Challenging Dogma - Spring 2011

Saturday, May 14, 2011

National Health Reform And Nutrition Labeling Requirements -- Anon.

March 23rd 2010 marked the inauguration of the Patient Protection and Affordable Care Act (ACA) into American law. The law was an attempt to reform the American medical system and reign in insurance companies abusive practices. Public health was arguably not the focus of the ACA, but hidden within the almost 1,000 page document was a provision for the Food and Drug Administration (FDA) to mandate nutrition labeling for “standard menu items at chain restaurants and food sold from vending machines” (1). The mandate signified an attempt to promote transparency within the restaurant industry so that consumers know the nutrition content of food. Moreover, the mandate reflected a general trend of thought that the federal government should and can respond to the growing obesity epidemic in the United States (2). However, as this paper will show, the reliance on nutrition labeling to influence food consumption behaviors is highly flawed. While it may present an opportunity for behavior change for some specific individuals, it should not be the sole effort to influence food behavior and the national obesity problem because it will not affect group behavior.

According to The National Health and Nutrition Examination Survey (NHANES), nationwide trends in overweight and obesity have increased steadily over the past fifty years in all age groups and races/ethnicities (3). Overweight is defined as having a body mass index (BMI) between 25 and 29.9 and obesity is a BMI over thirty (4). NHANES data from 2007-2008 indicates that the overall prevalence of obesity in the US exceeds 30 percent for all ages and genders except for men aged 20-39 years (3). The burden of the obesity problem lies in the southern states where the prevalence of obesity exceeds 30 percent in every state (5). There are also significant differences by race and ethnicity: in comparison to the white Non-Hispanic population, blacks have a 51 percent higher prevalence of obesity and Hispanics have a 21 percent higher prevalence (5). The concern over rising overweight and obesity levels stems from the fact that both have been associated with chronic diseases such as Type II diabetes, hypertension, high cholesterol, stroke, heart disease, cancers, and arthritis (3).

The ACA built upon a historical trend of government involvement in the campaign to curb the proliferation of obesity. The Nutritional Labeling and Education Act (NLEA) of 1990 authorized the FDA to require nutrition labeling for its regulated foods and control nutrient and health claims (6). NLEA specifically exempt foods served and sold in restaurants and foods sold for immediate consumption (6). Therefore, the ACA mandate for restaurant and vending machine labeling can be seen as an extension of the FDA requirements under NLEA. The ACA specifically requires that the caloric content of every standard menu item be placed next to the item and that the calories be placed “within the context of recommended total daily caloric intake” (7). Further nutrition information must be available upon consumer request, and a statement detailing such availability must be “prominent, clear, and conspicuous” (7). The ACA also supersedes state and local level labeling laws, such as the laws implemented in New York City in 2008 (8). However, state laws such as those in New York also point to the growing interest in government endorsed obesity prevention and “treatment.” Given the focus on labeling and government involvement, it is essential to look at the evidence base surrounding consumer knowledge and habits. Unfortunately, the evidence is not in favor of labeling requirements.

Flaw #1: Consumers are Nutrition Label Illiterate

The primary concern in the effort to influence consumers’ eating habits via nutrition labeling is the fact that few consumers actually comprehend and can effectively utilize nutrition information. A systematic review of consumer understanding and use of nutrition labeling found that “although some consumers could understand some of the information on nutrition labeling, in general they reported finding nutrition labeling confusing, especially the use of some technical and numerical information” (9). Consumers reported better understanding of the information when a benchmark was provided along with individual product information (9). The review identified twenty-one studies examining consumer nutrition knowledge and found that it was moderate to low (9). Moreover, the elderly and those with lower levels of education were least likely to comprehend the labels’ content (9). Another study identified differences in ethnicity, income, and gender in relation to nutrition knowledge (10).

Admittedly some consumers are more likely to read and understand labels, but this is a very specific subset of the population. For example, consumers who self-identify as interested in health and nutrition were more likely to report reading labels and using them to make food choices (9). Consumers who report recognizing a link between food consumption and risk for disease are also more likely to read and understand labels (10).

Dickson-Spillmann and Siegrist discuss two different forms of knowledge that are particularly appropriate for discussions of food choices. The first form, declarative knowledge, is described as knowledge of facts and things (11). On the other hand, procedural knowledge is knowing how to perform a specific task for a desired outcome (11). In the context of nutrition and food choices, declarative knowledge would be knowing the U.S. Department of Agriculture’s (USDA) Dietary Guidelines and procedural knowledge would be knowing how to follow those guidelines to make healthy food choices. Clearly both forms of knowledge must work in tandem in order to produce healthy food choices. Interestingly, the authors found that women had higher procedural knowledge scores in relation to nutrition than men; age and education level were also highly correlated with procedural knowledge levels (11). Consumers who followed specific and strict diets also reported high levels of procedural knowledge (11). In contrast, individuals who had low levels of procedural knowledge found it difficult to take the food pyramid into account and did not fully understand the term “balanced diet” (11). Less knowledgeable consumers also thought that eating healthy meant eating less and that fat should be completely eliminated from one’s diet (11).

This study and the others previously mentioned highlight the spectrum of nutrition knowledge within a population. Assuming that nutrition information via labeling will be effective does not account for this variation and has virtually no affect on the less knowledgeable members in the population.

Flaw #2: Knowledge does not always change behavior

Given this discussion of nutrition knowledge, it is worth exploring whether or not knowledge even changes or influences food choices. Ostensibly the goal of the ACA mandate is to influence consumers’ food choices and behaviors outside the home. However, the evidence base surrounding the issue of nutrition knowledge and food choices is inconclusive, which mainly stems from the inability to assess the multitude of proposed labeling mechanisms (12). Like the distinction between declarative and procedural knowledge, it appears that consumers’ knowledge of one does not always impact knowledge of or capability to perform the other.

Furthermore, the mandate is based on the flawed premise that knowledge leads to intention, which is a core value of the Health Belief Model and the Theory of Reasoned Action (13). Both models propose that once knowledge of a problem is acquired individuals will use such knowledge to change their behaviors. However, both approaches fail to account for the fact that people do not always act rationally; that is to say, knowledge does not always translate into calculated action.

One study examining the impact of calorie labeling and food choices following the New York City mandate did not find a statistically significant difference in calories purchased/consumed (8). Following labeling implementation just 54 percent of respondents reported noticing the nutrition information. Only 28 percent of those who saw the labels reported that the information affected their food choices, and of this group almost 88 percent “indicated that they purchased fewer calories in response to labeling” (8). However, those that reported that the calorie labels affected their choices did not actually purchase items with fewer calories. The researchers also found “non-significant decreases in calories purchased for groups who indicated that the labels mattered to them” (8). Overall, the study demonstrated an insignificant affect of calorie labeling on food choices and revealed that even those who think they are making good choices may be fooling themselves.

Another study randomized frequent fast food goers to receive a menu with calorie information or one without and had similar findings to the NYC study. This study is particularly informative because it mimics the menu standards the FDA set forth; that is to say, researchers included a column indicating calorie and daily value information in a column directly beside the menu item (12). Even so, among those with the calorie menu, just over half reported noticing the calorie listing (12). However, those who noticed the listings purchased items of similar caloric content than those who did not notice the listing. Interestingly, males in this study seemed to use calorie listings to purchase higher calorie foods. This finding recalls the idea that males and females possess different knowledge of nutrition and therefore make different food choices. However, this is certainly not the intent behind nutrition labeling in restaurants.

Flaw #3: An individual-level model in disguise

Even though nutrition labeling exemplifies a “population-based approach aimed at helping to make the food selection environment more conducive to healthy choices,” (9) the policy actually works on the individual level. The legislation will indeed affect entire populations nationwide, but the specific decision of whether or not to take the information into account occurs on an individual basis.

The tension between the population approach to an individual choice or action is exemplified through the Diffusion of Innovations Theory. This theory describes how a behavior is adopted in a population over time: early adopters will conform to the new behavior first, the general population will start to adopt the behavior at the “tipping point,” and the “laggers” will be the last to adopt (14). This theory recognizes that people conform to behaviors at different rates; it allows for a certain degree of individuality within the population rather than assuming people will be affected equally. In this way, the theory seeks to account for both population-level and group-level changes.

At its core the Diffusion of Innovations Theory relies on what several theorists and social scientists describe as human beings’ “herding” tendency (15). Simply put, humans tend to mimic the behaviors of others. Humans are social learners; they are easily influenced, or “nudged,” to behave a certain way (15). Moreover, humans like to conform and so they are highly susceptible to even the gentlest of nudges and especially to peer pressure (15). It is via this mimicking and nudging system that behaviors are diffused throughout a population and new behaviors are adopted.

However, it is unlikely that a group-based intervention like nutrition labeling will disseminate through the population the way the Diffusion of Innovations Theory would postulate (and they way the ACA framers would hope). Eating is a highly social activity and peer groups tend to have similar eating habits; as a result, eating habits are probably more likely to work through the social network mechanism that the Social Network Theory proposes (16). This theory suggests that behavior is spread through close contacts and peer networks (16), and there has been evidence of this in relation to obesity. One study found that a person’s “chances of becoming obese increased by 57% if he or she had a friend who became obese in a given interval” (17). Because of this clumping effect within the population of obese and non-obese, it is unlikely that they would affect one another’s eating habits and choices. If a behavior does not spread between different social groups it cannot achieve universality the way the Diffusion of Innovations Theory models.

Proposed Intervention to Remedy Identified Flaws

Nutrition labeling and calorie listings should not be used in isolation to influence healthy eating habits in the population. As it stands currently, the policy is poised to only affect a certain subgroup of the population: those who understand the labels and who choose to incorporate the information into their lifestyle. The proposed interventions will focus on the younger segment of the population as they will grow up under health care reform’s contributions. The interventions will need to address a knowledge deficit, while recognizing that knowledge does not always lead to behavior change. Finally, the interventions will need to attempt to infiltrate social networks so that it can be processed on a group level. In effect, the interventions will be presented as part of an ecological model that must be addressed if the ACA mandate is to influence consumers’ choices.

Nutrition Education

The first issue to address is undoubtedly the knowledge deficit if a policy like nutrition labeling is to have any impact on consumers’ food choices. This “intervention” will take the form of mandated education and guidance in primary and secondary schools on the Dietary Guidelines for Americans and the Food Pyramid Guide. As the CDC indicates, schools are an ideal location to initiate and disseminate nutrition information, and it should be the focus of nutrition education efforts (18).

Schools are an attractive location for dietary interventions because of the shear amount of children they reach and because of the opportunity for support systems. Schools reach not only a majority of the population, but a wide range of ages as well. School-based nutrition programs in health or physical education classes should be age-specific and appropriate for the child’s level of understanding. Moreover, because food is served in schools, children and adolescents have the opportunity to directly utilize the information to make healthy eating choices (provided that healthy options are available; there has been pressure to achieve this goal). The CDC reports that almost half of youth eat one major meal at school, and one in ten youths eats two major meals at school (18). Clearly, schools are poised to significantly impact the food knowledge, options, and choices of their students, and they should be considered a crucial ally in the attempt to curb obesity.

School-based intervention approaches to influence nutrition education are extremely varied and have reported diverse results. However, there is some indication that interventions based upon the Social Cognitive Theory (SCT) may be successful (18). SCT incorporates “outcome expectancies, self-efficacy, observational learning, and self-regulation,” (19) all of which are invaluable to approaching nutrition education and obesity in youth. One study looking at a nutrition education intervention based on SCT found that students who received the intervention had a greater decrease in BMI and increased their fruit and vegetable intake relative to the control group (19). Interestingly, the observational learning component of this intervention involved hands-on food preparation and taste trials of unfamiliar foods (19). This approach appears particularly effective for increasing youth’s knowledge of, exposure to, and comfort with new and unfamiliar foods. Interventions such as this should be considered for schools nationwide; however, further research into other effective approaches needs to occur to identify the best option.

Schools are also an appealing option because they often have considerable ties with the community at large; schools can and should be used as educational sites to reach parents and the greater community. Schools can establish health advisory councils to “engage community resources and organizations to respond to the nutritional needs of students” (18). Moreover, parents can also be reached through schools. Nutrition education interventions targeted towards adults should be offered at schools to complement the information children receive. Once school staff (teachers, food service personnel, and counselors) is trained in nutrition and in intervention techniques, they can lend their knowledge and expertise to community-wide interventions (18). In this way, knowledge can permeate into the community as well. Also, involving parents in nutrition education and the push for healthy eating will increase the likelihood that children understand and adopt similar healthy practices. Indeed, children are “most likely to adopt healthy eating behaviors if they receive consistent messages through multiple channels and from multiple sources” so partnerships between schools and parents are essential (18).

Eating Practices Among Social Groups

While expanding people’s knowledge of nutrition is essential if they are to understand nutrition labels, interventions must also address the fact that eating is a social practice and therefore exists on the group level. Interventions will need to be specific to the composition of the social group and use models appropriate to that composition.

Schools are perfectly placed to address the social component of eating because school staff can have considerable insight into students’ social groups. The CDC suggests that “schools can teach students how to resist social pressures . . .school-based programs can directly address peer pressure that discourages healthy eating and harness the power of peer pressure to reinforce healthy eating habits” (18). School staff implementing the intervention should be taught to recognize both advantageous and deleterious social eating practices. Furthermore, schools should use friend groups and social networks to its advantage to diffuse healthy eating practices and to broaden its reach beyond the school building and into the community.

While school and parental involvement may be key for younger children, for older children and young adults, interventions that delve into peer groups should be utilized in order to rectify unhealthy social eating practices. Recently, peer-led interventions have been used in educational settings to influence behavior change and are recognized as a particularly effective method for reaching teens (20). Peer initiatives have been used in a variety of domains from substance abuse to bullying to increase knowledge, and influence attitudes, behaviors, and self-efficacy (20). These interventions are effective because they take place in the “social environment, can provide positive role models, and can help change social norms” (20). Therefore, peer-led interventions do not work solely on the individual level, but rather endeavor to implicate the entire group or social network. This approach is more likely to be successful for older age groups because they account for the social aspect of eating.

Addressing Gap Between Knowledge and Behavior

In order to avoid the pitfall of increased nutrition knowledge not influencing food choices, the behavior itself (healthy eating) should be encouraged directly. This intervention will involve transforming the food environment so that healthy options are well placed and visually appealing.

Even though Americans’ knowledge of nutrition is generally low, and a component of any intervention addressing food choices and habits must certainly address this lack of knowledge, knowledge does not always lead to behavior change because humans are irrational (21). Rarely do people plan actions so meticulously the way the Theory of Reasoned Action would presume (21). On the contrary, people continue to eat unhealthy foods and lead generally unhealthy lifestyles not because they do not know better, but because what they do know does not affect them.

To address this gap between knowledge and behavior, the behavior itself should be encouraged first to allow for the effect of cognitive dissonance. The Theory of Cognitive Dissonance supposes that if there is a conflict between an attitude and a behavior one of them must change to regain equilibrium (22). This concept is linked to the idea of ownership in that once you own something you consider it of higher value (22). This belief change occurs so you can justify the purchase: if you spent money on an object you must convince yourself that it is worth it. In the realm of nutrition and food choices, the Theory of Cognitive Dissonance can be employed to encourage and provide appealing, healthy food choices in the environment, which would entice consumers to choose the healthy options versus the unhealthy ones.

Researchers have recently begun to exam “nutrition environments” in an effort to move away from individual knowledge and behavior and look to the “influences of the social and built environments on individuals’ access to affordable, healthful food and activity-friendly communities” (23). This effort is reflective of an Ecological Model of health and well-being, which “aims to identify the environmental causes of behaviour because they create opportunities for intervention and remove barriers for maintaining a healthy diet” (24). Going even further than a group-level model, the Ecological Model implicates the environment itself and the systemic causes of poor health.

The Ecological Model helps foster the notion of promoting action (healthy eating) to invoke cognitive dissonance. Interventions should utilize the Ecological Model to promote healthy options that are not only available in schools and restaurants, but also that are well placed and visually appealing. One study focusing on fruit appeal for children found that children chose the “visually appealing fruit” almost twice as often as the regular fruit (25). This approach lends to the notion that people are visual eaters and their behavior can be manipulated through just visual cues rather than education. This systems approach requires a transformation of the food environment, rather than relying on individuals to sift through the healthy and unhealthy options. This way, people are more likely to choose healthy options and invoke cognitive dissonance.


Every level and variable of social organization must be involved in order to curb the spread of obesity. These levels or variables include: policy variables, environmental variables, individual variables/sociodemographics, and finally behavior (23). The ACA mandate operates as a policy variable, but such efforts must be coupled with other components of the Ecological Model in order to be effective. Only mandating nutrition labeling in restaurants and on vending machines is a flawed approach because it does not address major barriers such as a general lack of nutrition knowledge or the fact that eating is a social process. This approach also presumes that knowing the calorie content of food will positively influence food choices. Taken form an ecological point of view, the ACA mandate signifies a top-down or policy-level approach to nutrition. While policy is certainly an integral part of the ecological model, it is not sustainable or effective without the other components. The proposed interventions outlined here seek to incorporate and influence all levels of the ecological model with a particular focus on children, as they will grow up under the new mandate. The ACA mandate can only succeed in affecting food choices and behaviors if it is viewed within a greater ecological context of food and nutrition.

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