ABSTRACT:
“Recent legislation passed by some governments worldwide requires mandatory nutrition labeling at all restaurants. The perceived benefits of nutrition labeling at restaurants are that consumers will have the ability to decide meals and dishes with more consumer information, thus potentially allowing those consumers to consume healthier foods, and potentially reduce caloric intake. The result from this may potentially allow for a reduction in obesity levels with healthier food choices by consumers, thus potentially reducing the overall impact of health costs on the economy and a positive effect on productivity levels. This article will look at the policy and see the potential impacts towards final consumers, restaurants, and the economy as a whole, and the benefits and costs associated with nutrition labeling. Last we shall look if other GCC Nations should follow the footsteps of other nations in Mandatory nutrition labeling.”
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INTRODUCTION
The Gulf Cooperation Council (GCC) currently faces an epidemic of high obesity levels (Al Nohair, 2014, requires access). With the transformation of the GCC due to increasing levels of wealth and standards of living, also came with changes in food consumption, socio-economic, physical activities, and urbanization rates which have ultimately added to the rise of obesity prevalence rates (Al Nohair, 2014, requires access).
The results of this are that GCC countries can be found within or near the top ten countries with the highest obesity rates (Al Nohair, 2014, requires access). Countries in the GCC such as Kuwait currently have obesity levels of 42.80%, which not far behind, countries such as Qatar have obesity levels of 35.20%.
With such high obesity levels, this has lead to health epidemics where health complications which are directly and indirectly related to obesity levels are on the rise and seem to continue to rise (Al Nohair, 2014, requires access). This has several serious consequences not only towards GCC citizen well-being but also towards constraints placed on current and/or future health resources, and also towards potential current and/or future productivity levels of GCC nations.
Therefore, Action is required to correct such rises in obesity levels in the Gulf so that future resources for healthcare will see less heavy constraints and potentially a rise in productivity levels of the general GCC population. One proposal suggests that all Restaurants should be required to display calorie content and ingredients in all meals and drinks.
Such proposals are under consideration in Bahrain (A’Ali, 2018, requires access). Therefore, this article will look at a brief history of nutrition labeling history, the effectiveness of such policies, and alternative proposals which could be implemented towards tackling the obesity epidemic in Bahrain and the GCC.
BRIEF HISTORY OF CALORIE LABELING AT RESTAURANTS
In most recent developments, calorie labeling has been passed by the UK government in 2018 (Swinford, 2018). Furthermore, the UK government Is also proposing on limiting the number of calories a single meal may have in restaurants and takeaway meals (Donnelly, 2018). However, these are not the first legislation which has been passed in regards to calorie labeling at restaurants (or control of nutrition at restaurants or takeaway) worldwide.
In 2006, New York City was one of the first cities in the United States to pass mandated calorie nutrition information to be displayed at all restaurants with fifteen or more locations (Swartz, Braxton and Viera, 2011, requires access). This regulation was then put into full effect and enforced in 2008. However, in 2010, with the passing of the Patient Protection and Affordable Care Act also came mandatory calorie nutrition labeling for restaurant chains with more than 20 locations (commonly known as Obamacare) (Swartz, Braxton and Viera, 2011, requires access) around the United States.
In essence, the United States was one of the first nations to pass a federal (national) law which mandated calorie nutrition labeling. As a result, research can be found on the effects of such calorie labeling which we will discuss below. Some research has also been conducted in countries such as the United Kingdom which is also included below.
EFFECTS OF CALORIE LABELING AT RESTAURANTS ON CONSUMERS
Research from Cecchini and Warin have found that calorie labeling is an effective measure. However, the measure did not significantly reduce calorie intake, but rather that it reduced the choice of unhealthy foods in substitution for more healthy foods (Cecchini and Warin, 2016, requires access) . The research pair has found that consumers had selected healthier foods (in terms of nutrition breakdown) by 17.95% and that such selection is statistically significant. However, the reduction in calorie intake was only 3.59%, which is also not statistically significant.
However, while the initial conclusion of the authors shows optimistic results for calorie/nutrition labeling, there are some flaws which we can point out on the conclusion. First, the study had only found nine papers out of 137 potential papers and articles which could be analyzed, and thus (which the authors have also voiced such concerns) more research is needed to conclude such results.
Furthermore, inspecting the nine papers which have been reviewed, we find that the results concluded from those nine papers may appear misleading. When separating the papers according to “Real-LIfe” settings, “controlled settings”, and “randomized online trials”, the statistical significance of the papers reviewed by the pair diminish. Below is a graph showing if the paper is “statistically significant” or “not significant”. Below is a bar chart visualizing the diminishing effect.
Click on the image to enlarge
From the graph above, papers set in “real-world” settings have found no statistical significance. When looking at “randomized online trials”, we find that the statistical significance increases. Therefore, there is some doubt surrounding Cecchini and Warins conclusion on the effects of calorie/nutrition labeling is as effective as the authors have claimed, as research done outside “real-world” settings seem to have greater statistical significance than those done via “real-world” settings, thus this may not actually reflect consumer behaviors properly.
Therefore, we look at more research done past Cecchini and Warins. The next paper which we will look at is more relevant to the topic this article, as Cecchini and Warins are related to overall calorie/nutrition labeling on the food
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industry as a whole. When looking at a study by Swartz Braxton and Viera, they find that nutrition labeling at restaurants menus for quick-service do not have the intended effects of decrease calorie purchasing or consumption (Swartz, Braxton and Viera, 2011, requires access).
What’s most significant is that five out of the seven research papers reviewed by Swartz Braxton and Viera. are placed in “real-world” settings, while the other two had been conducted in laboratory settings which variables were subjected to manipulation. Furthermore, all studies had compared calorie ordering and purchased with calorie labeling against a control of no calorie labeling. Below is a summed up result of the papers according to them being “statistically significant” or “not significant”. Below is a bar chart visualizing similar diminishing effects as seen with Cecchini and Warins
Click on the image to enlarge
The results are shown for “Real-World Settings” are essentially nearly identical to the results of “real-world settings” in Cecchini and Warins papers, where the majority of papers have found no statistical significance. One study reviewed by Swartz Braxton and Viera is particularly interesting. Finkelstein et al managed to review multiple chains in King County WA, which they had the ability to track total monthly transactions and had complete sales data towards all chains. The results are that they found no changes in choices between healthy and unhealthy meals, or any reduction in calorie intake which is significant between multiple chains before and after calorie information being posted. This paper is likely the best out of all of the seven reviewed as it manages to capture a large amount of data, thus allowing for a better representation of consumer behavior.
When looking in detail at the results of Cecchini and Warins paper and Swartz Braxton and Viera paper, it’s clear that the effects of nutrition or calorie labeling on restaurants/individuals are not as strong as proponents of such policies believe. We look at one last paper in terms of effects that calorie/nutrition labeling has on consumers when at “full-setting” restaurants and service centers rather than “quick-service” ones.
Sinclair, Cooper, and Mansfield. look at studies which have conducted experimental or semi-experimental studies on providing nutritional information towards consumers in restaurants and other food services. This paper differs from Swartz Braxton and Viera as they look at normal full-service restaurants and services, while Swartz Braxton and Viera look at “fast-food” restaurants and service centers. With the research papers, they find that pure calorie labeling by itself does not lead towards a statistically significant reduction in consumption of calories (67 calories), however, when
introducing interpretive nutrition labeling, they did find a statistically significant reduction in consumption of calories (81 calories), however, the amount is not clinically significant (Sinclair, Cooper and Mansfield, 2014, requires access) . Interpretive nutrition labeling is also found to be more effective in Cecchini and Warins paper, and also Swartz Braxton and Viera’s paper (although more effective, this does not necessarily mean they are statistically significant or clinically significant).
Other interesting things which arise from Sinclair, Cooper and Mansfield’s paper is that sex had an influence on the selection of consumption of calories. They found that women are more likely to reduce their calorie consumption when calorie/nutrition labeling is introduced (in both simple and interpretive formats) in comparison to their counterpart males. However, while the group has found a reduction in calories in full-service restaurants and services (such as university cafeterias etc), they still assert that food taste plays a much larger dominant role towards the selection of foods and beverages. Furthermore, they also find that potentially, consumers may reduce appetizers and main meals, but they may increase their consumption of desserts and beverages with the introduction of calorie/nutrition labeling, hence why the clinical significance of interpretive caloric/nutrition labeling is weak.
From the studies above, we can see that the effects which calorie/nutrition labeling in restaurants may vary in results. However, even when they vary in results, the most optimistic results (as found with Sinclair, Cooper and Mansfield’s paper) find only an 81 calorie reduction in consumption, which is not clinically significant. Furthermore, even with the most optimistic number, the average American consumes around 134 calories per meal (Ellison Lusk and Davis 2012) meaning that at most, the average individual will still be consuming 53 additional calories per meal when applying the reduction in caloric intake if interpretive caloric/nutrition labeling is introduced.
When we further break down the studies reviewed in each of the three papers, we find that when more “real-life” setting studies are present, the less the statistical significance is associated with such papers. This would explain the optimistic results which Cecchini and Warins, and Sinclair, Cooper and Mansfield’s paper present as they are geared towards more controlled or experimental studies. The results in detail show that nutrition/caloric labeling in either interpretive terms or simple terms have very little to no reduction in calorie consumption and is likely to be statistically and clinically insignificant. The reasons why such labeling does not work (which is commonly cited by at least two of the papers explored) is because consumers have a preference towards taste, or/and that consumers may not understand the labeling itself.
This part only looks at the consumer's side, and changes in the behavior of consumption (which is relatively little), this does not include the regulatory costs which restaurants may incur as a result of such regulatory compliance. Therefore, we explore the “cost-benefit” of calorie/nutrition labeling in the next section.
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REGULATORY COSTS AND THE “COST-BENEFIT” ASSOCIATED WITH CALORIE/NUTRITION LABELING AT RESTAURANTS
When we integrate how much costs are incurred by restaurants, not only do we look at the incurred costs in terms of calculating, and adding nutrition labeling, but also in potential lost revenues because of potential changes in consumer tastes and behaviors as a result of selecting different foods. We turn towards one important and well-executed paper by Ellison Lusk, and Davis. The group had managed to conduct their study in a restaurant called “The Ranchers Club” at their local university, which is considered an upscale restaurant with average spending prices of 14 US Dollars per meal (Ellison Lusk and Davis 2012).
The research pair has designed three different menus, one with no calorie labeling, one with basic nutrition labeling, and one with the “traffic light” calorie labeling with an interpretive description added. They’ve ensured that all party guests on the same table receive the same menu. Furthermore, on the twelfth week of the research, the research group had manipulated prices to reflect what a “fat tax” and “thin subsidies” would look like and their changes towards consumer behaviors.
The fat tax is essentially a tax which increases the price of items with “high-calorie content”, which was defined as 800 calories and above. The group aimed at charging higher calorie items between 17 to 23%. The thin subsidy is essentially a reduction in prices (10% reduction in prices) towards items with 400 calories and below. (Ellison Lusk and Davis 2012). The research had yielded 1,532 usable observations over a nineteen week observation period.
To ensure that customers do not know that they are under a study, the research group had taken extra measures by training staff on the understanding of nutrition labeling, so that consumers with questions are able to seek answers. Furthermore, the research group did not state during the nineteen week period towards any customers within the restaurant that they are under a research study. Thus, allowing for the study to flow as natural as possible without any indication that the restaurant is under observation by researchers.
The results which the group found that with symbolic calorie labeling (interpretive labeling), an increase in the orders of low-calorie items (400 calories or less) was observed from 29.90% of items towards 38.80% of items, while high-calorie items had the opposite effect moving from 34.50% towards 28.10%. However, medium-caloric items were the most popular regardless of menu type which accounted for 38.40% of all meals ordered. As a result, calorie labeling in interpretative format did significantly increase the amount of more low calorie and medium-caloric items in comparison towards high-caloric items (p-value of 0.01).
To further expand on the results, the research group had found that with no-labeling, calorie intake is 641.03 calories, however simple nutrition labeling decreased calories by 27.43 calories, and interpretive nutrition labeling decreased calories by 55.62 calories, which both were statistically significant on the 5% confidence interval. However, the “thin subsidy” and the “fat tax” only reduced calorie intake by 11.51 and 21.98 calories, which both were not statistically significant.
However, while a reduction of calories was found, what would happen towards the net returns towards restaurants? Net returns per meal per person for “the Ranch Club” is
6.94USD per person per meal with no labeling. Numeric labeling reduces this return by 0.14USD, while symbolic labeling reduces it by 0.27USD. Fat Tax, interestingly enough, increases the net returns by 0.16USD, while thin subsidies would cause the largest decrease in net returns by 0.34USD.
When looking at the benefits of the reduction in caloric consumption using interpretative labeling (yielding the best reduction in caloric consumption), they found that the benefits only yield approximately 0.13USD per person per meal. Thus, as a result, the benefit-cost ratio is only 0.481. This means, despite the increase information provided towards consumers (and as a result of their changes in consumption behavior which leads towards the 0.13USD per person per meal in benefits), the costs incurred by restaurants outweighs the total amount of benefits (a total reduction in net returns of 0.27USD per person per meal).
From this, we can see that even in best case scenarios where caloric consumption decreases which yield additional health benefits, those benefits are unlikely to outweigh the regulatory cost burdens which are incurred, and potentially, the loss in revenues from changes in consumer behavior. As a result, the potential reduction in returns may reduce future output in the food industries as new potential entrants into the market may now be discouraged to open restaurants and other food services. Such a reduction in output may affect future employment as well in the food industry, leading to potentially under-employment additional to the reduction in future output.
Furthermore, when referencing back to Swartz Braxton and Viera, their paper explores the effects of calorie/nutrition labeling on fast food consumption (Swartz, Braxton and Viera, 2011, requires access), because the vast majority of papers reviewed under the research paper finds no statistically significant reduction in caloric-consumption, it’s likely the benefits of 0.13USD per person per meal found from Ellison Lusk, and Davis’s paper will also significantly decrease or become non existent, which as a result, the benefit-cost analysis will likely move more towards zero in the fast food industry.
Thus, when looking at the overall food industry, it’s more than likely that the benefit-cost associated with caloric/nutrition labeling is lower than 0.481, especially that legislators are only looking at simple caloric/nutrition information rather than interpretive caloric/nutrition information, and that moving away from high-end restaurants yield in lower reductions in caloric-consumption.
The likely outcome from such policies is that costs are likely to increase in the food industry, either in terms of regulatory compliance, or/and reduction in revenues as a result of a reduction in consumption. Therefore, the question which should be asked in the GCC is, how can we reduce obesity levels without causing harm towards the food industry in both the short and long-run?
EDUCATION POLICY TO CORRECT INCREASES IN OBESITY LEVELS IN THE GCC:
From the research we identified above, not only do nutrition labeling in both simplistic terms and interpretive terms not yield a significant reduction in calories either in statistical or significant terms, but that even if such statistically significant or clinically significant results show a reduction in calorie consumption, such reductions, and their benefits ultimately do not outweigh the costs attached in terms of potential net return reductions.
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Therefore, if regulatory, subsidy and tax measures do not work on reducing calorie consumption, how can we reduce both calorie consumption and also increase physical activity participation of the general population without causing harm towards the economy? The answer may be found in reforming education to focus more on nutrition and physical education.
Langford et al. focus on the Health Promoting Schools Framework and what essential components and barriers are assigned to implementing the HPS framework in schools. The group had reviewed several different research papers and had look at what methods would work in reducing caloric consumption, increasing physical activity participation, and increasing consumption of healthy nutrition.
Langford et al. found that several themes are needed for the success of promoting the HPS framework in schools. They must be tailored towards individual school’s needs, aligning interventions with schools core aims, working with teachers to develop programmes (and potentially students), and provide ongoing training and support (Langord et al, 2016).
First, the group finds that training of staff is essential towards the implementation of an HPS framework in schools. With training, comes with good communication, and higher motivation and interest from teachers directing the material towards students, thus this will likely increase fidelity rates amongst students.
Second, Langford et al. stress that promoting the HPS framework must become a “core business” of schools so that it aligns teachers and other stakeholders goals to those of the students. By ensuring that the HPS framework is a “core business” of a school, it would result in health-promotion in schools to become a priority rather than a “backseat” type of program which is just a requirement.
Third, in regards to teachers developing intervention programmes, this means that teachers within specific schools should have control over what material and how the material is delivered towards students in schools. The HPS framework should act as an overall aim on what education is trying to achieve in terms of health-promotion in schools, and that it should act as a guideline rather than a specific set of instructions towards teachers.
Fourth and final integrating the HPS framework into schools being individually tailored towards each school means that the HPS framework should look at being implemented towards the need of students within that specific school so that both academics and nutrition/physical education are both attended to by the teachers and students in schools. This will ensure to maximize both academic and physical well-being of students.
From these measures being taken, the results show that caloric consumption decreases, physical education participation (and physical fitness) increase and that nutrition intake generally improves the more schools implement the four key themes in implementing the HPS framework in schools. Unfortunately, none of the studies reviewed by Langford et al. measured the relationship between health outcomes and educational attainments, however, the group cites research that overweight and
obese students achieve poor academic performance and that physical activity and nutrition can help improve academic achievement (although these studies cited have weak methodology, thus it should be cautioned on the causality found).
Therefore, from what we can ascertain from the research conducted by Langford et al. on several different papers measuring the effects of the HPS framework on caloric intake, physical activity and fitness, and nutrition intake is that to successfully reduce caloric intake, increase physical activity and fitness, and increase the intake of better nutrition, the need for an HPS framework being implemented into schools must follow the four key themes as outlined by the research papers reviewed.
By successfully implementing an HPS framework per the four key factors for success, it’s likely to achieve healthier students, which is likely to reduce obesity levels from school and onwards. The increase in academic achievements is uncertain, although if more research proves that a reduction in obesity levels and increases in physical fitness will result in higher academic achievements, then this may also result in a more skilled labor force in the future due to increases in academic attainments.
CONCLUSION:
In conclusion, caloric/nutrition labeling at restaurants and service centers for food are unlikely to work with their intended effect. The reason behind this is because a mixture of consumers value food taste over nutrition value, and/or consumers are unable to interpret basic caloric/nutrition labeling. However, when considering interpretive caloric/nutrition labeling, statistical significant results may appear in more full-service restaurants, however, those results are not clinically significant in terms of reducing obesity levels. Furthermore, when considering the cost towards the regulation requirement of caloric/nutrition labeling, at most, the benefit-cost analysis has shown to be at only 0.481. When including the fact that research at fast food restaurant from Swartz Braxton and Viera find no statistical significance in the reduction of calorie intake, this likely reduces the benefit-cost analysis performed by Ellison Lusk, and Davis.
From this, we can take away that such regulatory burden would not really benefit consumers, reduce current and/or future constraints on healthcare resources, and potentially increase productivity levels due to health benefit increases. The reality of caloric/nutrition labeling is likely to increase regulatory cost, thus affecting both output and future employment levels of the food industry.
The solution, is education. With education, a strong public and private education system must look at integrating health promoting frameworks as being a “core essential” towards the business/operational model of schools, and that such health promoting frameworks must be on a individual school level to cater towards the schools students, with teachers having input on creating the framework (while also receiving periodic training).
The likely outcomes of integrating the health promoting framework is that it will reduce obesity rates due to the likelihood of students consuming better nutrition intake, and reducing their caloric intake. However, what is uncertain is if this will translate towards higher education attainments as current research (as sighted by Langford et al.) used weak methodology to look at the effects of obesity and academic attainments. If more research is conducted on measuring the effects of obesity and academic attainments, then we may see a clearer picture towards what extent health promoting frameworks have on education, and thus ultimately, potential future productivity levels.
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SOURCES
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