Challenging Dogma - Spring 2011

Monday, May 23, 2011

The Patient Protection and Affordable Care Act: Menu and Vending Machine Labeling. Will Consumers Digest The Information? – Crysta Jarczynski

The Problem
Obesity is a heated topic these days in the world of public health. From community interventions, to policy, to first-lady-led movements, citizens of the United States likely hear something about the issue a few times a week; and for good reason. The prevalence of unhealthy weight in adults is high: over 30% of adults are obese (BMI30) and 68% of adults are overweight (BMI25) (1). 20.1% of males and 17.3% of females ages 6-19 have a BMI in the 95th percentile (2). Obesity is associated with an increased risk of diabetes, hypertension, dyslipidaemia, heart disease, cerebrovascular disease, obstructive sleep apnoea, asthma, gastrointestinal system complications, osteoarthritis, cancer, psychosocial dysfunction, gynecological and obstetric complications, surgical complications, chronic kidney disease, and death (3). So one can see why such a health concern is on the national radar at this time. According to the Centers for Disease Control and Prevention (CDC), there are many factors that can lead to obesity, including eating too many calories, not getting enough physical activity, genetics, behavior, environment, culture, and socioeconomic status (4). This may explain why there are so many varied approaches to combating obesity.
One specific contributor to obesity is the availability of high calorie and sugary foods outside of the home. According to the National Health and Nutrition Examination Survey (NHANES) from 1999-2000, 41% of the population reported eating commercially prepared foods three or more times weekly, and higher eating-out frequency was associated with adverse nutritional consequences (5). A survey done in New York City found that one-third of lunchtime purchases were over 1,000 calories. Shockingly, “combination meals” at hamburger chains accounted for 31% of all purchases, and averaged over 1,200 calories (6). Vending machines, another form of eating away from home, are also contributing to poor eating habits, especially because of their availability in schools. Even though some schools have taken action to combat this problem, foods and beverages offered in vending machines continue to be high in fat and calories (7). Food consumed outside of the home is a big problem area in the obesity epidemic, so the federal government took steps to solve that problem.

The Solution: The Patient Protection and Affordable Care Act
The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 30, 2010. Section 4205 of the PPACA was created to address some of the issues mentioned above. The first part of Section 4205 requires nutrition labeling of standard menu items in restaurants and similar retail food establishments. In order to be covered by the requirements, restaurants and similar food establishments must be:
part of a chain with 20 or more locations,
doing business under the same name, and
offering for sale substantially the same menu items in their different locations (8).

Qualifying establishments are required to list calorie content information on standard menu items on restaurant menus and menu boards, including drive-through menus. Additional nutrition information, including total calories, fat, saturated fat, cholesterol, sodium, total carbohydrates, sugars, fiber and total protein, must also be available in writing upon request (9).
Vending machines are included in Section 4205. Any business owning or operating 20 or more vending machines must display the calorie information for the food inside if the nutrition labels on the food packaging are not visible from the outside. Specifically, the calorie count must be displayed in close proximity to each individual product inside or the selection button (10). Any restaurants, similar retail food establishments, and vending machine operators not covered under the requirements may voluntarily register to be covered. The Food and Drug Administration hopes that having caloric information visibly displayed will help consumers make healthier food choices (11).

Does Action Follow Intent?
Section 4205 of the PPACA is based on the health belief model. The health belief model centers on the idea that a cue to action will cause people to consider if they are susceptible to a certain outcome and how severe that outcome will be. Then they compare that susceptibility to the benefits and barriers of engaging in the behavior. From that, they build an intention and the action logically follows (12). The health belief model applied to Section 4205 would look something like this: Andy goes to a fast food restaurant and is about to order a cheeseburger combo, when he notices that it has 1000 calories. He remembers hearing somewhere that he should have 2000 a day and he’s surprised that this is half of his daily recommended value. He thinks about the risks of eating too many calories: heart disease, specifically, because he has a family history. He feels susceptible because his grandfather died of heart failure, and he thinks death is severe. He then considers the benefits of eating a lower calorie meal, mainly his good health. The barriers are low because there are some 700-calorie meals on the menu and they look adequate. He intends to eat a lower calorie meal and then chooses the lower calorie meal.
This seems like a plausible method, but the health belief model takes a few things for granted. The first big assumption is that consumers will make a rational decision (choosing a lower calorie meal) based on their intention (to eat healthier). The model, and therefore Section 4205 of the PPACA, is placing a lot of confidence in the individual’s self-control to stand by that intention when faced with the alternative of instant gratification. The negative effects of a high calorie diet are often long-term and so not of as much importance in the immediate moment. When given the option of instant gratification—choosing to eat whatever one desires at that moment—a person must practice self-control. Unfortunately, people tend to over-indulge in activities with immediate rewards and delayed costs (13). While providing the calorie information for food items may increase healthy choices some of the time, they may cause a rebound affect of binge eating or create feelings of guilt in people who continue to choose higher calorie food.
Consumers may also irrationally believe that they are not susceptible to the negative outcomes of eating a high calorie diet. Most people can recall a friend or family member who lived well past their expected age, despite participating in risky health behaviors. Since numbers on a menu lack any context, people will more likely recall stories they are familiar with and feel some connection to (14). These unframed numbers are competing with a world of context and familiarity around these high calorie foods, which has been created through advertisements. Adolescents have a specifically optimistic thought process when it comes to risk behaviors. When deliberating on whether or not to engage in a certain activity, in this case eating high calorie food, the teen brain tends to focus on the benefits, i.e. eating whatever they want, rather than the costs (15). When irrational optimism is at play, displaying caloric content will have little effect on decision making.

Are We Alone in Our Decisions?
The health belief model is an individual level model, and therefore Section 4205 puts the responsibility of choosing a lower calorie menu option entirely on the individual. The reality is that people do not live and, more often, do not eat in a social vacuum. This can cause the intended behavior to backfire for a number of reasons. Social modeling plays a key role in deciding whether or not to participate in a particular health behavior (15). If a person is deciding what food to order in a group context, and that group does not value eating a lower calorie diet, the person may be reluctant to choose a lower calorie food, especially if they already want to indulge in their favorite meal. The fact that they are following the herd makes it easier to make a potentially unhealthy decision because they are not alone in this decision.
Another social factor that may impede the decision to eat lower calorie meals is the perceived societal value of that decision. The media plays a large role in creating these social norms (15). Although diet solutions are portrayed in the media, there is also a juxtaposition of effortless weight control. Often, slender people are portrayed as naturally slender, and therefore can eat whatever foods they want. Conversely, most of the time it is the overweight person shown trying to change or control his or her weight. This attaches a certain stigma to weight control, creating the image that only overweight people are unhappy with their bodies count calories and display other food-related health concerns.
Because of these media images, it is likely that cue to action—calories on the menu—will evoke thoughts of weight control. Even though there are other negative side effects to eating a high calorie diet that may manifest outside of weigh gain, this policy lacks a frame; therefore the individual will create one based on social norms. The media-influenced frame carries a stigma and may impede the intended behavior by making someone who chooses to count calories feel like the only person trying to maintain a healthy weight. According to the media, this society values slender bodies that are kept that way with ease, and stigmatizes weight watching.
Given the increasing public health focus on obesity, it is likely that many young people have experienced some form of nutrition education. Because of this, they may choose to react to the cue to action by doing the opposite of what they have been taught. The nutrition education suggests how to eat healthy and that may feel like a threat to the young person’s freedom, so s/he may choose to rebel (16). This rebellious behavior may be magnified by the presence of peers, at which point choosing to order higher calorie food may become competitive. This links back to a social norm among many adolescents: that they are just too cool to care about health.
What Do (and Should) Calories Mean to Children?
The part of Section 4205 that applies to vending machines has the same weaknesses mentioned above but there are some separate flaws, given the prevalence of vending machines in schools. One study in Minnesota evaluated 20 secondary schools and found a median of 12 vending machines per school (17). As mentioned above, Section 4205 requires that vending machines display calorie numbers without providing any sort of context. This is already less effective with adults who may know something about calories, but many children have no frame of reference for the numbers they will see in the vending machines.
A review done by the World Health Organization found some striking results about food promotion to children. Advertisements targeting children seek to establish brand loyalty from a young age. Food advertisements aimed at children are outnumbered only by toy advertisements, and are received through television, the internet, and print/signage. The “big four” in food promotion are sugar sweetened breakfast cereal, confectionary products, savory snacks, and soft drinks. Multiple studies found that advertisements had an effect on food behavior that was equal in importance to the effect of family, parents, and peers (18). Three of the “big four” in food advertising aimed at children are commonly found in vending machines. Displaying calorie information without any context will have an insignificant impact compared to the familiarity children feel from seeing certain foods in advertisements (14), and therefore children will continue to make their food choices based on these advertisements.
The fact that children do not have a frame of reference for calories is a good thing. Introducing the idea of calories to young people can create a disordered way of looking at food. For instance, Lara Pence, a clinical psychologist from Renfrew, an eating disorder treatment center in Dallas, explained that new smartphone applications that count calories are feeding into the eating disorder mentality of obsessively controlling food intake (19). Such applications encourage hyper-monitoring of calorie intake. Posting calories on vending machines without any context may alert children to a way of thinking about food that leads to unhealthy food behaviors. Research also suggests that parental eating patterns influence a child’s eating patterns (20). The sudden increase in visual calorie cues may increase conversations about calories that could negatively influence the eating habits of young people.

Recommendations to Address These Weaknesses
While Section 4205 was created with noble intentions, it is simply not adequate enough to change the desired behavior on its own. This public health intervention is a special case, however, because it is policy-based and there are limits to what Congress can mandate food retailers to do. While there may be creative methods to address the flaws listed above through policy, there is also the options of partnering with various departments, non-profit organizations, or research projects. For instance, in 2010 the Department of Health and Human Services partnered with the HealthySocial Project, created by Children’s Hospital Boston and Harvard Medical School (21). Together they developed a Facebook application called I’m a Flu Fighter! which allows Facebook users to tell their friends that they were given their flu shot and find more information about flu vaccines in their area (22). A similar approach could make Section 4205 a more effective public health campaign.
A Facebook or smartphone application could potentially make choosing healthier menu options more fun and social. When the application is first downloaded, the user is primed with a short survey that can also be used for research purposes. The survey includes some demographic data and then the prime, “Do you intend to eat lower calorie meals when you eat out?” The mere-measurement effect tells us that asking this question of users will increase their likelihood of acting in a way that corresponds with their intentions (23). The last part of the short survey is a question about receiving further information via email. The material sent through email serves as a visual cue to keep users informed of their intent to eat lower calorie meals when eating out.
The application itself is rather complex and will take some cooperation on the part of fast food restaurants. The idea is that when a person eats at a restaurant chain, they receive a code on their receipt that corresponds with the calories in their meal choice. The user then enters any codes into the application and is awarded points based on their meal choices. The application does not keep track of actual calories consumed, nor does it display these calories anywhere. It will instead operate on a point system such that more points are awarded for lower calorie meal choices. The points are also adjusted depending on the number of times the person is eating out within a given time period. This adjustment is based on the assumption that meals consumed at home are generally healthier than meals consumed outside of the home. For example, if a person chooses a lower calorie meal and has only eaten out once in the past week, s/he will receive more points for that meal choice than for someone who chooses the same meal but has also eaten out four times that week. No one but the user knows how many times s/he has eaten out or the calorie content of the chosen meals.
The points awarded for meal choices are then used to earn badges for the user’s profile and to interact with others in a game. The success of games such as Farmville and Pet Society suggest that basing a game on building a virtual world of some kind would be an addictive and enticing way to approach this campaign. Perhaps the points that players earn from choosing lower calorie meals can be used to build an online restaurant. Then the players can take their healthy food choices a step further by choosing to sell healthier foods in their virtual restaurants. It may be a challenge to get restaurants on board with the point system at first, but there would only need to be one or two well known chains involved in the beginning stages. Those restaurants will start by giving point codes and advertising, and then the application will grow in popularity. Once it goes viral, or reaches a “tipping point,” the application will gather enough users to make it profitable for more restaurants to provide point codes on receipts (24).
The application would compliment Section 4205 by addressing some of the weaknesses previously mentioned. First, it would provide an intervention that does not rely on rational thought. While consumers would hopefully have some awareness of the health benefits of choosing lower calorie meals, health would no longer be the primary incentive for choosing those meals. With the application, consumers would be motivated by social incentives. The points rewarded would act as a stimulus to reinforce the desired behavior, choosing a lower calorie meal, and therefore consumers would be driven to acquire points and compete with their peers (25). The application would also replace the long-term benefits of health with a more short-term motivator, winning points for the online game. This would take care of the issue of instant gratification because it would be much more reasonable for a person to put off choosing a meal they desire that might have higher calories for the reward of going home and entering their points.
The application addresses these weaknesses by creating a social network that supports and encourages communities to strive together to eat lower calorie meals, even if the incentive is not health. It changes the norms around healthy eating from stigmatized or not important, to fun and social. While the norms are not directly changing, the behavior is changing by way of incentive. When an individual is part of a social network, s/he begins to pick up and perform the dominant behaviors as they spread through the network (26). The social network diminishes individual responsibility for food choices and replaces it with a group level behavior change. While both adults and children/adolescents use Facebook and smartphone applications, teens will most likely have a higher exposure to the norms of the social network. This will increase their familiarity with the idea of eating healthier foods and therefore decrease the likelihood of reactance (16). If enough people use the application, the perceived societal value of eating healthier meals will increase such that even people who are not using the application will follow the new norms. It is much more efficient to rely on people to spread behavior change through a network than to count on each individual to change on their behaviors alone.
Including vending machines in Section 4205 is an incomplete approach to addressing the problem of obesity, as well as potentially risky to children. Providing calories without any context could lead to disordered ways to look at food. The World Health Organization’s review of food advertising for children found that most food marketing uses themes focused on fun, fantasy, and novelty (18). If Section 4205 hopes to compete with these advertising techniques, it would be wise to approach vending machine requirements from a similar angel. Instead of displaying calories next to foods in vending machines, the vending machines themselves could become interactive. For instance, vending machine products could be stocked in such a way that lower calorie foods and drinks are in the top rows and higher calorie options are in the bottom rows. Then when a person, or more specifically a child, buys an item from the top shelf, the machine lights up and plays a tune. As the purchases move down the rows, the response to the purchase becomes less and less exciting, until the bottom row where there is hardly any fanfare at all.
Interactive vending machines would supply a context for food purchasing that children can relate to. Since the calories would no longer be the primary focus of the purchase, it removes the danger of creating an unhealthy obsession of calorie counting at a young age. Instead, children will begin to associate healthier, top-row foods with feelings of fun, excitement, and fantasy. These associations will create a new form of brand loyalty based on healthy eating. Policies like Section 4205 could instead regulate what requirements vending machine foods must meet to be considered top-row items. Section 4205 cannot require vendors to get interactive vending machines, but they could perhaps provide incentives to vendors who invest in these machines.

Section 4205 of the Patient Protection and Affordable Care Act is, in most ways, a positive direction for the U.S. to be heading in. However, alone it cannot accomplish the desired behavior change of choosing healthier foods, and in some cases it runs the risk of creating unhealthy relationships with foods. If the proponents of the PPACA instead, or additionally, invested their budget into changing the social norms surrounding healthy food consumption, they would have a much larger impact on the health of the country. It would be beneficial to invest in intervention methods that make purchasing healthy foods while eating out fun and socially valued, in addition to the menu and vending machine labeling requirements.

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