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How state and local governments can address the obesity epidemic

With simple and innovative measures, public agencies at state and local levels can play a significant role in promoting healthier eating habitssteps that could make a difference in curbing the nation's obesity epidemic. One effective option, according to researchers at the Johns Hopkins Bloomberg School of Public Health, is requiring restaurants to include calorie counts on menus, along with the physical activity equivalents required to burn off a meal. The researchers, who examined studies on calorie labeling and regulatory options available to local governments, offer several recommendations to enhance the effectiveness of menu labeling. The suggestions are especially applicable to chain restaurants with fewer than 20 locations, a category that represents more than half of the restaurants in the U.S. These eateries are not subject to the federal Affordable Care Act's menu- labeling provision. It requires chain restaurants with more than 20 locations to provide calorie information on their menus and menu boards, as well as a statement addressing daily recommended caloric intake. The findings are featured in a Perspective in the May 9 issue of the New England Journal of Medicine.

"The current standard is for restaurant menu boards to present information as the absolute number of calories, such as telling customers that a hamburger has 450 calories. If customers do not understand what 450 calories means or how it fits into their overall daily requirements, posting that information on menu boards may not be that useful," said Sara N. Bleich, PhD, lead author of the Perspective and an associate professor with the Bloomberg School's Department of Health Policy and Management. "All of the recent research suggests that if you make calorie information easy for consumers to understand you have a bigger impact on their purchasing behavior. This is particularly true for minority groups at higher risk for obesity since they often have lower than average levels of nutritional literacy."

The authors recommend presenting calorie information to consumers in the form of a physical activity equivalent, e.g., telling consumers the amount of running required to burn off a particular food or beverage. According to the authors, this approach has been shown to reduce calorie consumption and lead to healthier choices. A 2011 study led by Bleich and colleagues examined the impact of calorie information on beverage choices and found that consumers were half as likely to buy a sugary beverage when presented with caloric information in the form of a physical activity equivalent. Another recommendation is that restaurants change their menu default options such as replacing default fries and soda in a kid-friendly meal with apple slices and low fat milk. According to the authors, empirical research has shown that changing the default items by listing healthy choices on the front of a menu is significantly associated with the purchase of lower-calorie sandwiches, whereas simply listing the calories on a menu is not as effective. The authors call for state and local governments to craft innovative menu-labeling regulations that focus on smaller chain restaurants and build on the current scientific data.

"A state or local government could pass a menu-labeling regulation that requires restaurants with fewer than 20 locations to list their lowest calorie food items first to encourage the selection of healthier, lower calorie items," said Lainie Rutkow, JD, PhD, MPH, co-author of the Perspective and an assistant professor with the Bloomberg School's Department of Health Policy and Management. "As the Food and Drug Administration finalizes the federal menu-labeling regulations, which will include specific requirements for how calorie information is presented on menus and menu boards, it's important to consider the opportunities that remain for states and localities. Local governments are well positioned to augment the potential effectiveness of the Affordable Care Act's menu-labeling provisions, in part, because they have already begun engaging in innovative regulatory activity related to obesity prevention."


Contact: Natalie Wood-Wright
Johns Hopkins University Bloomberg School of Public Health

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