Changing the food environment

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{***Noah***}

Coming up on Harvard Chan: This Week in Health…Changing the food environment.

{***Sara Bleich Soundbite***}
(It’s restaurants making changes. It is not people making changes. And all of us have had a New Year’s resolution that we have broken, because we, as human beings, are very resistant to change. And so if you just make the environment a little bit lower calorie, you are helping people. And it’s much more sustainable over time.)

New research shows that some of America’s largest chain restaurants are dropping high calorie items from their menus. In this week’s episode, we explore what that could mean for the country’s fight against the obesity epidemic.

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{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health. It’s Thursday, January 18, 2018. I’m Noah Leavitt—Amie Montemurro is off this week.

In May of this year, the U.S. government will be rolling out broad new regulations for menu labeling.

As part of the Affordable Care Act, restaurants and other food outlets with more than 20 locations will be required to post calorie counts right on their menus. And these rules are broad—going beyond fast food restaurants to include grocery stores, movie theaters, even amusement parks and vending machines.

On any given day, a third of U.S. adults and children eat out at a fast food restaurant. So this one of the largest policy initiatives yet aimed at addressing obesity in America.

And the new rules may be having an impact before they even go into effect. Many large chains have already added calorie counts to their menus. And new research from the Harvard Chan School shows that large chains have already started dropping higher calorie items from their menus.

In this week’s podcast we’re talking to the author of that study, Sara Bleich, who is a professor of public health policy at the Harvard Chan School.

Her research focuses on policy approaches for addressing obesity—particularly among those at highest risk. And we spoke with her about what these changes at restaurants could mean for America’s fight against obesity.

But we also broadened the discussion to talk about other strategies for addressing obesity—including sugary beverage taxes. At the heart of the issue: researchers and policymakers are looking for ways to change America’s unhealthy food environment—whether that means increasing the availability of healthier items at chain restaurants or finding ways to entice kids to choose water over soda when they visit their local convenience store.

Take a listen.

{***Sara Bleich Interview***}

NOAH LEAVITT: I noticed as part of the background in this paper you noted that many large chain restaurants have already started reducing calorie counts on their menus. So what has driven that sort of recent change in reducing calorie counts?

SARA BLEICH: Yes. So our research has looked at large chain restaurants, and we’ve done several studies. And what those results suggests is that the largest restaurants in the country– these are 66 of the largest revenue-generating restaurants– appear to be reducing or reformulating the calories in their menu items. And so what specifically seems to has happened– and this is on a voluntary basis, because the law has actually not yet been implemented– is that among these large restaurants, the calories in newly introduced menu items appear to be dropping by about 60 calories, or 12%.

And we saw those trends from 2012 until 2014. And there are a small number of restaurants around the country, which have voluntarily posted calories on their menu in advance of menu labeling. And those appear to have lower average calories than restaurants that have not voluntarily posted calories on their menu.

And so in the most recent paper, which we’re talking about today, we looked at calories among items that have actually fallen off the menu. And what we found is that the highest calorie things are falling off. So when you put all this together, what this research suggests is that restaurants are not just reducing average calories in their menu items, but they’re also dropping the highest calorie items from their menus.

So we don’t know what’s driving this change. Our best guess is that is anticipation of the menu labeling regulations, which were included in the 2010 Affordable Care Act, and are expected to be implemented in May of 2018.

NOAH LEAVITT: We’ll talk a little bit more about menu labeling in a few minutes, but you just touched on there that with this most recent paper you’re looking at the items that were dropped off menus. So can you explain a little bit more about what you were looking at with regards to calorie counts?

SARA BLEICH: Sure. So with this most recent study, we were doing two things. We were comparing average calories among menu items that stayed on the menu in all years. You can think of this as your Big Macs and things that are common to menus. And we compared those to items that dropped. And the second comparison was average calories among newly introduced items that stayed on the menu, compared to newly introduced items that dropped off the menu.

And what we found is that menu items that were dropped from the menu had 71 more calories than items that were on the menu in all years. And that new items that were dropped had 52 more calories than new items that stayed on. So the punch line is that for both categories of menu items, things like Big Macs that stay on the menu, and things that are new and come on the menu, for both those categories, the highest calorie items are being taken off the menu.

NOAH LEAVITT: And so with regard to the types of food or beverages the restaurants remove, were there specific types that were more likely to be removed? So appetizers versus burgers, things like that.

SARA BLEICH: Yeah. So with this data, we’re able to look at broad categories of food, like pizza, sandwiches, and so on. And what we found is that when you look among the items that stayed on the menu compared to those that were dropped, the high calorie things that were falling off the menu were in the categories of pizza and sandwiches, particularly among full service restaurants. And that among the newly introduced items that were dropping off the menu, this was mostly driven by high calorie entrees and sandwiches that were being taken off the menu, particularly in fast food restaurants.

NOAH LEAVITT: And so you mentioned that these are some of the largest chains in America. So if this trend in calorie reductions were to continue, I guess, can you talk a little bit about the potential public health impact of that?

SARA BLEICH: So the reason why we care a lot about what restaurants are doing is that on a typical day, a third of US adults and a third of US children are eating in a fast food restaurant. And we spend a huge amount of money, something like $600 billion a year in these 900,000 or so restaurants. And so reducing the calories that customers are being exposed to in chain restaurants could actually substantially reduce our daily calories that we’re taking in as adults and children.

And so I mentioned that it’s a drop of about 66 calories, or 12%, among these newly introduced items, which sounds really small. But if you look over time at the extra daily calories among adults and kids that are driving obesity, it’s about 220 extra daily calories among adults and about 165 extra daily calories among children. So if you could bring that number down by roughly 65 calories, that could actually go a long way in impacting the obesity epidemic.

And the other reason why this is really important is because it’s restaurants making changes. It is not people making changes. And all of us have had a New Year’s resolution that we have broken, because we, as human beings, are very resistant to change. And so if you just make the environment a little bit lower calorie, you are helping people. And it’s much more sustainable over time.

NOAH LEAVITT: So you touched on it a couple of minutes ago that there are these new menu labeling rules that are set to go into effect in May 2018. So what will those new rules entail?

SARA BLEICH: So the new menu labeling rules are mandating that calorie information be posted on menus and menu boards in food restaurants or in similar retail establishments for places that have more than 20 outlets. So all the major chains that you could imagine. Now what’s interesting is that this rule applies to a wide variety of food outlets. Places like bakeries, and cafeterias, and coffee shops. Even entertainment venues like amusement parks; ice cream shops; takeout delivery, such as pizza takeout; grocery stores; superstores; and table service restaurants.

This is significant because in the proposed rule that first came out when the menu labeling legislation was first introduced, they originally had just included primarily chain restaurants and vending machines. And the final rule was expanded to think about all the different ways that we eat. And so when the law does go into effect in May of 2018, the expectation is that we will see calories in wide release across all these different venues where we get food.

NOAH LEAVITT: And so I’m guessing the next step would then be to, once these regulations have been in place for a while, to go and see if that does have any effect on calorie consumption?

SARA BLEICH: So that is the big question, because to date all we’ve been able to look at are what are restaurants doing in anticipation of what’s to come? But once the law goes into effect, we’ll be able to very cleanly say, what did calories look like before the law? And what do calories look like after the law?

And then the really important question is, well, if calories are changing, do they, in fact, have an impact on obesity risk? And so that’s the key next question in this area of research.

NOAH LEAVITT: And so it sounds like what you’re saying is that these regulations as they will be enacted are actually more comprehensive than was originally proposed. So what drove that change in order, I guess, to make them more comprehensive?

SARA BLEICH: So the difference– that’s exactly right. So the reason why there was this change between the proposed rule and the final rule is that the proposal came out. FDA solicited comments. And there were many, many, many comments from people saying, when we think about the way that we eat today, it’s not just in restaurants. It’s not just in vending machines. But it’s in all these other places.

And so what the FDA, with a lot of pressure from consumer groups and different advocacy groups, decided to do was to actually update the rule and to modernize it. Now it is notable that there are industry groups, like the pizza industry, like the convenience industry, which have really pushed back, which are in part the reason why the rule has not yet been implemented to date. My sense is there’s every indication that the rule will go into effect on May of 2018, which will create a really nice opportunity to finally understand the impact of this broad menu labeling rule on both consumer behavior, restaurant behavior, and potentially even consumer health outcomes, like obesity.

NOAH LEAVITT: And so you mentioned this idea of industry kind of self-regulation before the government regulation is really common. I mean, I was just in a chain restaurant last week, and all the calorie counts were already on the menu. So are there– have we seen other examples of this where the food industry kind of preemptively self-regulates itself in anticipation of something else that’s coming down the road?

SARA BLEICH: Yes. Absolutely. There are many examples of the food industry doing this. In large part, because it’s sort of an effort to thwart the heavy hand of government coming in. So two examples that are recent and very relevant. One is the Kids Live Well campaign, which was a voluntary action that aimed to increase the number of nutritious menu items available to children. There was a recent evaluation done by Alyssa Moran, who’s a doctoral student at the School of Public Health here, and she found that there was actually very little progress towards improving nutrition of children’s menu items based on that commitment.

Another example is the Healthy Weight Commitment Foundation. It’s a pledge, which includes 16 of the nation’s leading consumer packaged goods groups. And they voluntarily said they want to remove one trillion calories from their products by 2012, compared against 2007. And they also want to remove 1.5 trillion calories by 2015. Now, what that research suggests is that those companies are part of that pledge, those 16 companies, met or exceeded their interim 2012 goal of selling 1 trillion fewer calories, and their overall goal of selling 1.5 trillion fewer calories from the US marketplace.

However, among households with children, the declines were smaller, which suggests that this may not be that sustainable over time.

NOAH LEAVITT: What strikes me as interesting is that the focus on calories now. Because I’m thinking back to like the whole low fat, fat. And there was this push, OK, we’ll drop the fat, but we up the salt. We up the sugar. So is that also an important distinction that retailers– and the industry is focusing on calories, which will hopefully have overall a healthier impact?

SARA BLEICH: So that is a highly debated question.

NOAH LEAVITT: [LAUGHS]

SARA BLEICH: So the first way to answer that is when we look specifically at restaurants and we say we know that they’re decreasing calories by about 66 calories, or 12%, the next natural question is, well, how are they doing that? And what our research has shown is the way that they’re doing is they’re pulling out the good fat, they’re pulling out the unsaturated fat, and they’re increasing the sugar. That is problematic because it has implications for satiety. If you have less good fat in your diet and more sugar, it’s more like a low fat diet. You tend to be more hungry.

But big picture, this question of what makes most sense from a health perspective? It depends on the outcome that you care about. So if you talk to people that care about heart health, they really care about the type of calories. If you talk to people that really care about obesity, then it becomes a numbers game. Take in fewer calories, and you should lose weight. Now even within that camp, there are arguments about but do we metabolize different calories differently?

The way that I fall in all this is that menu labeling is one small piece of legislation which increases transparency around a concept, calories, which consumers don’t understand very well. If we were to further complicate that by adding in proteins and fats, it would just make it that much harder. And where the benefit from menu labeling comes in is not because you or I change our behavior, it’s because restaurants start reformulating.

And if, based on this legislation, the response is items have fewer calories, we are all better off. What we’ll have to keep an eye on, if restaurants continue to reformulate, is what shape that reformulation is taking. And to the extent to which it pulls out a lot of the good fat, then maybe we start pushing on that. But from an overall population health obesity perspective, pulling calories out of the restaurant environment is a very good thing.

NOAH LEAVITT: And it seems like that one of the hopes is probably that if restaurants are already kind of in this reformulation mode, maybe that will also entice them to start offering just overall more healthy options on their menus.

SARA BLEICH: I think that’s right. And I think for restaurants in general, they have this core set of items that are just a part of their business. I mentioned McDonald’s. The Big Mac at McDonald’s. It could be the Whopper at Burger King. There is just a core part of the restaurant’s business. But restaurants are introducing new items all the time. And it provides both an opportunity to attract a different type of clientele. So the fact that McDonald’s puts salads on their menus was an intentional way of getting parents or moms in the door, which brought their children in, which creates a new line of business.

And so I suspect that this transparency may change the types of people that end up shopping at different restaurants, based on what they learn. The other thing that could happen is it could be an area where restaurants choose to innovate. And so the restaurants and food outlets subject to this rule are the big ones. They have to have at least 20 outlets. But the smaller chains are not. And it could be that a smaller chain says, well, my customers care a lot about health. They think a lot about calories. Let me give them this information in a way that matters more. So let me– rather than tell them that their hamburger has 500 calories– let me tell them the minutes of walking on the menu. Maybe with a stick figure. And maybe that drives a certain type of clientele.

So I think that it remains to be seen how restaurants use this. I think we can be assured that we will see reformulation. The extent to which this brings in different types of clientele probably depends on how far restaurants choose to push this.

NOAH LEAVITT: That’s an interesting point about the how many minutes of walking. OK, I use like a program for like indoor cycling. And they measure it in like, not just calories, but it’s like how many pizzas you burned with your workout. It’s kind of like jokey and hokey, but it also makes sense. Like if you’re not a numbers person, oh, I burned 1.5 pizzas. That’s awesome. So I could see the appeal of something like that.

SARA BLEICH: There’s no question that if you make calories matter more to people, you can have a bigger effect. And there’s a growing number of studies in this area. So we’ve done work around sugary beverages, where we went into corner stores and we gave kids the information in a bottle of soda, when they opened up the beverage case, a bottle of soda is 250 calories. And then we randomized information that was the exact same information, but presented in a different way.

So we told the kids that that same bottle of soda was 50 minutes of running, five miles of walking, or 16 teaspoons of sugar. What we found is that when the kids saw the miles of walking sign, they bought less soda. They bought fewer calories from soda. And a lot of them actually walked out with no drink at all.

So when you make information matter in any context, I think you have a much better chance of changing behavior. The caveat is that behavior is a tricky thing to sustain over time. And so the fact that, in the context of this research, that the environment surrounding people is changing is a very positive thing for public health.

NOAH LEAVITT: And that segues well, because I wanted to ask– because, I mean, this is one part of a larger approach that focuses on policy, but also in the environment to address things like obesity and diabetes. So why is this kind of approach viable?

SARA BLEICH: So this approach is viable, number one, because it’s federal, meaning it’s going to happen all over the country. Generally, it’s been the case that with approaches based on either addressing the obesity or diabetes epidemic, they’ve largely incubated at the state and local level, which is a good thing. Which means you’ve got innovative things happening in places like New York or Philadelphia. But what you don’t have is all around the country some things that are being done to help consumers make better choices or promote the environment.

So menu labeling is a great example of an idea that incubated starting in New York City in 2008, and then bubbled its way up to the 2010 Affordable Care Act. It’s important, because it brings visibility to the issue. It is important, because it is bipartisan. It is information. So Democrats or Republicans can get behind it. And it is important, again, because it is encouraging this reformulation, which may improve public.

Now, all that said, when we think about these broad epidemics of obesity and diabetes, one rule, like menu labeling, is not going to solve them. And so what you need is lots of different things happening in concert. And I know we’re going to talk in a minute about sugary beverage taxes, but that’s sort of the other end of the spectrum. Information versus actually really changing people’s behavior through incentives or restrictions.

NOAH LEAVITT: And so, yeah, I mean, you even just touched on it a minute ago with working around sugar sweetened beverages. But you mentioned kind of the city level being an incubator. I know Philadelphia has done a lot of work with sugar sweetened beverage taxes. So can you explain a little bit more about what that approach has been? And maybe some of the effects we’ve seen from those taxes?

SARA BLEICH: So sugary beverage taxes are receiving a huge amount of attention right now in the states. The first sugary beverage tax in the US passed in 2014 in Berkeley. And what those results suggest is that, in the first year, sales of sugary drinks dropped by a little bit under 10%. And that when it looked at consumption, they found that in Berkeley where the tax passed compared to comparison cities, that consumption of the sugary beverages dropped by 21% in Berkeley, which was covered by the tax.

So that suggests that these taxes may work. Now since Berkeley, there have been six other locations around the country, which have passed sugary beverage taxes. There’s definitely momentum growing. The second of which was Philly. It has a 1.5 cent per ounce tax which passed in the summer of 2016. We are doing a very large evaluation of that tax. It’s not yet available yet. But it’ll be really interesting to see how Philly results compare to Berkeley, and the different taxes around the country.

The other reason that this area is interesting is that each tax is different. And so of those seven places, two, Albany, California and Philadelphia, included artificially sweetened beverages and sugar sweetened beverages. And the size of the tax varies. So you have one cent per ounce in Berkeley up to 1.75 cents per ounce in Seattle, Washington.

And what those different sizes imply is an impact on revenue generated. So when you compare Albany, California, it stands to make $200,000 in the first year, compared to Philadelphia, which stands to generate $91 million in the first year. And so given all the interest now around sugary beverage taxes, which is a very strong tool for altering behavior, and the potential revenue for states and cities that are facing fiscal crises, I think that we’ll probably see more of them. But it’s important to get a good look at the results from Philly and other cities that already have taxes to really understand the potential impact. Not only on the population overall, but particularly for groups at highest risk.

So for low income populations, Black and Hispanic populations, consumption of sugary drinks is higher. Obesity is higher. Do these taxes have a differential effect?

NOAH LEAVITT: And, I mean, you talked a lot about altering behavior. I mean, has there been a shift in focus when we talk about that? Like kind of that obesity and diabetes is like a personal failure, or a failure of will power, to acknowledging that the environment that exists is just conducive to obesity and diabetes, so we need to change that environment, and change behavior along with that.

SARA BLEICH: So the fascinating answer to that question is, it depends on who you ask. So if you ask scientists that do work in obesity or diabetes, they will overwhelmingly say that both of those epidemics are driven by the broader environment. If you take the pulse of the public, they’re going to point to me. And they’re going to point to you. And they’re going to say it’s our bad choice of diet. Not surprisingly, much of the legislation reflects that perspective. It is based on individual behavior.

Now that’s changing in the context of sugary beverage taxes and things that are more blunt instruments, that are actually altering the environment. But there are many more types of legislation which are targeted at individual behavior. And, unfortunately, that is not where you’re going to get the biggest impact.

NOAH LEAVITT: So there’s a last question, because talking about environment, and, I mean, there are so many factors. There are food deserts, availability of healthy food. So I guess other– I mean, you mentioned sugar sweetened beverage taxes are really getting a lot of attention now, but are there are other potential policy approaches that we should keep an eye out for in the years ahead that may gain some traction?

SARA BLEICH: Yes. So other potential things would be restrictions on marketing, which have proven to be a real third rail issue in public health advocacy. It remains to be seen if there will be effective efforts to actually reduce marketing among young children. We know without a doubt that marketing works. So the question is, can you restrict that during TV times, for example. So that’s one important thing to keep an eye on.

I would say another important thing to keep an eye on are issues related to financing to put supermarkets, for example, in areas where they didn’t already exist. And the way that tends to happen is through subsidies, because supermarkets make choices based on profit per square foot. In many neighborhoods, it’s just not possible to reach that profit, and so then they’re subsidized to reach the threshold they need, so they can be put in these neighborhoods.

Now, access does not imply better consumption. And so, with any sort of intervention, thought needs to be put in. What other things have to be in place to actually promote the behaviors that we want? But I think those will be two to potentially keep an eye on.

{***Noah***}

That was our conversation with Sara Bleich on calorie counts on restaurant menus.

If you want to learn more about that recent research—or Bleich’s broader work—we’ll have much more information on our website, hsph.me/thisweekinhealth.

Coming up next week: big data in public health. Researchers are harnessing vast amounts of information to assess what works in medicine. This new data driven approach holds promise—but there are also potential risks. And we’ll speak about that with Miguel Hernan, the Kolokotrones Professor of Biostatistics and Epidemiology at the Harvard Chan School, and an expert in the field of causal inference.

In the meantime, you can always listen to older episodes of this podcast on Souncloud, iTunes, and Stitcher.