Image Courtesy of the New York City Health Department
I read the report on initial results of New York City's calorie-labeling laws in Monday's New York Times with more puzzlement than dismay. Why was the sample size (1156 people) so small? Why was the most recent data a year and a half old, just weeks after the city's calorie-labeling rules began? Why did the Times reporter go to one McDonald's in a poor neighborhood to do man-in-the-street interviews that seemed to have very little to relation to the study she was reporting on?
I read the study, whose lead author is Brian Elbel, of NYU, and talked to Cathy Nonas, director of nutrition programs for the health department (as did the Times reporter) and to other public-health advocates including our own Marion Nestle, who posted on this--and my own spouse, the Massachusetts commissioner of health and who passed the second statewide calorie-labeling law, after California. I'm hardly impartial!
But I did notice a number of limitations of the study aside from the ones that struck me when reading the initial story, many of which the authors themselves pointed out. And I got a better sense of the bigger picture of the real intention behind the regs, as public-health lingo calls regulations, and the effect they're already having--the picture and the importance that bloggers, the media, and the food industry have ignored as they've dug into the conclusions with a gotcha glee as if they hadn't had a meal of any number of calories in weeks.
Getting individuals to recalculate calories at the cash register was never the main point of the rules, and isn't now, when similar rules might be written into health reform. Public health is about protecting the whole public.
Data takes a long time to analyze, but this study is really preliminary--the reason, of course, it's gotten so much attention. The New York calorie-labeling rules began on March 31 of last year, with a grace period until July 19, when violations with penalties--fines--would be issued. Many McDonald's, Burger Kings, and Wendy's didn't actually start posting calories on menu boards until July 18. Even then, placement and font size were not what the city required; by the end of the year the menu boards looked much different and were more prominent than they were in July.
The before portion of the study was July 8, and the after portion was about a month later--just three weeks after the chains targeted (McDonald's, Burger King, Wendy's, and KFC) starting posting calories. The sample size was small, 1156 people, and deliberately chosen from poor areas where obesity and diabetes are particularly severe--a logical choice, but also areas where people deliberately search for the most value for their money, meaning the most calories per dollar.
Here's the discouraging part, the point everybody picked up on:
About half of the NYC respondents in our postlabeling sample reported noticing calorie information, and only a quarter of these reported that the information influenced their food choices. Even those who indicated that the calorie information influenced their food choices did not actually purchase fewer calories according to our data collection. We note again that our study sample consisted primarily of racial and ethnic minorities residing in relatively low-income areas; other groups may respond differently to labeling.
The authors note that other groups might respond to labeling differently, but don't point out that half of the people in their survey noticing the information translates to millions of people--and that effect just a few weeks after the information was posted. They admitted that had they conducted the study later, the impact on behavior might have been greater and the results different, and that the smaller typeface and placement of the labels might have had a greater impact after the city brought the restaurants into compliance months later. They pointed out that after the study was done the city did begin an educational campaign on subways and in buses telling people that they should eat about 2,000 calories a day; that could have changed later behavior, too.
But getting individuals to recalculate calories at the cash register was never the main point of the rules, and isn't now, when similar rules might be made national and written into health reform--the main reason the Times article got such traction. Yes, it's extremely difficult to get people to change their eating habits--the first thing the authors pointed out in their conclusion, the first thing anyone on any side of the debate starts out with.
Public health is about protecting the whole public, not any subset, even if underserved and strongly affected subsets are of course its frequent focus. It's about making society safer and healthier. That's where it rubs plenty of people (like my libertarian colleague Megan) the wrong way. The nanny state is the cuddlier term for the fascist state, and activist health commissioners like Thomas Frieden, now the head of the CDC, and his successor, Thomas Farley, are pet targets of people who use the word "activist" as a smear.
New York City was ridiculed when it banned trans fats, as I pointed out in a piece asking what the fate of the doughnut would be after the ban. (It survived quite nicely--and, as calorie-labeling has made painfully clear, doughnuts frequently have many many fewer calories than healthful-seeming muffins, especially in the colossally caloric pastry cases at Starbucks). But, as Frieden, then the New York City health commissioner, pointed out when I talked to him about the ban, the real impact was on McDonalds and the other chains (yes, Dunkin Donuts) that, once they went to the expense of complying with New York's rules, would likely change production for the whole country or much of it.
Calorie labeling has already had remarkable impact on the foods that fast-food companies make and serve. Yuppie avatar Starbucks immediately changed its default milk from whole to 2 percent, so it wouldn't have to admit that a Frappuccino could amount to practically as many calories as you should eat in a whole day; it recently removed high-fructose corn syrup from its baked goods, though unfortunately didn't make them lower-calorie--that's said to be in the works--or better-tasting, which I hope is in the works too.
And the big players, the ones health departments hope will change, are in fact changing. Just this week, Nonas told me--the day after the Times story came out--Burger King began a new ad campaign telling how customers could eat a full meal for 650 calories or less. McDonalds took .7 ounces and 70 calories out of its standard portion of french fries. Dunkin Donuts introduced an egg-white breakfast. KFC put grilled skinless chicken on its menu--not something anyone expected to see at KFC.
"We still feel it's a restaurant's responsibility to make affordable healthy choices available to the public," Nonas told me, but added that calorie posting is "one important piece but not the whole piece." She mentioned new education programs the city is running and new ways to get fresh produce into poor neighborhoods and into schools--the current focus of every health and school official you talk to, and of our own Josh Viertel and Helene York.
Nonas and colleagues are now analyzing their own study. It has ten times the number of participants, is drawn from more neighborhoods than the NYU study, and was conducted over six weeks--like the NYU study, shortly after the regulations were made enforceable. She said she had no idea what the results would show, and emphasized the difficult of picking out and cleaning the data.
They might be disappointing. It's entirely possible that the New York and other follow-up studies will show, like all studies of all diets, that people say one thing and do another and have little idea of the number of calories in what they eat--a problem dietitians have too, Nonas told me with a rueful chuckle, meaning herself. The data might show that after labeling, few people actually order less calories when they order food.
Does that mean calorie-labeling should be scrubbed? Nope. Is the fact that it's really, really hard to stop smoking reason to take pressure off cigarette manufacturers or relax anti-smoking laws? Of course not. Even if a bit better than a quarter of fast-food restaurantgoers notice and are influenced by calorie labeling--a percentage that seems to be emerging from initial and post-regulation studies--that will be a large part of the US population. If fast-food producers are pressured into lowering calories, however modestly, across the board or in significant areas, the whole public will be better off. And you might get a doughnut instead of a muffin out of it!
As book after article after book points out, food producers don't reduce calories, sugar, or fat unless they have to. Witness the end run Coke is trying to make in advance of tighter labeling laws on soda, exactly like the one KFC and other fast-food companies tried to make with menu-board labeling: listing calories per portion, rather than the fact that a typical large bottle of Coke has 800 calories, and a 12-piece bucket of fried chicken 3,090--both of them listed as multi-serving, both of them frequent single servings over the course of an evening or even a long ride home.
The study itself had the last word:
At the same time, our study does not necessarily imply that labeling is an ineffective policy. On the contrary, we found that some subset of consumers used the information to eat more healthfully. Calorie labeling could result in changes that do not rely primarily on alterations in consumers' food choices. Menu labeling regulations may encourage chain restaurants to offer more nutritious or otherwise improved menu offerings, which could be profoundly influential. [italics mine] Public health experts have shown that creating "default" incentives to improve well-being is essential to improving public health. By indirectly influencing restaurants to offer more lower-calorie items, menu labeling regulations could help encourage such default options for consumers.
Those changes don't always work, the authors say. Most changes don't always work. Some do, somewhat. Some do a good deal of good. Calorie labeling is one of them.