Short Run for a Long Slide

See Article by Liu et al

The Nutrition Labeling and Education Act in 1990 mandated that packaged foods display nutritional information, including caloric content. This does not apply to restaurant foods. Restaurant menus have remained relatively unpoliced and exempt from displaying information at the point of sale. Since restaurants are a major source of the one-third of calories consumed by Americans outside of the home, many meals are consumed without complete knowledge of their caloric content. However, as of 2018, restaurants with ≥20 locations are now required to display an item’s caloric content on the menu. Additional macronutrient information (eg, fat, sugar, and sodium content) is not required to be displayed but can be obtained elsewhere (eg, online). Although real-world data are not yet available on the impact of displaying caloric contents on menus nationwide, prior nationwide food labeling changes have proved to be efficacious. For example, the addition of trans fats to packaged food nutrition labels in 2006 was associated with lower levels of trans fats in the blood and promoted companies to reformulate products to have lower trans-fat content.^1–3

In this issue of Circulation: Cardiovascular Quality and Outcomes, Liu et al⁴ report on the potential health and economic outcomes from the recently implemented national restaurant calorie menu labeling laws in the United States. To their credit, the authors made several conservative methodologic choices, such as estimating a 50% predicted caloric replacement from consuming lower calorie meals. Despite conservative assumptions, this relatively small change to how foods are labeled at restaurants is predicted to provide large gains in population health via prevented cases of cardiovascular disease and diabetes mellitus, saved quality-adjusted life-years, and billions saved in healthcare and societal costs. Rather than the proverbial long run for a short slide, calorie labeling on menus is a relatively short run for large gains. These policies are predicted to be rapidly beneficial. They will be efficacious within 2 to 3 years and cost-saving in the fourth year, with larger gains beyond that. Other nutritional policies have similarly found effects within short periods of time. For example, sugar-sweetened beverage taxes lower sales substantial within 1 year (38% in Philadelphia),⁵ and trans-fat restrictions in restaurants decreased myocardial infarction and stroke at ≥3 years after implementation.⁶

Several findings deserve particular focus and highlight the importance of nutritional policy. Liu et al found that younger populations have the largest potential disease prevention from calorie menu labeling. This can only further suggest that populations younger than those studied are expected to find gains as well. Dietary choices are lifelong factors, and any policies that influence food choices are likely to be cumulative. Nutrition policy can shift the curve on preventable disease given that the changes will be experienced over an entire lifetime.

This policy also offers potential improvements in health equity. There was a greater effect for low-income and minority populations, who share a disproportionate burden of diet-related diseases. Other nutritional policies, including those that decrease the intake of sugar-sweetened beverages are also similarly poised to benefit those that have the highest burden of disease. Particularly since low-cost calorie-dense unhealthy foods are disproportionately advertised to those of low-income and socioeconomically disadvantaged backgrounds.^7,8 This highlights that thoughtful consideration to future health policies and how they affect particular at-risk groups that have historically been marginalized should be a consideration of nutrition policy decisions.

Diet-related diseases are now the top cause of preventable death in the United States.⁹ Nutrition policies that shift consumers to healthier choices are essential for curbing the epidemic morbidity and mortality from preventable illnesses. Cost savings and gained quality-adjusted life-years from nutrition policies can be seen as a win-win. However, some will see additional nutrition policies as an impingement upon individual choice and corporate freedoms. In the case of menu labeling, this argument is hard to consider seriously when the only change is giving consumers more information. However, additional policies that are more likely to be viewed as infringing on free choice might be met with stronger opposition, for example, taxes on sugar-sweetened beverages. Thus, it is important to consider ways to incite consumer and corporate acceptance by offering benefits that are likely to aid in maximizing policy efficacy. In the current case example of caloric menu labels, the added cost for reformulation and generating new menus is substantial. However, as shown by Liu et al, these reformulations greatly enhance the policy’s efficacy. Thus, future policy considerations should focus on integrating industry-friendly benefits that encourage shifting restaurants to healthier meal options rather than solely adding more regulations, for example, offering incentives to restaurants that manage to reformulate specific unhealthy meal options and replacing them with more healthy versions or new options.

Over years, cost savings from adopting improved nutrition, such as suggested by Liu et al, can add up to billions of dollars in savings and thousands of quality life-years gained. Additional win-win situations, wherein healthcare costs are reduced and lives are saved, will be necessary to curb our current healthcare crisis. We continue to move into an era where food is being adopted as medicine. Take medically tailored meals for example, which have the potential to keep at-risk individuals from being hospitalized and greatly reduced healthcare costs.¹⁰ Nutritional policy offers the possibility to change baseline choices and result in a lifetime of different health exposures. To truly curb the epidemic of preventable disease in the United States, additional policies that change how products are labeled or the cost of products (ie, sugar-sweetened beverage taxes) are likely necessary to meet these goals. Studying the population health impact of these policies, such as that by Liu et al, is essential to ensure that future policy choices are data driven, equitable, and maximally efficacious. If done right, these policy changes will improve population health and act as a cornerstone for a healthier America with a lower burden of preventable chronic disease.

Footnotes