By Lea Borgi, MD
May 16, 2018
Americans consume about a third of their calories outside the home,1 but estimating the calorie count of a restaurant’s meal can be extremely difficult. In a cross-sectional study of 1,877 adults and 330 school age children, two thirds of participants underestimated the calories of fast food meals.2 The larger the ingested meal, the larger the discrepancy between the estimated and the actual calorie content of that meal. In another study, participants consistently underestimated both the fat and calorie content of a range of menu items, where the actual content was up to 2 times greater than expected by consumers.3
With this in mind, policymakers have pushed towards requiring restaurants to display calorie counts on their menus. In 2010, Congress passed the Nutrition Labeling of Standard Menu Items at Chain Restaurants law.4 After an 8-year delay and several pushbacks from the restaurant and grocery trade organizations,5 the national law finally went into effect on May 7, 2018.6 Restaurant chains with 20 or more locations now have to list calories for menu items, and, if prompted, be able to provide more detailed nutrition information (such as macronutrient composition).6
However, the question remains – Does menu labeling lead to healthier food choices?
The studies examining the effects of menu labeling on the amount of calories ordered have shown inconsistent results.7 A systematic review from 2016 which analyzed the results of 38 studies, showed little overall effect of menu labeling. Of the studies conducted in restaurants, 9% showed a positive influence on food choices (i.e., participants picked healthier meals with lower calories), 50% showed a partial effect and 41% showed no effect.7 In this analysis, a greater effect of menu labeling on ordering behaviors was seen in studies of cafeterias. However, the studies analyzed were generally of small size, variable quality, and used different methodological approaches, making it difficult to draw any robust conclusions. Furthermore, while studies conducted in artificial settings point towards a positive effect on parents, adolescents, and children, real-world studies of menu labeling did not demonstrate changes in food-purchasing behaviors.8
The mixed results of these initial studies have been disappointing for the public health community. Cultural change and greater population education may be required for menu labeling to be more effective. However, change also needs to come from within the food industry itself. Transparency may prove a useful tool in this regard—by having to disclose calories and nutrition information, restaurant chains may choose to modify meals and decrease their calorie content. Indeed, in an analysis of 66 out of 100 of the largest US restaurant chains obtained from the MenuStat project (a nutritional database of foods offered at restaurant chains), newly introduced meals and beverages had 12-20% fewer calories.9
In conclusion, adding calorie information to menu items highlights the calorie-dense nature of many restaurant meals and increases transparency for consumers. However, additional steps are needed to help individuals make healthier choices. The traffic-light system, where green corresponds to lower calories or an overall healthier, nutrient-rich meal might be such an example. Indeed, when the traffic-light system supplemented menu labeling, purchased calories were found to be lower.10 Finally, more research is needed to understand and overcome the barriers to healthier food choices and maximize the potential benefit of menu labeling.
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 Seguin RA, Aggarwal A, Vermeylen F et al. Consumption Frequency of Foods Away from Home Linked with Higher Body Mass Index and Lower Fruit and Vegetable Intake among Adults: A Cross-Sectional Study. Journal of Environmental and Public Health. 2016;2016:3074241. doi:10.1155/2016/307424.
 Block JP, Condon SK, Kleinman K, et al. Consumers’ estimation of calorie content at fast food restaurants: cross sectional observational study. BMJ 2013; 346 :f2907.
 Burton S, Creyer EH, Kees J et al. Attacking the Obesity Epidemic: The Potential Health Benefits of Providing Nutrition Information in Restaurants. American Journal of Public Health. 2006;96(9):1669-1675. doi:10.2105/AJPH.2004.054973.
 Department of Health and Human Services, US Food and Drug Administration. Food Labeling: Nutrition Labeling of Standard Menu Items in Restaurants and Similar Retail Food Establishments. Final Regulatory Impact Analysis. FDA–2011–F–0172.
 Common Sense Nutrition Disclosure Act of 2018. H.R.772. Retrieved from https://www.congress.gov/bill/115th-congress/house-bill/772.
 Menu Labeling: Supplemental Guidance for Industry. U.S. Department of Health and Human Services Food and Drug Administration Center for Food Safety and Applied Nutrition. May 2018. Retrieved from https://www.fda.gov/downloads/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/UCM583492.pdf.
 Ana C, Fernandes, Renata C, et al. Influence of menu labeling on food choices in real-life settings: a systematic review, Nutrition Reviews, Volume 74, Issue 8, 1 August 2016, Pages 534–548.
 Sacco, J., Lillico, H. G., Chen, E, et al. The influence of menu labeling on food choices among children and adolescents: A systematic review of the literature. 2017. Perspectives in Public Health, 137(3), 173-181.
 Bleich SN, Wolfson JA, Jarlenski MP. Calorie Changes in Chain Restaurant Menu Items: Implications for Obesity and Evaluations of Menu Labeling. American Journal of Preventive Medicine. 2015;48(1):70-75. doi:10.1016/j.amepre.2014.08.026.
 Ellison B Lusk JL Davis D. The impact of restaurant calorie labels on food choice: results from a field experiment. Econ Inq. 2014; 52 : 666 – 681.
Dr. Borgi’s clinic research focuses on the link between nutrition and chronic diseases, such as hypertension and kidney disease. Dr. Borgi is also interested in food policy, and is completing a Master in Nutrition Sciences and Policy at the Friedman School of Nutrition Science and Policy at Tufts University. Dr. Borgi is currently interested in the recent changes made in food government programs regarding the inclusion of potatoes in food stamps.