Tuesday, January 1, 2013

“Rightsizing” vs. Downsizing: The Impact of the Food Labeling Mandate on Obesity Rates –Amy Glynn

            Obesity continues to be a national epidemic with one-third of children and two-thirds of adults overweight or obese (20).    Obese individuals face many chronic diseases including an increased risk of Type II diabetes, cardiovascular disease, hypertension, obstructive sleep apnea, and may face psychological and economic consequences (11).  Proper nutrition is an important factor in fighting obesity (20).  According to the National Restaurant Association, Americans eat four to five meals commercially prepared each week (14).  With half of Americans dining out in the past year, fast food and chain restaurants have been targeted as a major contributor to the increasing obesity rates (21). 
One strategy to promote healthier eating is to require calorie labeling in chain and fast food restaurants so that consumers can make educated decisions about the food they purchase and consume.  In 2008, New York City became the first U.S. jurisdiction to implement this type of legislation (7).  Although specific regulations vary across the nation, the 2010 Patient Protection and Affordable Care Act requires fast food and chain restaurants with twenty or more locations in each state to visibly post the caloric content of regular menu items (22).  Now more than thirty cities and states in the United States have introduced legislation which mandates food labeling (7).  This policy is designed to provide information in order to help consumers make healthier food choices.  This report analyzes the effectiveness of calorie labeling legislation using relevant theories, critiques the design of the intervention, and then provides an alternative approach to curtailing the obesity epidemic. 

Critique #1: Ignores Theory of Cognitive Dissonance

            The food labeling mandate is based on the assumption that if individuals are given knowledge about the nutritional factors of the food they are about to consume, they will in turn alter their attitudes and perceptions about unhealthy food choices, and change their behaviors to pick more nutritious food choices (8).  This concept of providing knowledge to influence attitudes in order to change behaviors, fails to consider the theory of cognitive dissonance (6,8).  Cognitive dissonance is when people reconcile conflicting beliefs to rationalize their decision (6).  Festinger’s theory of cognitive dissonance explains why humans seek to reach consonance between their expectations and realities (8).  To achieve this agreement, Festinger claims people will decrease the significance of one of the conflicting elements, add factors of consonance, or change the dissonant qualities (8).  Thus, just posting nutritional factors about regular food items may not be enough to influence people’s rationalization for eating unhealthy food items.
Most Americans know that fast food is not a very healthy food option.  Yet, people continue to go to fast food restaurants.  Many consumers who dine-out cite the importance of taste, quality, convenience, and affordability offered at restaurants (9).  The theory of cognitive dissonance provides an understanding of why people, who probably already know fast food is not healthy, continue to purchase these items.  The theory of cognitive dissonance shows that people will reconcile the knowledge that fast food is bad with a rationalization to eat it.  For example, perhaps the person had a bad day so might feel he deserves a Big Mac, or he has been eating healthy all week so this is a little splurge.  Although nutritional education is important, this knowledge has to compete with matters of taste, affordability, convenience, and other unrelated health factors.  Unfortunately fast food companies take advantage of these other desires by heavily advertising and promoting these core values (9).  People value their bad food choices, and will continue to reconcile the health consequences associated with eating fast food and the desire to indulge in it.
Although the food labeling mandate may provide new information to the customers, it does not necessarily result in a change in behavior.  In order to be effective, behavior change must come first, then attitude transformation and knowledge follows (8).  This concept is supported by the fact that although consumers were more aware of health content post-food labeling, studies on current food labeling mandates have not found any significant impact on calorie consumption (15).  Regardless of whether detailed nutritional facts are provided or not, people continue to rationalize why eating a milkshake and fries is a justifiable health decision.

Critique #2: Fails to Convince Consumers of Harm, Focus on Individual Behavior

            The food label mandate utilizes the health belief model (HBM) in order to change people’s behavior to buy healthier food items.  The HBM is based on the assumption that decisions about one’s health is like a cost-benefit analysis (3).  Consumers must feel personally susceptible to the health problem, feel the problem can cause severe harm, know appropriate actions to avoid harm, and believe the costs will outweigh the benefits (or vice versa) (13).  This model oversimplifies the decision-making process by assuming behaviors are reasoned (but as discussed before, people do not make rational decisions). 
The menu label policy assumes that when consumers see nutritional facts, they in turn will weigh the risks with the benefits, thereby changing their purchasing behavior.  However, a study of the New York City food labeling menu policy found that although calorie information on menus increased consumers’ awareness of nutritional content, there was not a significant change in calories purchased after the calorie labeling was put into place (7).  This fact emphasizes the flaw in the HBM which assumes there is a straight line from intent (see how unhealthy a food item is so intend to not buy it ) to behavior change (buy the unhealthy product regardless of nutritional content). 
Providing nutritional information alone does not necessarily convince consumers that they are susceptible to the harmful effects junk food may have on them.  Obese adults have a higher chance of developing diabetes, cardiovascular disease, and have higher rates of mortality from these chronic diseases (3).  However, these long-term potential threats are usually overcome by the temptation of fast foods and immediate pleasure it gives individuals. Similar to the addictive process found in substance abusers, studies have found links between high-sugar diets and addiction (3).  This food “high” interferes with an individual’s ability to make a rationale decision.  The HBM ignores these environmental and biological factors that hinder individual food-making decisions (16).  The food labeling policy places the responsibility to choose healthy foods at the individual level.  However, research has shown that environmental conditions can easily override the physical and psychological systems in an individual, thus hindering a person’s capability to make reasoned decisions (4). 
In addition, this intervention assumes that everyone will be able to read and understand the food labeling menu at the same level, in order to take actions to select healthier decisions.  This model does not take into account the uneven levels of understanding appropriate caloric intake information since no educational component is incorporated alongside food labeling.  In fact, most consumers can not clearly distinguish between nutrient content and health claims (23).  Thus, providing detailed nutritional information may just confuse consumers or complicate their food choice decisions.  Most restaurants already have a green check mark next to healthier items or specify low fat/low sodium items.  This simple check mark provides a more clear and consistent message that is easier for consumers to process (15).  Furthermore, studies have shown that consumers assume food claims have already been approved and regulated by governmental authorities even if this is not valid (23).  Thus, it is imperative that nutritional information about food items is presented in an easily understandable, clear, and consistent manner.
According to Cialdini’s The Psychology of Persuasion, both humans and animals have an automatic response built into their system called “fixed-action patterns” (5).  This automatic response is stimulated by the “trigger feature.”  For example, by walking into a Panera Bread cafe, the smell of bread can trigger people’s response to consume carb-heavy items.  The idea of an automatic response explains the concept of mindless eating: it is an automatic behavior triggered by food placed in front of someone (15).  Although the nutritional factors in fast food restaurants are meant as a visual cue to prevent this automatic response of mindlessly eating to occur, it is not a persuasive enough cue to effectively alter behavior (18).  In fact, one study found that “most consumers only read labels when they are contemplating buying a new product for the first time or when an alternative brand is on special” (23).  This suggests that just having the information available to consumers may not even be enough for people to notice and become more knowledgeable about what they are purchasing. 

Critique #3: Americans have Little Self-Control, Especially during Hot State
The food labeling mandate also assumes that people have the self-control to decline junk food temptations if they know the nutritional information.  This assumes that people are rational beings, and can control their desire for junk food with information.  However, most people know when they walk into a Pizza Hut they are not making the healthiest dinner choice, yet people continue to go there.  Providing nutritional information about the greasy pizza sold at Pizza Hut may give consumers more detailed nutritional facts on their food choice, and just reinforces what most already know: greasy pizza is not that healthy.  So why do people continue to go to these unhealthy fast food and restaurants?
According to Ariely’s Predictably Irrational book, people have very little self-control.  In fact, he argues individuals in cool states are able to make more rational, long-term decisions vs. individuals in hot states where immediate gratification is available, which make it difficult for people to stick to their more rational decisions chosen in cool states (1).  A fast food restaurant places people in a hot state where temptation of delicious foods overcomes people’s rational, cool state mindset.  A restaurant with so many immediate gratifications influences people’s decision-making abilities by appealing to their emotion-provoking mindset.  People see and smell the greasy pizza, signals are sent to their brain, and now their logical mindset to make reasoned decisions is overcome by an emotional need for pizza.
Unfortunately, a visible nutrition label does not have much power or influence over this arousal provoking temptation (7, 15).  Studies have shown that when the food labeling mandate was implemented in New York City,  only half of customers even noticed the caloric information, and only a quarter of those that noticed said the information influenced their food choices (7).  However, even the few who did say the calorie labeling influenced their food choices did not actually purchase fewer calories (7).  This public health intervention bases its design on the premise that people can activate their self-control, but when people are in a hot state with lots of temptations, it is not easy to stick to one’s self-control.

Alternative Approach: “Rightsizing” Your Food Options
Dan Airely and Klaus Wertenbroch from MIT conducted a study about how people deal with their self-control problems (2).  For example, why do people on a diet, enter a restaurant saying they will not buy that banana split sundae, yet when the time comes and temptation arises, the dieters purchase the sundae, and then later may feel bad about their food choice decision?  These two researcher examined ways students handle procrastination with paper deadlines.  They found that although students did not request early paper deadlines, they did readily accept the early deadlines when offered (2).  This finding suggests an externally imposed intervention is a means to help deal with issues of self-control and effective decision-making.  This behavioral science approach can be applied to public health as a way to activate self-control and improve people’s food making decisions (15). 
This report’s alternative approach attempts to apply Ariely’s study in a public health context.  People for the most part know that they overeat (12).  Perhaps an imposed restriction on portion size may be a more effective approach than food labeling to reduce calories consumed while still maintaining the value people give to their food choices.  Instead of simply providing information about the food, this report suggests a campaign to “rightsize” food options (15).  This campaign will create a community of people fighting for more food choices by proposing wait staff and cashiers ask customers if they want to “rightsize” their food by reducing it to a smaller size or suggesting sides like fresh fruit and vegetables (instead of fries and a Coke).  This campaign to “rightsize” one’s meal will promote healthier food choices and give people control over their decision-making.
It is important to note that although this report is pointing out the flaws to food labeling interventions and offering an alternative campaign approach, it is not suggesting that providing nutritional information to consumers is detrimental.  Obesity prevention requires a multi-faceted solution to change how much individuals both consume and expend.  Focusing on what individuals consume is just one aspect of the energy balance equation (what people take in and what people burn off). 

Intervention Section 1: Apply Behavior Change First, so Knowledge and Attitude Follow

Policies to eliminate unhealthy behaviors have been aimed at helping individuals manage self-control.  Banning all unhealthy food products would be ideal, but is not a viable option.  Providing information about the food choices is how the food labeling policy attempts to help individuals manage self-control but fails to consider people are not rational decision-makers.  Thus, instead of providing knowledge first to the consumers in order to evoke behavior change, the proposed alternative intervention is to change the environment in which food choices are made.  People will always use cognitive dissonance theory to rationalize their irrational decisions.  Thus, public health advocates should assume people will make irrational choices and focus on environmental change first then knowledge and attitude will follow (19).
To change behavior, the default for people’s food choice environment should be healthy options.  Unfortunately in most cases, people are asked if they want to supersize their value meal as opposed to substitute their milkshake for fruit.  People will continue to go out to eat and buy meals that are not the healthiest.  According to the 2011 Food & Health Survey, taste, price, and where their food comes from continue to be the leading motivators of consumers’ food choices, not nutritional factors (9).  People want tasty, affordable food choices, and this is what companies leverage by advertising the taste and affordability of their products.  Companies utilize pricing strategies to get consumers to buy more such as buy one Big Mac get another one half priced.  These pricing mechanisms, manipulate people’s perception of normal portion sizes (15).  Instead of promising healthy options, which are not high on consumers’ lists of core values, public health officials need to promote an environment where healthy options are the default. 

Intervention Section 2: “Rightsizing” Group Effort Reframes Core Values

In order to implement a healthier environment, a “rightsizing” movement must be instilled.  According to communication theory, in order for a message to be effective the person delivering it must be likeable, familiar, and similar to the people the message is intended to reach (5).  In addition, people are more likely to be persuaded if the message is associated with positive images (5).  Thus, it is important all consumers of various ages, backgrounds, and weights rally to promote the “rightsizing” campaign in order to appeal to a broader audience.  The focus is on “rightsizing” rather than on “downsizing” portion sizes because not only does it evoke a more positive reference, but “rightsizing” also suggests that consumers have been wronged by the food industry thus they are demanding their “rights” back.  This slogan can be used to communicate the mission of the “rightsizing” campaign so consumers have the power over their life.
The theory of persuasion focuses not on changing people’s core values, but reframing it in a way to instill behavior change (5).  Just like in the 84% smoking campaign which created a non-smoker identity, there should be a “rightsizing” identity.  This new identity for people to associate with enables individuals to be part of a “rightsizing” community which advocates for control over their food portions.  The core value of control and freedom resonates very strongly with most Americans, especially compared to the core value of health which the food labeling policy tried to leverage (16).  Reframing healthy food decisions as a means to regain autonomy will reinforce consumers’ own core values but position it in a way that encourages healthy behaviors (16). 

Intervention Section 3: Promote Intervention during Hot State to Regain Control

            So how do we get people to resist the temptation of junk food to start a movement about “rightsizing” food portion sizes?  One way to give Americans some self-control over their food choices is by going beyond just the visual cues of posting nutritional information, but actually having wait staff and cashiers ask customers if they would like to “rightsize” their meal (15).  Instead of the typical questions asked at restaurants like “do you want fries with that” or “would you like to supersize that for an extra fifty cents,” the “rightsizing” campaign can advocate for healthier food prompts. 
In a study done by Schwartz et al., diners at a local Chinese fast-food restaurant perceived their portion sizes as too big but would not ask for smaller sizes on their own; however, they were willing to accept smaller sizes when prompted by wait staff (15).  When researchers had wait staff ask customers if they would like a smaller portion size, thirty-three percent of customers accepted the smaller size.  Interestingly enough, more customers (21%) accepted the smaller portion size before food nutritional facts were presented than after (14%).  Calorie labeling did not impact the amount of calories purchased, instead more calories were eaten after the food labeling policy was enacted (15).
It is important to note that this study was conducted in three parts, a) to assess the baseline where wait staff do not offer smaller portion sizes, b) to see if people accepted a smaller portion size at a discount rate, and c) to examine whether customers accepted the smaller portion size without a discount rate.  Study investigators found that there was no difference in acceptance rates among the smaller portion sizes with or without the twenty-five cent discount (15).    The results showed that people who received the smaller portion size ate significantly fewer calories than those who did not (15).  In fact, those that chose smaller entrée sizes did not overcompensate by ordering desserts or other food options later on. 
            Why did asking someone if they wanted less food result in fewer calories eaten when simply posting the nutritional information did not?  This case is similar to the study mentioned above about procrastination.  Students performed better when their teacher imposed an earlier paper deadline than when the students self-imposed an earlier deadline.  The rationale behind why they performed better or why customers ate healthier is that the imposed deadline or smaller size food prompt interrupted customers’ expected ordering flow process, which activated customers’ self-control.  The environment was changed, thereby allowing for behavioral change (2).  The mindless eating process was disrupted by the waiter.  Customers who entered the restaurant were thrown into the hot stage of thinking by the food temptations, but were brought back into their rational, cold stage when the waiter interrupted their normal decision process flow (1).  Thus, customers were better able to make a more reasoned decision about their food choice.
            Thaler and Sunstein’s book, Nudge, further this point of reasoning by their explanation of the two systems of thought: automatic and reflective.  The automatic system is where rapid and instinctive decisions occur, whereas the reflective stage is when people deliberate and think through their decision (19).  Thaler gives the example of a way to increase organ donation rates is to automatically place people as organ donors when they renew driver licenses, so the default is to opt into the program, not opt out (19).  Thaler suggests making the default to be an organ donor will drastically increase the number of people who are organ donors.  This concept can be applied to food choices where the default should be vegetables as sides and fruit for dessert, so people are more likely to eat healthier, rather than having to ask for these substitutions.


            Making healthy food decisions is difficult given all the temptations and unhealthy environment in which Americans live.  In order for public health advocates to effectively change behavior, a group effort that disrupts the normal decision-making process is needed to “rightsize” food choices and give people the autonomy to take control of their lives.  Although the food labeling intervention provides important information, it is not a powerful enough message to get people to actually change their behaviors. Focusing on reframing existing core values and utilizing the strength of a large community will help overcome the bombardment of unhealthy temptations and advertisements that continue to exist so that healthy eating becomes the default.
1.    Ariely, Dan and Klaus Wertenbroch.  “Procrastination, Deadlines, and Performance: Self-Control by Precommitment.”  Psychological Science. 2002; 13(3).

2.   Ariely, Dan.  “Predictably Irrational, Revised and Expanded Edition: The Hidden Forces That Shape Our Decisions.”  New York: Harper Perennial, 2010.

3.   Baker JL, Olsen LW, Sorenson TIA.  “Childhood body-mass index and the risk of coronary heart disease in adulthood.  New England Journal of Medicine.  2007; 357(23): 2329-2337

4.   Brownell, Kelly, R. Kersh, D. Ludwig, R. Post, R. Puhl, M. Schwartz, W. Willett.  “Personal Responsibility and Obesity: A Constructive Approach to a Controversial Issue.”  Health Affairs.  2010; 29(3): 379-387.

5.    Cialdini RB.  Influence: The Psychology of Persuasion (Intro-Ch. 1: Weapons of Influence).  New York: Harper Collins Publishers, 2007: pp. xi-xiv and 1-16.

6.   Edberg, M.  “Essentials of Health Behavior: Social and Behavioral Theory in Public Health: Individual Health Behavior Theories (Ch. 4).  Massachusetts: Jones and Bartlett Publishers. 2007, pp.35-49.

7.   Elbel, Brian, R. Kersh, V. Brescoll, and L. Dixon.  “Calorie Labeling and Food Choices: A First Look at the Effects on Low-Income People in New York City.”  Health Affairs. 28(6). 2009.

8.   Festinger, Leon.  “A Theory of Cognitive Dissonance.”  California: Standford University Press, 1957

9.   Food Insight.  “2011 Food and Health Survey: Consumer Attitudes Toward Food Safety, Nutrition, and Health.”  2011.  <http://www.foodinsight.org/Resources/Detail.aspx?topic=2011_Food_Health_Survey_Consumer_Attitudes_Toward_Food_Safety_Nutrition_Health >

10.                  Janz, N. K.; Becker, M. H. (1 January 1984). "The Health Belief Model: A Decade Later". Health Education & Behavior.

11.Kaiser Foundation: State Health Facts. Percentage of High School Students Not meeting Recommended Physical Activity Level, 2009. Kaiser Foundation: 2009. <http://www.statehealthfacts.org/comparemaptable.jsp?typ=2&ind=766&cat=2&sub=27&sortc=1&o=a >

12.                  Pew Research Center.  “Eating more: enjoying less.”  Washington DC: Pew Research Center 2011.  <www.pewsocialtrends.org/2006/04/19/eating-more-enjoying-less/ >

13.                  National Cancer Institute.  Theory at a Glance: A Guide for Health Promotion Practice. Part 2.  Bethesda, MD NCI, 2005, pp9-21. 

14.                  National Restaurant Association. “Americans’ Dining-Out Habits.” 2000.  <http://www.restaurant.org/tools/magazines/rusa/magarchive/year/article/?articleid=138>

15.Schwartz, Janet, J. Riis, B. Elbel, and D. Ariely.  “Inviting Consumers to Downsize Fast-Food Portions Significantly Reduces Calorie Consumption.”  Health Affairs, 31(2). 2012.

16.                  Siegel, Michael and CL Menashe.  “The Power of a Frame: An Analysis of Newspaper Coverage of Tobacco Issues – United States, 1985-1996.  Journal of Health Communication. 1998;3(4): 307-325.

17.                  Stein K. A national approach to restaurant menu labeling: the Patient Protection and Affordable Health Care Act, section 4205. Journal of American Dietetic Association. 2010;110(9):1280-1289

18.                  Swartz, Jonas, D. Braxton, and A. Viera.  “Calorie menu labeling on quick-service restaurant menus: an updated systematic review of the literature.”  International Journal of Behavioral Nutrition and Physical Activity. 2011.

19.                  Thaler, Richard and C. Sunstein.  “Nudge: Improving Decisions about Health, Wealth, and Happiness.”  Connecticut: Yale University Press, 2008.

20.                 Trust for America’s Health. F as in Fat: How Obesity Threatens America’s Future. Washington D.C.: Trust for America’s Health, 2011. <http://www.healthyamericans.org/assets/files/TFAH2011FasInFat10.pdf >

21.                  U.S. Census Bureau, Statistical Abstract of the United States: 2012. Table 1240 Adult Participation in Selected Leisure Activities by Frequency. http://www.census.gov/compendia/statab/2012/tables/12s1240.pdf

22.                 U.S Food and Drug Association.  New Menu and Vending Machines Labeling Requirements.  2012.                                                                                                             < http://www.fda.gov/food/labelingnutrition/ucm217762.htm>. 

23.                 Williams, Peter.  “Consumer Understanding and Use of Health Claims for Foods.”   Nutrition Reviews; Vol 63, No. 7. 2005.



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