Calorie count dilemma: New labeling proposal aims to protect vulnerable diners

03 Sep 2024 --- Researchers suggest making it mandatory for businesses to provide calorie-free menus alongside menus with calories to accommodate people with eating disorders who may find seeing calorie information on menus challenging. The University of Liverpool, UK, research team bases this proposal on several studies addressing the potential influence of calorie labeling on people with an eating disorder.

As of April 2022, England enforces mandatory calorie labeling in its out-of-home food sector as part of the UK government’s strategy to tackle obesity. The policy requires businesses with 250 or more employees selling foods for immediate consumption to provide the public with information “to make healthier decisions.”

They need to display the energy content of unpackaged foods and non-alcoholic drinks in kilocalories (kcal) and contextual kcal reference information. 

At the same time, the policy may increase the vulnerability of those at risk from an eating disorder, exacerbate symptoms for people already diagnosed and perpetuate weight stigma. 

Menus without calories

The government permits businesses to provide menus without calories on request to accommodate people with an eating disorder. 

However, the researchers note that anecdotal experiences suggest that these are not always available, with one study finding that only 12% of 90 food outlets examined had a calorie-free menu on request. Moreover, the team cautions that requesting such a menu may be distressing for people with such a disorder.

The researchers caution that calorie labeling should not be at the detriment of people diagnosed with an eating disorder and should not increase weight stigma or encourage restrictive eating. 

“Perhaps the best solution would be for all establishments to mandatorily provide menus with and without calories, either online or via QR code, and thus eliminate the need to request a menu without calories publicly,” they explain. 

Calorie labeling may increase the vulnerability of people at risk from an eating disorder, exacerbate symptoms and perpetuate weight stigma.A global study published last year estimated that 22% of children and young adults struggle with eating disorders. The authors cautioned that these are “one of the most life-threatening mental health conditions,” defining them as psychiatric disorders characterized by abnormal or weight control behaviors, which can lead to serious health problems.

Impact on eating disorders

The researchers caution limited studies are addressing the influence of calorie labeling on people with an eating disorder, listing four qualitative and three quantitative studies. 

In their perspective published in the International Journal of Obesity, the researchers explain that recurrent themes describe that “calories on menus can lead to a hyper-fixation on calories, restrict food freedom (meals are chosen for their calorific value rather than what was wanted or appropriate for hunger levels), reduce eating out opportunities, increase feelings of anxiety, guilt and shame around food choices and inhibit eating disorder recovery.” 

“Some participants in these studies expressed anger over the messaging from ‘trusted’ public health authorities on the normalization of calorie counting because calorie counting had played a pivotal role in the development of their eating disorder,” the authors detail. 

The available studies also found several positive impacts of calorie labeling, as this policy can increase feelings of reassurance, control and accountability for the food eaten. For some, the information may help to reduce overconsumption and the subsequent guilt. 

Quantitative data suggests that calorie labeling may worsen eating disorder symptoms among 55% of 583 in one study. In another research, 91% of 399 participants stated they had experienced challenges due to calories on menus. 

Support for calorie labeling

The researchers highlight that calorie labeling likely has “modest effects” on consumer behavior regarding kcal purchased. Moreover, the policy may promote product reformulation. The team cites a meta-analysis that finds calorie labeling in the out-of-home sector was associated with a statistically significant reduction of 15 kcal per dish. 

At the same time, they caution that calorie labeling has received some criticism after its implementation, partly reflecting public concern about the impact on people with eating disorders. For example, Beat, a UK eating disorder charity, criticized the policy for potentially causing distress to people at risk of developing an eating disorder or exacerbating the conditions in people already diagnosed. 

The researchers suggest making it mandatory to provide menus with and without calories, either online or via QR code.Despite the perceived negative impact of adding calories on menus, the team notes that “many people living with an eating disorder understand the need to address population-level obesity, and a significant proportion support calorie labeling.” 

Meanwhile, research on nutrition labels reveals promising outcomes for health. A study on Nutrition Facts labels links their use to healthy eating habits among US teens, while “high in” nutrition symbols may improve diets and reduce diet-related diseases. 

Research limitations and priorities

According to the researchers, there is limited evidence regarding objective changes to an eating disorder due to calorie labeling. One study found no significant differences in eating disturbance scores, anxiety and body image satisfaction, unhealthy weight-related behaviors and calorie consumption when calorie labels were absent or present in a university cafeteria. 

However, the team cautions that these participants did not have a formal eating disorder diagnosis, calling for further research on the impact of calories on menus. 

Meanwhile, the researchers call for more studies on “impacts among those living with obesity and an eating disorder, and understanding impacts among those with different types of eating disorders, including binge eating disorder, anorexia nervosa and bulimia nervosa.” 

In addition to more and more extensive studies, the team calls for studies to examine if calorie labeling leads to disease development, if it exacerbates current eating disorders or both. 

By Jolanda van Hal