Repeal the "Healthy Menu Choices Act"
In January 2017, the Healthy Menu Choices Act will come into force. Under this Act, chain restaurants (defined as those with 20 or more locations) will be required to prominently display nutritional information on their menus. Calorie counts will be listed in a font size at least as large as the price of the item. The act is unspecific regarding other nutrition information. We oppose this Act on the grounds that having calorie counts prominently displayed on menus will be detrimental to many individuals with eating disorders and in recovery from eating disorders.
A conservative estimate of the prevalence of eating disorders is 1-3%. While this figure may not sound impressive, it equates to approximately 130 000 individuals when extrapolated to Ontario’s population. Importantly, this figure does not include those who are never diagnosed with eating disorders because of the significant barriers to obtaining a diagnosis (including stigma, shame, and lack of physician training to address and diagnose eating disorders in all but the most obvious and stereotypical of cases). Eating disorders carry the highest mortality rate of all mental illnesses, and have significant impacts on the quality of life and health status of those suffering and their family members. Those with eating disorders, at risk for eating disorders, or in recovery from eating disorders will be negatively impacted by legislation that forces them to encounter caloric information whenever they look at a menu.
The argument will be made that obesity is of graver concern than eating disorders right now in Ontario and worldwide. We encourage a separation, however, between a body size and a mental illness. Anyone, regardless of body size, ethnicity, socioeconomic status, gender, ability, etc. may experience eating disorders - including restrictive eating disorders. Further, those who are most targeted by such initiatives may actually be at a greater risk of developing eating disorders. A recent study by Lebow, Sim & Kransdorf (2015) revealed that adolescents who had been overweight or obese “represent a substantial portion of treatment-seeking adolescents with restrictive eating disorders,” and argue that extreme weight loss is problematic in the adolescent context in particular.
We argue that this act is unhelpful insofar as it positions caloric content as the most important aspect of decision-making around food. This is a dangerous perspective regardless of a person's body size or the presence or lack thereof of an eating disorder. Dietary science is continually in flux, particularly where weight loss is concerned. Researchers disagree about the relative importance of calories in overall health. We know still less about the effects of displayed calorie counts on both health behaviours and health outcomes. Leaving aside a debate about whether weight loss is a desirable outcome, we should consider whether implementing calorie counts on menus actually leads to the suggested outcome: a reduction in overall caloric intake.
The evidence around the effectiveness of providing calorie counts on menus is limited and conflicting (Capacci et al., 2012; Sacco, Lillico, Chen & Hobin, 2016). While some researchers suggest that providing calorie counts on menus will reduce overall caloric intake (e.g., Pulos & Leng, 2010) and argue for policy changes like the Healthy Menu Choices Act (e.g. Roberto, Larsen, Agnew, Baik & Brownell, 2010), others suggest that attempts to change behavior by offering information is unlikely to lead to long-term change, if it has an impact at all. For adolescents in particular, "providing menu labels in their current format may not be an effective strategy to increase healthy food selection" (Evans, Weiss, Meath & Chow, 2015). Researchers have found that the implementation of calorie counts on menus leads to no change (Tandon et al., 2011).
Beyond being ineffective, we argue that providing calorie counts on menus will be harmful to a significant segment of Ontario’s population. The assumption that underpins such legislation is that a reduction in caloric intake is necessarily a positive thing. These efforts are put forth in the interest of reducing obesity by reducing calories; providing calorie counts does nothing to provide information about eating in tune with bodily cues, honouring hunger and fullness, and engaging in healthful behaviours.
The impact of calorie counts on menus on people with eating disorders and in recovery has not been studied directly. We can, however, draw obvious links between the tracking and monitoring behavior many with eating disorders engage in and the danger of calorie counts on menus. People with eating disorders are often meticulous about intake: common symptoms of eating disorders include reducing amount of food, following strict food rules (including calorie count limits), food rituals, social competitiveness around eating, feeling guilty after eating, and more (Treasure, Claudino & Zucker, 2010).
People with eating disorders cannot simply “choose not to look” at calorie counts on menus. By having this information readily available and prominently displayed on menus, those with eating disorders and in recovery are confronted with numbers that can impact their choices and, consequently, their health. Many seeking to recover from their eating disorders will be actively working to challenge themselves to eat foods for which they do not know the nutritional content; this is often a step forward in recovery that this legislation precludes.
We urge you to repeal the Healthy Menu Choices Act, which infringes on the mental and physical health of people living with and in recovery from eating disorders. Given the lack of evidence for the effectiveness of calorie counts on menus and the possible danger of this information, this Act is highly problematic and should be reconsidered.
While the research supports our argument, it does not capture the experiences of those who will be impacted by this Act. Amanda Acchione's story captures the challenge of navigating this world.
A Letter from Amanda Acchione
Hello Ms. Wynne,
I am writing to you in connection with Healthy Menu Choices Act which is set to take effect in January 2017. I feel strongly compelled to write you this letter because I know the effects that this legislation will have on a segment of the population that I do not believe was given due consideration in the process of developing this legislation.
I am speaking of people who, like myself, struggle with an eating disorder.
Ms. Wynne, I suffer from anorexia. I am in the midst of a very painful recovery period which involved hospitalization and continued intensive therapy. I was diagnosed with anorexia in the beginning of 2015, and prior to my formal diagnosis I had struggled in silence with the illness for 18 months.
I think it is very important for you and others to understand some of the factors that contributed to this disorder and how the new legislation will have a direct impact on my ability to live healthily in a recovered state.
In October 2014, I downloaded a phone application that would track all of the information that the new legislation hopes to clarify through its nutritional labelling requirements (and more). I thought it would be a fun or funny experiment to see how my daily intake lined up with the arbitrary guidelines that were set up as a preset in this application. They were loosely linked to Health Canada’s estimated energy requirements and they had Percent Daily Values that vaguely reminded me of the numbers I saw on food labels. I had always struggled to understand labelling, how could I, a 25 year old female and my father, a 56 year old male both be consuming 28% of our daily sugar intake by eating one cookie? Nevertheless, I bought in. It all seemed to make sense at first, I had found the key to ensuring that I was making “wise choices” (Government of Canada slogan)! I told myself that I couldn’t possibly be trusted to make my own decisions like I had been for the past 20 years. It made sense, we were going back to the beginning like in elementary school with low-fat, no meat, and whole wheat “pizza” (in what world is that pizza?!) days. My school taught that when it comes to nutrition, we certainly don’t know what is best and need to be told how to regulate ourselves. They made the food manufacturers and the restaurants the “bad guys”, painting a Machiavellian villain image of a boardroom full of people waiting to turn unsuspecting adolescents into food addicts.
By December 2014, I was only eating things that were explicitly labelled. Meaning, if a restaurant didn’t have nutritional information available – I wouldn’t eat there. I would only eat at places where I could know with certainty what I was eating, what kind of “room” it would leave me in my day for other foods, and how little I could possibly eat to get by without fainting.
I tracked my food religiously. I was meticulous, I didn’t (because I thought I couldn’t) leave a thing to chance. If there was no nutrition label, I wouldn’t eat it. In fact, when I started hearing stories in August 2015 about how the Government of Canada had proposed changes to food labelling to show all of us laymen how much dangerous sugar was lurking in our foods just waiting to give us heart disease I stopped eating all added sugar. One might say that is a near impossibility, to which I would reply, nothing is impossible if you are hell-bent on killing yourself and all the traps are there to continuously reinforce and nourish that need.
My weight went down, and my mood soon followed. I felt sad, desperate, and alone; I was a hopeless spectator in my life as I watched the days pass by. The feelings of love from my family and friends started to feel dim and disconnected with reality. The only thing that brought me joy was seeing that I had made it through another day under my intake “goals”. I looked at my body and I wanted to occupy as little physical space as possible and I was inundated with the tools that could help to get me there. I can only imagine (and fear to think about) how much “easier” it will become to live that way with the increased access to nutritional information.
Soon, being under my intake goals wasn’t enough. In the absence of food, I over-exercised and abused laxatives. I needed to see bigger drops, train my body to be a temple, after all, I was above eating at a fast food establishment. A fitness tracker became an extension of my arm. Because I was so malnourished, I couldn’t risk elevating my heart rate too much for fear of fainting, but I certainly could walk. An arbitrary goal of 10,000 steps set by the Heart Association? Sure, but let’s double it just to be “safe”. I would pace around my room at night until I got the notification on my wrist that I had met yet another goal and finally let me rest.
The activities that fed my eating disorder were always in part motivated by the idea that I was not and could never let myself become the slovenly “out of control” caricature that we are so often chastised with as children as part of our elementary school curriculum. That was my future as everyone had always described it, right? Well at least that is what I heard ... Something that I would later come to understand as a thought distortion that reinforced my negative core beliefs of failure and lack of worth.
Finally, at the encouragement of my wonderfully supportive family and friends I recognized that there was a problem and I needed to seek medical treatment. I was accepted into an eating disorders patient treatment program, and was there for 15 weeks. Every day when I wake up I am now motivated by the goal of re-establishing a healthy weight and a more loving attitude towards myself and my body. I am so lucky that I have a team that cares about me helping me through every step of my journey. I wish I could say the same for everyone, I know that many people in my treatment program were not as lucky as I am.
They say that there is a war on fat, sugar, obesity. Has anyone ever wondered why? And at what cost? Has the WHO or any other governmental organization thought about whether there is any other possible reasons for the increase in obesity rates aside from the fact that we are all idiotic and cannot be trusted to make our own decisions? As the rates of obesity rise, so to do the rates of diagnosed eating disorders. I found this to be an interesting correlation, but it is not something that was discussed in any of the research that I did as part of writing you this letter.
It is also worth noting that the nutritional information for the restaurants that are being legislated is already available, as I could very easily find it when I was doing my research. Individuals who require the information for medical purposes do not need to see it plastered on menu boards, as they already know where and how to access it. Again, I come to the question of “who does this benefit?” as I have been unable to find a satisfactory answer in my research.
When you decided to put a label on a cheeseburger at a fast food restaurant that shows its nutritional value, did you ask yourself …
Whose daughter or son are you making feel so ashamed for eating that cheeseburger that he or she will go home that night and force themselves to vomit?
Whose sister or brother are you making feel so worried about eating that cheeseburger that he or she will never step into a fast food establishment again and become paralyzed by social anxiety?
Whose mom or dad are you making feel so uncomfortable in her own skin that he or she will go for a three hour run after eating that cheeseburger and take laxatives to get it out of their body?
Did you think about the fact that there are people who are on all ends of the weight spectrum that suffer from disordered eating and eating disorders who will feel the burden of this new labelling every time they leave their homes, turn on their television or interact with others?
Ms. Wynne, the face of eating disorders has changed in response to advances in technology, messaging in the media, and the wars that the government has started against its citizens. I am sad to say that I am one of the many faces of an eating disorder and there are stories like mine that are being told all across our province and country right now. Did my picture even flash before your eyes when you all voted to pass this legislation?
I am not ignorant of the fact that we need to be informed eaters. But I ask you to please be mindful of the fact that in life, like in clothing, there is (and should not be) not a “one size fits all” approach that will work.
I am ready to keep this conversation open. I hope that you are as well.
Capacci, S., Mazzocchi, M., Shankar, B., Macias, J.B., Verbeke, W., Perez-Cueto, F.JA., Koziol-Kozakowska, A., Piorecka, B., Niedzwiedzka, B., D’Addesa, D., Saba, A., Turrini, A., Aschemann-Witzel, J., Bech-Larsen, T., Strand, M., Smillie, L., Wills, J. & Traill, B. (2012). Policies to promote healthy eating in Europe: A structured review of policies and their effectiveness. Nutrition Science ßà Policy, 70(3), 188-200.
Evans, A.E., Weiss, S.R., Meath, K.J. & Chow, S. (2015). Adolescents' awareness and use of menu labels in eating establishments: results from a focus group study. Public Health Nursing, 19(5), 830-840.
Lebow, J., Sim, L.A., & Kransdorf, L.N. (2015). Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders. Journal of adolescent health, 56(1), 19-24.
Pulos, E. & Leng, K. (2010). Evaluation of a Voluntary Menu-Labeling Program in Full-Service Restaurants. American Journal of Public Health, 100(6), 1035-1039.
Sacco, J., Lillico, H.G., Chen, E. & Hobin, E. (2016). The influence of menu labelling on food choices among children and adolescents: A systematic review of the literature. Perspectives in Public Health, published online ahead of print July 2016, doi: 10.1177/1757913916658498
Tandon, P.S., Zhou, C., Chan, N.L., Lozano, P., Couch, S.C., Glanz, K., Krieger, J. & Saelens, B.E. (2011). The impact of menu labeling on fast-food purchases for children and parents. American Journal of Preventive Medicine, 41(4), 434-438.
Treasure, J., Claudino, A.M., Zucker, N. (2010). Eating disorders. The Lancet, 375, 583-593.
Roberto, C.A., Larsen, P.D., Agnew, H., Baik, J. & Brownell, K. (2010). Evaluating the impact of menu labelling on food choices and intake. American Journal of Public Health, 100(2), 312-318.
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