Nutritional Content on Fast Food Restaurant Menu’s and the ACA By Kirstie Linza

Affordable Care Act What is it? Law; signed on March 23, 2010 Patient Protection and Affordable Care Act Comprehensive health reform What is the focus of the law? Expanding health insurance coverage (for individuals and small businesses) Control health care costs Improve health care delivery system

Nutritional Aspects: Section 4205 Require chain restaurants and food sold from vending machines to disclose the nutritional content of each item. FDA Objective: “Implement Section 4205 of the Patient Protection and Affordable Care Act – Nutrition Labeling of standard menu items for chain restaurants, similar retail food establishments and vending machines. Providing understandable and accurate food labeling will aid consumers in selecting more healthful diets.”

Requirements The number of calories in each standard menu item on a menu or menu board (the calorie disclosure must be “clearly associated with” and “adjacent to” the name of the standard menu item). A statement on the menu or menu board that puts the calorie information in the context of a recommended total daily caloric intake. Additional nutrition information for standard menu items in written form (“written nutrition information”), which must be made available to consumers upon request. A “prominent, clear, and conspicuous” statement on the menu or menu board regarding the availability of the written nutrition information. The number of calories (per item or per serving) adjacent to self- service food and food on display. These foods include food sold at salad bars, buffet lines, cafeteria lines or similar self-service facilities and self-service beverages and food on display that is visible to consumers.

Milestone Description Milestone DateMilestone Status Milestone Completion Date 1. Publish proposed rule 3/23/2011Completed4/6/ Review all comments on proposed rule 9/30/2011Completed7/31/ Prepare summary of comments 12/2/2011Completed8/19/ Prepare final rule 3/30/2012Delayed 5. Publish final rule 6/30/2012Delayed

Initial opinions or thoughts? Importance of this law?

Child and adolescent fast- food choice and the influence of calorie labeling: a natural experiment By B. Elbel, J Gyamfi, and R. Kersh

Objective To examine children and adolescent food choices at fast food restaurants and the influence of calorie labels in low-income communities in New York City and Newark, New Jersey.

Methods Restaurant Sample: McDonald’s, Burger King, Wendy’s, and KFC Aligned neighborhoods in NYC and NJ, lower income areas Data Collection: 2 week period before implementation, same time period after Tuesday, Wednesday, Thursday Lunch and dinner Collected receipts

Surveys Age, sex, race Dine in or take out Did they notice any calorie information? If so, did the calorie information influence their food choice? Adolescents: With their parents? Who decides what they eat at home? Do their parents influence their food choices? What is most important to them when purchasing fast food? Estimate the total amount of calories consumed in the food and drink they just purchased.

Sample Results 427 children and adolescents (78 excluded) 76% was from NYC 47% male 54% adolescents years old 66% Black 24% Latino 11% mixed race or White 69% with parent/caregiver - 31% alone

Results General Averaged 645 calories 72% = taste was most important factor in choosing food 57% = ease mattered the most in other set of factors Underestimating calories: 63% before labeling 59% after labeling Nutritional Labeling No caloric differences were observed before or after labeling. 57% noticed calorie information after labeling in NYC (only 18% in NJ) 9% were influenced in their meal choice 9% purchased fewer calories

Strengths and Limitations Strengths Consistent methodology Implemented in the “real world” Collection of food receipts Studied potentially low income population and a diverse and minority populations Limitations Short study period Studying food behavior changes = extremely difficult to change

Conclusion A little over half of the people noticed the calorie information… But there was no significant effect on purchasing behavior… What do you think about the outcome of this study?

Evaluating the Impact of Menu Labeling on food Choices and Intake By C. Roberto, P. Larson, H. Agnew, J. Baik, and K. Brownell

Objective Menu labeling influences total calories orders and consumed during dinner, as well as food consumed after dinner. Effect of providing information about recommended daily caloric requirements.

Sample 303 people from New Haven, Connecticut 18 years and older 49% male 56% = White 20% = African American 15% = Asian 3% = Hispanic Remaining 6% = biracial, Pacific Islander, American Indian Education: 22% graduate degree, 30% BA, 32% completed some college, 11% completed high school

Method Participants were given 1 of 3 different menus: No calorie label, with calorie label, and with calorie label and provided recommended daily caloric intake. 2 area restaurants used Order their meal by circling what they wanted Dietary recall the next day

Results Participants ordered more calories when using a menu with no calorie information. Participants ate less calories during dinner than they chose. 59% underestimated and 41% overestimated calories Total consumption for dinner and evening was almost equal for the no calorie menu and the only calorie information menu.

Conclusion Strengths Randomization within the study Menu options were contained both high and low calorie items Capture how food labels affect food consumption at a later time Limitations Calorie values were estimated through dietary recalls No price information on menu Participants were not followed over time Convenience sample (highly educated)

Reflection and Discussion Has your original opinion changed about this topic or this part of the law? Do you think this law will make a difference or influence the choices of the general public? Is it the restaurants responsibility to ensure proper nutrition, or should that be left up to the individual?

References 1. Focus on Health Reform: summary of the Affordable Care Act. 2013; Accessed October 09, 2013, U.S. Food and Drug Administration. Guidance for Industry: Questions and Answers Regarding the Effect of Section 4205 of the Patient Protection and Affordable Care Act of 2010 on State and Local Menu and Vending Machine Labeling Laws 2013; on/LabelingNutrition/ucm htm. Accessed October 09, 2013, Group BEaHR. All Fast Food Places: Elbel B, Gyamfi J, Kersh R. Child and adolescent fast-food choice and the influence of calorie labeling: a natural experiment. International Journal of Obesity. 2011;35(4): Roberto C, Larsen P, Agnew H, Baik J, Brownell K. Evaluating Impact of Menu Labeling on Food Choices and Intake. American Journal of Public Health. 2010;100(2): Obesity YRCfFPa. Fast Food F.A.C.T.S. 2013; Accessed October 09, 2013, 2013.