APHA Student Reflection Series: Calorie Labeling: How Nutrition Strategies Can be Leveraged to Cost-Effectively Improve Population Health and Equity

Written by 2L student in the Health Law and Policy Clinic, Navjit Sekhon

Rates of childhood obesity continue to increase in the United States, posing a critical threat to public health. However, nutrition-related policy strategies can be used to offset this alarming trend and alleviate growing concerns. The Childhood Obesity Intervention Cost-Effectiveness (“CHOICES”) Project at the Harvard T.H. Chan School of Public Health aims to identify cost-effective strategies across a variety of settings that can help kids achieve and maintain healthy weight. As structural racism and social determinants of health have great influence on childhood obesity, with Black and Hispanic children affected at much higher rates than other children, the CHOICES Project also aims to promote health equity in their research. At the 2022 American Public Health Association (APHA) Annual Meeting & Expo, members of the CHOICES Project presented their findings. 

One strategy highlighted during the CHOICES Project APHA presentation stood out: looking at the cost-effectiveness of calorie labeling at large fast-food chains in the United States. The Affordable Care Act introduced a requirement that restaurant chains with 20 or more locations provide “accurate, clear, and consistent nutrition information, including the calorie content of foods.” The CHOICES Project looked at data from millions of fast-food restaurant transactions and found that calorie labeling led to customers purchasing 5% fewer calories. Using microsimulation models developed by the CHOICES Project, researchers found that the Affordable Care Act’s calorie labeling requirement may prevent hundreds of thousands of childhood obesity cases, while also leading to billions in health care cost savings.  

At a glance, I was struck by the profound public health impact of this 5% reduction in calorie purchases. Extrapolated across several years, a 5% reduction in calorie consumption for an individual can stave off the weight gain that might otherwise lead to obesity and related health complications. Thus, a 5% reduction in calories for an entire population would undoubtedly lead to much better population health.

I found myself even more intrigued by another detail in the study results. Researchers assumed that the effects of calorie labeling were similar across all population sub-groups. However, as the CHOICES Project itself has noted, the effects of structural racism and the social determinants of health on childhood obesity are well-established, so it is unlikely that this assumption holds true across all population sub-groups. This led me to wonder whether the calorie-labeling requirement can be built upon further to promote the principles of health equity by more directly targeting the disparities in childhood obesity rates.

While there are a number of potential strategies that could improve health equity by leveraging calorie labeling, one immediately came to mind. In New York City, bodegas are much more prevalent than fast food or chain restaurants, but much less likely to provide nutrition information on food products. As a result, for many children from the communities most deeply affected by childhood obesity, especially in places like New York City, the calorie-labeling requirement may have little or no effect at all. One might consider extending the requirement to smaller establishments and/or chains, perhaps by establishing a New York state or city-level law for bodegas and delis. However, this may be far too burdensome for these small establishments, especially without the resources of a national chain to help them comply with such a law. A better option might be to directly engage with bodega and deli owners to encourage the provision of healthier options, and even provide grant funding or launch pilot programs to help them do so. Officials might also consider creating incentive and/or assistance programs for establishing calorie labeling at bodegas. 

Ultimately, it is clear that childhood obesity is a problem, and without action, its effects will only continue to grow. While the CHOICES Project has identified cost-effective strategies like calorie-labeling to address this growing problem, we must also recognize the importance of ensuring that those strategies also work to improve health equity.