Can calorie counts on menus really reverse the obesity crisis?

In 2018, the Scottish Government set a target to halve childhood obesity by 2030, but rates of obesity and overweight in Primary One pupils are rising faster now than at any time since records began in 2001 with 15.5 per cent at risk of obesity in 2020/21 compared to 10% the year before the pandemic.

Among adults in Scotland, takeaway consumption soared in all age groups, with twice as many 25 to 34-year-olds (49%) and three times as many over-65s (14%) getting a home delivery at least once a week in 2021 compared 2020.

READ MORE: Online apps linked to huge rise in takeaway consumption

Little surprise then that half of women and 44% of men say they have gained weight since March 2020 - an ominous sign in a population where two thirds of adults were already overweight or obese pre-Covid.

So what can be done?

In England, mandatory calorie displays on restaurant and takeaway menus - including online ordering platforms - came into force this week, although the legislation only applies to businesses with at least 250 employees. Restrictions on junk food promotions in shops and supermarkets are due to be implemented in October.

Both policies should have been in place already in Scotland but were paused in 2020 due to the impact of Covid on hospitality and retail; the Scottish Government plans to consult on the former and reintroduce a Bill for the latter during the current parliament.

Rates of obesity and overweight combined in P1 pupils, by deprivation status

There is no silver bullet for obesity, but the evidence for calorie labelling in the out-of-home sector is slight.

New York City was the first place to demand that fast-food chains display calorie counts in-store and on menus back in 2008. At first, consumers reported noticing and using the information, but the New York Times notes that the effect wore off in time until “customers started to ignore the labels”.

It added: “More significantly, at no time did the labels lead to a reduction in the calories of what diners ordered. Even if people noticed the calorie counts, they did not change their behaviour.”

This was echoed by research carried out over three years across the 104 outlets of a fast food chain in Louisiana, Texas and Mississippi comparing what diners purchased before and after calorie information was added to in-store and drive-thru menus in April 2017.

Source: 'Estimating the effect of calorie menu labelling on calories purchased in a large restaurant franchise in the southern United States', BMJ, October 2019

The study found an average reduction of 60 calories per transaction immediately after calorie counts were added, but this dwindled to just 23 calories per transaction within a year which the researchers estimated “roughly translates to a loss of one pound (0.45 kg) over three years in adults”.

As in New York, they concluded that “customers initially responded to the novelty of calorie labels but stopped noticing them over time”.

However, they also stressed that, at a population level, “even such a small decrease in calories could result in tens of thousands of fewer cases of obesity and substantial savings in annual healthcare costs”.

READ MORE: How Covid pandemic has worsened obesity - and stalled efforts to tackle it

Calorie intake is only one element of a healthy diet, of course: a medium avocado has around 300 calories, compared to 230 in a standard Mars bar, but the former is packed with vitamins, minerals and monounsaturated fats associated with reducing inflammation and heart disease risk.

Nonetheless, perhaps the short, sharp shock of having your Dominos large stuffed-crust pepperoni pizza delivered in a box emblazoned with pictures of clogged arteries and sticker warning of the 2,560 calories it contains would be a wake-up call for some.

For over a decade there have been calls to tackle obesity like we did smoking.

In 2008 Professor Boyd Swinburn, a public health scientist and adviser to the World Health Organisation, said governments had to “lead the way they did with the tobacco epidemic”, adding: “We need hard-hitting messages”.

Chains like McDonalds will be affected by mandatory calorie labelling laws now in force in England, but independent takeaways like a high street chip shop will not

Last year, research from Glasgow University revealed that obesity had overtaken smoking as a cause of death in Scotland and England for the first time in 2017.

Decades of the ‘eat less, move more’ personal responsibility mantra has let the food industry off the hook and failed miserably in the face of a proliferation of junk food and spiralling portion sizes.

By 2030, half the world’s adult population will be overweight or obese, but could we ever really crackdown on excess calories like we did tobacco: banning in-store displays of everything from crisps to cheesecakes; stocking calorie-packed, low- nutrient items under-the-counter in plain packaging with grisly health warnings of diabetic ulcers and fatty livers; cigarette-style taxes;outright bans on advertising and sports sponsorship?

READ MORE: Obesity overtakes smoking as leading cause of deaths in Scotland and England 

Unlikely. But there is a middle ground between these draconian measures and the futile tinkering attempted so far.

In 2014, a comprehensive analysis by global economic think tank McKinsey scored 74 possible interventions for their population impact (in terms of reducing years lost to obesity-related disability and sickness) and cost if applied UK-wide.

Top was portion control: reducing the size of the food and drink served in restaurants, takeaways, workplace canteens, or sold through retail outlets, by just 1-5% was projected to have 3.7 times the impact of calorie labelling for a fifth of the cost, and 32 times the impact of active travel for around an 80th of the cost (although it stressed that increased city cycling and walking does benefit cardiovascular and mental health, and also cuts carbon emissions).

Impact and cost by Disability-adjusted Life Years (DALYs) ('Overcoming Obesity: An Initial Economic Analysis', McKinsey)

Reformulation of products to reduce their calories, fat, and sugar, and reducing impulse consumption of high-calorie items - for example by removing vending machines from schools and banning snack and confectionary displays at supermarket checkouts - were the second and third most beneficial measures for weight loss, and also carried a low cost.

Knowing what we can and should do to reverse obesity is not the problem; the problem is finding any government, anywhere, willing to do what it takes.