Obesity

A number of efforts to address and reverse this public health crisis have been and are being undertaken in the public, private, and nonprofit sectors. This report is the final work product of one such effort—the Keystone Forum on Away-From-Home Foods: Opportunities for Preventing Weight Gain and Obesity.

The Keystone Forum was requested and funded by the U.S. Food and Drug Administration. 2 The Forum brought together a wide diversity of participants to develop joint recommendations for action. The participants included representatives from industry, government agencies, civic-sector organizations, and academia. (A complete list of participants can be found in Appendix A of the report.)

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The Forum Process

The Keystone Forum on Away-From-Home Foods commenced in December 2004 with a small-group planning meeting. Three full-group plenary sessions were subsequently held in Washington, DC, in 2005, and numerous work group discussions were held between plenary meetings. The Forum was convened and facilitated by The Keystone Center, a nonprofit public policy and dispute resolution organization with offices in Colorado and Washington, DC. The Consensus Building Institute provided additional facilitation expertise, and Larmer Consulting assisted with the compilation and editing of this report. 3

Keystone Forum participants agreed throughout the process to abide by a set of “operating protocols,” which outlined objectives, roles, responsibilities, and a number of discussion principles. Participants were asked to represent their personal views in the discussions and were understood to be speaking on behalf of themselves, not on behalf of their organizations or constituencies. By including their names in Appendix A, Forum participants are indicating that they “generally support” the recommendations and overall content of this report, though they may find some sections more acceptable and compelling than others.

Forum participants organized the final report, and also this executive summary, into three sections corresponding to the Forum’s three primary topics of discussion: (1) Understanding and influencing consumer behavior with regard to away-from-home foods; (2) increasing the availability of lower-calorie products, menu items, and meals at establishments that provide away-from-home foods; and (3) providing consumers with nutrition information regarding away-from-home foods.

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The Forum’s Purpose, Scope, and Rationale

The purpose of the Keystone Forum on Away-From-Home Foods was to consider what can be done, given what is currently known, to support consumers’ ability to manage calorie intake with respect to preventing undue weight gain and obesity, within the scope of away-from-home foods. Forum participants hope that the American public will be the ultimate beneficiary of the Forum’s work. Toward that end, participants expect that this report will be useful to foodservice operators and their suppliers, policymakers, public health and medical professionals, culinary professionals, patient and consumer advocates, and research scientists.

The Forum’s discussions focused on obesity and away-from-home foods. The term obesity was used to refer to overweight and obesity together. 4 Similarly, the term foods was frequently used to refer to both foods and beverages. Away-from-home foods include full meals and single ready-to-eat items (including take-away foods) purchased at restaurants, prepared-food counters at grocery stores, institutional foodservice settings, and other outlets. 5

The concepts of calorie density and nutrient density were important parts of the Forum’s approach to caloric intake in the area of away-from-home foods. Calorie density (also known as energy density) refers to the amount of calories (i.e., energy) contained in a unit of food (measured by weight, e.g., kcal/g). 6 Nutrient density refers to the amount and availability of nutrients in a unit of food. 7 The Forum focused on assisting consumers with managing appropriate caloric intake pursuant to obesity prevention. However, while appropriate caloric intake is essential to addressing the problem of obesity, it is also important for consumers to get the most nutritional value from their calories.

The report does not focus on any particular subgroup of the U.S. population. However, participants acknowledged the unique concerns relating to children, since that population group faces significant long-term health consequences due to the obesity epidemic. Therefore, some of the recommendations include consideration of children’s unique needs.

Forum participants agreed to consider the role of food in the context of what is known about obesity—in other words, in light of the fact that food, wherever consumed, is a major factor but not the only factor affecting the incidence of obesity. Because obesity and undue weight gain result from sustained energy imbalance (i.e., caloric intake exceeding caloric expenditure), physical activity is also an essential element in obesity prevention and treatment. While this inquiry focused on food choice and consumption, Forum participants recognized that the broad societal effort to reduce obesity incidence must consider both sides of the energy balance equation.

As of this decade, Americans are eating away-from-home foods more frequently and consuming more calories from away-from-home establishments than ever before. Thus, a wider range of less-calorie-dense, more-nutrient-dense food and beverage choices in away-from-home food outlets, coupled with consumer education and information (especially about energy balance), can help Americans to manage their weight more effectively.

While several recent studies have explored various contributors to obesity, as yet there does not exist a conclusive body of evidence establishing a causal link between the availability or consumption of away-from-home foods and obesity. Preliminary research indicates, however, that the consumption of away-from-home foods can be a factor in determining calorie consumption and body weight, and an important one for many individuals. Participants did not seek resolution on this question, but rather focused on proposing implementable solutions to the challenge of obesity.

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The Forum’s Recommendations

A summary of Forum participants’ recommendations follows. Please note that Chapter 1 does not contain recommendations and so is not summarized below. It describes key observations and background regarding changes in the food environment over the past three decades, and it provides an overview of the research base regarding the relationship between away-from-home foods and body weight. Chapters 2 through 4 also include extensive background information, not summarized here, that provides context for the recommendations and suggested implementation steps.

Chapter 2: Understanding and Influencing Consumer Behavior

To reverse the increase in obesity and undue weight gain in the United States, Forum participants believe the current consumer preference for large quantities of calorie-dense foods should shift to an emphasis on intake appropriate to an individual’s needs and to increased consumption of foods lower in calorie density. However, it can be difficult to change consumers’ day-to-day food and activity behaviors, despite the potential longer-term consequences of those behaviors. Thus, messages and education programs directed at consumers should be carefully crafted; they must impart the knowledge and skills consumers need, and they must reach and motivate consumers successfully. Also, strategies should be tailored as needed to specific demographic and cultural audiences.

Much of the existing data and information about consumer eating behavior and attitudes is either not specific to away-from-home foods, not sufficiently timely, or not publicly available. Thus, a research agenda is also needed to augment the publicly available knowledge base and inform the continual development of consumer education programs. It must be stressed, however, that while the knowledge base needs to be improved, enough is known to recommend many important actions. Forum participants believe that reasonable strategies to assist consumers with healthy energy intake should be pursued now, and then augmented going forward as new information becomes available.

Forum participants offer seven recommendations for influencing consumer behavior and attitudes.

Recommendation 2.1: Shift the emphasis of marketing. The marketing of lower-calorie and less-calorie-dense foods should increase, accompanied by a reduction in marketing that highlights higher-calorie (or calorie-dense) foods or encourages large portions.

Companies, government, health organizations, and others should expand and align marketing initiatives (both commercial and social) that help consumers to manage their calorie intake. Foodservice companies and venues should use their full range of creativity and resources to promote food choices and eating behaviors that are consistent with healthy weight management. In addition, companies, government, health organizations, and others should conduct market research to determine:

• how best to market low-calorie and less-calorie-dense menu options to different populations in ways that assist consumers with weight management efforts, and
• how to shift the prevailing value proposition away from large portions, and how best to market more appropriate portion sizes to different populations.

Recommendation 2.2: Update marketing standards. Industry, government, health and nutrition experts, consumer representatives, and other stakeholders should work together to review and update standards for marketing away-from-home foods to children.

The Children’s Advertising Review Unit (CARU), which is funded by members of industry, could work with key stakeholders from the public, private, and civic sectors to review and update its standards for marketing to children, including the marketing of away-from-home foods. CARU maintains self-regulatory guidelines for children’s advertising, and as of this writing has announced an extensive and consultative review of those guidelines.

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Recommendation 2.3: Promote low-calorie-dense dietary patterns. Strengthen and/or create education and promotion programs regarding away-from-home foods that promote the consumption of fruits, vegetables, no- and low-fat milk and milk products, whole grains, and foods low in saturated fats and trans-fatty acids, as recommended by the 2005 Dietary Guidelines for Americans. 8

For example, the national 5 A Day for Better Health program could be significantly expanded and strengthened, and the U.S. Department of Agriculture (USDA) could create a federal marketing matching program for promoting fruits and vegetables. Federally sponsored consumer research could be undertaken to develop behavior change strategies for closing the gap between recommended intakes and current consumption.

The Milk Matters program at the National Institute of Child Health and Human Development, as well as the Powerful Bones, Powerful Girls program at the Centers for Disease Control and Prevention, could also be significantly expanded and strengthened to build skills for selecting foods and beverages away from home. The programs could include a large-scale social marketing campaign to promote the intake of three daily servings of low-fat and nonfat milk and milk products, consistent with the Dietary Guidelines.

Recommendation 2.4: Promote enhanced “lifestyle education” programs. Use a combination of social marketing campaigns and consumer education programs to provide “healthy lifestyle” education to help individuals eat more healthfully in today’s food environment. Existing campaigns and programs could be enhanced or, as necessary, new ones could be created.

Both campaigns and programs in various sectors should aim to help individuals understand how to make decisions within the food environment healthfully—i.e., how to navigate the wide range of away-from-home food choices available in today’s often harried, time-pressed, convenience-driven world. A social marketing campaign should focus on those areas with the most supporting evidence and strongest justification for action. 9 For example, a campaign could seek to change the social value proposition of “more food” to “better-quality food,” and/or to promote the concept of energy balance—i.e., balancing caloric intake with physical activity expenditure.

Recommendation 2.5: Review the effectiveness of existing programs. The U.S. Department of Health and Human Services (HHS) and the USDA should, in partnership together, coordinate a comprehensive survey and analysis of existing government-sponsored education and social marketing campaigns related to managing weight gain and reducing obesity in the context of away-from-home foods.

With HHS and USDA as the coordinators and conveners, key federal agencies should pool resources to sponsor a systematic survey and analysis of education and social marketing campaigns directed at consumers who are trying to manage weight gain and obesity. Individual agencies should be responsible for analyzing the programs they administer. A standard evaluation tool should be developed for assessing the relative success of each program in helping consumers with healthy weight management.

The analysis should seek to identify the target audiences (and any key audiences that have been missed), the kinds of programs implemented, and their effectiveness against criteria developed by the study team, such as ease of understanding by consumers, consumers converting that understanding to action, and costs. The analysis should offer recommendations for how to streamline government efforts to use resources more efficiently, increase the frequency and consistency of messages, and ultimately, more effectively influence consumers’ behavior.

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Recommendation 2.6: Improve government access to data on consumer behavior and attitudes. Federal agencies should act immediately to increase the access of government researchers and policymakers to syndicated commercial databases. Key agencies should establish recurring line items in their respective budgets, thereby ensuring continual and timely access to the needed commercial data sets.

Key agencies should coordinate needs and resources in order to purchase relevant commercial data sets from syndicated research organizations. Interagency collaboration is needed to ensure adequate funds for an initial purchase, to promote coordinated policies and programs that result from an analysis of the data, and to encourage the widest possible access to the data.

Recommendation 2.7: Ensure public availability of information. A means must be developed for continually improving the publicly available knowledge base regarding consumer interests, attitudes, and behaviors regarding away-from-home foods.

Since government access to commercial data sets, while very important, is typically accompanied by nondisclosure terms that may limit direct analysis of the data by other stakeholders, a collaborative research agenda could also be developed to allow for wider access to timely information regarding consumer behavior and attitudes in the area of away-from-home foods. Alternatively, the scope of existing data-gathering initiatives could be expanded to provide more detail regarding behaviors and attitudes regarding away-from-home foods, both nationwide and within key demographic groups. Data should not only be collected, but it should be analyzed and shared with the public, policymakers, health professionals, and other interested stakeholders.

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Chapter 3: Increasing the Availability of
Lower-Calorie Products, Menu Items, and Meals

The foodservice industry faces a number of challenges in its efforts to provide menu items and meals that help consumers effectively manage their calorie intakes and thus maintain healthy weight. These challenges can be viewed as opportunities for the industry to take a proactive role in combating the national problem of overweight and obesity. With this in mind, Keystone Forum participants sought to propose some achievable, action-oriented strategies for the foodservice industry, including bold and innovative approaches (in which taste was a non-negotiable “must”) with regard to products, menu items, and meal choices, to assist consumers with managing calorie intake.

To address the Forum’s goal of reducing obesity, the recommendations and operational tips provided in the report focus on manipulating the calorie content, including the calorie density, of menu items and meals through several strategies: providing appropriate portion sizes, plate composition, menu pairing, and beverage options; increasing fruits and vegetables; reducing total fat content; and decreasing the use of ingredients that are high in refined starches, added sugars, and saturated and trans fats and low in nutrient density.

Forum participants articulated four recommendations, directed primarily at the foodservice industry, to address these issues. The recommendations are followed by specific operational tips, which are meant to serve as examples of how the recommendations could be implemented and should not be considered all-inclusive.

Recommendation 3.1: Promote the wider inclusion in foodservice of less-calorie-dense menu items and calorie-sparing cooking techniques that are widely accepted by consumers and that take into account constraints on operators.

To implement this recommendation, Forum participants believe that culinary educational facilities should provide chefs and foodservice operators with the necessary education, resources, and skills to produce menu choices that will help customers achieve and maintain a healthy weight. They should, for example, provide educational programs that illustrate how to develop less-calorie-dense menu items and that overcome the perception that healthy menu items lack creativity and flavor. Chefs and restaurateurs should also be encouraged to offer more lower-calorie choices on children’s menus.

In addition, appropriate government agencies should, in conjunction with industry, stimulate initial educational and leadership efforts. They should provide grants to help culinary schools develop curricula or other resource materials that reflect the current consensus within the scientific community about cooking methods and approaches that help consumers achieve and maintain a healthy weight.

Finally, the synergy between producers/manufacturers, distributors, and operators should be enhanced, in order to facilitate the purchase and use of the products that are needed to produce new or reformulated menu items and meals, to help consumers manage their energy intake. Chapter 3 suggests numerous ways this could be done; for example, industry leaders and appropriate government agencies should encourage manufacturers to offer foodservice-size packaging for products such as evaporated fat-free milk, lower-fat cheeses, and precut vegetables, all of which can be used to make less-calorie-dense menu items.

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Recommendation 3.2: Foodservice providers should develop and promote portion-size, plate composition, and menu-pairing options that help consumers in their efforts to manage their energy intake.

The chapter offers numerous implementation strategies geared toward chefs, menu developers, servers, and customers. For example, these individuals are encouraged to:

• Reduce total calories in mixed dishes by combining moderate reductions in calorie density with changes in portion size.
• Retool menu items to provide lower-calorie-dense choices.
• For sandwiches, offer more fruit and/or vegetable options than just lettuce and tomato. For example, offer roasted red peppers, roasted eggplant, cucumbers, etc.
• Provide more options and promote meal bundles with fruits and vegetables (including salads), while maintaining traditional side options as well.
• Offer several portion sizes of each menu item.
• Adopt approaches to support portion-size reduction and/or curtail emphasis on “bigger means better” messages.

Recommendation 3.3: Foodservice providers should develop, make available, and promote beverage options that help consumers to reduce calorie intake.

To do this, Forum participants suggest that industry leaders:

• Increase the range of low-calorie or zero-calorie beverage choices available to consumers and provide smaller portion sizes (e.g., 10-fluid-ounce sizes, 100-calorie servings, etc.).
• Increase the selection of low-fat or nonfat milk beverages, especially with children’s meals.
• In specialty venues such as coffee shops, offer lower-calorie selections and smaller portion sizes of specialty and frozen drinks, in addition to the standard versions.
• Expand the range of beverage options available to consumers to include a wider array of cup and bottle sizes.
• Consider pricing approaches that make smaller sizes and lower-calorie options more appealing.
• For bundled meals, offer lower-calorie beverage options, such as water, and encourage reasonable portion sizes.

Recommendation 3.4: Industry and academia should conduct—collaboratively, if possible—research on the topics and questions listed in Chapter 3. In addition, a specific scientific survey should be conducted about the experiences of operators and restaurateurs in developing menu items that could aid in weight management.

Chapter 3 sets forth a number of potential research questions that should be addressed through collaborative research. The questions address basic research needs as well as suggestions for the development of specific, scientifically sound strategies that will lead to a better-informed public, industry, and academic community. The questions are categorized into four topics: calorie density and portion size; increasing fruits and vegetables; product formulation; and packaging and marketing.

In addition, a scientifically rigorous survey should be conducted after the conclusion of the Forum to gather information from chefs and restaurant owners about their experiences helping customers to manage their weight and health, particularly via product reformulation and innovation.

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Chapter 4: Providing Consumers with Nutrition Information

When making decisions about away-from-home foods, consumers often may not have access to nutrition information to inform their selections and eating behaviors pursuant to appropriate calorie intake. Whereas a growing number of foodservice venues voluntarily provide some information about the calorie and nutritional content of their menu items, many do not. Available information may be provided in different formats (e.g., websites, brochures, kiosks), focus on a variety of nutrients (e.g., calories, carbohydrates, fat), and take a variety of forms (e.g., numerical values, symbols, written characterizations of health attributes). In the absence of any nutrition information, consumers typically are unable to assess the caloric content of foods.

Forum participants offer the following two recommendations regarding the provision of nutrition information to consumers.

Recommendation 4.1: Away-from-home food establishments should provide consumers with calorie information in a standard format that is easily accessible and easy to use.

Forum participants believe that information should be provided in a manner that is easy for consumers to see and use as part of their purchasing and eating decisions. Information should be provided for any standard menu item offered on a regular and ongoing basis that is prepared from a standardized recipe, whether the item is an entire meal or a meal component. Non-standard items, including daily specials and experimental items, may be exempted. Information should be provided for the standard menu item as usually offered for sale (i.e., the base product, in the portion size as offered for sale), since most means of providing information cannot easily account for changes due to customization and special orders. Also, information should be accompanied by a caveat regarding variations owing to preparation, customization, and server variability.

Single-store operations and small chains may not be able to provide nutrition information. Other foodservice venues, such as contract dining services, that have variations in sourcing and preparation, or that do not have standard menus, may also have difficulty providing information that is accurate, reliable, and consistent. However, restaurants and other foodservice operators are encouraged to provide the information to the extent feasible.

In addition to these implementation tips, the chapter’s discussion of Recommendation 4.1 addresses the cost of providing nutrition information, methods of nutritional analysis, means of delivering the information, possible unintended consequences, and considerations regarding the provision of nutrition information beyond calories, children’s needs, and the accuracy of the information.

Recommendation 4.2: Research by multiple sectors should be conducted on how consumers use nutrition information for away-from-home foods; how this information affects their calorie intake at that venue; how and why nutrition information affects operators’ decisions, costs, and revenues; and unanticipated consequences.

There is a clear need for more research regarding how the provision of nutrition information, claims (such as “low calorie”), and symbols influence consumer preference and choice for away-from-home food consumption situations. Of particular concern is how, when, and why consumers use nutrition information and claims during their decision-making processes. More specifically, a better understanding is needed of the types of factors that moderate consumers’ responses to the provision of nutrition information and claims for away-from-home foods. The chapter concludes with a list of suggested research questions for addressing these topics.

Taken together, the recommendations in this report address important challenges, and also provide opportunities for multiple sectors to have a positive impact on the task of helping consumers manage their energy intake with respect to away-from-home foods. It is hoped that all sectors—public, private, and civic—can take action based on these recommendations and implementing strategies to help address the growing problem of obesity in the United States.

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Footnotes from Executive Summary

1 E.A. Finkelstein, I.C. Fiebelkorn, and G. Wang, “National Medical Spending Attributable to Overweight and Obesity: How Much, and Who’s Paying?” Health Affairs W3 (2003): 219-226. See www.cdc.gov/nccdphp/ dnpa/obesity/economic_consequences.htm.

2 The content of this publication does not necessarily reflect the views or policies of the U.S. Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

3 See www.keystone.org, www.cbuilding.org, and www.larmerconsulting.com.

4 The National Institutes of Health define “overweight” in adults as a body mass index (BMI) of 25.0 to 29.9 and “obesity” as a BMI of 30.0 or higher. BMI is defined as the ratio of a person’s bodyweight in kilograms divided by the square of his or her height in meters. See www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/ risk.htm#limitations.

5 The topic of school meals was not included in the scope of the Forum’s discussions. Although foods sold in schools are a significant source of calories for school-aged children, there was a need to limit the scope of the dialogue to a manageable area of inquiry consistent with the U.S. Food and Drug Administration’s own core capabilities and activities.

6 See www.health.gov/dietaryguidelines/dga2005/report/HTML/G1_Glossary.htm. Less calorie-dense foods are generally those with a higher water content, such as fruits, vegetables, and soups. While energy density and calorie density can be used interchangeably, this report generally uses the latter term.

7 See www.diet-and-health.net/glossary.html. Nutrient-dense foods provide substantial amounts of vitamins and minerals, and relatively fewer calories. For an extensive review of literature on nutrient density, see A. Drewnowski, “Concept of a Nutritious Food: Toward a Nutrient Density Score,” American Journal of Clinical Nutrition 82, no. 4 (2005): 721-732.

8 U.S. Department of Health and Human Services (HHS) and U.S. Department of Agriculture (USDA), Dietary Guidelines for Americans 2005 (6th ed.) (Washington, DC: HHS and USDA, 2005).

9 “Social marketing” programs typically seek to improve personal or societal welfare—for example, by promoting healthy eating, active living, avoidance of illegal drug use, or proper use of seat belts.

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