CW: calories, eating disorders
Many will be aware of the public concern which erupted when the government passed legislation making it compulsory for eateries with over 250 employees to label menus in England with calories alongside the message that “adults need around 2000kcal a day”. Much of this reaction centred around the risk to those suffering from and vulnerable to eating disorders.
But how significant is this risk, given the scale of the obesity ‘crisis’? After all, an estimated 63 percent of adults in England are classed as overweight or obese, and thus are at higher risk of cancer, diabetes, coronary heart disease, mental health issues and are prone to lower life expectancy. Around 14 percent of reception age children are obese; this rises to 25 percent for year six.
Surely a strategy designed to tackle what the Department of Health & Social Care calls “one of the greatest long-term health challenges this country faces”, (a challenge which disproportionately affects those of deprived groups) cannot be so problematic?
The experts — and the facts — suggest otherwise.
Eating disorders (EDs) are mental health conditions, which, simplistically put, involve an unhealthy and obsessive relationship with food. The UK’s leading eating disorder charity, Beat, has repeatedly raised concerns regarding the government’s scheme. They have pointed to research which shows that faced with a hypothetical menu with calorie counts, people with anorexia and bulimia are more likely to make a choice with notably fewer calories, those with binge-eating disorder (which is linked to obesity): the opposite. Ask anyone with experience of one and they will tell you that EDs thrive off numbers: weight lost or gained, clothes sizes, amount of time spent exercising, amount of time spent fasting, number of calories burnt, number of calories consumed… and so on. Part of ED recovery is learning to stop measuring worth by these arbitrary digits, by widening focus from narrow Venn diagrams of food, weight and control towards a more holistic conception of health.
Another component is learning to eat out again.
To eat out covers a wide range of situations: enjoying a birthday meal with friends or family, going to a restaurant for a date, grabbing something from Starbucks at a service station or the airport, sharing a plate of chips at a pub, queuing for a Najar’s on a Saturday evening. These situations can already be challenging: in Beat’s November 2020 survey of over 1000 people, 95% who had first or second hand experience of an ED flagged that calorie labelling would only increase the anxiety and distress eating out can induce. For many, without the recovery safety ropes provided by the familiar factors of meal time, content, and location, the ED voice suddenly sounds very loud.
This is not to say that the government has completely ignored campaigners like Beat: following mounting pressure, they’ve dictated that eateries are allowed to offer a menu without calorie labelling on request. The key words here are “allowed” and “on request”. What if you don’t feel comfortable asking? What if they don’t have one? What’s to stop you glancing across at the menu of the person next to you? The very fact that there are labels is likely to catalyse an increased frequency of conversations regarding calories. Just as it doesn’t take a great stretch of the imagination to see how the proliferation on social media of diet pill adverts and body-tuned photos negatively impacts body image, these mealtime “diet talk” conversations are much more likely to generate mental distress than physical wellbeing. Although such sociocultural discourses do not solely cause EDs – which are incredibly complex illnesses – there is a widespread recognition that our cultural and social fixation of thinness and ‘clean’ eating are facilitating factors. For example, Orthorexia (fixation with righteous eating) is strongly associated with the social media ‘healthy eating movement’, more often than not propped up by pseudoscience and unqualified influencers.
So, it’s not difficult to see how the calorie strategy will challenge ED sufferers, but – especially compared to the scale of the obesity crisis – why should we care? We could argue that only a minority of people in the UK suffer with an eating disorder: an estimated 1.25m, around 2 percent of the population. However, for comparison, alcohol dependency comes in at around 0.9 percent. Furthermore it’s widely believed that more people than officially diagnosed have eating issues, owing to a variety of factors ranging from antiquated diagnosis guidelines to ignorance on the part of medical practitioners (the number of hours spent on EDs at medical school is less than two on average) to stereotypes regarding ED sufferers. Contrary to the trope of the white female anorexic, EDs affect people of all ethnicities, classes, and gender identities (1/4 sufferers are male), and refer to more than anorexia: the majority of sufferers are diagnosed with “Other Specified Feeding or Eating Disorders” (OFSED, 47%) or Binge Eating Disorder (22%). Another misconception is that having an ED leads to weight loss. Actually, binge eating disorder is strongly linked to having an ‘overweight’ BMI. Given the documented links between obesity and ED behaviours (with the latter posited as a causal factor), the exacerbation of eating disorder cognitions may contribute to, not detract from, obesity – as BEAT’s hypothetical menu study suggests. To throw some more statistics into the mix, EDs have the highest mortality rates among psychiatric disorders and a September 2021 report found that they cost the UK a shocking 9.4 billion pounds a year. In comparison, the cost of obesity comes in at a lower count: £6.1 billion in 2014/15. This number is projected to increase to £9.7 billion in 2050, but – especially given the impact of the pandemic, which has seen hospital admissions and waiting list numbers increase by almost 50 percent – it is not wild speculation to say the financial cost of EDs will surpass this.
Furthermore, there is little evidence to suggest that calorie labelling on menus will actually work. Much like the outdated and contested BMI scale (developed in the 1830s on a scientific basis which is wanting by today’s standards), calorie-tracking has many critics. Calorie counting is one method of judging what we eat, and one that doesn’t necessarily assist healthier choices. For example, a chocolate bar may have less calories than a regular meal, but sugary processed foods compare poorly in terms of nutritional content. Our bodies are not designed to use food in a simplistic in and out calculation, but work through processes of digestion, absorption, and excretion: you may ingest 100 calories but 100 calories is not necessarily what your body takes in. Additionally, the message that 2000kcal a day is optimal does not accord with NHS guidelines that “ideal daily intake of calories varies depending on age, metabolism and levels of physical activity, among other things”. In fact, many people will need a great deal more than this on a daily basis, including adolescents and those repairing their metabolisms and/or gaining weight in ED recovery: two risk groups for triggers exacerbating disordered behaviours.
But what about the non-ED sufferer aiming to lose weight? Well, the research doesn’t look particularly promising on that front either. The 2018 Cochane review found only a small body of low quality evidence to suggest calorie counts on menus lead to reduced calories consumed. This accords with a recent study in the US concerning calorie labelling in fast food restaurants: despite an initial 4 percent reduction in calories per order, this dried up during a one year follow up, suggesting calorie labelling doesn’t translate to sustainable impact. Moreover, is there much sense in putting calories on menus when, especially compared to European countries, the British don’t actually eat out that much? 40 percent only dine out once a month, and only 8.5 percent more than once a week. Given the rise in the cost of living, these percentages are certainly unlikely to increase. One group of people who may be disproportionately affected however, is ED sufferers, many of whom prefer the predictability of high street and chain eateries, finding comfort in a familiar menu.
Stuart Flint, the head of Obesity UK, also views the scheme as misdirected: “The reality is that we’ve had 14 policies over the last 20 years related to obesity, and it hasn’t decreased, it’s increased. And the reason is that most of those are focused on individual changing.” He points out that, “Obesity is very complex. If it was as simple as eating less or more, people wouldn’t gain weight to the extent we have at the moment, and people would be able to lose weight more easily.” Experts echo Flint’s point: a simplistic approach to weight management ignores the socioeconomic factors contributing to rising obesity rates, namely the link between obesity and deprivation. For example, the prevalence of obesity in the most deprived 1/10th of children is twice that of the least deprived 1/10th. Low income families have limited food choices, budgets, access to physical activity, and time. Is it that outlandish to argue that we should be addressing these factors, and the fundamental wealth inequality which they stem from, coupled with promoting preventative healthcare and education? The latter is a point which food campaigners and experts stress: over half of children do not learn cooking basics at school, leaving them ill-equipped to cook healthy meals whilst balancing financial restrictions as adults. Giving children and adolescents these tools would not not only foster health benefits but hopefully ecological ones too, by promoting the use of seasonal ingredients and choice of climatarian-friendly foods. Acknowledging the webs of causality behind the obesity crisis, including the structural factors, is bound to be a more impactful strategy than shifting the blame onto individuals and responsibility onto the hospitality industry.
Indeed, Kate Nicholls, chief executive of trade body UK Hospitality, has appealed to the government to delay their plans as the food hospitality industry continues to struggle in the pandemic aftermath. Co-founder of Wahaca, Mark Selby, summarised the sector’s concerns when he emphasised the increased logistical and financial challenges of creating a system whereby chefs were using the same amount of ingredient across branches every day. Sven-Hanson Britt, Masterchef winner, warned of the detriment to the creativity of the cooking industry, fearing that “Kids will grow up in restaurants, hotels and cafes only looking at that little number below a dish. Choices will be made based on a number alone. The love of flavour, ingredients, history, cooking, craft or nutrition will be lost and masked by a newly perceived focus.” Given the likelihood of quotidian human errors and swaps (anyone who has worked in a restaurant or somewhere similar will tell you that meal preparation is no exact science), how can restaurant-goers even be certain of the accuracy of these ‘little number[s]”? Additionally, the legislation does not apply to items on the menu for less than 30 days. Hence, any argument in favour of the health benefits of calorie labelling is redundant for anyone ordering a special, and we may see a proliferation of temporary menu items, as eateries work their way around this restrictive new plan.
All this considered, the government may find neither safety nor strength in numbers given the limited evidence for the effectiveness of calorie labelling, the logistical and economic inconvenience falling on a floundering hospitality industry, and the complex socioeconomic causes of obesity. Those struggling with eating disordered thinking who are encountering this new case study in under-researched virtue signalling will be understandably anxious, but there are resources and strategies to cope.
Beat UK has published guidance on eating out with calories on menus, which stresses that planning ahead can go a long way: this may mean discussing potential triggers and anxieties with a friend, treatment team, or family member. This sort of discussion is best limited to a single treatment session or conversation, and researching the menu, beyond familiarisation with options, should be kept to a minimum. Calling ahead or requesting a calorie free menu on the day, and asking the rest of the group to do so too – if comfortable with this – may constitute useful preparation. This approach may not be available for every situation, especially with lots of people- but a trusted person among the group will likely be happy to keep an eye out, for example by steering the conversation away from diet talk discussion. Alternatively, the propensity of email-checking, snapchatting, and Wordle-completing which comes (free of charge!) with most dining out experiences means that friends or family can easily be at the end of a message to provide support. In any situation, but particularly among strangers, relying on mental strategies and fact-checking ED thoughts is key. Remind yourself that the 2000kcal recommendation is not a law or a goal but an approximate, that calories themselves are a disputed method of determine the nutritional quality of foods, and that each person needs different amounts of food: any comparison to what another person is eating is necessarily based on an incomplete picture of their nutritional requirements, relationship with food, and past and present food intake. Calories on menus may seem like just another string to the bow of a culture which seems so counterproductive to ED recovery, but as countless people will be able to tell you, progress is possible. And there will come a day where you’ll be able to say “Pipe down Karen, no one cares that you’re having something called a sandwich despite the fact it has no bread and no butter and just looks like a suffocated fern just because it’s the lowest calorie option” whilst tucking into a chunky sarnie, those pesky little numbers as irrelevant as an English student’s opinion on quantum gravity*.