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Nashville is on the brink of becoming the first city in the Southeast … and among the earliest adopters nationwide … to embrace caloric menu labeling for food service establishments with 15 or more outlets.

"Because the rate of consumption of away-from-home meals has increased dramatically, the distinction between requiring nutrition information for packaged but not restaurant products is no longer reasonable," opined Jennifer L. Pomeranz, JD, MPH, and Kelly D. Brownell, PhD, in the September 2008 issue of the American Journal of Public Health.

Proponents of the proposed Nashville regulation hail the move as a method to provide crucial caloric information at the point of purchase in the face of a nationwide obesity epidemic. Opponents say they fundamentally agree with the sentiment behind the regulation but balk at the implementation of localized rules ... preferring instead to wait for a uniform federal mandate.

The expectation is that the Metropolitan Board of Health will issue a final vote on the regulation at the February board meeting. Alisa Haushalter, DNP, RN, director of the Bureau of Population Health for the Metro Public Health Department, said there have already been small meetings with key stakeholders, a public hearing, and the required public comment period. The November 6 public meeting at the Lentz Health Center attracted an estimated 80 interested audience members and featured comments by nearly a third of the attendees. The group ranged from medical researchers to physicians to hospitality industry representatives.

Haushalter said comments fell along anticipated lines with a strong showing of support within the medical community and concern about the increased regulation among the restaurant industry attendees.

Walt Baker, interim executive director of the Tennessee Restaurant Association and CEO of the Tennessee Hotel & Lodging Association, was one of the speakers who voiced concern about the operational issues and timing of the proposed regulation.

"The biggest concern that we have is just the execution of it. It's never been about the aspect of nutritional labeling," he said, adding the restaurant industry has been particularly active on a federal level in pushing for national menu labeling through the LEAN Act (HR-7187/S-3575).

Haushalter, however, noted federal legislators did not pass either LEAN or MEAL (HR-3895/S-2784), which is the federal legislation preferred by the public health community, in various incarnations since voting on the subject began in 2003. Although she would be pleased to see a nationwide effort to provide additional nutritional information, she noted, "We do not know when it will pass at the federal level and anticipate it will take a minimum of two years to implement once it does."

In the meantime, Haushalter noted, Nashville and the nation continue to face a growing obesity epidemic.

"We do know between 1980 and 2000 — so in a 20 year period — there was a tripling of obesity among young people in the United States. Locally, studies show that at least half of our adults are overweight or obese," she noted.

In his article, "Obesity in Nashville: Using Facts to Make Informed Decisions," David G. Schlundt, PhD, associate professor of psychology at Vanderbilt, underscored Nashville's part of the obesity epidemic based on data from the CDC's Behavioral Risk Factor Surveillance System (1997-2007) and Nashville REACH 2010 project (data collected 200-2004). In the decade between 1997 and 2007, Nashville recorded an annual 1.1 percent rate of increase in clinical obesity. During that same period, those designated at extremely obese (BMI ≥ 40) jumped from 2 percent to 5.6 percent of the population. If the trajectory doesn't change, Schlundt's research showed by the year 2022, 43 percent of Nashville's adult population would be obese and more than 19 percent would be extremely obese.

With evidence-based research that directly links obesity to a number of chronic and acute conditions including cancer, heart disease, diabetes and arthritis, Haushalter said the long-term outcomes of obesity could be measured in "billions of dollars" in terms of cost to the healthcare system and toll on quality of life.

She is quick to say the MPHD does not see this measure as a panacea to the obesity epidemic.

"There are many solutions that as a nation we need to implement to help people be healthier," she noted. "One strategy … among many … is to give people tools to make informed decisions."

In announcing the November meeting, Director of Health for Nashville and Davidson County Bill Paul, MD, said, "Eating at a restaurant is for many an everyday event. Most people underestimate the calories they take in when they are eating out."

MPHD provided a handful of examples that highlighted calorie surprises that might trip up consumers even when trying to "be good" — McDonald's Grilled Chicken Sub contains 530 calories … 20 more calories than the Quarter Pounder with Cheese (510).

Haushalter said listing calories on menus and menu boards is a "simple, easy tool" to help the public make an informed decision prior to placing an order. She stressed the regulation stipulates the caloric information be easily visible, printed in a size equal to that of the price and be readily available at the point of purchase.

She added those opposed to the proposal argue nutritional information is already available for most chain restaurants. However, she countered, that information is often on the Web site or tucked behind a counter and not easily visible at the point of sale.

Haushalter noted the department has made some changes to the original regulation based on comments and meetings with hospitality industry representatives including extending the compliance period to the end of 2009 to give restaurant operators time to update signage and menus.

The small tweaks, however, are not enough to answer the operational concerns of those impacted by the regulation.

Baker said the fast food chains primarily targeted in the regulation produce menu boards in quantity. He added the cost to change paper menus isn't nearly of as much concern as the large drive-thru and backlit signage. Adding to the restaurant industry's frustration is that localized rules — which have cropped up in places like New York City, Seattle, Philadelphia, California and potentially Nashville — all have their own specific parameters that make it impossible to mass produce signage and thereby increase operational costs.

"It needs to be done with a little common sense behind it that allows for economies of scale," Baker said, adding that is why the industry would prefer to implement a national set of standards.

While the execution is the main concern, it's not the only issue. Baker said the local industry is also worried about "how loosely the language is written in this regulation." He questioned whether or not advertisements on billboards, banner signs or coupons would require the inclusion of caloric content. He noted that national advertising campaigns could unintentionally cause problems for local operators.

Similarly, he has questioned the scope of those impacted by the rule. While 'mom and pop' restaurants are clearly excluded, what about individual restaurants in chain hotels … C-stores in gas stations with a deli … theaters selling popcorn and hot dogs … grocery stores that offer prepared meals or food products?

Baker has called for more clarity in the language to answer some of these questions. He has also expressed concern over the failure to address business liability. With the potential for variation from a menu's stated caloric content due to preparation or portion size, would a restaurant face legal ramifications if a patron subsequently suffered a heart attack? While many fast food chains have pre-set, standardized portions, this regulation would also impact chain restaurants such as Ruby Tuesday's or The Cheesecake Factory where meals are individually prepared by various chefs.

"You're forcing restaurants in Davidson County to this rigid set of standards that might be completely different the minute you step into Cool Springs," Baker stated. "The obese issue does not stop or start at the Davidson County line," he said.

"It doesn't make sense to try to solve the problem one pin prick at a time," he continued of local or statewide regulations. "They're all well intended and nobody's opposed to the intent behind it. It's just not practical to try to solve the problem one city at a time … particularly when you have a willing industry pushing for a national solution."

From Haushalter's perspective, the citizens of Davidson County for which she is responsible cannot wait for national action that might or might not come in the near future.

She added that in addition to giving restaurant patrons easily accessible caloric information, the new regulation would quickly activate a large-scale educational component designed to help consumers effectively use the menu-labeling tool and offering evidence-based information on ways to change bad habits into healthier behaviors.

Tags:

Alisa Haushalter, American Journal of Public Health, Bill Paul, caloric menu labeling, David G. Schlundt, Jennifer L. Pomeranz, Kelly D. Brownell, LEAN Act, MEAL Act, Metro Public Health Department, Obesity in Nashville: Using Facts to Make Informed Decisions, Walt Baker

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