Harmonising Health Debates Around Food Abandon Unhelpful Ideologies and Seek the Common Ground
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FOOD FOR THOUGHT EDITORIAL Harmonising health debates around food Abandon unhelpful ideologies and seek the common ground hristmas is coming, and it’s not served by fast food chains, and 1033 kcal in to both sides of the ideological debate. just the geese that are getting dishes served by full service restaurant chains. It can be characterised as providing fat. Celebrations over the Comparable figures reported by Roberts customers with information they can holidays often revolve around and colleagues from Brazil, China, Finland, use, if they wish, to make healthier gathering and feasting. In the Ghana, India, the UK, and the US combined choices. In this framing, it is a high Cnorthern hemisphere, baby it’s cold outside were 1317 kcal and 809 kcal. agency intervention requiring and the long, silent nights may contribute England’s national public health agency individuals to read, understand, to seasonal variations in physical activity.1 2 recently recommended that midday and interpret, and apply the information Together, increased opportunities for eating evening meals contain no more than 600 kcal provided. Current evidence suggests a small and decreased propensity for physical activity each.10 Robinson and colleagues found that impact of menu labelling on purchasing and likely contribute to the 0.4-0.9 kg weight gain 89% of full service dishes and 83% of fast consumption.16 found in adults home for the food dishes were over this But menu labelling could also be seen holidays.3 The Prevention Strategy limit. Figures from Roberts as a low agency intervention, requiring people Mason and colleagues was about people being and colleagues were 94% to use few personal resources to benefit. (doi:10.1136/bmj.k4867) naughty or nice, stressing and 72%, respectively. Those Cross sectionally, US chain restaurants that target prevention of personal responsibility deep-pan, crisp, and even voluntarily label their menus, serve dishes weight gain over the bleak pizzas aren’t helping. with fewer calories than those that do midwinter holidays.4 Their intervention The tension between targeting individuals not, suggesting that menu labelling could combined regular self weighing with written and environments represented in these three encourage portion size reduction by the information describing seasonally adapted studies is laid bare in recent UK government chains themselves.17 “10 Top Tips” to help habit formation,5 and a policy. The second chapter of the Childhood So far, the evidence supporting high or low list of the physical activity caloric equivalents Obesity Plan,11 published in June 2018, agency impacts of menu labelling is weak. But of common holiday foods they checked twice. includes proposals for food environment if ideology is more important than evidence Their randomised trial found an adjusted interventions that require people to invest of effectiveness when deciding which public mean difference of −0.5 kg in weight gain at few resources to benefit (low agency health interventions to implement, the 4-8 weeks in the intervention group compared interventions). These gifts include further menu labelling story highlights the potential with controls. restrictions on unhealthy food advertising, value of advocates being creative in how they It is intuitively attractive to focus on bans on supermarket price and location based “sell” evidence informed interventions to preventing weight gain during, rather than promotions of unhealthy food, and greater different constituencies. achieving weight loss after, the holidays. But support for using planning regulations to focusing on individual weight change perhaps improve local food environments. Peace on earth deals with the symptom, rather than the By contrast, November’s Prevention It might also be important to think further cause. Environmental factors are increasingly Strategy,12 was more about whether people about how different types of interventions recognised to be potent determinants of are naughty or nice, emphasising personal work together. Rather than either/or, some eating, as well as other, behaviours.6 responsibility for “lifestyle decisions” and combinations of interventions may have requiring them to invest substantial personal synergistic effects. For example, the (high Deep-pan, crisp, and even resources to prevent weight gain (high agency agency) intervention to prevent weight gain Portion size is one environmental factor interventions). trialled by Mason and colleagues might have known to affect consumption.7 Robinson and Although some evidence exists on the a greater effect in those living in environments colleagues (doi:10.1136/bmj.k4982) and relative benefits of high versus low agency where restaurants serve lower calorie meals Roberts and colleagues (doi:10.1136/bmj. interventions,13-15 the tension between (a low agency intervention). Researchers k4864) both conducted surveys of the these two often comes down to ideology. In could do more to investigate such potential energy content of main meal dishes a context where action on environmental synergies to understand under what served by full service and fast determinants of health behaviours often circumstances they do and do not occur. food restaurants.8 9 In the United requires government regulation, and hence Rather than allowing themselves to Kingdom, Robinson and colleagues political will, ideology concerning the fall into ideological camps, if the public report a mean energy content of 751 palatability of government regulation in health community really wants to effect kcal in main meal dishes general can become a deciding factor. change, they need to find ways to transcend Both Robinson and colleagues ideological debates, appeal to all sides, and Jean Adams, senior and Roberts and colleagues mention acknowledge the potential value of many lecturer, Centre for Diet & Activity Research, University the possibility of providing instore different approaches. of Cambridge School of information on the calorie content of Cite this as: BMJ 2018;363:k5028 Clinical Medicine restaurant dishes. Menu labelling is an Find the full version with references at [email protected] example of an intervention that might appeal http://dx.doi.org/10.1136/bmj.k5028 436 15-29 December 2018 | the bmj FOOD FOR THOUGHT ORIGINAL RESEARCH Multi-country cross sectional study BMJ OPINION Measured energy content Susan B Roberts and Sai Krupa Das Everyday living as inspiration of frequently purchased for weight control research restaurant meals Daily living is a rich source of inspiration for scientists Susan B Roberts, Sai Krupa Das, Vivian Marques Miguel Suen, Jussi Pihlajamäki, specialising in weight management, and our interest in Rebecca Kuriyan, Matilda Steiner-Asiedu, Amy Taetzsch, Alex K Anderson, Rachel restaurants began with a simple problem—what to eat for E Silver, Kathryn Barger, Amy Krauss, Leila Karhunen, Xueying Zhang, Catherine lunch when trying to lose weight? Our research building at Hambly, Ursula Schwab, Andresa de Toledo Triffoni-Melo, Priscila Giacomo Fassini, Tufts University has no cafeteria. There is yummy Chinese Salima F Taylor, Christina Economos, Anura V Kurpad, John R Speakman food just a block away, and one of us (SBR) was both partial Objective To measure the energy content of frequently ordered meals from full to Chinese food and finding it hard to lose pregnancy service and fast food restaurants in five countries and compare values with US data. weight. We measured the calories of some favourite meals using bomb calorimetry, which is the gold standard method Design Cross sectional survey. for measuring food energy, and the horror of finding that Setting 223 meals from 111 randomly selected full service and fast food a single takeout has more calories than needed for a restaurants serving popular cuisines in Brazil, China, Finland, Ghana, and India whole day during weight loss led to a series of studies that were the primary sampling unit; 10 meals from five worksite canteens were also continues today. studied in Finland. The observational unit was frequently ordered meals in selected Our first protocols found that our Chinese takeouts were not restaurants. unusual, and that most large chain restaurants in Boston serve Main outcome measure Meal energy content, measured by bomb calorimetry. meals containing far more calories than needed at a single Results Compared with the US, weighted mean energy of restaurant meals was 1-3 meal. We were also shocked to learn that low calorie menu lower only in China (719 (95% confidence interval 646 to 799) kcal versus 1088 items often contain more calories than stated2—thus thwarting (1002 to 1181) kcal; P<0.001). In analysis of variance models, fast food contained the best intentions of people, like us, ordering the sensible 33% less energy than full service meals (P<0.001). In Finland, worksite canteens choices to manage their weight. After that, it was a natural provided 25% less energy than full service and fast food restaurants (mean 880 step to check whether restaurants across America overfeed (SD 156) versus 1166 (298); P=0.009). Country, restaurant type, number of meal 4 their customers (yes, they do). Our Low calorie components, and meal weight predicted meal energy in a factorial analysis of 5 2 most recent study examined whether menu items variance (R =0.62, P<0.001). Ninety four per cent of full service meals and 72% of fast food meals contained at least 600 kcal. Modelling indicated that, except in American restaurants are unusually often contain bad on a global scale. Our observation China, consuming current servings of a full service and a fast food meal daily would more calories of meals in the different countries we supply between 70% and 120% of the daily energy requirements for a sedentary visited for research meetings led us to than stated woman, without additional meals, drinks, snacks, appetisers, or desserts. suspect that restaurants were a problem everywhere, but the Conclusion Very high dietary energy content of both full service and fast food widespread lack of nutrition information meant that we had restaurant meals is a widespread phenomenon that is probably supporting global nothing to base our suspicion on except intuition.