The publics' understanding of daily caloric recommendations and their perceptions of calorie posting in chain restaurants

As experts increasingly point to the environment as the primarily driver of obesity [1‐3], calorie posting on menus or menu boards at restaurants (hereafter referred to as "calorie posting"), alongside price, has received growing attention as a potential policy lever to reduce energy intake and promote energy balance (equilibrium between energy intake and energy expenditure). To date, calorie posting legislation has passed in two cities (New York City, Seattle) and one state (California) and is currently under consideration in more than 20 states, cities and counties in the United States [4]. In the United Kingdom, the Food Standards Agency has asked fast food restaurants to voluntarily post calories on menus [5]. Theoretically, calorie posting should have a larger impact on individuals with greater caloric literacy (defined as an understanding of federal energy intake guidelines) given that perceived risk is a critical precursor to behavior change [6].

Shifts in consumption patterns and poor nutritional literacy give strong justification for calorie posting, particularly in chain restaurants which account for approximately half of all restaurant visits [7]. Over the past three decades, Americans have greatly increased the percent of their food dollars spent on food away from home; from roughly a third in 1970 to a half in 2001 [8]. Foods eaten away from home, especially fast food, are more energy dense and have a higher percentage of fat and sugar [9]. In addition, foods with a higher energy density are associated with excess energy consumption [10].

A key challenge to limiting energy intake is the publics' significant underestimation of the amount of calories in the foods they consume [11, 12]. A recent study that asked participants to estimate the caloric content of nine restaurant entrées found that 90% underestimated the calorie content of less-healthy items by an average of more than 600 kcal [12]. In the same study, when calorie information was provided on food items, consumers chose high calorie items roughly a third less often. Since most surveys evaluating nutrition literacy primarily focus on nutrient composition (e.g., percent fat, percent fiber) rather than overall energy needs (e.g., "caloric count"), they are of limited usefulness for informing current efforts around calorie posting.

To our knowledge, little research has assessed consumer understanding of overall daily energy requirements or perceived effectiveness of calorie posting [13]. This study - which is the first to use nationally-representative public opinion data to address this research question - will fill this gap in the knowledge base. We hypothesized that the publics' caloric literacy (e.g., understanding of federal daily caloric recommendations) will be poor, and that Americans will strongly support calorie posting initiatives. In addition to looking at overall knowledge patterns and views about calorie posting, we additionally stratified our results by race/ethnicity and gender given the disproportionate impact of obesity on minorities and women [14]. Findings from this study may be useful for policy makers looking to pass calorie posting legislation and for researchers interested in exploring the impact of such initiatives.

The central aims of this study were to assess the public's knowledge of daily energy requirements and their beliefs about the perceived usefulness of caloric information on chain restaurant menu boards - overall and among subgroups at higher obesity risk. This is the first national poll to assess public beliefs about calorie posting initiatives which require some chain restaurants to post caloric information on menus or menu boards alongside price.

Overall, we found that most Americans were knowledgeable about energy requirements for moderately active men and women, but tended to underestimate energy requirements for inactive adults. Only about half of the public perceived themselves as sufficiently knowledgeable to make lower calorie choices in chain restaurants. Americans expressed a positive attitude towards calorie posting in chain restaurants; a majority viewed it as very or somewhat useful, reported being more likely to eat in a chain restaurant with calories posted in the menu and reported being more likely to select a low calorie food where calories were posted. Given that price, convenience and taste [23, 24] are the major motivators for food purchasing decisions, our finding that Americans were evenly divided between purchasing an item based on calories or price is very encouraging for calorie posting initiatives.

Our findings also suggest that calorie posting initiatives may be more salient among certain sociodemographic groups. Blacks, Hispanics and women, who are disproportionately impacted by obesity [14], were more likely than their counterparts to perceive calorie posting as very useful, to report they would eat in a chain restaurant with calorie posting and to report that caloric posting would encourage their selection of a lower calorie food. Therefore, mandatory calorie posting initiatives may be more salient among women and racial/ethnic groups.

These results further suggest that the best mode for communicating caloric information in chain restaurants may not be calorie count (e.g., a hamburger is equal to 300 kcal) - the dominant mode of communicating caloric information in chain restaurants to date. Rather the public is pretty evenly divided between three possible presentation formats: number of calories, physical activity equivalent, or percentage of total daily energy intake. Our finding that most Americans favor a mode of communication other than a calorie count is consistent with prior research suggesting that interpretational aids help consumers with nutritional labels [25]. It also may partially explain mixed findings on the impact of calorie labeling on purchasing behavior in New York City; some studies show an impact [26] whole others show none [27].

This study makes three important contributions to the evidence base. To our knowledge, this is the first study to assess consumer understanding of overall daily energy requirements and perceived effectiveness of calorie posting in a nationally representative study sample. Previous research has focused on sub-populations and small geographic areas [13]. Second, it identifies groups at higher risk for obesity who are most likely to be positively affected by calorie posting initiatives. Third, the results from this study may inform the recent legislative interest in mandating calorie posting in chain restaurants in the United States and other developed countries.

There are limitations to this analysis which deserve discussion. First, this cross sectional analysis only allows us to address associations. Second, we asked our respondents to think abstractly about how they might use caloric labeling at the point of purchase. Given that individuals are inclined to have an optimism bias - tendency to be overly positive about the outcome of their planned actions [28] - our results may be somewhat inflated. Third, that the public appeared to have a good understanding of the recommended federal energy requirements for moderately active adults but did not perceive themselves as sufficiently knowledgeable to make lower calorie choice, may be more related to the plethora of dietary guidelines based on the 2,000 kcal diet and less a reflection of true caloric knowledge. Fourth, because the range of calories in the correct response category for the caloric knowledge question was broad, our finding of relatively high caloric knowledge may be biased upwards. Fifth, given that the correct answer to the caloric literacy questions was the same for all groups (e.g., moderately active men, moderately active women and inactive adults), some respondents may have assumed the answer should change across groups. This would bias our results downwards and may partially explain our finding of low caloric literacy about inactive adults. Sixth, we relied on self-reported height and body weight to calculate body mass index which may lead to an underestimation of the obese population [29]. However, research suggests that the self-reported height and body weight bias do not differ by race/ethnicity[30] Seventh, random digit dialing, which was used to capture the study population, omits individuals who rely sole on cell phones or individuals who cannot afford a land line in their home. Finally, that McDonalds and Subway were provided as examples of chain restaurants in the survey questions may have affected respondent views on calorie posting. The direction of the bias would have depended on their perceptions of those chain restaurants.

Despite these limitations, this study has several strengths. It is consistent with state and local efforts in the United States to mandate calorie posting in chain restaurants as well as with the current federal priorities to reduce the prevalence adult obesity [31‐33]. Second, it is very timely. Given wide-spread recognition among experts that the obesity epidemic is largely driven by environmental changes [1‐3], there is considerable interest in designing effective societal-level interventions which reduce energy. Third, a better understanding of public perceptions about calorie posting may encourage policy makers to adopt this policy tool which is likely low cost, particularly for large food outlets with standard menus. In turn, the likely "calorie shock" about the high number of calories in food options, which has been reported in the mass media, may encourage restaurant chains to highlight lower calorie options and/or introduce healthier options. Some restaurants may also begin voluntarily providing caloric information. For example, YUM! Brands (owners of Pizza Hut and KFC) have announced plans to begin providing caloric information in their 20,000 outlets nationwide by 2011, regardless of legislative requirements.

The results from this study suggest the need for more research in two key areas. First, that a majority of Americans miscalculate the energy requirements of inactive adults (which characterizes most Americans [34]) suggests a poor understanding of energy balance. Second, more research is needed to understand whether the most effective mode for presenting consumers with calorie information and whether it varies by sociodemographic characteristics.

To conclude, mandating calorie posting in chain restaurants may be a useful policy tool for promoting energy balance, particularly among Blacks, Hispanics and women who are at higher risk for obesity [14]. Improved knowledge about how to maximize the effectiveness of calorie posting in chain restaurants may encourage policy makers to adopt this relatively low cost policy tool.

Caloric literacy

1 Less than 1500 calories

2 1500 to less than 3000 calories

3 3000 to less than 4500 calories

4 4500 calories or more

1 Less than 1500 calories

2 1500 to less than 3000 calories

3 3000 to less than 4500 calories

4 4500 calories or more

1 Less than 1500 calories

2 1500 to less than 3000 calories

3 3000 to less than 4500 calories

4 4500 calories or more

Perceptions of caloric labeling in chain restaurants

1 Yes, know enough

2 No, do not know enough

1 Very useful

2 Somewhat useful

3 Not very useful

4 Not at all useful

1 More likely to eat at chain restaurants reporting caloric information alongside price

2 Less likely to eat at chain restaurants reporting caloric information alongside price

3 Not more or less likely to eat at chain restaurants reporting caloric information alongside price

1 Select a higher calorie food

2 Select a lower calorie food, or

3 Would it not influence your food purchase at all?

1 Yes, would feel guilty for picking a higher calorie food

2 No, would not feel guilty for picking a higher calorie food

1 Pay attention to the price

2 Pay attention to the calories

Perceptions of calorie posting legislation

1 Favor

2 Oppose

1 Responsibility of the federal government

2 Responsibility of state and local government