Consumers’ estimation of calorie content at fast food restaurants: cross sectional observational study OPEN ACCESS

Objective To investigate estimation of calorie (energy) content of meals from fast food restaurants in adults, adolescents, and school age children. Design Cross sectional study of repeated visits to fast food restaurant chains. Setting 89 fast food restaurants in four cities in New England, United States: McDonald’s, Burger King, Subway, Wendy’s, KFC, Dunkin’ Donuts. Participants 1877 adults and 330 school age children visiting restaurants at dinnertime (evening meal) in 2010 and 2011; 1178 adolescents visiting restaurants after school or at lunchtime in 2010 and 2011. Main outcomemeasure Estimated calorie content of purchased meals. Results Among adults, adolescents, and school age children, the mean actual calorie content of meals was 836 calories (SD 465), 756 calories (SD 455), and 733 calories (SD 359), respectively. A calorie is equivalent to 4.18 kJ. Compared with the actual figures, participants underestimated calorie content by means of 175 calories (95% confidence interval 145 to 205), 259 calories (227 to 291), and 175 calories (108 to 242), respectively. In multivariable linear regression models, underestimation of calorie content increased substantially as the actual meal calorie content increased. Adults and adolescents eating at Subway estimated 20% and 25% lower calorie content than McDonald’s diners (relative change 0.80, 95% confidence interval 0.66 to 0.96; 0.75, 0.57 to 0.99). Conclusions People eating at fast food restaurants underestimate the calorie content of meals, especially large meals. Education of consumers through calorie menu labeling and other outreach efforts might reduce the large degree of underestimation. Introduction A recent international policy approach to obesity prevention, driven by the growth in consumption of fast food, is to require restaurants to print calorie content on menus. From 2006 to 2010, many states andmunicipalities in the United States passed laws on provision of calorie content on restaurant menus. These efforts culminated in the federal Patient Protection and Affordable Care Act of 2010, which included a provision that will require all chain restaurants with more than 20 sites in the US to print calorie contents on menus. These policies were driven by the belief that individuals might consume excess calories when they are eating restaurant meals because of limited awareness of the calorie content. Previous research has shown that adults and children underestimate the calorie content of their meals, often by large amounts. These studies, however, were conducted in experimental settings with no monitoring of consumer choices at actual restaurants, 2 focused on a narrow range of fast food restaurants in samples with limited racial/ethnic diversity, 3 or were unable to examine differences between age groups or between fast food restaurant chains. 5 We quantified the difference between estimated and actual calorie content of meals purchased by adults, adolescents, and school age children at six fast food restaurant chains in four cities in New England, US, and assessed the correlates of underestimation. Correspondence to: J P Block [email protected] Extra material supplied by the author (see http://www.bmj.com/content/346/bmj.f2907?tab=related#webextra) Appendix: Additional predictors of estimated calorie content No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2013;346:f2907 doi: 10.1136/bmj.f2907 (Published 23 May 2013) Page 1 of 10