Christina A. Roberto

Evaluating the Impact of Menu Labeling on Food Choices and Intake

OBJECTIVES We assessed the impact of restaurant menu calorie labels on food choices and intake. METHODS Participants in a study dinner (n=303) were randomly assigned to either (1) a menu without calorie labels (no calorie labels), (2) a menu with calorie labels (calorie labels), or (3) a menu with calorie labels and a label stating the recommended daily caloric intake for an average adult (calorie labels plus information). Food choices and intake during and after the study dinner were measured. RESULTS Participants in both calorie label conditions ordered fewer calories than those in the no calorie labels condition. When calorie label conditions were combined, that group consumed 14% fewer calories than the no calorie labels group. Individuals in the calorie labels condition consumed more calories after the study dinner than those in both other conditions. When calories consumed during and after the study dinner were combined, participants in the calorie labels plus information group consumed an average of 250 fewer calories than those in the other groups. CONCLUSIONS Calorie labels on restaurant menus impacted food choices and intake; adding a recommended daily caloric requirement label increased this effect, suggesting menu label legislation should require such a label. Future research should evaluate menu labelings impact on childrens food choices and consumption.

Patchy progress on obesity prevention: emerging examples, entrenched barriers, and new thinking

Despite isolated areas of improvement, no country to date has reversed its obesity epidemic. Governments, together with a broad range of stakeholders, need to act urgently to decrease the prevalence of obesity. In this Series paper, we review several regulatory and non-regulatory actions taken around the world to address obesity and discuss some of the reasons for the scarce and fitful progress. Additionally, we preview the papers in this Lancet Series, which each identify high-priority actions on key obesity issues and challenge some of the entrenched dichotomies that dominate the thinking about obesity and its solutions. Although obesity is acknowledged as a complex issue, many debates about its causes and solutions are centred around overly simple dichotomies that present seemingly competing perspectives. Examples of such dichotomies explored in this Series include personal versus collective responsibilities for actions, supply versus demand-type explanations for consumption of unhealthy food, government regulation versus industry self-regulation, top-down versus bottom-up drivers for change, treatment versus prevention priorities, and a focus on undernutrition versus overnutrition. We also explore the dichotomy of individual versus environmental drivers of obesity and conclude that people bear some personal responsibility for their health, but environmental factors can readily support or undermine the ability of people to act in their own self-interest. We propose a reframing of obesity that emphasises the reciprocal nature of the interaction between the environment and the individual. Todays food environments exploit peoples biological, psychological, social, and economic vulnerabilities, making it easier for them to eat unhealthy foods. This reinforces preferences and demands for foods of poor nutritional quality, furthering the unhealthy food environments. Regulatory actions from governments and increased efforts from industry and civil society will be necessary to break these vicious cycles.

Influence of Licensed Characters on Children's Taste and Snack Preferences

OBJECTIVE: The goal was to study how popular licensed cartoon characters appearing on food packaging affect young childrens taste and snack preferences. METHODS: Forty 4- to 6-year-old children tasted 3 pairs of identical foods (graham crackers, gummy fruit snacks, and carrots) presented in packages either with or without a popular cartoon character. Children tasted both food items in each pair and indicated whether the 2 foods tasted the same or one tasted better. Children then selected which of the food items they would prefer to eat for a snack. RESULTS: Children significantly preferred the taste of foods that had popular cartoon characters on the packaging, compared with the same foods without characters. The majority of children selected the food sample with a licensed character on it for their snack, but the effects were weaker for carrots than for gummy fruit snacks and graham crackers. CONCLUSIONS: Branding food packages with licensed characters substantially influences young childrens taste preferences and snack selection and does so most strongly for energy-dense, nutrient-poor foods. These findings suggest that the use of licensed characters to advertise junk food to children should be restricted.

Should Amenorrhea Be a Diagnostic Criterion for Anorexia Nervosa

OBJECTIVE The removal of the amenorrhea criterion for anorexia nervosa (AN) is being considered for the fifth edition of The Diagnostic and Statistical Manual (DSM-V). This article presents and discusses the arguments for maintaining as well as those for removing the criterion. METHOD The psychological and biological literatures on the utility of amenorrhea as a distinguishing diagnostic criterion for AN and as an indicator of illness severity are reviewed. RESULTS The findings suggest that the majority of differences among patients with AN who do and do not meet the amenorrhea criterion appear largely to reflect nutritional status. Overall, the two groups have few psychological differences. There are mixed findings regarding biological differences between those with AN who do and do not menstruate and the relationship between amenorrhea and bone health among patients with AN. DISCUSSION Based on these findings, one option is to describe amenorrhea in DSM-V as a frequent occurrence among individuals with AN that may provide important information about clinical severity, but should not be maintained as a core diagnostic feature. The possibilities of retaining the criterion or eliminating it altogether are discussed.

Are dietary restraint scales valid measures of dietary restriction? Additional objective behavioral and biological data suggest not

Prospective studies find that individuals with elevated dietary restraint scores are at increased risk for bulimic symptom onset, yet experiments find that assignment to energy-deficit diet interventions reduce bulimic symptoms. One explanation for the conflicting findings is that the dietary restraint scales used in the former studies do not actually identify individuals who are restraining their caloric intake. Thus, we tested whether dietary restraint scales showed inverse relations to objectively measured caloric intake in three studies. Four dietary restraint scales did not correlate with doubly labeled water estimates of caloric intake over a 2-week period (M, r=.01). One scale showed a significant inverse correlation with objectively measured caloric intake during a regular meal ordered from an ecologically valid menu (M, r=-.30), but a significant positive relation that was qualified by a significant quadratic effect, to objectively measured caloric intake during multiple eating episodes in the lab (M, r=.32). In balance, results suggest that dietary restraint scales are not valid measures of dietary restriction, replicating findings from prior studies that examined objective measures of caloric intake.

A test of different menu labeling presentations.

Chain restaurants will soon need to disclose calorie information on menus, but research on the impact of calorie labels on food choices is mixed. This study tested whether calorie information presented in different formats influenced calories ordered and perceived restaurant healthfulness. Participants in an online survey were randomly assigned to a menu with either (1) no calorie labels (No Calories); (2) calorie labels (Calories); (3) calorie labels ordered from low to high calories (Rank-Ordered Calories); or (4) calorie labels ordered from low to high calories that also had red/green circles indicating higher and lower calorie choices (Colored Calories). Participants ordered items for dinner, estimated calories ordered, and rated restaurant healthfulness. Participants in the Rank-Ordered Calories condition and those in the Colored Calories condition ordered fewer calories than the No Calories group. There was no significant difference in calories ordered between the Calories and No Calories groups. Participants in each calorie label condition were significantly more accurate in estimating calories ordered compared to the No Calories group. Those in the Colored Calories group perceived the restaurant as healthier. The results suggest that presenting calorie information in the modified Rank-Ordered or Colored Calories formats may increase menu labeling effectiveness.

Rationale and Evidence for Menu-Labeling Legislation

Menu-labeling legislation is a proposed public health intervention for poor diet and obesity that requires chain restaurants to provide nutrition information on menus and menu boards. The restaurant industry has strongly opposed menu-labeling legislation. Using scientific evidence, this paper counters industry arguments against menu labeling by demonstrating that consumers want chain restaurant nutrition information to be disclosed; the current methods of providing nutrition information are inadequate; the expense of providing nutrition information is minimal; the government has the legal right to mandate disclosure of information; consumers have the right to know nutrition information; a lack of information reduces the efficiency of a market economy; and menu labeling has the potential to make a positive public health impact.

The Clinical Significance of Amenorrhea as a Diagnostic Criterion for Anorexia Nervosa

OBJECTIVE Amenorrhea is a DSM-IV criterion for the diagnosis of anorexia nervosa (AN). Several studies have reported few differences between patients who meet the full DSM-IV criteria for AN and those who meet all but the amenorrhea criterion. Although this suggests that the absence of menses does not provide critical diagnostic information, many of these studies are limited by small sample sizes. This study aims to examine the clinical utility of amenorrhea as a criterion for the diagnosis of AN. METHOD A chart review was conducted of 240 consecutive patients admitted for inpatient treatment at the NY State Psychiatric Institute from 1993 to 2006. Menstrual data were collected from the Eating Disorder Examination conducted upon admission. Independent samples t-tests were performed to evaluate differences in clinical variables, including age, lifetime lowest body mass index (BMI), admission and discharge BMI, previous number of hospitalizations, duration of illness, Beck Depression Inventory total score, Beck Anxiety Inventory total score, and Eating Disorder Examination subscale scores. RESULTS The amenorrheic and menstruating groups differed significantly only on lowest lifetime BMI and admission BMI, with individuals with amenorrhea having lower BMIs on both measures. CONCLUSION These results indicate that amenorrhea does not distinguish between groups on a number of important measures of clinical severity. It may be that amenorrhea reflects weight and nutritional status, rather than providing useful diagnostic information. Future studies are needed to examine the potential prognostic value of menstrual status.

An Observational Study of Consumers' Accessing of Nutrition Information in Chain Restaurants

In this observational study, we determined how frequently consumers accessed on-premises nutrition information provided at chain restaurants. The number of patrons entering and accessing nutrition information was recorded at 8 locations that were part of 4 major restaurant chains (McDonalds, Burger King, Starbucks, and Au Bon Pain). Only 6 (0.1%) of 4311 patrons accessed on-premises nutrition information before purchasing food. This very small percentage suggests that such information should be more prominently displayed, such as on restaurant menu boards, to help customers make informed decisions.

The Smart Choices front-of-package nutrition label. Influence on perceptions and intake of cereal.

Numerous front-of-package (FOP) nutrition labeling systems exist, but it is unclear if such labels influence behavior. A single-summary label called Smart Choices (SC) appeared briefly on products in the United States in 2009. The current study aimed to evaluate (1) the influence the SC symbol has on the serving and consumption of cereal; and (2) the impact of providing calorie and serving size information on a FOP label. Two hundred and sixteen adults were randomized to a high-sugar breakfast cereal that had either (1) no label; (2) the SC symbol; or (3) a modified SC symbol with serving size information. Participants rated perceptions of healthfulness, taste, and purchase intent, estimated calories per serving and poured and ate the cereal for breakfast. Participants in the SC label conditions were better able to estimate calories per serving, but there were no differences across groups on perceptions of healthfulness, taste, purchase intent, and levels of vitamins, and sugar or amount of cereal poured or consumed. These results suggest that calories per serving information on FOP labels can increase knowledge, but the SC symbol had little impact on behavior. Studies examining FOP label influence on purchasing, consumption, and product reformulation are greatly needed to determine label utility.