Posting calorie counts on menus should be just one strategy of many

In this episode of the Leading Voices in Food podcast, Norbert Wilson of Duke University's Sanford School of Public Policy speaks with researchers Jean Adams from the University of Cambridge and Mike Essman from Duke's World Food Policy Center. They discuss the mandatory calorie labeling policy introduced in England in April 2022 for large food-away-from-home outlets. The conversation covers the study recently published in the British Medical Journal, exploring its results, strengths, limitations, and implications within the broader context of food labeling and public health policies. Key findings include a slight overall reduction in calorie content offered by food outlets, driven by the removal of higher-calorie items rather than reformulation. The discussion also touches on the potential impacts on different consumer groups, the challenges of policy enforcement, and how such policies could be improved to more effectively support public health goals.

Interview Summary

Now everyone knows eating out is just part of life. For many, it's a place to make connections, can be a guilty pleasure, and sometimes it's just an outright necessity for busy folks. But it is also linked to poor dietary quality, weight gain, and even obesity. For policymakers, the challenge is identifying what policy changes can help improve population health. Jean, let's begin with you. Can you tell our listeners about the UK's menu labeling intervention and what change did you hope to see?

Jean - Yes, so this was a policy that was actually a really long time in coming and came in and out of favor with a number of different governments. So maybe over the last 10 years we've had various different suggestions to have voluntary and/or mandatory calorie labeling in the out-of-home sector. Eventually in April, 2022, we did have new mandatory regulations that came into a force that required large businesses just in England - so not across the whole of the UK, just in England - if they sold food and non-alcoholic drinks and they had to display the calories per portion of every item that they were selling. And then have alongside that somewhere on their menu, a statement that said that adults need around 2000 calories per day. The policy applied just to large businesses, and the definition of that was that those businesses have 250 or more employees, but the employees didn't all have to be involved in serving food and drinks. This might apply also to a large hotel chain who just have some bars or something in their hotels. And the food and drinks covered were things that were available for immediate consumption. Not prepackaged. And then there was also this proviso to allow high-end restaurants to be changing their menus regularly. So, it was only for things that were on the menu for at least 30 days.

You mentioned that this policy or a menu labeling might have at least two potential modes of impacts. There's first this idea that providing calories or any sort of labeling on food can somehow provide information for consumers to make what we might hope would be better choices. Might help them choose lower calorie options or healthier options. And then the second potential impact is that businesses might also use the information to change what sort of foods they're serving. It might be that they didn't realize how many calories were in the foods and they're suddenly embarrassed about it. Or as soon as their customers realize, they start to put a little bit of pressure on, you know, we want something a little bit lower calorie. So, there's this potential mechanism that operates at the demand side of how consumers might make choices. And another one at the supply side of what might be available to consumers. And we knew from previous evaluations of these sorts of interventions that there was some evidence that both could occur. Generally, it seems to be that findings from other places and countries are maybe null to small. So, we were thinking that maybe we might see something similar in England.

Thank you for sharing that background. I do have a question about the length of time it took to get this menu labeling law in place. Before we get into the results, do you have a sense of why did it take so long? Was it industry pushback? Was it just change of governments? Do you have a sense of that?

Jean - Yes, so I think it's probably a bit of both. To begin with, it was first proposed as a voluntary measure actually by industry. So, we had this kind of big public-private partnership. What can industry do to support health? And that was one of the things they proposed. And then they didn't really do it very well. So, there was this idea that everybody would do it. And in fact, we found maybe only about 20% of outlets did it. And then definitely we have had government churn in the UK over the last five years or so. So, every new prime minister really came in and wanted to have their own obesity policy threw out the last one started over. And every policy needs consulted on with the public and then with industry. And that whole process just kind of got derailed over and over again.

Thank you. That is really helpful to understand that development of the policy and why it took time. Industry regulated policy can be a tricky one to actually see the results that we would hope. You've already given us a sort of insight into what you thought the results may be from previous studies - null to relatively small. So, Mike, I want to turn to you. Can you tell us what came out of the data?

Mike - Thank you, yes. So, we found a small overall drop in average calories offered per item. That amounts to a total of nine calories per item reduction in our post policy period relative to pre policy. And this is about a 2% reduction. It was statistically significant and we do in public health talk about how small effects can still have big impacts. So, I do want to sort of put that out there, but also recognize that it was a small overall drop in calories. And then what we did is we looked at how different food groups changed, and also how calories changed at different types of restaurants, whether it was fast food, restaurants, sit downs that we call pubs, bars, and inns. And then also other different types of takeaways like cafes and things like that where you might get a coffee or a cappuccino or something like that.

What we found was driving the overall reduction in calories was a reduction in higher calorie items. So, as Jean mentioned at the outset, one of the things we were trying to identify in this analysis was whether we saw any evidence of reformulation. And we defined reformulation as whether specific products were reduced in their calories so that the same products were lower calories in the post period. We define that as reformulation. And that would be different from, say, a change in menu offering where you might identify a high calorie item and take it off the menu so that then the overall calories offered goes down on average. We found more evidence for the latter. Higher calorie items were removed. We separated into categories of removed items, items that were present in both periods, and new items added in the post period. There were higher calorie items in the removed group. The items that were present in both periods did not change. The new items were lower calorie items. What this says overall is this average reduction is driven by taking off high calorie items, adding some slightly lower calorie items. But we did not find evidence for reformulation, which is a crucial finding as well.

We saw that the largest reductions occurred in burgers, beverages and a rather large mixed group called Mains. So, burgers reduced by 103 calories per item. That's pretty substantial. One of the reasons that's so large is that burgers, particularly if they're offered at a pub and might even come with fries or chips, as they say in the UK. And because they have such a high baseline calorie level, there's more opportunity to reduce. So, whether it's making it slightly smaller patty or reducing the cheese or something like that, that's where we saw larger reductions among the burgers. With beverages, typically, this involved the addition of lower calorie options, which is important if it gives an opportunity for lower calorie selections. And that was the main driver of reduction there. And then also we saw in Mains a reduction of 30 calories per item.

A couple of the other things we wanted to identify is whether there was a change in the number of items that were considered over England's recommended calories per meal. The recommended calories per meal is 600 calories or less for lunch and dinner. And we saw no statistical change in that group.

So overall, we do see a slight reduction in average calories. But this study did not examine changes in consumer behavior. I do want to just briefly touch on that because this was part of a larger evaluation. Another study that was published using customer surveys that was published in Nature Human Behavior found no change in the average calories purchased or consumed after the policy. This evaluation was looking at both the supply and the demand side changes as a result of this policy.

Thanks, Mike and I've got lots of questions to follow up, but I'll try to control myself. The first one I'm interested to understand is you talk about the importance of the really calorie-heavy items being removed and the introduction of newer, lower calorie items. And you said that this is not a study of the demand, but I'm interested to know, do you have a sense that the higher calorie items may not have been high or top sellers. It could be easy for a restaurant to get rid of those. Do you have any sense of, you know, the types of items that were removed and of the consumer demand for those items?

Mike - Yes. So, as I mentioned, given that the largest changes were occurring among burgers, we're sort of doing this triangulation attempt to examine all of the different potential impacts we can with the study tools we have. We did not see those changes reflected in consumer purchases. So, I think sticking with the evidence, the best thing we could say is that the most frequently purchased items were not the ones that were being pulled off of menus. I think that would be the closest to the evidence. Now, no study is perfect and we did in that customer survey examine the purchases and consumption of about 3000 individuals before and after the policy. It's relatively large, but certainly not fully comprehensive. But based on what we were able to find, it would seem that those reductions in large calorie items, it's probably fair to say, were sort of marginal choices. So, we see some reduction in calories at the margins. That's why the overall is down, but we don't see at the most commonly sold. I should also mention in response to that, a lot of times when we think about eating out of home, we often think about fast food. We did not see reductions in fast food chains at all, essentially. And so really the largest reductions we found were in what would be considered more sit-down dining establishment. For example, sit-down restaurants or even pubs, bars and ends was one of our other categories. We did see average reductions in those chains. The areas you kind of think about for people grabbing food quickly on the go, we did not see reductions there. And we think some of this is a function of the data itself, which is pubs, bars and inns, because they offer larger plates, there's a little bit more space for them to reduce. And so those are where we saw the reductions. But in what we might typically think is sort of the grab and go type of food, we did not see reductions in those items. And so when we did our customer surveys, we saw that those did not lead to reductions in calories consumed.

Ahh, I see this and thank you for this. It sounds like the portfolio adjusted: getting rid of those heavy calorie items, adding more of the lower calorie items that may not have actually changed what consumers actually eat. Because the ones that they typically eat didn't change at all. And I would imagine from what you've said that large global brands may not have made many changes, but more local brands have more flexibility is my assumption of that. So that, that's really helpful to see.

As you all looked at the literature, you had the knowledge that previous studies have found relatively small changes. Could you tell us about what this work looks like globally? There are other countries that have tried policy similar to this. What did you learn from those other countries about menu labeling?

Jean - Well, I mean, I'm tempted to say that we maybe should have learned that this wasn't the sort of policy that we could expect to make a big change. To me one of the really attractive features of a labeling policy is it kind of reflects back those two mechanisms we've talked about - information and reformulation or changing menus. Because we can talk about it in those two different ways of changing the environment and also helping consumers make better choices, then it can be very attractive across the political landscape. And I suspect that that is one of the things that the UK or England learned. And that's reflected in the fact that it took a little while to get it over the line, but that lots of different governments came back to it. That it's attractive to people thinking about food and thinking about how we can support people to eat better in kind of a range of different ways. I think what we learned, like putting the literature all together, is this sort of policy might have some small effects. It's not going to be the thing that kind of changes the dial on diet related diseases. But that it might well be part of an integrated strategy of many different tools together. I think we can also learn from the literature on labeling in the grocery sector where there's been much more exploration of different types of labeling. Whether colors work, whether black stop signs are more effective. And that leads us to conclusions that these more interpretive labels can lead to bigger impacts and consumer choices than just a number, right? A number is quite difficult to make some sense of. And I think that there are some ways that we could think about optimizing the policy in England before kind of writing it off as not effective.

Thank you. I think what you're saying is it worked, but it works maybe in the context of other policies, is that a fair assessment?

Jean - Well, I mean, the summary of our findings, Mike's touched on quite a lot of it. We found that there was an increase in outlets adhering to the policy. That went from about 20% offered any labeling to about 80%. So, there were still some places that were not doing what they were expected to do. But there was big changes in actual labeling practice. People also told us that they noticed the labels more and they said that they used them much more than they were previously. Like there was some labeling before. We had some big increases in noticing and using. But it's... we found this no change in calories purchased or calories consumed. Which leads to kind of interesting questions. Okay, so what were they doing with it when they were using it? And maybe some people were using it to help them make lower calorie choices, but other people were trying to optimize calories for money spent? We saw these very small changes in the mean calorie of items available that Mike's described in lots of detail. And then we also did some work kind of exploring with restaurants, people who worked in the restaurant chains and also people responsible for enforcement, kind of exploring their experiences with the policy. And one of the big conclusions from that was that local government were tasked with enforcement, but they weren't provided with any additional resources to make that happen. And for various reasons, it essentially didn't happen. And we've seen that with a number of different policies in the food space in the UK. That there's this kind of presumption of compliance. Most people are doing it all right. We're not doing it a hundred percent and that's probably because it's not being checked and there's no sanction for not following the letter of the law. One of the reasons that local authorities are not doing enforcement, apart from that they don't have resources or additional resources for it, is that they have lots of other things to do in the food space, and they see those things as like higher risk. And so more important to do. One of those things is inspecting for hygiene, making sure that the going out is not poisonous or adulterated or anything like that. And you can absolutely understand that. These things that might cause acute sickness, or even death in the case of allergies, are much more important for them to be keeping an eye on than labeling.

One of the other things that emerged through the process of implementation, and during our evaluation, was a big concern from communities with experience of eating disorders around kind of a greater focus on calorie counting. And lots of people recounting their experience that they just find that very difficult to be facing in a space where they're maybe not trying to think about their eating disorder or health. And then they're suddenly confronted with it. And when we've gone back and looked at the literature, there's just not very much literature on the impact of calorie labeling on people with eating disorders. And so we're a little bit uncertain still about whether that is a problem, but it's certainly perceived to be a problem. And lots of people find the policy difficult for that reason because they know someone in their family or one of their friends with an eating disorder. And they're very alert to that potential harm.

I think this is a really important point to raise that the law, the menu labeling, could have differential effects on different consumers. I'm not versed in this literature on the triggering effects of seeing menu labeling for people with disordered eating. But then I'm also thinking about a different group of consumers. Consumers who are already struggling with obesity, and whether or not this policy is more effective for those individuals versus folks who are not. In the work that you all did, did you have any sense of are there heterogeneous effects of the labeling? Did different consumers respond differentially to seeing the menu label? Not just, for example, individuals maybe with disordered eating?

Mike - In this work, we mostly focused on compliance, customer responses in terms of consumption and purchases, changes in menus, and customers reporting whether or not they increase noticing and using. When we looked at the heterogeneous effects, some of these questions are what led us to propose a new project where we interviewed people and tried to understand their responses to calorie labeling. And there we get a lot of heterogenous groups. In those studies, and this work has not actually been published, but should be in the new year, we found that there's a wide range of different types of responses to the policy. For example, there may be some people who recently started going to the gym and maybe they're trying to actually bulk up. And so, they'll actually choose higher calorie items. Conversely, there may be people who have a fitness routine or a dieting lifestyle that involves calorie tracking. And they might be using an app in order to enter the calories into that. And those people who are interested in calorie counting, they really loved the policy. They really wanted the policy. And it gave them a sense of control over their diet. And they felt comfortable and were really worried that if there was evidence that it wouldn't work, that would be taken away. Then you have a whole different group of people who are living with eating disorders who don't want to interact with those numbers when they are eating out of home. They would rather eat socially and not have to think about those challenges. There's really vast diversity in terms of the responses to the policy. And that does present a challenge.

And I think what it also does is cause us just to question what is the intended mechanism of action of this policy? Because when the policy was implemented, there's an idea of a relatively narrow set of effects. If customers don't understand the number of calories that are in their items, you just provide them with the calories that are in those items, they will then make better choices as rational actors. But we know that eating out of home is far more complex. It's social. There are issues related to value for money. So maybe people want to make sure they're purchasing food that hasn't been so reduced in portions that now they don't get the value for money when they eat out. There are all sorts of body image related challenges when people may eat out. We didn't find a lot of evidence of this in our particular sample, but also in some of our consultation with the public in developing the interview, there's concern about judgment from peers when eating out. So, it's a very sensitive topic. Some of the implications of that are we do probably need more communication strategies that can come alongside these policies and sort of explain the intended mechanism impact to the public. We can't expect to simply add numbers to items and then expect that people are going to make the exact choices that are sort of in the best interest of public health. And that sort of brings us on to some potential alternative mechanisms of impact and other modes of labeling, and those sorts of things.

Mike, this has been really helpful because you've also hinted at some of the ways that this policy as implemented, could have been improved. And I wonder, do you have any other thoughts to add to how to make a policy like this have a bigger impact.

Mike - Absolutely. One of the things that was really helpful when Jean laid out her framing of the policy was there's multiple potential mechanisms of action. One of those is the potential reformulation in menu change. We talked about those results. Another intended mechanism of action is through consumer choice. So, if items have fewer calories on average, then that could reduce ultimately calories consumed. Or if people make choices of lower calorie items, that could also be a way to reduce the overall calories consumed. And I would say this calorie labeling policy, it is a step because the calories were not previously available. People did not know what they were eating. And if you provide that, that fulfills the duty of transparency by businesses. When we spoke to people who worked in enforcement, they did support the policy simply on the basis of transparency because it's important for people to understand what they're consuming. And so that's sort of a generally acceptable principle. However, if we want to actually have stronger population health impact, then we do need to have stronger mechanisms of action.

One of the ways that can reduce calories consumed by the consumers, so the sort of demand side, would be some of the interpretive labels. Jean mentioned them earlier. There's now a growing body of evidence of across, particularly in Latin America. I would say some of the strongest evidence began in Chile, but also in Mexico and in other Latin American countries where they've put warning labels on items in order to reduce their consumption. These are typically related to packaged foods is where most of the work has been done. But in order to reduce consumer demand, what it does is rather than expecting people to be sort of doing math problems on the fly, as they go around and make their choices, you're actually just letting them know, well, by the way, this is an item that's very high in calories or saturated fat, or sodium or sugars. Or some combination of those. What that does is you've already helped make that decision for the consumers. You've at least let them know this item has a high level of nutrients of concern. And you can take that away. Conversely, if you have an item that's 487 calories, do you really know what you're going to do with that information? So that's one way to have stronger impact.

The other way that that type of policy can have stronger impact is it sets clear thresholds for those warnings. And so, when you have clear thresholds for warnings, you can have a stronger mechanism for reformulation. And what companies may want to do is they may not want to display those warning labels, maybe because it's embarrassing. It makes their candy or whatever the unhealthy food look bad. Sort of an eyesore, which is the point. And what they'll do is they can reformulate those nutrients to lower levels so that they no longer qualify for that regulation. And so there are ways to essentially strengthen both of those mechanisms of action. Whereas when it's simply on the basis of transparency, then what that does is leave all of the decision making and work on the consumer.

Mike, this is great because I've worked with colleagues like Gabby Fretes and Sean Cash and others on some menu labeling out of Chile. And we're currently doing some work within the center on food nutrition labels to see how different consumers are responding. There's a lot more work to be done in this space. And, of course, our colleagues at UNC (University of North Carolina-Chapel Hill) have also been doing this work. So, this work is really important because it tells us how it can help consumers make different choices, and how it can affect how companies behave. My final question to the two of you is simply, what would you like policymakers to learn from this study? Or maybe not just this study alone, but this body of work. What should they take away?

Jean - Well, I think there's lots of information out there on how to do food labeling well, and we can certainly learn from that. And Mike talks about the work from South America particularly where they're helping people identify the least healthy products. And they're also providing messaging around what you should do with that - like choose a product with fewer of these black symbols. But I think even if labeling is optimized, it's not really going to solve our problem of dietary related diseases. And I think I always want policymakers to know, and I think many of them do understand this, that there is no one magic solution and we need to be thinking about labeling as part of a strategy that addresses marketing in its entirety, right? Companies are using all sorts of strategies to encourage us to buy products. We need to be thinking of all sorts of strategies to support people to buy different products and to eat better. And I think that focuses on things like rebalancing price, supporting people to afford healthier food, focusing advertising and price promotions on healthier products. And I also think we need to be looking even further upstream though, right? That we need to be thinking about the incentives that are driving companies to make and sell less healthy products. Because I don't think that they particularly want to be selling less healthy products or causing lots of illness. It's those products are helping them achieve their aims of creating profit and growth for their shareholders. And I think we need to find creative ways to support companies to experiment with healthier products that either help them simultaneously achieve those demands of profit or growth. Or somehow allow them to step away from those demands either for a short period or for a longer period. I think that that requires us to kind of relook at how we do business in economics in our countries.

Mike?

Yes, I think that was a really thorough answer by Jean. So, I'll just add a couple points. I think most fundamentally what we need to think about when we're doing policy making to improve diet is we need to always think about are we helping to make the healthier choice the easier choice? And what that means is we're not implementing policies that merely provide information that then require individuals to do the rest of the work. We need to have a food environment that includes healthier options that are easily accessible, but also affordable. That's one thing that's come through in quite a lot of the work we've done. There are a lot of concerns about the high cost of food. If people feel like the healthier choices are also affordable choices, that's one of many ways to support the easier choice. And I really just want to reiterate what Jean said in terms of the economics of unhealthy food. In many ways, these large multinational corporations are from their perspective, doing right by their shareholders by producing a profitable product.

Now there are debates on whether or not that's a good thing, of course. There's quite a lot of evidence for the negative health impacts of ultra-processed (UPF) products, and those are getting a lot more attention these days and that's a good thing. What we do need to think about is why is it that UPFs are so widely consumed. In many ways they are optimized to be over consumed. They're optimized to be highly profitable. Because the ingredients that are involved in their production means that they can add a lot of salt, sugar, and fat. And what that does is lead to overconsumption. We need to think about that there's something fundamentally broken about this incentive structure. That is incentivizing businesses to sell unhealthy food products with these food additives that lead to over consumption, obesity, and the associated comorbidities. And if we can start to make a little progress and think creatively about how could we incentivize a different incentive structure. One where actually it would be in a food business's best interest to be much more innovative and bolder and produce healthier products for everyone. That's something that I think we will have to contend with because if we are thinking that we are only going to be able to restrict our way out of this, then that's very difficult. Because people still need to have healthy alternatives, and so we can't merely think about restricting. We also have to think about how do we promote access to healthier foods.

This is great insight. I appreciate the phrasing of making the healthy choice the easy choice, and I also heard a version of this making the healthy choice the affordable choice. But it also seems like we need to find ways to make the healthy choice the profitable choice as well.

Bios:

Jean Adams is a Professor of Dietary Public Health and leads the Population Health Interventions Programme at the University of Cambridge MRC Epidemiology Unit. Adams trained in medicine before completing a PhD on socio-economic inequalities in health. This was followed by an MRC Health of the Population fellowship and an NIHR Career Development Fellowship both exploring influences on health behaviours and socio-economic inequalities in these. During these fellowships Jean was appointed Lecturer, then Senior Lecturer, in Public Health at Newcastle University. Jean moved to Cambridge University to join the MRC Epidemiology Unit and CEDAR in 2014 where she helped establish the Dietary Public Health group. She became Programme Leader in the newly formed Population Health Interventions programme in 2020, and was appointed Professor of Dietary Public Health in 2022.

Mike Essman is a Research Scientist at Duke University’s World Food Policy Center. His background is in evaluating nutrition and food policies aimed at improving diets and preventing cardiometabolic diseases. His work employs both quantitative and qualitative methods to explore drivers of dietary behavior, particularly ultra-processed food consumption, across diverse environments and countries. Mike earned his PhD in Nutrition Epidemiology from the University of North Carolina at Chapel Hill, where his research focused on evaluating the impacts of a sugary beverage tax in South Africa. He completed MSc degrees in Medical Anthropology and Global Health Science at the University of Oxford through a fellowship. Prior to joining Duke, he conducted research at the MRC Epidemiology Unit at the University of Cambridge, where he evaluated the impacts of calorie labeling policies in England and led a study examining public perceptions of ultra-processed foods.