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If you have recently been to a restaurant or cafe, you may have noticed calorie information displayed on the menu for each item. This is one example of so called “out-of-home” nutritional labels, referring to any food and drink bought outside the home which is not already prepackaged. Several countries have introduced these types of menu labels to reduce obesity levels.
Spotting menu labels can lead to different reactions in different people. Some may not pay much attention, others may use the information to make a choice about their order.
While there is recent evidence that such labels lead to small reductions in calories selected, concerns have been raised about the effect these labels have on people with eating disorders. We have recently reviewed all the available studies on how menu labels affect people with eating disorders and found evidence of mainly negative impacts.
Eating disorders are serious psychiatric conditions. Common symptoms include restricting food intake and being preoccupied with thoughts about weight. It is these symptoms that people are concerned about when thinking about menu labels.
In our review of the existing evidence, we found that people with eating disorders said they felt as if they were being ordered to cut down on what they eat and that the labels reinforced their beliefs about overeating. People with eating disorder symptoms said they were more likely to notice menu labels and change their behaviour based on seeing menu labels compared to people without these symptoms.
People with eating disorders also said that their eyes are drawn to calorie information on menus. And this is supported by evidence from eye-tracking research.
But food choices are not the only aspect of eating out. For many, going to a restaurant or cafe is a social experience. Something fun to do with friends or family. A way to celebrate a special occasion.
But for people with eating disorders eating out can be difficult and distressing. Menu labels can complicate this further. Our review found that for some, menu labels trigger their eating disorder thoughts and lead to distress, although for others these labels can be freeing and reassuring.
A common concern with anti-obesity policies such as menu labels is the focus on weight or calorie intake as a single indicator of health. Physical health is far more complex than can be measured by a single indicator.
This simplification may make for easier messaging, but exposure to anti-obesity messaging focused on weight can amplify harmful stereotypes equating thinness with health. Such beliefs are not only risk factors for eating disorders, but also perpetuate the stigma surrounding weight.
Obesity rates are rising globally. Governments and public health officials are continuously looking for solutions to this trend. However, it is important for these solutions to consider potential harms to people with eating disorders.
Obesity and eating disorder prevention are not mutually exclusive. In reality, many things that would help prevent obesity are also helpful in preventing eating disorders. These include reducing weight stigma, improving body image, and increasing family meals.
Menu labels represent a policy that involves giving people information and putting the onus onto them to change their behaviour. But this type of strategy can come with negative side-effects. For one person, encouraging them to eat fewer calories may be helpful, but for another it may be harmful.
Other policies, such as advertising bans, that change behaviour by changing our environment might not have this problem. A recent study showed a marked difference in how people with eating disorders perceive these policies compared to menu labels.
While over a quarter said that menu labels would make their symptoms much worse, only around 2% said the same thing about policies like advertising bans on unhealthy foods or banning “buy one get one free” deals for unhealthy food and drinks.
Much of the discussion around this topic has focused broadly on “people with eating disorders”. But people with eating disorders are a diverse group.
Some people may have symptoms primarily focused on restricting food, whilst others may have symptoms relating to binge eating. And these symptoms can be affected differently by menu labels. Most of the research to date has focused on those with restrictive symptoms, who primarily report negative effects.
Our review found that very little research has included people with binge eating, and few of those studies included men with eating disorders. The most notable gap, however, was that no studies have yet been conducted with young people below the age of 18.
Therefore, while we know that menu labels can cause harm to people with eating disorders, much more research is needed across the full spectrum of age, gender and types of eating disorders.
Effective public health policies are vital in addressing society’s big challenges, like obesity. But effective policies need to balance benefits with harms.
Tom Jewell receives funding from the NIHR Policy Research Programme, NIHR205226. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
Nora Trompeter receives funding from the NIHR Policy Research Programme, NIHR205226. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
