Introduction
Approximately one in three of American adults and one in six American children are obese (1). The rise of obesity in America is a result of a verity of complex factors, one of which is the way that Americans eat has changed (1). Americans now consume approximately one third of their calories outside of the home and spend almost half of their annual food budget outside of the home (2,3). These restaurant and fast foods are typically higher in calories, sugar and fat and their calorie content is usually underestimated by the consumers (2,3). On November 25, 2014 the Food and Drug Administration (FDA) finalized two rules under the 2010 Patient Protection and Affordable Care Act to address this issue of lack of awareness and overconsumption of calorie dense food (4). The rules require that chain restaurants, similar food establishments and vending machines with 20 or more locations must clearly list calorie information on menus and menu boards next to the name or price of the item. The objective of the rules is to help consumers make informed and healthy diet choices for themselves and for their families (2, 4). Although some states and restaurants have already implemented calorie labeling on menus, this new legislation sets a uniform standard for all states (2). In order to help patrons recognize the significance of the calorie information menu boards will display this statement “2,000 calories a day is used for general nutrition advice, but calorie needs vary” (2).
The theory behind menu labeling is that if consumers are confronted with the calorie content of their food at the point of purchase, they may adjust their purchasing pattern and by doing so, may influence food localities to offer healthier options (5). The design of the Calorie Labeling Policy follows a Health Belief Model (HBM), which does not align appropriately with the target population, consumers. The objective of the Calorie Labeling Policy is to present consumers with facts, in this case, calories about their food options when eating out, thus “cueing” them to choose healthier food options. In addition to this cost-benefit analysis, “cues to action” are used to “push” individuals to act; in this case, the calorie labels are a “cue to action” (7).
There are multiple flaws within the design of the Calorie Labeling Policy. To begin with, the policy assumes that consumers undergo a rational weighting of health costs and benefits when making food choices at the point of purchase. In fact consumers often prioritize taste, convenience, price and hunger over health when making food based decisions. Additionally, the policy uses calorie labeling on menus to inform and influence consumer behavior, however this may confuse consumers more than it helps them. Finally, the policy assumes that by informing consumers on the nutritional content of their food, they motivate them to make healthier food choices. The problem is that intention doesn’t always lead to action. These fundamental flaws in the policy prevent it from accomplishing its objectives.
Flaw 1: Assuming that consumers make rational choices.
The Calorie Labeling Policy assumes that by increasing consumers awareness on calorie content will allow consumers to make a rational cost-benefit-analysis about what food item to choose in relation to how it will impact their health and or weight (6-9). This model, like other individual level models, is flawed because assumes that individuals always undergo a rational weighing of cost and benefits when making a health related decision. In the context of the Calorie Labeling Policy, it also assumes that consumers value their health and nutrition and will use the calorie labels to weigh the costs and benefits of choosing an item in relation to how it will affect their health. The use of this model underestimates the strength of other factors consumers are confronted with when deciding what food to order. Taste, price, convenience, along with the bombardment of media and advertising influences are likely play heavily in consumer behavior (6).
In a qualitative study by Schindler et al of 105 low-income New York City residence it was found that the majority of participants had noticed or heard of menu labels, but had not used them (14). The study found that habitual ordering, confusion over labels, price and hunger were common barriers to menu label use. For example, some participants mentioned that they go to fast food restaurants because they are hungry and choose their food items based on its ability to relieve hunger. One focus group participant mentioned, “I notice the calories, but if I’m really hungry…gimme that beef and potato, you know I’m looking for something to fill me. (14)” Other participants noted that the calorie count does in fact prompt them to weigh the risks and benefits of ordering the item, however they end up rationalizing ordering what they want. For example, one focus group participant came to the conclusion that “It [calorie label] doesn’t really affect what I eat because I’ll say, oh ok I’ll just run it off this week or in my sleep I’ll burn the calories. (14)” These focus group participants demonstrate that at times consumers may in fact go through a cost-benefit analysis when ordering food items, however they are not weighing it in relation to their health, rather in relation to other factors, like hunger.
Habits, consumer loyalty and marketing influences also play strongly on consumers’ inability to rationally weigh the health costs and benefits of a food item. In the Study by Schindler some participants mentioned that they know what food item they are going to buy before they even enter the food establishment (14). This demonstrates the influence of fast food marketing and its influence on consumer loyalty to a product. The pervasiveness of fast food marketing in America and its impact on consumer purchasing patterns has huge impactions on the ability of American consumers to make rational diet decisions. This policy falls short because it does not understand what consumers’ value and it overestimates consumers’ ability to make rational health choices at the point of purchase.
Flaw 2: The Cue to Action results in inaction
The calorie labeling policy is based on the fact that most consumers underestimate the number of calories and fat in foods they order away from home (2,3). According to the Health Belief Model (HBM), after an individual has undergone a cost-benefit-analysis, “cues to action” are needed to motivate an individual to act. In the case of the Calorie Labeling Policy, the calorie labels are meant to push or motivate consumers to make healthier food options. The fundamental problem with the “cue to action in this policy is that not all consumers understand the “cue”.
In a review of New York fast food restaurant boards, where calorie labeling has been in effect since 2008, it was found that calorie ranges for combination meals; flavor differences and customizations can vary substantially. This makes it difficult for consumers to determine the calorie content of a specific food item (17). Additionally, in a cross-sectional study by Pulos et al in Piece County, WA, it was found that 49% of customers did not understand the food labels (20). Schindler et al explains that not only are ranges confusing, but the relative value of the calories also present difficulties for consumers. Study participants mentioned confusion about the meaning of calories as well as presentation of large calorie ranges for combination meals was unclear. This confusion even led some focus group participants to distrust the label’s accuracy (14).
Though the policy attempts to help consumers understand the caloric significance of each food item by labeling each menu with the declaration that “2,000 calories a day is used for general nutrition advice, but calorie needs vary”, it is not sufficient enough to help consumers understand the calorie impact of their food. As demonstrated in the work of Schindler et al, often consumers do not know what the caloric value of their other daily foods are, so they might not understand how this one meal fits into their entire day (14). Additionally, the ambiguity of the statement “but calorie needs may vary”, may lead consumers to believe that they are an exception to the rule and therefor not use the calorie label to make their meal choice. Without providing clear tools for consumers to understand the calorie content of food items, this policy fails on “cuing” consumers to make healthier food choices.
Flaw 3: Intention does not lead to action
In a study by Ebel et al it was found that 27.7% of consumers in Philadelphia who saw calorie labels reported that it influenced their food choice, however when Ebel compared those customers to a control group in Baltimore, no changes were detected in the number of calories purchased (15). The empirical research thus far supports Ebel’s findings. Changes in consumer intention to purchase healthier options does not result in changes to their purchasing patterns (14, 18-20).
There is empirical evidence showing that there is often disconnect between intention and action with health related behaviors. In a review of 47 studies on social cognition models, like HBS, over two thirds of the studies found that a belief in ones ability to preform an action did not actually correspond to action (21). This is explained in the fact HBS and the Calorie Labeling Policy are based on the notion that behavior results from knowledge, desire and intent. The policy does not take into account the strong emotional and habitual nuances of human behavior. In the book Predictably Irrational by Dan Ariely he explains, “ We all systematically under-predict the degree to which [emotional] arousal completely negates our superego, and the way emotions can take control of our behavior. (22)” In terms of the Calorie Labeling Policy, labeling calories doesn’t work because eating is not only a physical need, but a social and emotional behavior. Food acts as comfort to individuals, it satiates our hunger both physically and emotionally. According to Ariely’s logic, this means that we cannot predict food choices or change them based on the acquisition of new knowledge on the number of calories in each portion.
This policy does not take into account human behavior or emotion, instead it takes a very simplistic view of behavior by assuming that exposure to caloric information on food and drink items will be enough to deter consumers from ordering high calorie items. In a New York Times article, George Lowenstein, a behavioral economist, enforces this point “There are very few cases where social scientists have documented that giving people information has changed their behavior very much…Changing prices and changing convenience have big impacts. Providing information doesn’t. (10)
Proposed Intervention
As an alternative to the Calorie Labeling Policy in food establishments, I propose a campaign to combat the influence of Big Food Corporations like Coca-Cola, McDonald’s, Pepsi, Burger King and other fast food conglomerates. The campaign would that use different group level behavior change tactics, like advertising and Theory of Diffusion Innovation to deter individuals from over-consuming high calorie dense foods. This campaign would involve a re-framing of the issue, the goal would no longer be prevent individual consumer behavior, but rather shift the blame and responsibility to the big food companies. This new frame would then be implemented through marketing and branding approach, using many of the theories and tactics of anti-tobacco campaigns like the “Truth” ads and targeted through school networks and media. The campaigns major objectives would be to impact the American population on an emotional level and expose the manipulation of the Big Food corporations and the consequences they have had on American families. This is in stark contrast to the rational choice model presented in the Calorie Labeling Policy.
Defense 1: The campaign focuses on freedom, not health
A frame is a method of packaging and arranging an issue so that it tells a certain story (23). One of the major flaws with the Calorie Labeling Policy is that it is framed in a way that places health as a core value and sends the message that it is the responsibility of the consumer to make rational, healthy options based on caloric information. The current Calorie Labeling Policy frame obstructs the idea of personal autonomy and life-style choices, when it should empower them. This proposed campaign would use fundamental American core value of individual freedom, a value that is deeply ingrained in American culture. According to Meashe and Siegel “although health is an important core value for the public and policy makers, personal freedoms, civil liberties and individual rights may be even more compelling values.(23)”
The core position of the proposed campaign would be that Big Food Corporations have manipulated Americans and thus caused negative effect of on American culture and that their advertising techniques have thwarted our ability to make independent choices. Images of individuals, particularly children, affected by obesity caused by Big Food would enforce our message and capture consumer emotion. By shifting the frame, we can shift the blame of the Obesity epidemic. Reframing the issue could have powerful effects not only on consumer behavior, but also on public health policy that gets to the route of the obesity problem.
Defense 2: The campaign fights fire with fire
An inherent flaw of the Calorie Labeling policy that it is based on the presumption that intention leads to action and that by empowering people with information, they will be able to overcome their predisposition for these convenient, high calorie, intensity flavorful and convenient food items. In his book Fast Food Nation, Eric Scholosser explains that (11);
McDonald’s spends more money on advertising and marketing than on any other brand. As a result it has replaced Coca-Cola as the world’s most famous brand. McDonald’s operates more playgrounds than any other private entitiy in the United States. It is one of the nation’s largest distributors of toys. A survey of American school children found that 96% could identify Ronald McDonald. The only fictional character with a higher degree of recognition was Santa Claus. The impact of McDonald’s on the way we live today is hard to overstate. The Golden Arches are now more widely recognized than the Christian cross. (11)
In a systematic review of 123 peer-reviewed studies by the Institute of Medicine, it was found that food marketing deliberately targets young children, who cannot distinguish advertising from truth, thus strongly motivating their food and drink preferences, requests and consumption (12,13). The study concludes that, “some forms of marketing increase the risk of obesity, cannot be rejected (12).” Fast food marketing is not exclusive to children, with decades of exposure the majority of American citizens have experienced of television, newspaper, magazine and environmental advertising, fast food companies have manipulated and continue to manipulate consumer choices regarding consumer choices and loyalties (6, 16).
In order to truly fight consumption of high calorie foods in chain restaurant establishments, Public Health Advocates and Legislatures need to fight fire with fire. Instead of simply attempting to educate consumers about the calories in their fast food choices, there needs to be a concerted effort to form marketing campaigns that fight against the presumptions made in fast food marketing. The proposed campaign will do this by using the same social marketing techniques employed by the anti-tobacco ‘Truth’ campaign.
The ‘Truth’ campaign looked for inspiration from the very population their campaign was targeting. They used focus groups and interviews to understand emotion behind smoking “we learned that a youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making. (24)” Branding was also used to create an identity for those who opposed the tobacco industry, this helped to accumulate awareness and bolster loyalty to the cause (24). By using these same techniques and focusing on those individuals who are affected by obesity and/or big food and target our campaign messages on the emotional factors that influence fast food consumer behavior.
Defense 3: The campaign uses social innovations theory
An alternative approach to intervening with consumers at the point of purchase and relying on a ‘cue to action’ is to use the theory of diffusion innovation to influence consumer behavior before they even enter food establishments or vending machines. The proposed campaign will use the Theory of Diffusion Innovation primarily with children and adolescents. Children and Adolescence are more easily influenced by media and peers and, spend approximately $30 billion of their own money on fast food and junk food and have significant influence over the eating habits of their families (13). The Theory of Diffusion Innovations states that “adoption of a new idea, behavior, or product does not happen simultaneously in a social system; rather it is a process whereby some people are more apt to adopt than others (25).”
A key component of the Theory of Diffusion of Innovation is the targeting of innovators, or people who are willing to take risks and who ultimately take the risks and start the innovation. Since one component of our campaign is to target schools, we would assess the social environment of each school and identify individuals who have the most social influence among their peers. These individuals would become the “innovators” of the campaign and according to the Theory of Diffusion Innovation, these innovators would then influence their peers to join the campaign (25). This method of using both school popularity and media presents a more effective platform for influencing consumer purchasing behavior because it focuses on changing social norms as opposed to changing consumer knowledge.
Conclusion
The Calorie Labeling Policy has been implemented to educate consumers on the nutritional content of the food they are purchasing in chain restaurants and vending machines. Though there is nothing inherently wrong with consumer education, however the reality is that it does very little to impact consumer behavior. Obesity is epidemic in America and if Public Health Advocates want any chance at denting fast food and junk food consumption, new strategies that target the emotions and not the knowledge of consumers is needed. Public Health Advocates can no longer rely on consumers to value their health or act rationally when making daily food choices. I propose a campaign that focuses on changing consumer behavior through emotion and taking the blame off of the individual and onto the shoulders of the Big Food corporations. This comprehensive campaign uses mass media and school advocacy to change the way that Americans not only view their food choices, but view the entire food system.
References
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