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Nutrition beyond the Numbers: Counseling Clients on

Nutrient Value Interpretation

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This article is reprinted from the De-cember 2010 issue of the Journal (2010;110:1800-1803).

A lthough extensive research hasbeen conducted to determine rec-ommendations for optimal diet,

hese guidelines generally apply to theaverage person” and specific demo-raphic groups. However, average peo-le do not typically have the requisitenowledge or training to understandnd practically apply the nutrition in-ormation they are provided.

This issue has returned to promi-ence of late as a result of Section205 of H.R. 3590, the Patient Protec-ion and Affordable Health Care Act,hich mandates, in part, that calorieata be posted on the menus of chainestaurants (1). Whether patrons athese restaurants will actually makese of the nutrient data when order-

ng meals has been largely viewed aswild card factor—in one study,

mong 4,311 patrons who enteredast-food establishments, only six ac-ually looked at the posted calorie in-ormation (2). But this effect may notecessarily be a function of lack of

nterest: true, dining out is still fre-uently considered a special occasionnd, thus, a reason for indulging (1),ut it is also worth noting that con-umers frequently underestimate theutrient values of the food they con-ume—many consumers “don’t knowhat’s in fast foods, and they’re often

hocked to find out,” says Kellyrownell, Yale University’s Rudd

This article was written by KarenStein, MFA, a freelance writer inTraverse City, MI, consultanteditor for the Nutrition CareManual, and a former editor atthe Journal.STATEMENT OF POTENTIALCONFLICT OF INTEREST: Seepage S30.

adoi: 10.1016/j.jada.2011.03.006

S28 Supplement to the Journal of the AMERICAN DI

enter for Food Policy and Obesityirector (3)—and possibly don’t knowow to make sense of the nutrition

nformation they receive (4).Many individuals likely need edu-

ation about how to apply nutritionnformation at the point of purchase,nd registered dietitians (RDs) aretaring in the face of a tremendouspportunity to assert themselves ashe go-to educational resource on howo use this information that will beewly readily available.

HY HELP IS NEEDEDccording to Marilyn Schorin, PhD,D, FADA—principal of Kentucky-ased consulting firm Schorin Strate-ies LLC—many fast-food restaurantsave said that consumers won’t patron-

ze a restaurant if it doesn’t offerealthful options, yet that doesn’t nec-ssarily translate to these same indi-iduals choosing to purchase thesetems. Full-service restaurants findhat among groups of friends or fami-ies dining together, there is a highikelihood that at least one person willeto restaurant suggestions based onhe availability of healthful options.et, others believe they have estab-

ished a routine and will assert thathey will eat what they want to eat—nd they will not look at the nutritionata when exploring meal options.If even just a percentage of custom-

rs were using these data to informheir meal choices, however, it couldranslate to a national impact on obe-ity. One 2008 study showed that if0% of chain restaurant patrons inos Angeles County ordered mealsith an average reduction in energy

ontent of 100 kcal, the area popula-ion’s annual weight gain could de-rease by 39% (4).Yet, the reality is that restaurant pa-

rons have a tendency to wildly miscal-ulate the fat and energy content of thetems they select. Among the 193

dults surveyed by Burton and col-

ETETIC ASSOCIATION © 2011

leagues (5), fat and energy contentwere underestimated, respectively, by96% and 90% for a 1,500-kcal dish offettuccine alfredo; 97% and 90% for a930-kcal chef’s salad; 97% and 99% fora 3,010-kcal dish of cheese fries withranch dressing; and 85% and 88% for a1,240-kcal meal of hamburger andfries. For some of these items, the esti-mates were off by at least half the truefat and energy content of these lesshealthful choices. Participants alsoerred in guessing nutrient values formore healthful selections, though thesepercentages were generally smaller—for example, the fat and energy valuesfor a 640-kcal chicken breast were un-derestimated by 37% and 78%, respec-tively.

However, other studies have notedthat when menu labeling is present,customers’ interest in buying foodshigh in fat and energy is minimized—particularly when there is a large di-vergence between estimated and ac-tual values (4). A study by Chandonand Wansink (6) compared study par-ticipants’ energy content estimates ofmenu items from two food establish-ments, including one that makeshealth claims regarding its menu.Even when items from the two res-taurants were equal in energy con-tent, consumers underestimated by awider margin the number of kilocalo-ries in offerings of the restaurantmaking health claims.

Furthermore, the sequence of consid-ering foods to order, especially in multi-component meals, may have an impacton consumer estimation of calorie con-tent. When shown a salad before acheeseburger, participants in one studyestimated the cheeseburger had 38%more calories than was estimated byindividuals who had seen the cheese-burger first. The estimates becameeven more disparate when meal combi-nations were composed of dissimilaritems, namely, a cheeseburger and afruit salad compared with a cheesebur-

ger and a slice of cheesecake—partici-

by the American Dietetic Association

TOPICS OF PROFESSIONAL INTEREST

pants estimated the former to behigher in calorie content (7).

Compounding the issue is a generaldecrease in mathematical skills.“Thanks to calculators,” Schorin notes,“people can’t add and subtract in theirheads as easily anymore, and [usingthe nutrient values on menus] re-quires, say, adding salad plus saladdressing. These values are meaningfulitem by item but not as the total meal.”

The Fuzzy Math of Nutrient CalculationsBefore calorie labeling was nationallymandated, some municipalities hadalready enacted laws requiring thatnutrient data be posted on chain res-taurant menus, and a majority of res-taurants were publishing these de-tails on their Web sites (1).

However, these values have oftenbeen presented “to the absurdly precisesingle calorie,” such as 497 kcal for onevenue’s club sandwich (8). But nutrientvalue calculation is inexact by nature—“Even if a restaurant does its best togive an accurate calorie count, thereare still variations and it’s just an esti-mate,” Schorin says. Thus, such preci-sion is confusing. RDs will know that amenu item listed as having 439 kcaldoes not contain exactly that amount ofenergy, “But because that number is soexact, it misleads the average con-sumer and they think it’s 100% accu-rate, when it’s not” (9).

Furthermore, even standardizedmenu offerings from chain restau-rants can show inconsistency acrossfranchises, from extra pickles to lesssauce, because, as Schorin says, “Ev-ery franchise in a restaurant chain isthe equivalent of a food plant.”

Some restaurants that allow varia-tions in orders provide value rangesto reflect that any change a patronmakes within the order can alter thetotal energy content. For example,Schorin says, if, for a sandwich, “acustomer chooses an English muffinversus dense bread versus a crois-sant, this will have an impact on en-ergy content.” However, such rangesmay be difficult for the consumer tounderstand, as they could span hun-dreds of kilocalories, for example, 170kcal to 780 kcal for a salad at onefast-food restaurant and 330 kcal to890 kcal for offerings at an ice creamshop (8). Still, Schorin says, theresimply is not enough space on menu

boards to provide a kilocalorie count

for every possible variation within agiven dish.

Needlessly specific energy valuesposted on menus are, of course, not in-tended to mislead consumers; rather,the industry is operating under mini-mal guidance regarding requirementsfor nutrient calculations, and manyhave not employed the expertise of RDsin calculating these numbers. The is-sue of calculation precision will likelybe resolved once the labeling laws arefinalized, as the US Food and DrugAdministration (FDA) has called forposted data to follow the rules govern-ing packaged goods (10):

Calorie disclosure should be ex-pressed in the nearest 5-calorie incre-ments for menu items containing upto and including 50 calories, and in10-calorie increments above 50 calo-ries, except that amounts less than 5calories may be expressed as zero.

Rounding the numbers could helpconsumers with calculating their in-take, says Schorin, as numbers thatend in 0 or 5 are generally easier tocalculate than others.

For individuals who struggle withon-the-spot calculations, Schorin pre-dicts that a smartphone applicationwill be developed to assist with addingup the nutrient totals while standing inline at a fast-food establishment orwhile perusing the menu at a full-ser-vice restaurant. Aside from posting thedata, she says, there is not much morea restaurant can do to inform its clien-tele of what they are eating. Schorinnotes that one proposed solution—res-taurants printing nutrition values onthe receipt, for instance, showing thenumber of kilocalories that were in agiven order or informing the patronwhat percentage of the day’s calo-ries—is less useful because informationis provided after the fact. Furthermore,this approach does not account forwhether the receipt reflects the ordersof multiple people combined for onepurchase.

Beyond the NumbersBecause calorie posting puts an em-phasis on numbers—and these num-bers apply only to the food that isbeing offered in the immediate mo-ment—consumers may become myo-pic and only consider the nutrient val-ues meal by meal, rather than ascontributing to a full day’s total in-

take. Martin Lindstrom, a prominent

May 2011 ● Supplement to the Journa

consumer psychologist, predicts thatin the long term, consumers will ulti-mately ignore the posted calorie dataand treat it as “wallpaper” (11); how-ever, this idea assumes that in perpe-tuity, such information will just existwithout being put to use. Until con-sumers better understand how to ap-ply nutrient values to their daily mealchoices, or until programs (such asthe smartphone applications) to as-sist with this task are brought to mar-ket and adopted by the public, con-sumers will benefit from awareness ofvarious factors that can affect thedaily diet, such as condiment use andcooking methodology, and their gen-eral attitudes toward eating.Condiments. Although a fast-food–sizedpacket of ketchup may contain negli-gible calories, a customer who emp-ties 10 packets onto a large order offries is only adding to the amount ofenergy and sugar being consumed.However, says Schorin, generallyspeaking, condiments are not calori-cally significant unless they have ahigh fat content, such as mayonnaise,salad dressing, and coffee creamers.“Frequency is the key,” she notes; ad-justing condiment use based on thecombination of how much is used andhow often will have the biggest im-pact on reducing energy intake.Cooking Methodology. The way in whicha food item is cooked can affect itsnutritive value. If a menu item isidentified as “grilled,” says Schorin,the customer won’t necessarily know(without asking) if the item is grilledwith oil, sauce, butter, or plain. How-ever, equipping consumers with basicknowledge of more- and less-health-ful cooking approaches (for example,she notes, “If you grill fish, somethingis added so it doesn’t get dried out”)can help them when making decisionsat the point of purchase.Attitudes. Individuals who do eathealthful meals frequently selectmore food as their personal reward.Called “calorie compensation,” byBrian Wansink, PhD, director of theCornell University Food and BrandLab, moderation at the lunch tablemay be used as justification to in-dulge at the dinner table (12).

In addition, it has been suggestedthat people, especially in the UnitedStates, put more emphasis on con-suming what they have purchased

above the long-term health implica-

l of the AMERICAN DIETETIC ASSOCIATION S29

TOPICS OF PROFESSIONAL INTEREST

tions of always cleaning one’s plate:“We hate to throw [food] out, so wejust keep eating” (12). Says Schorin,“Dietitians can talk to individualsabout how they can change not justthe portion sizes they order but whatthey eat” to address this common at-titude of waste aversion.

Furthermore, says Schorin, con-sumers should be cognizant “not justabout kilocalories but the nutrientdensity of what they are eating. Ahigh-fiber bread might contain morekilocalories in total, but it remains amore healthful choice.”

Patrons should also be encouragedto not be shy when frequenting a res-taurant that allows order customiza-tion—although restaurants have of-fered variation or customization ofmeals for quite some time, some con-sumers may need to be reminded ofthe option. Schorin’s suggestions forcutting back on the number of calo-ries in given dishes include ordering apizza with less (or no) cheese or order-ing sandwiches without sauce; sheadds that consumers will benefit frombeing proactive when ordering.

RDs TOO BENEFIT FROM BEINGPROACTIVEEven if every consumer could (andwould) do on-the-spot calculations todetermine how much energy he or sheis consuming and even if every restau-rant provided accurate values to beused in these calculations, none of itmatters if consumers don’t or are un-willing to understand what they aresupposed to do with the information.

Public resistance to knowing what’sin fast-food and full-service chain res-taurant offerings is possible (see textbox), as many see it as a public intru-sion into their private lives. However,noting to those individuals that thegovernment has long mandated thatconsumers know the ingredients oftheir clothes, cosmetics, and cleaningproducts as well as the nutritional com-position of the packaged foods they pur-chase (13) may be a useful approach indemonstrating that posted calorie dataare meant as an informative tool.

For consumers who are interested inlearning how to use nutrient data tomake informed choices, although a pri-vate practice RD may work with a sin-gle client to discuss personalized di-etary concerns, the public at-large will

need assistance with making sense of

S30 May 2011 Suppl 1 Volume 111 Number 5

new information once they are con-fronted with the modified menus andmenu boards at fast-food and full-ser-vice chain restaurants. As Schorin ob-serves, RDs will be needed to help con-sumers navigate what calories are andhow much are needed. “The amount ofmisinformation is extraordinary,” shesays, “And this provides great opportu-nities for dietitians.”

Many industry, political, and socialactivist groups have argued that menucalorie labeling is an overstep of gov-ernment authority and posit thatthere is no evidence that it will worka

and that the truth may be that con-sumers don’t want the information onmenusb or don’t actually want to knowhow many calories are in their food.cd

Is menu labeling generally disfa-vored by consumers? Some opinionpolls indicate otherwise. In nationalpolls, there has been majority supportfor calorie information posted onmenus and menu boards, including78% of 1,003 respondents in a 2008survey conducted by an opinion re-search corporation and 74% of 2,500respondents in a 2007 consumer nutri-tion survey. At the local level, resultshave included 82% of 501 respondentsin a 2007 poll implemented by theUniversity of Connecticut and 84% of538 respondents in a 2007 survey con-ducted by a California public healthadvocacy group.e

Although it is true that menu label-ing may not affect the dietary habits ofall individuals, no one has touted it asa surefire approach to quickly eradi-cating obesity. Intended as a tool ofconsumer empowerment, it is merelya means for consumers to consider theimpact of these high-calorie items ontheir daily intake.

aReference (3).bGupta S. Counting calories on fast foodmenus. CNN.com Web site. http://www.cnn.com/HEALTH/blogs/paging.dr.gupta/2008/01/counting-calories-on-fast-food-menus.html. Published January 22, 2008. AccessedSeptember 30, 2010.cSulzberger AG. Plan would let diners count cal-ories on menu. The Oregonian. July 27, 2008.http://www.oregonlive.com/news/oregonian/index.ssf?/base/portland_news/121703732021620.xml&coll�7. Accessed September 30, 2010.dLerner M. How many calories would youlike with those fries? Minneapolis Star Tri-bune. http://azdailysun.com/lifestyles/food-and-cooking/article_b8bfaadc-7a07-56a1-a6ea-a56bb1a7dc8c.html. Published April 18, 2010.Accessed September 30, 2010.eReference (13).

STATEMENT OF POTENTIAL CON-FLICT OF INTEREST: No potentialconflict of interest was reported by theauthor.

References1. Stein K. A national approach to restaurant

menu labeling: The Patient Protection andAffordable Health Care Act, Section 4205.J Am Diet Assoc. 2010;110:1280-1289.

2. Roberto CA, Agnew H, Brownell KD. An ob-servational study of consumers’ accessing ofnutrition information in chain restaurants[abstract]. Am J Public Health. 2009;99:820-821.

3. Robert Wood Johnson Foundation, Healthy Eat-ing Research. Menu labeling: Does providing nu-trition information at the point of purchaseaffect consumer behavior? http://www.rwjf.org/files/research/20090630hermenulabeling.pdf. Accessed August 29, 2010.

4. Rosenbloom S. Calorie data to be posted atmost chains. New York Times. March 23,2010. http://www.nytimes.com/2010/03/24/business/24menu.html. Accessed September30, 2010.

5. Burton S, Creyer E, Kees J, Huggins K. At-tacking the obesity epidemic: The potentialhealth benefits of providing nutrition infor-mation in restaurants. Am J Public Health.2006;96:1669-1675.

6. Chandon P, Wansink B. The biasing healthhalos of fast-food restaurant health claims:Lower calorie estimates and high side dishconsumption intentions. J Consumer Res.2007;34:301-314. http://foodpsychology.cornell.edu/pdf/health_halos-JCR_2007.pdf. AccessedAugust 31, 2010.

7. Medical News Today. Low-calorie cheese-cake? Why we have trouble estimating calo-ries. September 22, 2010. http://www.medicalnewstoday.com/articles/201910.php.Accessed September 30, 2010.

8. Nestle M. Health care reform in action—Cal-orie labeling goes national. N Engl J Med.2010;362:2343-2345.

9. Peregrin T. Next on the menu: Labeling lawcould mean new career opportunities forRDs. J Am Diet Assoc. 2010;110:1144-1147.

10. US Food and Drug Administration. DraftGuidance for Industry: Questions and An-swers Regarding Implementation of the MenuLabeling Provisions of Section 4205 of thePatient Protection and Affordable Care Actof 2010. http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/FoodLabelingNutrition/ucm223266.htm. Accessed August 25, 2010.

11. Gregory S. Fast food: Would you like 1,000calories with that? Time. June 29, 2009.http://www.time.com/time/magazine/article/0,9171,1905509,00.html. Accessed October5, 2010.

12. Wharton School of the University of Penn-sylvania. Serving up smaller restaurantportions: Will consumers bite? KnowledgeWharton. May 16, 2007. http://knowledge.wharton.upenn.edu/article.cfm?articleid�1737. Accessed August 31, 2010.

13. Rudd Center for Food Policy & Obesity, YaleUniversity. Menu Labeling in Chain Restau-rants: Opportunities for Public Policy. 2008.http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddMenuLabeling

Report2008.pdf. Accessed September 30, 2010.