Damage Control

Photo by Richard Ellis

My friend Dr. Yoni Freedhoff caused a bit of a firestorm in the media over the past couple days after he posted a survey sent to Dietitians of Canada's Ontario members in response to a provincial bill that, if passed, would see foodservice establishments with annual revenues of over $5 million be required to post calorie information on menus, menu boards, or as tags on the individual food items. The bill also proposes limits on (what else?) trans fats.

A helpful RD provided some of the survey results:

In response to the question, "Is the posting of caloric content of food at point of purchase (e.g. menu boards or menus) an effective means of public education and modifying food choices?" 47% of the respondents said "Yes", 23% said "No", and 30% said "Not sure"

In response to the question, "Is a mandatory trans fat ban/restriction required to encourage foodservice operators and manufacturers to change product offerings?" 71% said "Yes", 11% said "No" and 18% said "Not sure"

Ignoring trans fat bans for a second, I'm sure Lynda Corby, DC's Director of Public Affairs, was caught off guard when she was called up to give a statement about this issue. Why else would she say that people thinking higher calories = tastier would be an "unintended consequence" of having calorie labelling on menus?

She finally took the time to compose herself and sent the following letter to all DC members:

Dear members,

In regard to the recent media reports on calorie posting on menus, Dietitians of Canada has not made a public statement about our position on this issue as we are currently completing an evidence review to answer the question “Does posting of calories on restaurant menu boards impact on consumers’ behaviour?”

Our evidence review will be completed shortly and we will provide the results of that review to members in Current Issues. We also plan to disseminate our position in a news release at that time. This is the same process we use for all policy statements, an approach that has garnered trust in our advice by the public.

The following issues will be addressed in this review.

If posting of energy values has an impact, we want to consider

• How do consumers use calorie information out of context with the nutrient composition? DC fully supports mandatory nutrition labelling where consumers can not only compare energy value of food but see it in the context of other nutrients.
  
• Which consumers are most likely to use this information – is it those people who are already motivated to make healthy choices, or is it helpful to those who are just contemplating a change?
  
• We know that taste and price and the two factors that most influence food choices. Will having the energy value make a difference?
  
• What format would be best to catch consumers’ attention? On a cluttered menu board in a fast food restaurant, for example, will consumers take the time to use the information?
  
• What is the cost associated with this policy change and is it justified given the impact of providing the information?
  
• Are there unintended consequences to posting calories on restaurant menus?
  

All these factors will be considered in making a policy recommendation.
Posted by Lynda Corby MSc, MEd, RD, FDC
Director Public Affairs

First of all, I know Dr. Freedhoff does not mean this as a slight to dietitians. In fact, he has two on his staff, and he's made it known that the door to his clinic would always be open to me (a dietitian) if I'm ever in Ottawa so I can "see how it's done". Dr. Freedhoff has dissed DC before, and as one can probably tell from the comments on his post, not all dietitians agree with all of DC's messages. What made me cringe was reading these comments:

"I don't think it's possible for many dieticians to be mortified. I have heard more crackpot theories from dieticians than from any other health professional -- except perhaps chiropractors.
They have an inflated sense of their own expertise that is sadly lacking in reality."

"Ha...I think this just adds further proof to my theory that Dieticians are the absolute last people you want to consult about food or health."

And of course, when people read the newspaper and see the headline "Dietitians think such and such!" It's easy for the public to point their fingers at all of us, and it doesn't help that only 47% of dietitians who responded to the survey answered "Yes" to the calorie labelling on menu boards question.

Regarding the nasty comments - I would really be interested to see if the commenters past experience with "dietitians" were actually with dietitians or nutritionists. Yes, I know there are "good" and "bad" dietitians, but we are all bound by our professional colleges and strive toward evidence-based practice, as opposed to "crackpot theories". On the other hand, anyone can call themselves a nutritionist, whether they've done four years of university and just didn't do an internship, 1-2 years at the Canadian School of Natural Nutrition or 10 months at a community college! Today, my company had its launch party and one of the guests I spoke with said her nutritionist recommended that she cut out wheat and dairy even though (from what I gathered) she didn't seem to have any problems with them!

So what about the fact that only 47% of dietitians agreed that "posting of calories on restaurant menu boards impact on consumers’ behaviour"? I will concede that the letter that DC sent out with the survey was biased... "Dietitians of Canada is concerned that there is limited evidence to support a move to posting energy content of foods on restaurant menu boards as a means of influencing consumers to make positive changes in their food selection at this point of purchase." But it's telling that 30% of the respondents simply said they're not sure. First of all, saying that you're "not sure" whether it's going to impact customer behaviour doesn't say anything in terms of whether you support Bill 156. And to be honest, most dietitians work in acute care and unfortunately issues like this simply aren't on their radar - these dietitians can probably tell you about the latest nutrition research in dysphagia, cancer, pediatrics, whatever, but calories on menus? They just don't know.

I definitely think Lynda Corby was caught off-guard during her interview, which is why she gave the unfortunate example that calories on menus might lead some to think that higher calorie foods are tastier. Of course not. But I do think that it's fair that DC is doing its own review of the research before making a statement, even if all these other organizations have thrown their support behind the cause. I mean, yes it could be perceived as a no-brainer, but I think DC wants to know what they are talking about before they talk about it, which is why I don't think Lynda should've gone into so much detail, but instead should have said something along the lines of, "While DC recognizes that our colleagues from different health professions and many of our own members have thrown their support behind Bill 156 and publishing calorie counts on menus, we would like to conduct our own literature review, which will be completed shortly, before making an official statement."

So it's ok, guys, DC is just taking its sweet time to read its papers, and then it's just going to agree with everyone else, right? Dr. Freedhoff helpfully provides us with some evidence from the Rudd Center for Food Policy and Obesity, which basically says that opinion polls show that consumers want it and that in the current state of things, people are eating out more while portion sizes are getting bigger, which may be contributing to the obesity crisis and most people, including nutrition professionals, tend to underestimate the number of calories in a fast food meal. On the "affecting consumer behaviour" side of things, they cite this study (subscription required), which found that on average, people who went to a Subway with calories published at point-of-purchase purchased 52 calories than those who went to a Subway without the calories posted. They also cited this study, which found that most people underestimate the calories of the foods that they eat, particularly for less healthful items, where actual calories were sometimes more than double the mean estimate! The researchers then gave participants the calorie, total fat and saturated fat counts for the menu items and found that they were 24-37% less likely to choose the unhealthy (less consistent with nutrition expectations) versus the healthier (more consistent with nutrition expectations) items.

Other studies are not as promising. In this literature review, the authors could only find six studies that met their selection criteria, and found that while five of them did provide evidence that calorie information may influence food choices, the effect may be weak or inconsistent. The authors were also the lead researchers in a later study which found that calorie labelling had an insignificant effect on subjects who often ate at fast food restaurants.

Based on my very brief literature search, I would agree with DC in saying there is currently limited evidence that calorie labelling on menus actually causes people to make different choices when it comes to their eating. But does that mean I don't support having them? No. This is obviously something consumers want, have the potential to benefit from, and are unlikely to be harmed by. Most of the restaurants that this bill will affect already have nutrition information available elsewhere, and if they don't, well, I'm sure they have the money to do it anyway (I'm looking at you, Moxies.) And maybe, just maybe, when calorie labelling is in place, it'll be a lot easier to do studies and find more evidence!

In conclusion, I don't think DC is unsupportive of calorie labelling on menus, I just think they're being very cautious before they do give their support. Yes, the evidence for it may be weak, but I don't think anyone's expecting it to be the answer to the obesity epidemic here. More importantly, I think DC's literature search is going to find that this is not going to be harmful to anyone, and that in the end, they're going to give it their support, stressing that this is only a very small piece of the puzzle.