness in low-income areas.
Health Belief Model: not the right approach
The Health Belief Model (HBM) is an individual level psychological model that tries to explain and predict an individual’s health behaviors by focusing only on his or her attitudes and beliefs, not addressing social and environmental factors (11). The model states that in order for someone to take an action to prevent illness, one needs to be influenced by the six concepts of the model, which are: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (12). In terms of perceived susceptibility on obesity, people (especially if already obese) are more likely to know that they are susceptible to suffer from the negative consequences of obesity. But still, not everyone knows whether or not they will be obese in the future. Moreover, they need to perceive the problem as severe in order to be ready to take an action (11). The problem as to why this model does not work for this intervention starts at this point. When assessing their level of susceptibility and severity, people tend to be optimistically biased, which means that they are likely to overestimate the likelihood of positive outcomes and underestimate the likelihood of negative outcomes, in this case, obesity and its related diseases (13). People have a “that won’t happen to me” attitude, and thus, they usually expect other people to become victims of negative outcomes, not themselves. Weinstein, in his research, states that “among negative events, the more undesirable the event, the stronger the tendency to believe that one’s own chances are less than average” (14). In terms of obesity, people are less likely to ignore the potential harm of foods and thought of suffering from obesity.
Besides the susceptibility and severity of the disease, people also need to have high-perceived benefits in order to engage in a protective behavior (15). When people make a healthy food choice, they expect to see an immediate benefit from it; but they lack the knowledge that the benefits from a healthy diet can be seen long term, not immediately. Therefore, since they have low benefits of eating healthy food, they hinder themselves from taking an action. As a result, they give up on spending time to choose a healthy option and go with “I only live once, so I’ll eat whatever I want” or similarly “one time won’t hurt” attitude, which leads them to consume excess calories.
Especially, in low-income areas, people mostly ignore the caloric content of the food and whether the food is high or low in calories. A recent study in the Journal of Health Affairs, found that among 1,156 adults who ate at fast-food restaurants in low-income, minority New York City neighborhoods, only half of the participants noticed the calorie labeling on menus and almost only 30% said the information had an effect on what they ordered. But when researchers looked at the receipts, they saw no difference in the calories they consumed compared with people surveyed in Newark, New Jersey, where the law didn't apply (16). In addition to that, same study showed that consumers in New York City were taking somewhat more calories after the law had passed (approximately 846 calories); whereas those in Newark were taking 825 calories on average. A similar study, among adolescents, also in low-income areas of New York City, stated that only 60% of the adolescents noticed the labels before ordering their food; but 90% said that the labels did not change what they ordered or what their parents ordered for them (17). Both of these studies show that people residing in low-income areas tend to ignore the calories on menus, hence the potential harm of foods on their body.
Health Literacy Model does not work in this context
HBM assumes that “everyone has equal access to, and an equivalent level of, information from which to make a rational calculation” (11). However, when it comes to nutrition, not everyone has adequate information to be able to make healthy food choices the same. This problem brings up another model that menu-labeling intervention is also based on: the Health Literacy Model. This model refers to people’s ability to obtain, process and understand basic health information and services needed to make appropriate health decisions (18). In the case of obesity, menu-labeling intervention is based on high health literacy, where people are regarded as having a similar level of knowledge on nutrition and are able to understand and use calorie information on menus effectively. However, it is a wrong approach to base an intervention on high literacy because low-income, minority populations have low levels of health literacy and low health literacy is seen as one of the largest contributors to the ongoing epidemic of obesity (19,20). Thus, patients with low health literacy are less likely to understand the importance of nutrition, hence will not participate in any preventative action. As a result, the obesity will continue to grow dangerously leading to an unhealthier nation.
Besides the low health literacy level, people also have a misconception on low calorie foods and the amount of calories they need to consume each day. Although they may generally know that they should avoid excess calorie intake, they still don’t know how much is sufficient, or insufficient. Studies show that most restaurant customers underestimate the calories, and overestimate the healthfulness of the menu items (21,22). Two studies that were done one year after the menu labeling became alive in New York City, showed that people are having a hard time identifying low calorie dishes on menus; 90% of the participants underestimated the actual calories of foods with as much as 650 calorie error per dish (23,24). These studies show clearly that caloric content of the food is only helpful if the individual can understand how many calories he or she needs to consume daily to maintain or lose weight. Therefore, throwing a bunch of numbers in people’s faces does nothing but confuse their minds more than ever. So how can one think that the menu-labeling intervention can be effective to plan a healthy diet, when people do not look at the labels and do not understand how to use such information?
Maslow’s Hierarchy of Needs: menu-labeling intervention is not going in the right direction of hierarchy
Another flaw in the menu-labeling intervention is the fact that it doesn’t consider the basic needs of humans according to Maslow’s hierarchy of needs. The theory states that in order for people to move to more complex needs in their lives, they first need to fulfill their most basic fundamental needs for survival (25). And if those basic needs are not satisfied, since physiological needs rule our system, other needs in the higher level of the hierarchy may become simply nonexistent or be ignored (26).
Many people who live in low-income neighborhoods have a hard time meeting their basic needs, especially food; and thus they cannot move up to meet the higher level needs. Thinking about obesity and making healthy choices in a diet to reduce their risk or prevent themselves from obesity is definitely a higher need. While these people are trying to save the day by feeding themselves and their family (if applicable) at the cheapest rate possible, they are unlikely to track how many calories they will consume over the day. Choosing healthier food options is beyond their thinking for the moment when their immediate lower level need of hunger is not met. Anecdotal evidence from low-income neighborhood residents states that people buy food mostly because it’s cheap and that they are looking for the cheapest meal they can get in order to stop their hunger as much as possible (27). Cheap foods consist of refined grains, added sugars and fats; and while they are cheap, they are also easily accessible and taste good. Whereas nutritious foods such as whole grains, lean meats, fish, fresh fruits and vegetables are expensive. Data supports that it’s more convenient for low-income people to feed on unhealthy junk food rather than healthy food; for a 2,000-calorie diet, it costs only $3.52/day with junk food versus $36.32/day with low-energy dense healthy foods (28). Looking at the data, it can be concluded that limited financial resources lie as the most important reason why people with low-incomes do not make healthy choices in their diet and thus obesity rates still continue to grow.
Change is needed in order for this intervention to work better
Clearly, this intervention, like many other obesity interventions, sees this epidemic as an individual level problem. But, it does not acknowledge the fact that lacking health literacy and not meeting the basic human needs prior to thinking about a healthy diet can be major contributors to its failure. Thus, a group dynamic approach can actually provide a stronger base and more success in the behavior change of low-socioeconomic groups, since nowadays experts agree that the solution to this growing epidemic needs to be looked at an environmental level, because the current environment in the United States encourages energy consumption rather than its expenditure (29).
The proposed intervention’s general concept is the design of a food truck that provides a weekly bag of healthy and fresh products (i.e. fruits, and vegetables, whole grain products, low-fat dairy products) to individuals and families residing in low-income neighborhoods. It is designed to correct the existing flaws of the menu-labeling intervention and create a more effective approach by targeting the environment, rather than individual.
Correcting the existing health illiteracy problem
As stated earlier, low health literacy, found mostly in low-income areas, is seen as one of the largest contributors to the ongoing epidemic of obesity. In order to correct this problem, the food truck providing fresh produce to low-income neighborhoods, will also provide small cards (in each produce bag) with nutritional information of the produce. Most importantly, every card will have the following succinct statement concerning suggested daily caloric intake from USDA: “An average adult should consume no more than 2,000 calories per day” (30). The information on the card will also include nutritional facts of that product (both in calories and percentages of total daily calories), easy and cost-effective recipes to use at home, the health benefits of the product and how that product can help them to become healthy overall. The most important factor while designing the cards should be the use of language. In order to address everyone, it is crucial to use a simple, easy to understand language, and not use complex names such as polyphenols and resveratrol. Moreover, some sample tastings (made from the produces provided that day) will be available, again with their recipes accompanied. This way, participants are introduced to various types of produce and are informed of easy ways of preparation in both affordable and nutritious way.
This correction towards the existing Health Literacy Model will help people to have the basic nutrition information that they need in order to understand the labels on the menus more effectively. It intends to develop people’s knowledge and hence push them towards making healthier food choices in the long run.
Correcting the Health Belief Model by shifting gears
Using the Health Belief Model for the menu labeling intervention might actually be useful; however, the important point is to know how to use it effectively. As explained earlier with the Optimistic Bias theory, people tend to have optimistic views of their health and think they have very low or no chance of suffering from obesity and/or its related diseases. In accordance with that, people also ignore the statistical numbers (i.e. disease susceptibility or outcome percentages in a certain population) when exposed; however, they tend to pay more attention to individual stories related to a disease, which leads to a decrease in persons’ optimistic bias towards that disease (31). For example, the Massachusetts Department of Public Health made a very successful campaign on smoking cessation by using an emotional story of a woman named Pam Laffin, who had died in 2000 from emphysema (32). When this commercial was compared to six other anti-smoking commercials that did not have a personal story, one study found that Pam’s commercial was the most effective (96.8% effectiveness) and most emotional advertisement that made people “stop and think”(33). This clearly shows that when people see or hear a real story, they can relate to it and understand how it is possible for any individual to be exposed to a disease. So, if using such strategy was effective on changing people’s views on smoking, why not use it to promote healthy eating?
The information cards provided by the food truck will also include quotes or short stories from people who are suffering from obesity or from friends/families of a person who died from obesity related condition(s). These stories will act as a cue to action (fifth concept of HBM), inspiring them to pursue improved eating habits. Moreover, as stated above, they will relate to it and will better understand the personal risks of obesity just like everyone else (perceived susceptibility), and if they are a victim of this disease then the negative outcomes will be inevitable (perceived severity). As these concepts change, people will also be more likely to think that eating healthy will help to prevent obesity (perceived benefits) and the costs of eating healthy is low (perceived barrier). Overall, as the perceived barriers are outweighed by the perceived benefits, individuals will be more likely to engage in a healthy eating behavior in order to prevent the negative consequences that obesity brings.
Correcting the direction of Maslow’s Hierarch of Needs by incorporating the Social Ecological Model
The design of a food truck will be beneficial to a certain extent; it will not create an ultimate solution to obesity. Thus, on the long run, the low-income population needs a bigger change to be able to fully engage in preventative actions towards obesity. Environment plays an important role here; because, how can we expect people to easily engage in a healthy eating behavior in an environment where healthy eating is not supported?
The Social Ecological Model (SEM) states that although individuals are responsible for establishing and maintaining the lifestyle changes they need in order to reduce their health risk and improve their overall health, their behavior is influenced to a large extent by their social environment (34). The model divides the environment into five levels of influence, which are individual, interpersonal, organizational, community, and public policy levels. So, in order to create an effective intervention, one needs to understand how these levels influence each other, and address each level.
Low-income neighborhoods are seen as “food deserts”, which means they have a very limited access to and availability of healthy and fresh produce (35,36). As stated earlier, limited financial resources lie as the most important reason why people do not make healthy choices in their diet. Anecdotal evidence from low-income women states that high costs of fresh produce stop them from buying although they like the taste (37). In order to remove these limits, the public policy of the SEM model needs to take the first step here. This level includes local, state, and federal laws that support the needed changes for a healthier nation. First of all, they might start by working on lowering healthy food prices and/or increase taxes on unhealthy foods. Many studies showed that when there was an increase in the price of unhealthy foods (e.g. soda, pizza, high fat snack, etc.) and a decrease in prices of healthy options (e.g. low-fat snacks, fruits and vegetables, etc.), people were more likely to choose healthy options and thus consume less calories overall (38-41).
Moreover, another important change can be made on the Food Stamp Program, which is a federal funded entitlement program for low-income individuals to be able to purchase food. The first goal of this program was to fight against hunger in the United States; however, it is shown that the participants of this program are now linked to poor dietary intake, and thus become overweight and obese (42). In order to correct this, one simple change may be to change regulations of the program and make the stamps for use of foods that are supported by the Dietary Guidelines for Americans.
Following the public policy level, the community members’ role is also important in the SEM; they can support organizing farmer’s market in the neighborhood with the option of using food stamps and/or giving discounts to food stamp users to promote easy access to fresh food. Moreover, at the organizational level, employers and other area social institutions may give incentives to low-income people such as coupons for discounts in grocery stores, farmer’s market, and for healthy foods in restaurants. Such incentives will also help lower the perceived barriers; individuals will see that high price of healthy products will not stand in their way to have a healthy diet. At the interpersonal level of SEM, friends, family, or anyone from the same social network play a role in influencing an individual’s behavior. So, when healthy foods are made affordable and easily accessible to people residing in low-income areas, people will begin to influence those in their network. That in turns will promote self-efficacy (sixth concept of HBM); and the individual who believes in his or her ability to take such preventative action will be more likely to adopt healthy eating patterns in time.
It is clearly seen that the menu labeling intervention to prevent and decrease the ongoing obesity epidemic did not meet its intentions and goals like many other obesity campaigns in the past. Without meeting people’s lower level needs and giving them the basic knowledge on nutrition, one cannot expect people to understand and use the caloric information on the menus effectively. Throwing a bunch of numbers into peoples faces and waiting for them to figure out the importance of healthy eating will not push them out of the restaurant and into their kitchens; neither will it eliminate the food deserts in the low-income areas. Thus, the change should start from the baseline, which is the environment in this case, and work its way up slowly in order to create a strong base of knowledge. Without this basic knowledge people will not be able to fight this epidemic threat effectively. Once again, educating and training people should be the main goal for all societies battling this massive problem. And looking at the recent numbers of this public health threat, clearly more deeply thought interventions targeting specific needs of different populations are needed.
1. Zizza CA, Xu B. Snacking is associated with overall diet quality among adults. Journal of the Academy of Nutrition and Dietetics 2012; 112(2): 291-296
2. National Restaurant Association. Restaurant industry facts 2008. Washington, DC. http://www.restaurant.org
3. United States Department of Agriculture. Let's Eat Out: Americans Weigh Taste, Convenience, and Nutrition. Washington, DC. Economic Research Service, 2006.
4. United States Department of Agriculture. Away-From-Home Foods Increasingly Important to Quality of American Diet. Washington, DC. Economic Research Service, 1999.
5. Young L, Nestle M. The contribution of expanding portion sizes to the obesity epidemic. Am J Pub Health 2002; 29:246-249.
6. Center for Disease Control and Prevention. Vital Signs: State-Specific Obesity Prevalence Among Adults. Atlanta, GA: Morbidity and Mortality Weekly Report, August 6, 2010.
7. Center for Disease Control and Prevention. Adult Obesity. Atlanta, GA: Center for Disease Control and Prevention. http://www.cdc.gov/obesity/data/adult.html
8. Stein K. A National Approach to Restaurant Menu Labeling: The Patient Protection and Affordable Health Care Act, Section 4205. Journal of the American Dietetic Association 2010; 110(9): 1280-1289.
9. Center for Science in the Public Interest. Comparison of Menu Labeling Policies. Washington, DC: Center for Science in the Public Interest. http://cspinet.org/new/pdf/comparison_of_ml_policies_6-9.pdf
10. Richard L, O’loughlin J, Masson P, Devost S. Healthy Menu Intervention in Restaurants in Low-Income Neighborhoods: A Field Experience. Journal of Nutrition Education 1999. 31 (1): 54-59.
11. Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp.35-49.
12. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896). http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf.
13. Bracha A, Brown DJ. Affective decision making: A theory of optimism bias. Games and Economic Behavior 2012; 75(1): 67-80.
14. Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39: 806-820.
15. Redding CA, Rossi JS, Rossi SR, Velicer WF, Prochaska JO. Health behavior models. The International Electronic Journal of Health Education 2000; 3: 180-193.
16. Elbel B, Kersh R, Brescoll VL, Beth Dixon L. Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City. Health Affairs 2009; 28(6): 1110-1121
17. Elbel B, Gyamfi J, Kersh R. Child and adolescent fast-food choice and the influence of calorie labeling: a natural experiment. International Journal of Obesity 2011; 35: 493-500.
18. Parker RM, Ratzan SC, Lurle N. Health literacy: a policy challenge for advancing high-quality health care. Health Affairs 2003; 22(4): 147-153.
19. Diamond C, Saintonge S, August P, Azrack A. The development of Building Wellness™, a youth healthy literacy program. Journal of Health Communication: International Perspectives 2011; 16(3): 103-118.
20. Carmona RH. Health Literacy in America: The Role of Health Care Professionals. Surgeon General, 2003.
21. Wansink B, Chandon P. Meal size, not body size, explains errors in estimating the calorie contents of meals. Annals of Internal Medicine 2006; 145 (5): 326-332
22. Chandon P, Wansink B. The biasing health halos of fast-food restaurant health claims: lower calorie estimates and higher side-dish consumption intentions. Journal of Consumer Research 2007; 34(3): 301-314.
23. Technomic Inc. Executive Summary: Consumer Reaction to Calorie Disclosure on Menus/Menu Boards in New York City. Chicago, IL: Technomic Inc. 2009 http://edhoman.com/public/files/HB783-3.pdf
24. Burton S, Creyer EH. What consumers don’t know can hurt them: consumer evaluations and disease risk perceptions of restaurant menu items. Journal of Consumer Affairs. 2004; 38: 121–145.
25. Association of Surgical Technologists. An Exercise in Personal Exploration: Maslow’s Hierarchy of Needs. Littleton, CO: Association of Surgical Technologists. http://www.ast.org/publications/Journal%20Archive/2009/8_August_2009/CE.pdf
26. Maslow A. Motivation and Personality: A theory of Human Motivation .(chapter 2). New York, NY: Harper & Row, Publishers, Inc., 1987.
27. Hartocollis A. Calorie Posting Don’t Change Habits, Study Finds. The New York Times. October 6, 2009. http://www.nytimes.com/2009/10/06/nyregion/06calories.html?_r=2
28. Drewnowski A. Obesity and the food environment – dietary energy density and diet costs. American Journal of Preventive Medicine, 2004; 27(3): S154–S162.
29. Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: Where do we go from here? Science 2003; 299(5608): 853-855.
30. United States Department of Agriculture. Dietary Guidelines for Americans, 2010. Washington, DC: United States Department of Agriculture. http://www.cnpp.usda.gov/DGAs2010-PolicyDocument.htm.
31. Siegel M. Social Network Theory, Maslow’s Hierarchy of Needs, the Law of Small Numbers, and Optimistic Bias and Illusion of Control. Social and Behavioral Sciences for Public Health. Boston University, Boston. April 4, 2012.
32. YouTube. . Life cycle of an anti-smoking campaign. San Bruno, CA: YouTube, LLC. http://www.youtube.com/watch?v=EypLrQf3rAA
33. Vardavas CI, Symvoulakis EK, Connoly GN, Patelarou E, Lionis C. What Defines an Effective Anti-Tobacco TV Advertisement? A Pilot Study among Greek Adolescents. International Journal of Environmental Research and Public Health 2010; 7: 78-88.
34. Gregson J, Foerster SB, Orr R, Jones L, Benedict J, Clarke B, Hersey J, Lewis J, Zotz K. System, Environmental, and Policy Changes: Using the Social-Ecological Model as a Framework for Evaluating Nutrition Education and Social Marketing Programs with Low-Income Audiences. Journal of Nutrition Education 2001; 33(1): S4-S15.
35. Cummins S, Macintyre S. “Food deserts” – evidence and assumption in health policy making. BMJ 2002; 325: 436-438.
36. Hendrickson D, Smith C, Eikenberry N. Fruit and vegetable access in four low-income food deserts communities in Minnesota. Agriculture and Human Values 2006; 23: 371–383.
37. Wiig K, Smith C. The art of grocery shopping on a food stamp budget: factors influencing the food choices of low-income women as they try to make ends meet. Public Health Nutrition 2009; 12(10): 1726-1734.
38. French SA. Pricing effects on food choices. Journal of Nutrition 2003; 133(3): 8415-8435.
39. Duffey KJ, Gordon-Larsen P, Shikany JM, Guilkey D, Jacobs DR, Popkin BM. Food price and diet health outcomes, 20 years of the CARDIA study. Archives of Internal Medicine 2010; 170(5): 420-426.
40. French SA, Story M, Jeffery RW, Snyder P, Eisenberg M, Sidebottom A, Murray D. Pricing strategy to promote fruit and vegetable purchase in high school cafeterias. Journal of the American Dietetic Association 1997; 97(9): 1008-1010.
41. Jeffery RW, French SA, Raether C, Baxter J. An environmental intervention to increase fruit and salad purchases in a cafeteria. Preventative Medicine 1994; 23(6): 788-792.
42. Dinour LM, Bergen D, Yeh MC. The food insecurity–obesity paradox: a review of the literature and the role food stamps may play. Journal of the American Dietetic Association 2007; 107: 1952–1961.