Lynn D. Silver

Purchasing behavior and calorie information at fast-food chains in New York City, 2007.

We surveyed 7318 customers from 275 randomly selected restaurants of 11 fast food chains. Participants purchased a mean of 827 calories, with 34% purchasing 1000 calories or more. Unlike other chains, Subway posted calorie information at point of purchase and its patrons more often reported seeing calorie information than patrons of other chains (32% vs 4%; P<.001); Subway patrons who saw calorie information purchased 52 fewer calories than did other Subway patrons (P<.01). Fast-food chains should display calorie information prominently at point of purchase, where it can be seen and used to inform purchases.

Changes in energy content of lunchtime purchases from fast food restaurants after introduction of calorie labelling: cross sectional customer surveys

Objective To assess the impact of fast food restaurants adding calorie labelling to menu items on the energy content of individual purchases. Design Cross sectional surveys in spring 2007 and spring 2009 (one year before and nine months after full implementation of regulation requiring chain restaurants’ menus to contain details of the energy content of all menu items). Setting 168 randomly selected locations of the top 11 fast food chains in New York City during lunchtime hours. Participants 7309 adult customers interviewed in 2007 and 8489 in 2009. Main outcome measures Energy content of individual purchases, based on customers’ register receipts and on calorie information provided for all items in menus. Results For the full sample, mean calories purchased did not change from before to after regulation (828 v 846 kcal, P=0.22), though a modest decrease was shown in a regression model adjusted for restaurant chain, poverty level for the store location, sex of customers, type of purchase, and inflation adjusted cost (847 v 827 kcal, P=0.01). Three major chains, which accounted for 42% of customers surveyed, showed significant reductions in mean energy per purchase (McDonald’s 829 v 785 kcal, P=0.02; Au Bon Pain 555 v 475 kcal, P<0.001; KFC 927 v 868 kcal, P<0.01), while mean energy content increased for one chain (Subway 749 v 882 kcal, P<0.001). In the 2009 survey, 15% (1288/8489) of customers reported using the calorie information, and these customers purchased 106 fewer kilocalories than customers who did not see or use the calorie information (757 v 863 kcal, P<0.001). Conclusion Although no overall decline in calories purchased was observed for the full sample, several major chains saw significant reductions. After regulation, one in six lunchtime customers used the calorie information provided, and these customers made lower calorie choices.

Consumer Awareness of Fast-Food Calorie Information in New York City After Implementation of a Menu Labeling Regulation

OBJECTIVES We assessed consumer awareness of menu calorie information at fast-food chains after the introduction of New York Citys health code regulation requiring these chains to display food-item calories on menus and menu boards. METHODS At 45 restaurants representing the 15 largest fast-food chains in the city, we conducted cross-sectional surveys 3 months before and 3 months after enforcement began. At both time points, customers were asked if they had seen calorie information and, if so, whether it had affected their purchase. Data were weighted to the number of city locations for each chain. RESULTS We collected 1188 surveys pre-enforcement and 1229 surveys postenforcement. Before enforcement, 25% of customers reported seeing calorie information; postenforcement, this figure rose to 64% (P < .001; 38% and 72%, weighted). Among customers who saw calorie information postenforcement, 27% said they used the information, which represents a 2-fold increase in the percentage of customers making calorie-informed choices (10% vs 20%, weighted; P < .001). CONCLUSIONS Posting calorie information on menu boards increases the number of people who see and use this information. Since enforcement of New Yorks calorie labeling regulation began, approximately 1 million New York adults have seen calorie information each day.

Cholesterol Control Beyond the Clinic: New York City's Trans Fat Restriction

Although blood cholesterol levels in the United States have decreased slightly since the late 1980s (1), consumption of saturated and trans fats remains above recommended maximum levels (2, 3), and only one quarter of U.S. adults with high cholesterol have it under control (4). Some 24 million U.S. adults report taking cholesterol-lowering medications (5). Changing a persons nutrition-related behavior to improve cholesterol control is challenging (6) and a source of frustration for clinicians (7). Public health action can complement health care provider efforts. The New York City Department of Health and Mental Hygiene adopted such a strategy when it restricted the use of artificial trans fat in restaurant food. We describe the rationale and process that led to this New York City Health Code amendment and the Departments experience implementing the rule. Artificial trans fat is an unnecessary ingredient that poses a substantial risk to heart health. Although no randomized, controlled trials have assessed the effect of trans fat consumption on cardiovascular events, evidence from experimental studies, dietary trials, and prospective observational studies (3, 8) demonstrates that consumption of trans fatty acids provides no apparent nutritional benefit and has considerable potential for harm. The Institute of Medicine (3) concluded that a positive linear trend exists between trans fatty acid intake and low-density lipoprotein cholesterol level, which increases the risk for coronary heart disease. Unlike saturated fat, trans fat also decreases high-density lipoprotein cholesterol levels (3, 8, 9). Trans fat intake has a large effect on cardiovascular health: A mere 2% increase in energy intake from trans fat may increase the risk for a coronary event by up to 23% (8). Other potential adverse effects have been noted, such as affecting insulin sensitivity and increasing systemic inflammation, which raises additional public health concerns (8, 10). Each year, 6% to 19% of coronary heart disease events and 30000 or more premature deaths are estimated to occur in the United States because of trans fat consumption (8, 11). The Institute of Medicine, the American Heart Association, the U.S. Department of Agriculture, and other leading health organizations recommend minimizing trans fat intake (3, 1215). To achieve this, health care providers are asked to counsel patients (12). However, such advice is unlikely to be broadly effectivemillions of Americans would need to routinely study package labels on groceries and actively seek information on trans fat in restaurant foods, where a growing proportion of calories are now consumed. Health would be better served by making the use of safer fats the default in food preparation. The Emergence of Artificial Trans Fat and Recognition of Its Risks Trans fats occur naturally in small amounts in some meat and dairy products (3); however, these sources make up only 21% of total trans fat intake (16). The remaining trans fat in the U.S. diet is artificial, produced by partial hydrogenation of vegetable oils and found mostly in processed foodsespecially baked and fried goods and spreads. Partial hydrogenation was patented in 1903. Eight years later, Crisco (J.M. Smucker, Orrville, Ohio) became the first such product widely marketed in the United States (17). These chemically modified oils, like several food ingredients in the 20th century, entered the food supply without a full evaluation of human health effects and were generally recognized as safe on the basis of experience (18). Industrial advantages, such as extended product shelf life and fry oil stability, led to increased use in the 1950s. In the 1970s, margarine made from partially hydrogenated oil was promoted as a healthier alternative to butter (19). However, by the 1990s, studies began to identify trans fat as a health hazard (9). In 2003, the U.S. Food and Drug Administration (FDA) required that all packaged goods display information on trans fat content by 2006 (20). The regulation allows products that contain less than 0.5 grams of trans fat per serving to be labeled zero grams trans fat. This prompted a widespread industry response of reformulating products to declare zero grams trans fat on front-of-package labeling (2123), although such products may still contain trans fat in small amounts, which can add up. The nutrition facts labeling allowed attentive consumers to avoid trans fat in packaged foods; however, restaurantswhich provide one third of daily caloric intake (24)generally do not disclose nutritional information, leaving consumers no practical way to avoid trans fat. At the time of the FDA action, only Denmark limited trans fat in its entire food supply (25). Although local health departments do not commonly regulate packaged goods, inspecting, licensing, and regulating restaurants and retail food outlets are core local public health functions (26). Building on its food safety infrastructure, the Department trained restaurant inspectors in May 2005 to assess the presence of artificial trans fat in products used for frying, baking, or cooking or in spreads by means of food label inspection. Because inspection visits are scheduled each year on the basis of original restaurant licensing date and compliance records, a survey fielded during regularly scheduled inspections approximates a random sample of these establishments. In May and June 2005, inspectors assessed the use of trans fat in oils, shortenings, and spreads used for frying, baking, or cooking or in spreads in 529 restaurants. Of the 478 restaurants that used fats for any of these purposes and for which complete data were collected, trans fat presence could not be determined in one third. Where it could be assessed, 50% of restaurants used artificial trans fat to prepare food. Educational Campaign In August 2005, the Department launched an educational campaign to reduce restaurant artificial trans fat use. Information was sent to the 30000 licensed food outlets in the city, 15000 suppliers and supermarkets, and hundreds of thousands of consumers. Mailings urged restaurants to remove artificial trans fat from food, suppliers to promote 0-grams trans fat products, and patrons to inquire about oils used. Press coverage was extensive (2729). More than 7800 restaurant operators received training on the issue during the mandatory food protection course. Nearly a year later, inspectors surveyed 1021 restaurants in April and May 2006 by following the same methodology as the previous year. Despite the educational campaign, prevalence of artificial trans fat use remained virtually unchanged at 51% in places where it could be assessed. Given survey findings of a wide range of restaurants that cooked without artificial trans fat, successful reformulation of packaged foods, and the Danish experience, the Department concluded that food choice and quality would be unaffected by replacing artificial trans fat and proposed using its regulatory authority to reduce artificial trans fat use (26). Crafting Regulation Department clinical staff, food safety experts, and lawyers considered a range of regulatory options, from disclosure-only requirements to content restrictions. Labeling trans fat would benefit only consumers who were aware of and would act on the dangers of trans fat and would be difficult to enforce. A restriction, however, would benefit all New Yorkers, regardless of language, literacy, level of health awareness, or age. Protecting children, who consume French fries and other quick-service foods that are common sources of artificial trans fat (30), was particularly important. Because artificial trans fat is both harmful and fully replaceable, allowing continued use, even with disclosure, could not be justified. Similarly, restricting trans fat in cooking oils and spreads onlyalthough easier to achievewould be insufficient because baked goods are the largest dietary source of trans fat (16). Given that an estimated one third of calories comes from away-from-home sources, removing most trans fat from restaurants could be expected to reduce trans fatassociated deaths proportionately. The Department drafted a broad proposal to restrict artificial trans fat use in fry oils; spreads; and all other ingredients and products, including baked goods. For the regulation to be clear and enforceable, the Department adopted the FDA threshold used for labeling of up to 0.5 grams of trans fat per serving for products containing any trans fat (20). The regulation would apply to all licensed food establishments, including restaurants, school cafeterias, caterers, senior centers, and street-food vendors. It intentionally did not affect products that contained only natural trans fat. The Department designed enforcement to rely on existing infrastructure. Inspectors check product labels, which restaurants now must maintain, during their regular annual inspections. The rule included a 6-month phase-out period for artificial trans fat in fry oils and spreads and 18 months for all other items, to give restaurants time to identify alternatives and reformulate (31). Fines for violations range from

Change in Trans Fatty Acid Content of Fast-Food Purchases Associated With New York City's Restaurant Regulation: A Pre–Post Study

200 to

Healthy Bodegas: Increasing and Promoting Healthy Foods at Corner Stores in New York City

2000. From Concept to Action The regulation was proposed as an amendment to the citys Health Code, approvable by the Board of Health. Nearly 2300 public comments were received, with supporters outnumbering opponents 31 to 1. Local, regional, and national organizations and professional medical associations made statements of support. Opposition came primarily from industry associations, including the National Restaurant Association and its state affiliate and the Grocery Manufacturers Association (32). The restaurant industry, which often opposes regulation on principle, alleged that the elimination of artificial trans fat would result in more expensive and less flavorful food and also claimed that the supply of alternative oils was insufficient and the regulatory timeline unre

New York City’s Fight Over Calorie Labeling

BACKGROUND Dietary trans fat increases risk for coronary heart disease. In 2006, New York City (NYC) passed the first regulation in the United States restricting trans fat use in restaurants. OBJECTIVE To assess the effect of the NYC regulation on the trans and saturated fat content of fast-food purchases. DESIGN Cross-sectional study that included purchase receipts matched to available nutritional information and brief surveys of adult lunchtime restaurant customers conducted in 2007 and 2009, before and after implementation of the regulation. SETTING 168 randomly selected NYC restaurant locations of 11 fast-food chains. PARTICIPANTS Adult restaurant customers interviewed in 2007 and 2009. MEASUREMENTS Change in mean grams of trans fat, saturated fat, trans plus saturated fat, and trans fat per 1000 kcal per purchase, overall and by chain type. RESULTS The final sample included 6969 purchases in 2007 and 7885 purchases in 2009. Overall, mean trans fat per purchase decreased by 2.4 g (95% CI, -2.8 to -2.0 g; P < 0.001), whereas saturated fat showed a slight increase of 0.55 g (CI, 0.1 to 1.0 g; P = 0.011). Mean trans plus saturated fat content decreased by 1.9 g overall (CI, -2.5 to -1.2 g; P < 0.001). Mean trans fat per 1000 kcal decreased by 2.7 g per 1000 kcal (CI, -3.1 to -2.3 g per 1000 kcal; P < 0.001). Purchases with zero grams of trans fat increased from 32% to 59%. In a multivariate analysis, the poverty rate of the neighborhood in which the restaurant was located was not associated with changes. LIMITATION Fast-food restaurants that were included may not be representative of all NYC restaurants. CONCLUSION The introduction of a local restaurant regulation was associated with a substantial and statistically significant decrease in the trans fat content of purchases at fast-food chains, without a commensurate increase in saturated fat. Restaurant patrons from high- and low-poverty neighborhoods benefited equally. However, federal regulation will be necessary to fully eliminate population exposure to industrial trans fat sources. PRIMARY FUNDING SOURCE City of New York and the Robert Wood Johnson Foundation Healthy Eating Research program.

What people buy from fast-food restaurants: caloric content and menu item selection, New York City 2007.

OBJECTIVES We assessed the effectiveness of an initiative to increase the stock and promotion of healthy foods in 55 corner stores in underserved neighborhoods. METHODS We evaluated the intervention through in-store observations and preintervention and postintervention surveys of all 55 store owners as well as surveys with customers at a subset of stores. RESULTS We observed an average of 4 changes on a 15-point criteria scale. The most common were placing refrigerated water at eye level, stocking canned fruit with no sugar added, offering a healthy sandwich, and identifying healthier items. Forty-six (84%) store owners completed both surveys. Owners reported increased sales of healthier items, but identified barriers including consumer demand and lack of space and refrigeration. The percentage of customers surveyed who purchased items for which we promoted a healthier option (low-sodium canned goods, low-fat milk, whole-grain bread, healthier snacks and sandwiches) increased from 5% to 16%. CONCLUSIONS Corner stores are important vehicles for access to healthy foods. The approach described here achieved improvements in participating corner stores and in some consumer purchases and may be a useful model for other locales.

Food Safety for the 21st Century

In 2006, New York Citys Health Department amended the city Health Code to require the posting of calorie counts by chain restaurants on menus, menu boards, and item tags. This was one element of the citys response to rising obesity rates. Drafting the rule involved many decisions that affected its impact and its legal viability. The restaurant industry argued against the rule and twice sued to prevent its implementation. An initial version of the rule was found to be preempted by federal law, but a revised version was implemented in January 2008. The experience shows that state and local health departments can use their existing authority over restaurants to combat obesity and, indirectly, chronic diseases.

Public Health Detailing: A Strategy to Improve the Delivery of Clinical Preventive Services in New York City

Fast‐food restaurants provide a growing share of daily food intake, but little information is available in the public health literature about customer purchases. In order to establish baseline data on mean calorie intake, this study was completed in the Spring of 2007, before calorie labeling regulations went into effect in New York City. Receipts were collected from lunchtime customers, at randomly selected New York City fast‐food chains. A supplementary survey was also administered to clarify receipt items. Calorie information was obtained through company websites and ascribed to purchases. Lunchtime purchases for 7,750 customers averaged 827 calories and were lowest for sandwich chains (734 calories); and highest for chicken chains (931 calories). Overall, one‐third of purchases were over 1,000 calories, predominantly from hamburger chains (39%) and chicken chains (48%); sandwich chains were the lowest, with only 20% of purchases over 1,000 calories. “Combination meals” at hamburger chains accounted for 31% of all purchases and averaged over 1,200 calories; side orders accounted for almost one‐third of these calories. Lunch meals at these fast‐food chains are high in calorie content. Although calorie posting may help to raise awareness of the high calories in fast‐food offerings, reducing portion sizes and changing popular combination meals to include lower calorie options could significantly reduce the average calorie content of purchases.