Sarah Watters, Wellth, New York
As the holidays and New Year approach, a common theme that consistently surfaces is the balance (or lack thereof) between indulgence and healthy behaviors, particularly when it comes to healthy eating. While this is a topic that is acute at this time of year, beyond the holidays, excess energy intake is a key public health challenge in many countries.
How and what we eat has shifted recently – with the help of the COVID-19 pandemic . During the peak of the pandemic, we were eating at home more often and, by and large, individuals reported that they were eating healthier.
But the changes in how and what we eat were not unequivocally favourable. Fueled by boredom, or, in some cases anxiety in the form of stress eating, snacking escalated during the pandemic. Others among us, myself included, were no stranger to over-indexing on indulgence, abiding more towards the what the hell effect end of the spectrum, rationalizing you only live once! But, unfortunately for us and our waistlines, our minds aren’t sophisticated in the calculus of our repeated bubbling over of the caloric thermometer.
While the balancing act between indulgence and healthy restraint is idiosyncratic (I, for instance, don’t bat an eye at candy but might inconvenience myself for some good chocolate), we’re not as on our own as (perhaps) we may think when it comes to our consumption behavior; environmental – contextual – influences may (and can) guide our behavior as well.
As we move back towards eating more outside our home and in social settings – in cafeterias, restaurants, and cafes, for example – the role external influences on our food choices once again becomes an acutely relevant policy question.
Why? When we eat outside our homes, our caloric consumption, more often than not, balloons. Individual weight loss, even when successful, is often ephemeral; therefore, policymakers might consider interventions to reign in such overconsumption as cornerstones of wider strategies to tackle an overweight population.
Governments in several countries have made attempts to curb energy intake, most often by adding labels on food and drinks to inform people about the energy content of the product. For example, in 2018, the US federal government sought to reduce caloric intake through the nation-wide implementation of mandatory labeling of calorie content on all menu items across major chain restaurants.
Inconclusive evidence
The resulting health and economic impacts of this policy remain unclear; however, and will be difficult to capture in the immediate future and even otherwise, given the pandemic and rerouting of longstanding behavioural patterns. Moreover, the literature on this sort of the effects of this type of intervention – providing caloric information at the point of decision making – is not compellingly conclusive but rather suggests that there might under some circumstances be some effect.
A study published in November by Reynolds et al. investigated the effects of physical activity calorie equivalent (PACE) labels on energy consumption. PACE, an alternative to labelling the energy content, supplements caloric information with the amount of physical activity – usually walking or running – needed to expend the energy in that product. To date the effectiveness of PACE labels, just like its calorie labeling counterpart, remains unclear and there is a dearth of evidence from real world versus laboratory studies, the latter of which, as discussed below, are immune to potentially mediating environmental influences.
Reynolds et al. set out to further our understanding of PACE labels in a real world setting by examining the effect of PACE labels on energy purchased in a randomised study of 15 worksite cafeterias. PACE labels were applied across several categories of food and drink, including hot meals, sandwiches, cold drinks, desserts.
Perhaps unsurprisingly, Reynolds et al found no overall evidence of PACE labels on energy purchased in cafeterias. What they did find was that PACE labels may show larger effects in cafeterias that sell more discretionary items (e.g., savoury snacks, confectionery), suggesting an effect of consumption that is less based on habit.
Why might labels have little effect?
There are a myriad of potentially unconsidered factors that might contribute to PACE and calorie-labels, more generally, not having a full time effect.
At the most basic level, it’s possible that people don’t know how many calories they should be consuming in a given meal or day (even if averages are posted), and accounting for a single meal choice is likely insufficient to drive behavior throughout the rest of the day.
Does time of day impact purchase? There is evidence that we’re more habitual in our purchases made in the morning and that variety seeking – including a tendency to buy relatively less healthy products – may be affected by our circadian rhythm. This effect may be complemented or further compounded by potentially depleted resources, cognitive or otherwise (perhaps we’d skipped or skimped on breakfast, lunch, or both). Similarly, did workers who purchased items later on in the lunch hour differ in their purchases from those who were more timely (and possibly less ravenous… )?
Another potentially important influence on purchasing and consumption behavior surely lies in social effects and peer influences. Just as we do in so many facets of our lives, we look to others – people we know or even complete strangers – to gauge how we should behave/what constitutes ‘appropriate’ behavior.
What are others (especially those with whom I’m dining) ordering? More generally, how does the behavior of the person in front of you or the people with you affect one’s own behavior? If someone in front of you picks up a candy bar, you’re likely to consider whether you might also grab one on the way by. Accordingly, if someone snags an apple, you might consider a similar healthy addition to your meal or for a snack later on. We know from the literature that if others eat more, we’re more likely to as well and we’re more likely to eat larger amounts when we eat in a grouprather than alone.
Reynolds et al. and many others don’t mention the potential role of others, possibly due to the challenges in researching these effects at scale. A simple proxy for future research might be to look at whether individuals enter the cafeteria alone or with others.
Another possibility is that we’re overlooking the role of habits and automaticity that ride alongside the hundreds of daily food choices we make (though many of which we’re unaware that we’re making); such that the individual may not even be dedicating the necessary attention to the energy information provided in order for it to have the desired effect.
We might begin to uncover whether habitual influences are at play by looking at whether individuals purchase the same items each day. Additionally, it would be interesting to know how long people spent in the cafeteria overall or, specifically, pre-purchase. Are people just grabbing and going – making quick decisions – or are they investing more effort in their decision? Heat maps might also offer interesting insight into the degree to which habits are of influence. Personally, I tend to return to the same aisles and sections of the grocer time and time again. How might we compel individuals to not frequent other parts of the cafeteria or store? This seems like a precursor to prompting towards particular healthier items.
It’s worth noting our inability to account for habit formation, social influences and other potential factors listed above in online studies that investigate the effect of these types of interventions. This is a shortcoming to the Daley review and others, which largely include hypothetical, online selection studies. In order to advance our understanding of food purchasing decisions, future research must investigate the various facilitators and interconnected drivers of behavior in real world settings.
One factor mentioned briefly in regards to inflation by Reynolds et. al, though deserving of greater attention, is the role of affordability. Depending on one’s perception of whether a product is within budget could ultimately trump everything we’ve covered above. Affordability is, in many senses, the gateway to choice and more diverse food options. From an alternative perspective, budgetary constraints that drive one to seek optimal value for money might steer us toward purchasing portion sizes that are unnecessarily large.
Finally, perhaps most pointedly, PACE (and other calorie labeling) interventions assume the individual is rational. By enabling the consumer to have full (or at least quasi-full) information through the provision of caloric content and required energy expenditure, at the moment of decision making, the underlying assumption is that the consumer will adequately weigh this information in their selection.
However, it’s of no surprise to anyone reading this post that we quite often act in less than rational ways (some might argue especially so when we’re hungry or tired). This begs the question: should interventions intended to encourage healthier food choices and reduce disease attend more or less to our rational selves?
It would seem misleading to state that our food choices are exempt from the irrationalities that seemingly infiltrate many of our behaviors. After all, we know that scent can impact food consumption behavior, as does physically architecting environments such that healthier items are strategically ordered or more visible (and, conversely, less healthy items out of sight). These approaches are much in line with the notion of epicurean nudging put forward by Pierre Chandon in his post.
The interventions listed above might be considered by some as overly paternalistic since the individual is likely unaware that their choice environment is purposefully being designed to drive particular behaviors. In any event, the question remains: How might we become more wise to the decisions we make when it comes to our food choices and what role should external parties have (and to what extent) in this affair?
There is certainly an argument to be made that purveyors of food away from the home are pushing the pendulum in the direction of overconsumption via increasingly large portion sizes, value for money deals, and other tactics; so, is there a resulting counterbalance to our cognitive, social, and biological vulnerabilities that would seem appropriate to the majority?
Alternative and complementary tactics
Alongside calorie labeling, there are other strategies that could be considered as choice preserving with minimal interference, such as including traffic light labels that offer consumers a heuristic upon which to judge their choices. Other interventions, such as (what has become widely known as) the soda tax approach the matter from yet a different angle.
The targeted context (e.g. the type of establishment or purchasing context – e.g. online or in person, or, discretionary versus basic purchases, for example) and personal characteristics have been shown to mediate the effectiveness of interventions aimed at reducing energy intake.
In some societies and in some circumstances, eating outside the home may be the cheapest option available and, as a result, draw more individuals belonging to lower socioeconomic levels. In other contexts, however, the opposite may be true: eating out is a luxury. It is important to keep these underlying divisions in mind when creating new policy measures.
In addition to socioeconomic differences, one might expect to see gender or age differences. For instance, a meta-analysis showed that women make more use of menu-labels than men did.
Where next?
Future investigations might wish to examine the effects of labeling in far more specific circumstances, possibly with more pointed objectives. For instance, do PACE or more simplistic calorie labels impact consumption at the start of the week (possibly accompanied by a fresh start effect) in an online setting?
As mentioned above, the pandemic has yielded some potential advantages in terms of our food purchasing and consumption behaviors. How might we leverage the effects of such a societal jolt for good? Grocery delivery, for instance, increased during the pandemic, and it might be interesting to examine the effects of PACE in this less emotionally salient choice environment compared to a cafeteria or restaurant.
Having more options available to preorder food might help obfuscate some of the environmental and emotional aspects that can lead us to making relatively less healthy choices. For instance, researchers might wish to leverage ordering time for the following day: once one has digested today’s meal – should I feel good today, I might order similarly the following day. Should I feel bloated, sleepy, or still hungry, for instance, I may opt for a different selection for tomorrow’s meal.
Moreover, Reynolds et al and others found effects of PACE labels on discretionary items compared to main meals. Do individuals have a pre-existing heuristic of packaged food items being unhealthier? Is it possible that individuals are more likely to note the PACE information for packaged versus unpackaged or fresh foods? Is it possible, for instance, that packaged foods were more appealing during the ‘peak’ pandemic? One might expect that packaged foods – if perceived as being more unhealthy in nature – are where we’d expect to see the greatest impact of PACE, but perhaps we didn’t see this effect because of COVID? These are questions future research may wish to explore.
Policymakers have a range of tools and levers at our disposal but uncertainty remains as to two key questions, one more readily answerable than the other. For starters, more targeted research is required to better understand what the most effective approach is in a given context. Second, and surely more philosophical in nature, is to what degree should external influences purposefully intervene to mediate individual energy consumption.
As in virtually all positive health behaviors, present bias can present a host of behavioral speedbumps that favor choices that work against our intents and desires to be healthier. Understanding how to compel or yield decisions in the moment, that align with these intents and desires, is integral to improving public health, particularly as we emerge from the pandemic, and once again, likely adopt new routines and behaviors in all facets of our lives, including feasting, fasting, and the space in between.