Menu Labeling: A Promising Strategy for Combating the

Obesity Epidemic

Jonathan Fielding, MD, MPHDirector and County Health Officer

Los Angeles County Department of Public Health

May 21, 2008

Prevalence of Overweight Among Children in the Prevalence of Overweight Among Children in the United States (Source: NHANES)United States (Source: NHANES)

4.2 4.0

6.5

11.3

15.3

4.66.1

5.0

10.5

15.5

0

5

10

15

20

1963-65 1971–74 1976–80 1988–94 1999–2000

NHANES Study Period

Pre

vale

nce

(%)

6–11 years of age 12–19 years of age

What’s at Stake?

• Overweight children overweight adults

• Overweight during adulthood associated with heart disease, stroke, diabetes, arthritis, and cancer

• Adverse effects during childhood

– medical (hypertension, dyslipidemia, type 2 diabetes, insulin resistance, asthma, hormonal changes)

– psychosocial (reduced HRQOL, stigma and social marginalization, poor school performance)

• Obesity epidemic accounted for 27% of the growth in health care spending in the U.S. from 1987 to 2001 (Thorpe, et al. Health Affairs, 2004)

• Inflation-adjusted hospital costs associated with obesity among children tripled during the 1980s and 1990s (Wang & Dietz, Pediatrics, 2002)

Prevalence of Obesity Among Adults in Los Angeles County, 1997-2005

14.3%16.7%

19.3%20.9%

0%

10%

20%

30%

40%

1997 1999 2002 2005

Year

Pre

va

len

ce

(%

)

Average Weight and Prevalence of Diabetes Among Adults in Los Angeles County

Los Angeles County Public Health, Office of Health Assessment and Epidemiology

19971997 19991999 20022002 200520050%0%

5%5%

10%10%

15%15%

20%20%

140140

150150

160160

170170

180180

Ave

rag

e W

eig

ht

Gai

n (

po

un

ds)

Ave

rag

e W

eig

ht

Gai

n (

po

un

ds)

Dia

bet

es P

reva

len

ceD

iab

etes

Pre

vale

nce

YearYear

5.7%5.7%6.7%6.7% 7.2%7.2%

8.1%8.1%

160.9 lbs160.9 lbs163.6 lbs163.6 lbs 164.5 lbs164.5 lbs

166.8 lbs166.8 lbs

The county’s adult population gained44 million pounds from 1997 to 2005

Trends in the Leading Causes of Death,Los Angeles County, 1994-2004

Rate (per 100,000) *

Cause of death 1994 2004 Percent change

Coronary heart disease 276 176 -36.2

Stroke 63 48 -23.8

Lung cancer 48 35 -27.1

Emphysema 35 31 -11.4

Pneumonia/Influenza 44 26 -40.9

Diabetes 20 25 +25.0

Colorectal Cancer 20 16 -20.0

Alzheimer’s Disease 5 16 +220.0

Breast Cancer (female) 30 23 -23.3

Homicide 17 10 -41.2

HIV/AIDS 27 5 -81.5

* age-adjusted to year 2000 U.S. standard population

Los Angeles County Public Health, Office of Health Assessment and Epidemiology

Rates of Gestational Diabetes, Los Angeles County

47.9

14.50

10

20

30

40

50

60

1991 1993 1995 1997 1999 2001 2003

Year

Ra

te/1

,00

0 M

oth

ers

20.4% 20.9% 21.9% 22.2%23.3% 22.9%23.0%

18.9%

0%

5%

10%

15%

20%

25%

30%

35%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Ob

es

ity

Pre

va

len

ce

Obesity Rate Among 5th, 7th, and 9th Graders inObesity Rate Among 5th, 7th, and 9th Graders inLos Angeles County Public Schools, 1999-2007, Los Angeles County Public Schools, 1999-2007,

California Physical Fitness Testing ProgramCalifornia Physical Fitness Testing Program

Healthy People 2010 Goal (<5%)

Prevalence of Obesity

Projected obesity prevalence assuming linear trend

10

Cities/Communities with Lowest and Cities/Communities with Lowest and Highest Childhood Obesity Rates Highest Childhood Obesity Rates

*Table excludes cities/communities where number of students with BMI data < 500.

Source: California Physical Fitness Testing Program, California Department of Education. Includes 5th, 7th, and 9th graders enrolled in LA County public schools.

Top 10*

City/Community Name

2005 Youth Obesity

Rate (%)

Rank of Economic Hardship (1 - 128)

Manhattan Beach 4.2 2

Palos Verdes Estates 6.3 5

Beverly Hills 6.9 19

San Marino 7.1 15

Agoura Hills 7.3 10

Calabasas 8.0 8

South Pasadena 9.0 17

La Canada Flintridge 11.4 18

Rancho Palos Verdes 11.6 13

Arcadia 12.3 35

Average 10 lowest 8.0%

Bottom 10*

City/Community Name

2005 Youth Obesity

Rate (%)

Rank of Economic Hardship(1 - 128)

Cudahy 29.4 123

West Whittier-Los Nietos 29.7 81

West Puente Valley 30.0 90

Bell 30.2 115

Willowbrook 30.5 116

Huntington Park 30.6 122

East Los Angeles 31.9 117

Florence-Graham 32.0 128

San Fernando 32.9 103

Maywood 37.4 121

Average 10 highest 31.5%

Many Factors Contributing to the Obesity Epidemic: a Partial List

• Increased marketing of junk food and sodas to children

• Increased portion size of food and beverages

• More meals consumed outside the home

• Decreased physical education in schools

• Fewer safe areas for exercise in communities

• Increased TV and computer time

• Less access to fresh, nutritious, affordable food in underserved areas (and more access to cheap calorie-dense unhealthy foods)

• Increased time spent in cars

• Community design that discourages walking and bicycling

Why do People Overeat?

• Eating influenced more by environmental factors than conscious choice (eating is an “automatic” behavior; Cohen, 2008)

• People served larger portions eat more food, regardless of other factors

• The amount of food eaten increases as the effort to eat it decreases

• Once people begin eating, they usually continue until all the food is gone or until some other external occurrence changes the situation

Implications for PreventionImplications for Prevention

• No single magic bullet—will require multiple strategies operating at multiple levels across multiple sectors.

• Reversing the epidemic will require changing dietary behaviors—a recent study suggests that most of the epidemic (an estimated 75%) in the U.S. is attributable to increased dietary intake rather than reduced caloric expenditure (Bleich et al., 2008).

• Changing dietary behaviors will require changing the “toxic” food environment.

Why the Interest in Menu Labeling?

• Americans eating out more than ever before--in LA County, one in four children 2-17 years of age ate fast food in the past day (2005 LA County Health Survey).

• Supersizing of restaurant food and beverage portions has become widespread.

• Fast food consumption linked with increased caloric intake and excess weight gain.

• Studies have shown that most people (even nutritionists) greatly underestimate the caloric content of restaurant menu items.

• Calorie and other nutritional information not generally available at the point of purchase in restaurants (in contrast to packaged food products which are required by the FDA to include nutrition information).

Menu Labeling Initiatives

• In December 2006, New York City passed an ordinance requiring menu labeling in restaurants that already provide this information (e.g., on websites).

• The New York State Restaurant Association sued in U.S. District Court in 2007 and the ordinance was overturned.

• New York City introduced a revised ordinance that to date has withstood legal challenge and is currently being implemented.

• In July 2007, Seattle-King County adopted a menu and menu board labeling ordinance in restaurant chains, to take effect in August 2008.

• In California, a menu labeling bill (SB 120) was introduced in 2007 (passed by the legislature but vetoed by the Governor) and reintroduced in 2008 (SB 1420).

• Alternative bill (AB 2572) also introduced in 2008.

• Recent county initiatives (San Francisco, Santa Clara)

2008 Menu Labeling Legislation

California Center for Public Health Advocacy, April 2008www.publichealthadvocacy.org 530 297-6000

Require chain restaurants with > 15 outlets in CA to provide nutritional information at point of purchase

- Menu Boards: calories

- Menus: calories, fat, sat/trans fat, carbohydrate, sodium

Applies to standard menu items only

SB 1420 - Menu Labeling

Because common sense doesn’t help

Which McDonald's option has the most calories?

2 Big Macs 1,080 cal 53%

2 Egg McMuffins 600 cal 8%

Large shake 1,160 cal 11%

4 Hamburgers 1,000 cal 22%

Field Poll, 523 registered voters, April 2007

Which McDonald's option has the most calories?

2 Big Macs 1,080 cal 53%

2 Egg McMuffins 600 cal 8%

1 Large shake 1,160 cal 11%

4 Hamburgers 1,000 cal 22%

Field Poll, 523 registered voters, April 2007

Which McDonald's option has the most calories?

2 Big Macs 1,080 cal 53%

2 Egg McMuffins 600 cal 8%

1 Large shake 1,160 cal 11%

4 Hamburgers 1,000 cal 22%

Field Poll, 523 registered voters, April 2007

Which McDonald's option has the most calories?

2 Big Macs 1,080 cal 53%

2 Egg McMuffins 600 cal 8%

1 Large shake 1,160 cal 11%

4 Hamburgers 1,000 cal 22%

Field Poll, 523 registered voters, April 2007

Which Denny’s option has the fewest calories?

Ham & Cheddar Omelet 595 cal 36%

Country Fried Steak & Eggs 464 cal 11%

French Toast w/ Syrup & Marg 1,003 cal 15%

Pancakes w/ Syrup & Marg 650 cal 29%

Field Poll, 523 registered voters, April 2007

Which Denny’s option has the fewest calories?

Ham & Cheddar Omelet 595 cal 36%

Country Fried Steak & Eggs 464 cal 11%

French Toast w/ Syrup & Marg 1,003 cal 15%

Pancakes w/ Syrup & Marg 650 cal 29%

Field Poll, 523 registered voters, April 2007

Which Denny’s option has the fewest calories?

Ham & Cheddar Omelet 595 cal 36%

Country Fried Steak & Eggs 464 cal 11%

French Toast w/ Syrup & Marg 1,003 cal 15%

Pancakes w/ Syrup & Marg 650 cal 29%

Field Poll, 523 registered voters, April 2007

Which Denny’s option has the fewest calories?

Ham & Cheddar Omelet 595 cal 36%

Country Fried Steak & Eggs 464 cal 11%

French Toast w/ Syrup & Marg 1,003 cal 15%

Pancakes w/ Syrup & Marg 650 cal 29%

Field Poll, 523 registered voters, April 2007

Field Research PollApril 2007

“Support requiring fast food restaurants to provide nutritional information on

menus and menu boards?”

84% of all registered voters supported;

78% Republicans, 88% Democrats

81% men, 88% women

83% Whites, 88% Latinos, 90% African Americans

>75% in every region of the state

>80% of every age group

85% making <$20,000, 81% making >$80,000

86% of ≤ high school, 90% graduate degrees

Support for Menu Labeling

Am Cancer Society (co-sponsor)

Am Heart Association (co-sponsor)

CA Optometric Association (co-sponsor)

Am Academy of Pediatrics

Am Diabetes Association

American College of Cardiology (CA Chapter)

CA Chiropractic Association

CA Medical Association

Stanford School of Medicine

Health Officers Association of CA

Counties: Alameda, Contra Costa, Marin, LA

But What is the Potential Impact of Menu Labeling on the Obesity Epidemic?

• LA County DPH recently conducted a health impact assessment (HIA) to quantify the potential impact of menu labeling, as specified in SB 1420, on the obesity epidemic in Los Angeles County.

• The study found that if menu labeling resulted in just 10% of restaurant patrons ordering reduced calorie meals (with an average reduction of 100 calories per meal), a total of 38.9% of the 6.75 million pound average annual weight gain in the county population (5 yrs and older) would be averted.

• Significantly larger impacts could be realized with increased consumer response to the posted calorie information.

Results (sensitivity analysis)

AverageAmount of

CalorieReduction

Percentage of Patrons Who Purchase a Lower-Calorie Meal as a Result of Menu Labeling

10% 20% 30% 40% 50%

25 9.7% 19.4% 29.1% 38.9% 48.6%

50 19.4% 38.9% 58.3% 77.7% 97.2%

75 29.1% 58.3% 87.4% 116.6% 145.7%

100 38.9% 77.7% 116.6% 155.4% 194.3%

125 48.6% 97.2% 145.7% 194.3% 242.9%

150 58.3% 116.6% 174.9% 233.2% 291.5%

175 68.0% 136.0% 204.0% 272.0% 340.0%

200 77.7% 155.4% 233.2% 310.9% 388.6%Green — population weight gain averted (net weight gain still exceeds net weight loss)Yellow — population weight gain averted (net weight loss now exceeds net weight gain)

How feasible are these calorie reductions?

• Analysis of data from three fast food chains indicate that changing:

- from a large to medium soft drink would save 95 calories

- from a large to medium order of french fries would save 163 calories

- from a double meat to single meat patty hamburger would save 244 calories

Conclusions

• Small reductions in calories consumed at large chain restaurants by a relatively small percentage of patrons have the potential to significantly reduce the obesity epidemic, as measured by population weight gain.

• Impact on population weight gain could be greatly enhanced with public education, pricing incentives, or other strategies to increase the percentage of patrons that order reduced calorie meals.

• Potential indirect benefits

- increased public awareness regarding portion size, potentially leading to social norm change toward smaller portions- create incentives for large chain restaurants to offer lower calorie menu options

Subway Menu Board in NYC