摘要：Objectives. We assessed consumer awareness of menu calorie information at fast-food chains after the introduction of New York City's health code regulation requiring these chains to display food-item calories on menus and menu boards. Methods. At 45 restaurants representing the 15 largest fast-food chains in the city, we conducted cross-sectional surveys 3 months before and 3 months after enforcement began. At both time points, customers were asked if they had seen calorie information and, if so, whether it had affected their purchase. Data were weighted to the number of city locations for each chain. Results. We collected 1188 surveys pre-enforcement and 1229 surveys postenforcement. Before enforcement, 25% of customers reported seeing calorie information; postenforcement, this figure rose to 64% ( P < .001; 38% and 72%, weighted). Among customers who saw calorie information postenforcement, 27% said they used the information, which represents a 2-fold increase in the percentage of customers making calorie-informed choices (10% vs 20%, weighted; P < .001). Conclusions. Posting calorie information on menu boards increases the number of people who see and use this information. Since enforcement of New York's calorie labeling regulation began, approximately 1 million New York adults have seen calorie information each day. In 2008, after a series of court challenges by the restaurant industry, New York City became the first jurisdiction in the United States to require restaurant chains to post calorie information on menus and menu boards. Adopting this regulation was part of a broader New York City Health Department public health response to rising rates of overweight and diabetes. These efforts draw on 2 decades of research that suggests a direct link between the growth of chain restaurant industries—both fast food and casual dining—and rising rates of obesity. 1 – 4 US fast-food sales increased exponentially between 1970 and 2000, from $6 billion to $110 billion. 5 During the same time, obesity rates among US adults doubled; one third of US adults now meet the criteria for obesity, and another third are considered overweight. 6 Research examining changes in individual dietary patterns confirms that fast-food consumption is associated with increased body mass index 7 and increased calorie intake. 8 On days when they report eating fast food, adults consume 205 more calories, and children and adolescents consume 155 more calories than on days when they do not eat fast food. 8 Choices at fast-food chains typically consist of high-calorie foods 9 served in large portions. 10 However, most consumers may not be aware of the high calorie content of such items because such information is often not easily accessible in fast-food establishments. Additionally, consumers have been found to consistently underestimate the calories in foods prepared outside of the home 11 , 12 ; even nutritionists and other health professionals underestimate the calories in typical chain restaurant foods. 13 Two studies have shown that few customers report seeing calorie information when it is provided in less accessible formats (e.g., posters, pamphlets) or after the point of purchase. 14 , 15 a Prominent placement of calorie information on menus and menu boards was proposed in New York City to assure that customers have ready access to calorie information when they make menu selections. In December 2006, New York City approved the nation's first regulation requiring calorie labeling in certain fast-food restaurants. That requirement, effective July 1, 2007, was overturned by a US District Court 15 b in September 2007. An amended regulation was approved in January 2008 and became effective March 31, 2008. The amended regulation requires restaurant chains with 15 or more locations nationwide to post calorie counts on menus, menu boards, and item tags. 16 Calories must be posted clearly and conspicuously, adjacent or in close proximity to the item name, using a font and format that are at least as prominent as the price or item name. The city began issuing violations for noncompliance in May 2008; full enforcement, including levying of fines, began on July 18, 2008. Because a lawsuit initiated by the New York State Restaurant Association was pending at the time the regulation went into effect, most restaurants waited until the enforcement date for financial penalties to begin posting calorie information. However, some chains began posting as early as 2007. A New York City Health Department study that we conducted before the city's Board of Health 2006 regulation became effective found that most customers left fast-food chains without seeing any calorie information despite industry claims that restaurants were making substantial efforts to convey such information. 14a Fewer than 4% of fast-food customers reported seeing calorie information. This percentage did not include customers at the fast-food chain Subway, which had posted calorie information for a select number of items before the posting requirement went into effect. The earlier study also found that 1 in 3 lunchtime customers purchased food containing more than 1000 calories at the lunchtime meal, 9 which accounted for more than half of the 2000-calorie daily intake recommendation for most adults. Immediately preceding and following the full enforcement (with levying of fines) of the calorie-labeling regulation, we assessed the impact of the regulation on customers’ awareness of calorie information and their report of its use in making food choices. The rationale that calorie information may help guide healthier choices was supported by data collected at Subway restaurant chains. Subway customers who reported seeing calorie information and using that information in making their food choices purchased 99 fewer calories than did customers who said they had not seen the calorie information. 14 a
