Improving obesity prevention at the local level--emerging opportunities.

n engl j med 368;19 nejm.org may 9, 2013 1761 One promising example stems from a recent federal obesity-prevention initiative: the menu-labeling provisions of the Affordable Care Act (ACA), which require chain restaurants operating 20 or more locations to provide calorie information on their menus and menu boards, along with a statement addressing daily recommended caloric intake. Despite widespread agreement in the scientific community that obesity is driven by environmental factors, the ACA’s menu-labeling provision is one of the first federal efforts to target a known environmental risk factor — consumption of food away from home, which is typically higher in calories and fat. Proponents of menu labeling offer two primary arguments in its favor: it may lead people to purchase foods with fewer calories, and its imposition may lead restaurants to reformulate higher-calorie menu items and develop more healthful offerings. Opponents often point to weak or inconsistent evidence regarding the effect of menu labeling on consumers’ purchasing behavior. They also express concern about the implementation of labeling for menu items that change frequently (e.g., seasonal items) or contain a range of calories. Aside from variation in study methods and data quality, a key reason for equivocal findings in studies of menu labeling may be related to the way calorie information is communicated. In jurisdictions that mandated menu labeling in restaurants before the passage of the ACA, calorie information is usually presented in terms of absolute calories (e.g., a hamburger has 250 calories). If customers don’t understand what 250 calories means or how those calories fit into their overall daily dietary requirements, posting that information on a menu may not be very useful. That difficulty may apply particularly to minority populations and those with low socioeconomic status, who are at highest risk for obesity and tend to have lower-than-average levels of nutritional literacy and numeracy,1 which may make it difficult for them to translate the inforImproving Obesity Prevention at the Local Level — Emerging Opportunities