Challenging Dogma - Fall 2011

Monday, December 19, 2011

Explaining the Failure of Calorie Labeling in Low-Income Neighborhoods: Addressing the Need for Public Health Policy Change – Laura Truex

In the United States today, obesity is a disease of epidemic proportions (1). Over the past twenty years, obesity rates (defined as having a Body Mass Index of 30 or greater) have skyrocketed from approximately 15% in 1990 to a high of about 34% in 2010 (2). Even more astounding is the incidence of overweight; according to the Body Mass Index, 68% of American adults and 33% of American children are considered overweight with a BMI between 24.9 and 29.9 (3). The adverse personal and public health consequences of overweight and obesity are numerous and well-documented, including such chronic diseases as hypertension, type 2 diabetes, and coronary heart disease, among others, that cost our nation over $68 billion each year in direct health care expenses (1).

In 1994, the Food and Drug Administration mandated that packaged foods carry labels listing their contents and nutrition facts; restaurants, however, were exempted from this requirement (4). In March of 2010 Congress changed that law by passing the Affordable Care Act, which contains a provision for listing calorie counts of menu items at chain restaurants with more than 20 locations nationwide (4). In addition, calorie counts for foods in vending machines across the country must be posted directly adjacent to the food items, in aclear and conspicuous manner(4). This legislation was influenced by the success of a pilot program in New York City, which began in 2008 and required chain restaurants with more than 15 locations throughout the city to post calorie counts on their menu boards (4). The hope behind the federal legislation is that people nationwide will be able to make informed decisions about their meal choices when they eat out, which has helped reduce the number of calories in the average restaurant meal by about 10% among New Yorkers (6). The scope of the potential impact of such legislation is quite large; the Los Angeles County Department of Public Health, for example, estimated in 2008 that such a measure could avert over 40% of the 6.75 million pounds gained yearly by the residents of Los Angeles County alone (5).

The pioneering calorie-labeling legislation in New York City was anticipated to be an important public policy intervention to decrease obesity at the population level, but in-depth analysis by researchers from New York University in 2009 found otherwise. Focusing specifically on low-income neighborhoods of the city, the study found that only half the customers at fast-food restaurants noticed the calorie postings, and of those 50% only about 28% changed their food order as a result (6). Low-income, minority populations were chosen for the study based on their higher rates of obesity and the higher frequency with which fast food and chain restaurants can be found in these neighborhoods (7). The efficacy of this public health intervention among this population is limited at best, as is demonstrated by this study and other studies like it. There are many reasons that an intervention such as this not an ideal one for a low-income population, and this paper aims to criticize this intervention by demonstrating three of these major flaws. Additionally, this paper will propose an alternative intervention to calorie posting on menu boards in low-income neighborhoods. The proposed intervention will attempt to take the weaknesses identified in the original intervention and turn them into strengths.

Hunger and Price vs. Longevity: Immediate Needs Supercede Health Concerns

When severe scarcity of necessary resources (such as money, time, or food) exists, people prioritize their needs in a fashion that Maslow described in his essayA Theory of Human Motivationas a Hierarchy of Needs Pyramid (8). Physiological needs such as food, shelter, and safety form the base of the Pyramid, and these needs must be filled before an individual can consider complex social needs such as acceptance and love or abstract concepts such as self-esteem and self-actualization. According to Maslow, an individual who is hungry is all-consumed by this need and the drive to eat, andcapacities that are not useful for this purpose[for example] the urge to write poetry, the interest in American history. lie dormant or are pushed to the background(8). Thus, when the immediate acquisition of food is at stake, the first thought in a hungry persons mind is not the caloric content or even the quality of the food available, but simply that there is food to be had. From Maslows perspective, the calorie-posting intervention in low-income neighborhoods is inherently flawed because a person who frequently does not have enough food to eat or is chronically hungry is unlikely to consider the consequences of the calorie content of a menu item before he orders it. Given that the current number of food-insecure people in the United States is approximately 49 million, many Americans are suffering from chronic hunger and are likely exhibiting this exact behavioral process (9). For these people, posting calorie counts on menu boards is an intervention too distal from their primary problem; their first concern is obtaining food, no matter what its nutritional value.

In addition, the price of healthier, lower-calorie options at fast food or quick-serve restaurants is often higher than the price of more calorie-dense options. Even if the prices are the same, such as on the McDonalds Dollar Menu, the caloric density per dollar is drastically different between unhealthy items and healthier choices – a McDouble burger sandwich, for example, provides 390 calories per dollar, whereas the side salad furnishes just 20 calories (10). For a person whose financial situation necessitates low-budget options such as the Dollar Menu, ordering a lower-calorie salad as an alternative to a hearty sandwich may not be a feasible suggestion to make. According to the Health Belief Model (HBM), for many low-income people the increased price of healthier options – or, conversely, the decreased value of these options – represents a barrier to action (11). If a barrier to action is a negative outcome a person believes will result from a given action, the action in this situation would be choosing a healthier, lower-calorie meal option based on a posted calorie count, and the negative outcome would be the money spent on this item that could have gone toward something larger and more satiating (11).

Another interesting concern surrounding calorie postings on menu boards in low-income neighborhoods is the phenomenon of psychological reactance. Psychological Reactance Theory states that the greater a free behavior is in importance to an individual, the greater the magnitude of the reactance, or pushback, that individual will feel when that free behavior is eliminated or threatened (12). Thus, when individuals in low-income neighborhoods see calorie counts posted on menu boards, they may experience psychological reactance to these numbers if the behavior (ordering high-calorie items) is something important to them (for instance, because these items are typically the cheapest options available). In this way, calorie postings may make people feel like someone is threatening to take these foods away from them, or judging them for ordering these items. This reactance may make people even less likely to choose healthier options, which is the exact opposite of the intervention’s desired effect and a clear flaw in its adoption in these communities.

Low Health Literacy Undermines Efficacy of Calorie Labeling

A second flaw with calorie-labeling legislation lies in the fact that it makes sweeping assumptions about the population’s general knowledge of health and nutrition-related issues. In order to recognize whether or not a particular menu item is healthy or unhealthy based solely on its caloric content, people must first have some idea of how many calories they require each day. According to a 2010 study from the NYU School of Medicine, only one-third of fast-food customers in low-income areas could properly identify the number of calories the average adult should consume each day as being between 1500 and 2500 (13). Without this knowledge, individuals making choices in fast food restaurants have no reference with which to compare the calorie content of their meals, and calorie postings on menu boards become meaningless. The study also found that racial and ethnic minorities, segments of the population who are likely to live in low-income neighborhoods, were the most likely to overestimate the recommended number of calories a person should eat in a day (13).

In addition to being unaware of the number of calories they need to be eating per day, individuals in low-income communities are often less likely to be educated on the links between poor diet and chronic disease, such as obesity (14). Low health literacy within a population poses a significant barrier to the successful adoption of an intervention such as calorie posting on menu boards, and the Health Belief Model (HBM) can be applied to explain this effect. According to the HBM, after a person realizes they are susceptible to the health condition and perceives the threat as severe, they then must perceive the benefit of the intervention to be high in order for any action to take place (11). For a population with limited resources and a limited knowledge base, the perceived benefits of choosing lower-calorie meal options is low, for the simple reason that the benefits of making healthier choices are not always immediate. Cutting calories by choosing leaner options may indeed lead to weight loss and a healthier life in the long term, but these changes take a large amount of effort on a daily basis for a small perceived benefit and are therefore unlikely to take hold on a large scale.

The Optimistic Bias can also help explain the lack of success of calorie posting in low-income neighborhoods. As identified by Weinstein in 1980, Optimistic Bias is “the tendency to see others as more vulnerable to risks than the self”; most people believe that they are less likely than other people to experience undesirable things (15). Thus, people may not believe they are susceptible to obesity and other chronic diseases such as type 2 diabetes and coronary heart disease, even though they may regularly eat high calorie fast food. If people do not see a direct connection between their behavior and their health, or if they don’t believe they could fall victim to disease, there will be little incentive to act to improve eating habits.

Barriers to Access: Healthier Choices Nowhere To Be Found

As discussed above, lack of health literacy and prioritization of lower-order concerns are major contributors to the failure of the calorie labeling law to effect change in eating habits in low-income communities. However, there is one more major flaw in this public health intervention, and it can be explained using the Social Ecological Model (SEM). The SEM recognizes that public health interventions that focus solely on behavior change on an individual level “often neglect the social and environmental context in which those behaviors occur and are reinforced” (16), and this is exactly why calorie labeling is ineffective among low-income populations. The food establishments most frequently found in low-income areas are quick serve or fast food restaurants, convenience stores, and small grocery stores that rarely stock a large selection of produce or low-fat dairy products (17). The calorie labeling intervention fails to recognize that individuals in low-income neighborhoods often have no outlet for obtaining healthier foods, even if they have the education and resources necessary to change their eating habits. Variations in the quality and availability of menu items among fast food restaurants themselves can be seen between neighborhoods of higher versus lower socioeconomic status; in middle- to upper-class neighborhoods, restaurants such as Chipotle and Starbucks are the norm, whereas in lower-income neighborhoods, chains like McDonalds and KFC are more common (22). At some of these chain restaurants, consumers might be hard pressed to find a menu item with significantly fewer calories than the others. Lack of access to venues at which to purchase healthier foods is a problem specific to low-income communities, and represents the largest barrier to the success of an intervention strategy such as calorie posting in restaurants. Unless this intervention specifically addresses the multiple levels of societal and environmental influence on individual behavior (as outlined by the SEM), it is destined to fail in low-income neighborhoods nationwide.

Designing a Better Intervention

Calorie labeling at quick-serve and fast food restaurants as a public health measure is bound to fail in low-income communities nationwide, as it did in New York, for the reasons outlined above. Certain barriers to the success of a program like this, such as the food deserts found in many low-income communities, cannot be changed by such simplistic interventions as slapping calorie counts on menu boards. Situations such as these are obstacles to the adoption of healthy habits that must be fundamentally changed on a policy level in order for any real change in individual habits to ever occur. One approach to address these fundamental inequalities in opportunities for successful intervention in low-income communities would be to include policy changes at the local level in public health interventions. A 2009 article in the New York Times entitled “Bringing Fresh Produce to the Corner Store” outlined several strategies for improving the food environment in low-income neighborhoods across the country, and the proposed intervention will make use of some of these ideas to increase access to healthy foods for people living in these communities (18).

The proposed intervention contains multiple components, each of which is designed to target one of the previously mentioned flaws of the original intervention and improve upon it. The first identified flaw of the original intervention discusses the effects of acute hunger among people of lower socioeconomic status, and how this influences their choices at fast food restaurants. It also addresses the original intervention’s lack of concern for value of healthy menu items compared to their high-calorie counterparts, and the effects of this difference on people with little disposable income. The proposed intervention will attempt to correct these flaws by informing the public of simple ways to cut calories from their fast food meals without outright choosing lower-calorie options.

The second flaw of the original intervention involves its lack of recognition that calorie postings may be meaningless to people with low levels of health literacy, due to the background knowledge required to interpret these data in a useful manner. To combat this issue, the proposed intervention discusses ways to improve menu boards to include necessary background and reference information, in order to increase the likelihood that people of low health literacy will be able to make informed decisions about food choices.

The third, and arguably most important, flaw of the original intervention is its failure to consider the social and physical environments in which calorie labeling takes place within low-income communities. The proposed intervention identifies potential changes to public policy that would serve to change the social and environmental barriers to obtaining healthy foods in low-income communities and improves the efficacy of calorie posting in these neighborhoods.

Emphasizing Small Changes

As identified earlier, the combination of poverty and food insecurity is a death sentence for simple calorie labeling in low-income communities. In order to make this intervention more effective, healthier choices must be tied to these lower-order concerns in such a way that works with people in these communities and gets them on board with the intervention. As discussed, calorie postings may induce psychological reactance in this population, and for this reason the focus should be on making familiar, higher-calorie menu items healthier through customization instead of suggesting people choose completely different options which may be more expensive. This kind of intervention is more likely to be perceived as helpful and supportive by this population, leading to improved efficacy. Suggestions for improving high-calorie fast food choices could include ordering sandwiches without cheese, asking for grilled meat instead of fried, substituting mustard for mayonnaise, a side salad for French fries, or even just ordering diet soda instead of regular. Billboards and television or radio advertisements could publicize this information utilizing a “did you know?” approach, which would help individuals feel that public health officials are sympathetic to their situation and trying to help them do the best with what they have. From the perspective of the HBM, small changes such as those suggested pose a much smaller barrier to action than does the implication of calorie labeling, which is that individuals need to completely change the foods they order at fast food restaurants.

Improving Health Literacy Through Information

The failure of calorie posting to change ordering habits in low-income neighborhoods demonstrates that the general education level of a population has a huge impact on whether or not a given public health intervention will succeed. While calorie labeling at fast food restaurants is no doubt a great way to raise consumer awareness about the health effects of such foods, it cannot be expected to do so on its own in areas where 67% of people do not know how many calories they should be eating each day (13). For this reason, reference ranges need to be included on menu boards in addition to information about the caloric content of foods. In fact, this technique has already been successfully used in some restaurants. Roberto et al. found that in the presence of a “prompt” on a menu board stating the daily calorie requirement of an average adult, individuals ordered fewer calories over the course of the day; when this prompt was absent, however, calorie labeling had no effect on food choices (19).

In order to take this idea and make it even more effective, the proposed intervention would change the calorie-labeling law to make an informative prompt such as “The 2010 Dietary Guidelines for Americans suggest consuming approximately 2000 calories each day”(20) mandatory on all menu boards. The prompt would appear as a single line at the bottom of the menu, above the allergen disclaimers already found on menus. The proposed intervention would also require restaurants to state the caloric value of foods expressed as a percentage of total daily calories directly next to the calorie values themselves on all menu boards. This way, people can easily see not only the numerical caloric value of the foods they choose, but also the percentage contribution of these foods to a 2,000 calorie-per-day diet. The caveat of this approach is that a 2,000-calorie diet is not ideal for everyone; however, most Americans today likely consume more than this amount on a daily basis given the high prevalence of overweight and obesity.

Providing background information such as reference ranges and percentages is an essential step towards improving the efficacy of calorie labeling in low-income communities where low levels of health literacy pose a significant threat to the success of public health interventions. Improving health literacy in these neighborhoods helps increase the perceived benefit (step three of the HBM) of choosing healthier options, because people will have a more complete understanding of how their food choices affect their overall diet and how their diet directly affects their health. Increasing the perceived benefit of making healthier choices may also help make the barriers to action seem less significant, which can lead to healthier choices on a larger scale in the long term.

Working for Community-Wide Change

The final component of the proposed intervention attempts to correct for the failure of the original intervention to consider the food environments of low-income neighborhoods by proposing policy changes that would make finding and choosing healthier options easier for the residents of these communities. The SEM posits that it is unrealistic to expect individuals to adopt behavior change when their physical and social environments are hostile to this change, which is undoubtedly the case in low-income neighborhoods. Because these neighborhoods are served predominantly by convenience stores and small, family-owned groceries, the proposed intervention aims to target these stores and give them the resources they need to become part of the solution instead of part of the problem. These local stores would be given free or reduced-cost equipment, such as produce and dairy coolers, to encourage them to stock more fresh fruits and vegetables and low-fat dairy products. Stores that agree to stock a certain percentage (say, 35%) of their inventory as healthy food choices such as whole grain cereals and breads or fruits and vegetables would be eligible for tax credits and would also be entitled to carry a sticker promoting themselves as a “Healthy Food Retailer” (18), indicating to community members that they are reliable sources of healthy foods.

Other possible initiatives include working with local governments on zoning ordinances to allow small grocery stores to sell produce on the sidewalk market-style, and providing stores with signs and posters promoting their healthy offerings. To encourage growth of new stores and healthier restaurants, cities can offer tax incentives such as eliminating sales tax on prepared foods or reductions in property taxes. Incentives such as these would help lower prices on healthy foods, which would make them more accessible to a low-income population and also help new businesses move a greater volume of these goods. These new businesses can help change the local food environment by providing healthier foods at lower prices, and in some cases may eventually be able to take EBT food stamp benefits for healthy foods in manner similar to many farmer’s markets today (21).

The proposed intervention will focus much of its resources on changing the food environment of disadvantaged neighborhoods, with the hope that such changes give residents more opportunities to choose nutritious and lower-calorie foods when they shop and dine out. Because the timeline to implement policy change is expected to be relatively long, the proposed intervention includes components that correct other key failures of the original calorie labeling law in order to achieve the original goal of this law: encouraging individuals to make healthier food choices.


While the calorie labeling law was certainly developed with good intentions, it is a one-size-fits-all approach to a problem with diverse root causes. As this paper demonstrates, the calorie labeling law has failed to consider the impact of education levels, immediate lower-order concerns, and the physical and social environment of low-income neighborhoods on the overall effectiveness of the original intervention. This paper has critiqued the original intervention using traditional theories such as the Health Belief Model and Maslow’s hierarchy in addition to alternative theories like psychological reactance and the Social-Ecological Model. An alternative intervention, which attempts to correct the failures of the original model, draws upon these theories to turn these failures into strengths. The proposed intervention is threefold and involves informing the public of small changes they could make, changing the labeling of menu boards to include background information, and making widespread policy changes to make the physical and social environments of low-income neighborhoods more welcoming to healthful eating. With 68% of Americans currently overweight or obese, it is clear that more public health interventions targeting this population are necessary. However, there is no “easy fix”; it is only when an intervention is designed to meet the specific needs of its target population that it can be successful and truly effect change.


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