Fast Food and Chain Restaurant Nutrition Labeling

Multnomah County Health Department



Fast Food and Chain Restaurant Nutrition Labeling
Policy Initiative



Prepared by:
The Chronic Disease Prevention Program
07.15.2008

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A HEALTHY ACTIVE MULTNOMAH COUNTY

In Multnomah County, as throughout the nation, obesity rates have reached troubling
proportions. Nearly two-thirds of adults in Multnomah County are overweight or obese
and at increased risk for a variety of chronic health conditions, including type 2 diabetes,
hypertension, heart disease, stroke, arthritis, fatty liver disease, gall bladder disease, sleep
apnea, and some forms of cancer. Nearly one in four teenagers is overweight or at risk of
becoming overweight, and children who are obese have a much greater likelihood of
being obese as adults. The social effects, such as stigmatization and discrimination, can
also be damaging, and children who are obese are more likely to suffer from low self-
esteem and depression. In 2001, the “Surgeon General’s Call to Action to Prevent and
Decrease Overweight and Obesity” estimated that obesity’s total costs to the nation were
$117 billion annually, with $61 billion in direct health care costs and $56 billion in
indirect costs1.

This disturbing trend does not have to continue. The Chronic Disease Prevention
Program is building a comprehensive strategy for obesity prevention by drawing from the
Healthy Active Oregon Statewide Physical Activity and Nutrition Plan. Based on the
work of dozens of local and state-wide organizations and institutions committed to
community health, the Statewide Plan is a roadmap for creating environments and
policies that support daily physical activity and access to healthy foods for all Multnomah
County residents, with the ultimate goal of reducing chronic diseases.

As the Institute for Medicine recognizes, “it is unreasonable to expect people will change
their behavior easily when so many forces in the social, cultural, and physical
environment conspire against such change”.2 A critical feature of the Statewide Plan is
the recognition that the environment has an enormous impact on the choices individuals
make about food and physical activity. The Plan acknowledges that fighting obesity and
chronic diseases requires a comprehensive approach addressing not only individual and
individual behaviors but also the environments and settings where children and adults
spend a significant part of their days, such as in schools, at worksites, in the home, in
health care systems, in outdoor built environments, and in a variety of community
settings. The Health Department is implementing a broad range of interventions operating
across multiple settings and levels to reduce barriers to healthy eating and physical
activity, such as:
• Convening community coalitions to promote healthy active living
• Supporting healthy eating and physical activity policies in schools
• Providing nutrition education and health screenings in county health centers
• Coordinating worksite wellness activities.

While there is no ‘silver bullet’ that will immediately solve the obesity crisis, Multnomah
County has many tools it can employ to inform and influence community-wide change.
From modeling healthy worksite practices to adopting nutrition policies that have
widespread impact across the county, Multnomah County can take the lead in creating the
community conditions that make it easier for its residents to engage in physical activity
and healthy eating in their daily lives and live in communities that support those choices.

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SUMMARY

One of the strategies included in the Healthy Active Oregon Statewide Physical Activity
and Nutrition Plan is expanding and promoting options for healthy foods, beverages, and
meals through nutrition labeling by restaurants (community objective III, strategy n).
Nutrition labeling in restaurants is being considered and adopted in several jurisdictions
across the country to help create the community conditions that make it easier for
residents to make healthy choices about what they eat. Fast food and chain restaurant
nutrition labeling policies have been adopted in New York City, San Francisco, and King
County, Washington.

The Health Department’s Chronic Disease Prevention Program undertook an analysis of
restaurant nutrition labeling to understand the potential health benefits and assess the
feasibility of implementation of such a policy in Multnomah County. This process
included: 1) a review of the research and policies being considered or adopted in other
communities, 2) gathering of input from local stakeholders, 3) an analysis of key
concerns and issues, and 4) development of a policy recommendation and
implementation proposal. Emerging themes from this analysis include:

• Taking action on the basis of best available data: While nutrition labeling is not
the solution to the obesity epidemic, there is sufficient evidence that nutrition labeling
at fast food and chain restaurants is an emerging practice to lessen the burden of
chronic diseases.

• Issue of right to know and transparency: Nutrition labeling at restaurants supports
consumers’ ability to make informed choices aligned with their personal preferences
about the products that they purchase and eat. Many community stakeholders who
support nutrition labeling do so for the reason of ‘right to know’.

• Recognition that voluntary efforts have not worked: Efforts to encourage
voluntary nutrition labeling have not created a level playing field among restaurants.
Typically, the information is not readily available at the point of purchase when the
information is most likely to influence decisions about what to purchase and eat.

• Broad support: Polling data demonstrates public support for fast food and chain
restaurant nutrition labeling. The majority of stakeholders who participated in the
Health Department’s community engagement processes agree that 1) there is an
obesity epidemic in the United States, 2) the restaurant industry, particularly fast food
and chain restaurants, have a role to play in addressing this public health issue, and
there is value to posting nutrition information at point of purchase.

• Positive benefit to cost ratio: There are identifiable implementation costs, and the
potential long-term benefits outweigh these. Multnomah County can strategically
focus nutrition labeling requirements to segments of the food service industry that
have sufficient financial resources to cover the costs of nutrition labeling.

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BACKGROUND

Nutrition labeling of pre-packaged food already exists and has been defined by the
federal Nutrition Labeling and Education Act. This Act requires mandatory labeling of all
packaged goods sold in the USA and intended for purchase by consumers, with some
limited exemptions.

Findings from the FDA’s Food Label and Nutrition Tracking System found that about
half of adult consumers report that that the nutrition labels caused them to change their
food purchasing habits, and more than half report using nutrition labels to decide between
similar foods3. Further, people who read nutrition labels are more likely to have a diet
lower in fat and cholesterol, and higher in vitamin C4. Some research has demonstrated
that labeling can help to reduce certain risk factors for disease including lower intakes of
total fat, saturated fat, and cholesterol5. Labels have been helped consumers to know
what they are choosing is safe to eat, such as assisting people with food allergies or
patients with high cholesterol who look for saturated fat and cholesterol on labels6.

The concept of fast food and chain restaurant nutrition labeling extends nutrition labeling
beyond packaged food to the restaurant environment with the intent of providing the
dining-out public with nutrition information as another factor in addition to price to
consider when deciding what to order.

Trends in Eating Out

Dining Out More: National trends show that Americans are dining out more. In 1970,
Americans spent just 26% of their food dollars on restaurant meals and other foods
prepared outside their homes. By 2003, Americans were spending almost half (46%) of
their food dollars on away-from-home foods and consuming a third of their daily calories
while eating out7.

Increasing Portion Sizes: Portion sizes have grown over time. It is not uncommon for a
single restaurant meal to provide half a day’s calories or a whole day’s recommended
calories. Restaurant foods are often served in large portions well beyond the
recommended standards of the Food and Drug Administration (FDA), and priced in a
way that makes larger serving sizes more appealing8. For example, a Double Gulp from
7-Eleven contains six servings, meaning it provides six times as many calories as would a
standard serving size of soft drink.

Increased Calorie Intake: Several studies have found a positive association between
eating out and higher calorie intake and higher body weights, and increased calorie intake
is a critical factor in rising obesity rates9. Children eat almost twice as many calories
when they at a restaurant compared to at home.10 Studies suggest that foods consumed
away from home are more calorie-dense and nutritionally poorer compared with foods
prepared at home. Foods that people eat from restaurants and other food service
establishments are generally higher in nutrients for which over-consumption is a problem

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(like fat and saturated fat) and lower in nutrients that people need to eat more of (like
calcium and fiber) as compared to home prepared food11.

Lack of Readily-Available, Easy to Understand Nutrition Information While Eating Out

Current nutrition labeling law exempts much of the food-away-from-home sector from
mandatory labeling regulations unless a nutrient content or health claim is made for a
menu item, such as "low-fat" or "low-carb"12.

Voluntary Labeling: Some chain restaurants voluntarily provide nutrition information;
however, the information is typically not presented in ways that immediately influence
consumers’ decisions about what to eat. Information is presented in multiple formats and
tends to be listed on a website, tray liners, or on food wrappers that customers see after
they make a purchase.

Estimating Caloric Content: Without readily available nutrition information, it is
difficult for consumers to compare food options and estimate the calorie and fat content
of food served in restaurants. A study conducted in 2006 found that nine out of ten
consumers underestimate the calories content of less healthy items by more than 600
calories, and when consumers have calorie information, they select high calorie items less
often13. In addition, a study conducted by the Center for Science in the Public Interest and
New York University found that even well-trained nutrition professionals could not
accurately estimate the calorie content of typical restaurant meals, consistently
underestimating the calories in restaurant foods and meals by large amounts14.

Benefits of Nutrition Labeling in Restaurants

Research findings about consumer use and understanding of nutrition labels are
promising. In 2005, a Public Health Nutrition journal article summarized the findings of
a systematic review of world-wide published and unpublished research into consumer
understanding and use of nutrition labeling15. The authors analyzed 103 papers to
determine the extent to which consumers understand and use nutrition labeling when
making point-of-purchase decisions on food selection and to identify methods by which
nutrition labeling could be improved. The review concluded that there is sufficient
evidence to suggest that improvements in nutrition labeling could make an important
contribution towards making the existing point of purchase environment more conducive
to the selection of healthy choices.

Informed Consumer Choices: Nutrition labeling in restaurants would allow consumers to
exercise personal responsibility and make informed choices about what they choose to
eat. People need nutrition information to manage their weight and reduce the risk of or
manage heart disease, diabetes, or high blood pressure.

Product Reformulation: A key benefit of mandatory nutrition labeling on packaged
foods has been the reformulation of existing products and the introduction of new
nutritionally improved products.16 For example, the labeling of trans fat on packaged

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food led many companies to reformulate their products to remove trans fat. Nutrition
labeling in restaurants may spur similar nutritional improvements in restaurant foods.


Health Impact Assessment of Nutrition Labeling in Restaurants

In May 2008, the Los Angeles County Department of Public Health completed a health
impact assessment in an effort to quantify the potential health impact of nutrition labeling
in restaurants17. The assessment focused on the model of nutrition labeling proposed in
California’s Senate Bill in 2007 and in the current Senate Bill (2008). Both bills require
that restaurant chains with 15 or more outlets across the state post calorie and other
nutrition information next to each item on the menu. The 2007 bill was approved by the
state legislature but vetoed by the Governor, and the 2008 bill is currently under
consideration by the legislature.

This health impact assessment used data on population weight gain from the California
Department of Education Physical Fitness Testing Program and the Los Angeles County
Health Survey to quantify the obesity epidemic in Los Angeles County. Using published
and unpublished sources, the researchers examined data to estimate the number of meals
served annually at large chain restaurants in the county, the percentage of restaurant
patrons that would order reduced calorie meals as a result of menu labeling, and the
amount of calorie reductions that would result from patron response to calorie postings.
Multiple scenarios of restaurant patron response to calorie postings were examined to
estimate a plausible range of impacts of nutrition labeling in restaurants on the obesity
epidemic.

The findings of the health impact assessment are striking: Using conservative
assumptions that calorie postings would result in 10% of large chain restaurant patrons
ordering reduced calorie meals, with an average reduction of 100 calories per meal, and
no compensatory increase in other food consumption, menu labeling would avert 38.9%
of the 6.75 million pound average annual weight gain among the county population aged
5 years and older. Further, substantially larger impacts would be realized if higher
percentages of restaurant patrons ordered reduced calorie meals or average per meal
calorie reductions increased.

The findings of this health impact assessment suggest that mandated nutrition labeling at
fast food and other large chain restaurants could have a “sizable salutary impact on the
obesity epidemic, even with only modest changes in consumer behavior”18.

Public Support

A survey by the National Restaurant Association found that 72 percent of adults say they
are trying to eat healthier now that they did two years ago19. Six national representative
consumer polls found that between 61% and 87% of Americans support requiring
restaurants to list nutrition information20. Poll after poll by nutrition advocacy groups and
by food service industry has resulted in similar findings.

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Question
Poll
% Support /
Agree
National Polls


Fast food and other chain restaurants
Caravan Opinion
78
should list nutritional information, such
Research Corp., 2008.
as calories, fat, sugar, or salt content on
menus and menu boards.
Question
Poll
% Support /
Agree
Restaurants should make nutrition
ARAMARK Corp.,
83
information available for all menu items.
2005.
Menu boards should list nutrition
Technomic Inc., 2007.
74
information for all items served.
Restaurants should be required to provide Global Strategy Group,
67
nutrition information, including calories,
2003.
on menus.
Statewide Polls


Support requiring fast food and chain
End Hunger
82
restaurants to display calorie content on
Connecticut, 2007.
menus or menu boards.
Support requiring fast food and chain
California Center for
84
restaurants to post nutrition information
Public Health
on their menus.
Advocacy, 2007.
Support a policy requiring fast food
Northwest Health
69
and chain restaurants to post the
Foundation, Oregon,
number of calories of food items on
2008.
their menu boards.
* poll references provided in end notes21

In addition to public support, key public health agencies recommend nutrition labeling in
fast food and chain restaurants as an emerging strategy to promote public health. The
Food and Drug Administration’s Obesity Working Group concluded that “point-of-
purchase nutritional information could have a positive impact on healthier eating and
potentially reduce the risk factors that cause obesity." The American Heart Association,
the American Diabetes Association, the American Academy of Pediatrics, the American
Public Health Association, and the American Medical Association endorse nutrition
labeling in restaurants as a strategy to address the increasing burden of chronic disease.

Actions Taken in Local Jurisdictions

Fast food and chain restaurant nutrition labeling policies have been adopted by the
City/County of San Francisco, New York City, and King County in the state of
Washington and are being considered in over twenty jurisdictions across the country.
Policy makers and public health advocates in these communities anticipate that the

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labeling will have a positive public health impact through two mechanisms, enabling
consumers to make informed choices and creating an impetus for the reformulation of
current menus and the introduction of healthier offerings.

While there are slight variations in the policies adopted in these communities, there are
key similarities:

1. All apply only to large chains with the financial resources to easily implement menu
labeling
2. All require the listing of calories.
3. All enable consumers to access nutrition information at point of purchase.

Communities who are considering fast food and chain restaurant menu labeling are
drawing from the model policy developed by the Center for Science in the Public
Interest. The following table provides a comparison of the model policy with the policies
adopted in New York City, San Francisco, and King County.

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Fast Food & Chain Restaurant Nutrition Labeling Policy Comparisons

New York City, NY
San Francisco, CA
King County, WA
CSPI Model Policy
Information Required
Calories
- Calories on menu boards
- Calories on menu boards or
Calories
on Menu Board
- Protein, fiber, calories, total fat,
other easily readable sign
Other information by request

saturated fat, trans fat,
adjacent to menu board and
cholesterol, sodium and
visible from line prior to
carbohydrates on readily visible
ordering
posters
- Saturated fat, sodium and

carbohydrates via menus,
pamphlets, posters or other
means at point of ordering

Information Required
Calories
Calories
Calories
Calories
on Printed Menu
Grams of Saturated Fat
Grams of Saturated Fat
Grams of Saturated Fat
Grams of Carbohydrates
Grams of Carbohydrates
Grams of Trans Fat
Milligrams of Sodium
Milligrams of Sodium
Grams of Carbohydrates
- On menu or other approved
Milligrams of Sodium
method including menu insert,
menu appendix, supplemental
menu, or electronic kiosk at each
table
Information Required
Calories
Calories
Nutrition labeling is not required
Calories
on Food Tags
on food tags

Definition of
15 or more locations nationwide
20 or more locations
15 or more locations nationwide
10 or more locations nationwide
Chain
within CA
and $1million in annual sales for

the entire chain
Prominence
- listed clearly and
- on printed menus, next to or
- on printed menus, next to each
- same size as price

conspicuously, adjacent or in
beneath each menu item using a
standard menu item and easily
close proximity such as to be
size and typeface that is clear
readable in a typeface similar to
clearly associated with the menu
and conspicuous
other information about each
item, using a font and format
- on menu boards and food tags,
standard menu item, no less than
that is at least as prominent, in
the font/format must be at least
9pt font
size and appearance, as that used
as prominent as that used to post
- on menu boards, must be easily

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to post either the name or price
name and/or price of the item
readable and in a typeface
of the menu item

similar to other information on
the menu board about the item
Enforcement
Fine enforced by Health Dept.
Fine enforced by the Department
Enforced by the Department of

restaurant inspectors
of Public Health; imposes a $350
Public Health
annual fee for implementation
Exemptions
Items on menu less than 30 days
- Items on menu less than 30
- Items on menu less than 90
- Items on menu less than 60

days
days
days
- Grocery stores
- Grocery/Convenience stores

- Foods in salad bars, buffet
lines, cafeterias, or other self-
serve arrangements
- Food served by weight or
custom ordered quantity
Covers Alcohol
Yes
No
Yes
Yes

Effective Date
Currently in effect
- July 22, 2008 for menus, food
December 31, 2008


tags, posters
June 6, 2008 fines in effect
- September 20, 2008 for menu
boards

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