In November’s monthly Journal Club we discussed the strengths and limitations of a study by Roberts et al. 2018 that looked at the calorie content of frequently purchased restaurant meals. The research controversially found that meals from fast food chains contained fewer calories than sit down meals. Further research by Theis & Adams, 2019 found that chain restaurants with nutritional information on the menu served nutritionally better food. Which poses the question – should all restaurants be listing calories on menus?

This is an approach that has been put forward by the Government in an effort to tackle obesity. It was first proposed in 2018 and, following consultation, the Government plans to legislate calorie labelling for large businesses (250+ employees) in England.

Eating out-of-home

The Government’s calorie labelling report states that, ‘it is likely that eating out frequently, including eating takeaway meals, contributes to [a] gradual overconsumption of calories’.

Eating out frequently, including eating takeaway meals, contributes to overconsumption of calories

Their research suggests that:

  • Eating out accounts for 20-25% of adult energy intake.
  • When someone dines out or eats a takeaway meal, on average they consume 200 more calories per day than if they eat food prepared at home.
  • On average, portions of food or drink that people eat out or eat as takeaway meals contain twice as many calories as equivalent to retailer own-brand or manufacturer-branded products.
  • Eating out or getting a takeaway is common: their surveys show that 96% of people eat out and 43% do so at least once or twice a week.
  • Eating out is on the rise: in 2014, 75% of people said they had eaten out or bought takeaway food in the past week, compared to 69% in 2010. 2016 evidence referred to in this year’s report showed that 68% of households with children under 16 had eaten takeaways in the last month, compared with only 49% of adult-only households.

Public Health England’s insights about Excess weight and COVID-19 (July 2020) identified the rising consumption of out-of-home meals as an important factor contributing to increasing levels of obesity. They also point to the fact that there are more food outlets than ever before, and the use of digital apps mean that the growth of takeaways and food deliveries has become very easy.

The Government’s recent revision of their ongoing obesity strategy (July 2020) set voluntary calorie reduction targets to reduce excessive calories in everyday foods by up to 20% by 2024 – including those eaten outside of the home (see our previous blog for more info). The new strategies are mentioned and supported in the latest National Food Strategy.

Research suggests fast-food chains may be healthier than sit down meals

The research by Roberts et al. 2018  controversially found that meals from fast food chains contained fewer calories than sit down meals. The paper provides the first multi-national data on measured energy contents of popular meals from sit down and fast-food restaurants. But its limitations must be taken into account:

  • Potential underestimation of calories consumed:
    • Only main course meals were analysed – sides, appetisers and desserts were not considered.
    • Frequency of meal purchases was not considered – some restaurant diners may consume multiple meals at the same sitting, or share dishes.
  • Seasonality was not considered, and sampling was restricted to a specific urban area in each country.

When discussing this research in our Journal Club, Dr Sue Reeves, University of Roehampton shared these thoughts: “There are a lot of ideas that fast food is the cause of obesity. We certainly see that in areas with a greater density of fast-food restaurants there are also higher levels of BMI.

“But it isn’t a simple cause and effect – there are many other factors which influence this. It may not actually be fast food per se, and this research has actually shown that restaurant meals can contain more calories than fast food.”

“I think one of the issues is that people are eating in restaurants and getting takeaways more frequently than they have in the past. If you are eating in restaurants on a more regular basis then this can make a significant contribution to the overall diet.

There is a real opportunity for dietitians and nutritionists to work with the industry to make it easier and sustainable to healthily

“I really want to make it easier for people to be able to eat out and eat healthily. So I do think there is a real opportunity there for dietitians and nutritionists to work with the industry to look at healthy options and how to make it easier and sustainable to eat healthily. There’s more practical work that needs to be done.”

Dr Emma Williams, Chair of the Nutritionists in Industry, shares: “Many of the larger chains now have registered nutritionists or dietitians working for them, with nutrition policies now embedded – and we have seen improvements in nutrition. However, not all do and many of the smaller chains are lagging behind. This will no doubt be impacting on the nutrition of the food being offered and the information provided for customers. So there is a big need to employ more to meet this important need within the sector.”

 

Would calories on menus work?

UK-based research (Theis & Adams, 2019) found that UK chain restaurants with nutritional information on the menu served food with less fat and salt – suggesting menu labelling may encourage reformulation of items served by restaurants, leading to public health benefits. Indeed, chains are under constant scrutiny and many (especially the larger ones) hire nutritionists to continuously improve the nutritional composition of their products and reduce calories.

Dr Sue Reeves said, “There is a whole debate on whether or not we should put calories on menus. But it’s not just about calories. Perhaps we need to highlight which are the healthy choices based on other factors such as number of portions of vegetables, or how much fibre and other nutrients as well. Sometimes you do see an asterisk or star on a menu indicating its part of a healthy menu and I think there is probably a market for that.”

 

What’s the answer?

When it comes to tackling the obesity epidemic, there is no single answer. We asked some of our MyNutriWeb experts to share their thoughts on the topic:

Tanya Haffner, Registered Dietitian and Founder of MyNutriWeb says: “Shocking statistics in the UK have reported that just 0.1% of the population are achieving the Government’s healthy eating guidelines. Obesity is a major public health concern and it’s never going to be a matter of one solution for all. It’s a multi-factorial health economic and planetary-related issue which requires urgent, multi-faceted action from all sectors – including out-of-home, which makes a significant contribution to our food intake.

“All restaurants and out-of-home caterers should have to abide by high nutrition standards, which should include following calorie, and portion size guidance. Nutritional data on the foods supplied should be made publicly available for those who find that information helpful.

The Government should set up nutrition support for independents and small out-of-home businesses

“Since the larger multi-nationals are more set up to achieve this, we believe that the Government should set up nutrition support for independents and small out-of-home businesses.

“We need to keep in perspective that this is just one support cog in the wheel for some (but not all) in helping to combat obesity. Still, in the words of one famous retailer…every little helps.”

Rhiannon Lambert, Registered Nutritionist & Founder of Rhitrition says: “Calories have proven useful in estimating the food requirements of large populations and are an important guide in terms of the energy food provides. But, it’s really not that simple as not all calories are created equal.”

“I have worked with people who feel they should maintain a minimal calorific intake at all costs, who can very quickly disregard the social and physical pleasures and traditions associated with eating.

Calories listed on menus could encourage an unhealthy relationship with food

“Calories listed on menus could encourage an unhealthy relationship with food and develop into counting calories, causing you to not eat what you really want. This could become all-consuming, cause more harm than good. Counting or restricting calories does not lead to a happy or long-term life choice. Rather than being dictated by calories, what we all need to be aware of is how to eat healthily, for life not just for weight loss!”

Helen Bond, Registered Dietitian, agrees: “Certainly, for some of my clients, knowing that a restaurant meal would supply a whole day’s calorie intake in a single entrée might make them think twice on whether it’s ‘worth it’. But many people simply ignore the calorie information.

What you eat and how you eat is just as – if not more – important than counting calories

“It’s also important to remember that calories are not the only thing that we should be focusing on when it comes to improving our nation’s health and weight. What you eat (5-a-day, fibre, sustainable plant protein sources) and how you eat is just as – if not more – important.

“Food not only nourishes our minds, bodies and friendly gut microbes, but it provides enjoyment and social interaction with friends and family. There is no quick fix for tacking obesity and this type of approach also has the potential to drive more people to disordered eating and trigger binge eating as a punishment for dining out on high calorie foods.”

 

Here are our thoughts summarising points to consider:

1. All restaurants forced to provide calories on menus

For:

  • Empowers/supports the public to make healthier choices
  • Encourages restaurants to improve their offerings

Against:

  • Can be dangerous for people with eating disorders (BEAT, a charity for eating disorders, have stated that ‘evidence shows that calorie labelling exacerbates eating disorders of all kinds’)
  • Simplifies nutrition to calories. Healthier choices can be higher calorie (e.g. nuts and seeds, which are important sources of nutrition, especially for those heading towards a more plant-based diet – see our Vegan diets – Person-centred practice webinar).

2. Restaurant chefs should work with nutritionists and dietitians to improve the nutritional quality and portion sizes of the food served

For:

  • Improves the offerings available to the public

Against:

  • Impractical and risks putting small businesses out of business without government support
  • Takes all choice and control from the public

3. Go back to basics – Educate the public on basic nutrition principles, highlighting positive attributes on menus e.g. high in fibre, one of your 5-a-day.

For:

  • Puts the choice back in the hands of the consumer
  • Does not reduce nutrition to calories alone
  • May be safer for eating disorders

Against:

  • Hard to implement across all outlets
  • May not work
We would love to hear your thoughts on this topical debate. Please use the comment box below!

 

Further background for obesity in the UK:

  1. Government policy paper, July 2020: Tackling obesity: Empowering adults and children to live healthier lives
  2. Public Health England, 2020: Excess weight and COVID-19: Insights from new evidence
  3. Government guidance, 2017: Health matters: Obesity and the food environment
  4. Centers for Disease Control and Prevention: Adult Obesity Causes and Consequences
  5. Cancer Research, 2018: Marketing unhealthy food to young people