Would you like 500 calories with that?

It’s a question customers could be asking themselves if Ontario’s Bill 45, the Making Healthier Choices Act, becomes law later this year. If passed, Ontario would be the first province to require caloric information to be displayed on menus and menu boards of chain restaurants.

The proposed law requires restaurants, supermarkets and other vendors that sell ready-to-eat food to display the total calories alongside menu options. The law will only apply to vendors with 20 locations or more, due to the expense of measuring calories and the requirement of a very standardized menu. Though the current bill doesn’t describe the method that restaurants use to measure calories, inspectors will be able to investigate to ensure accuracy. Companies in violation of the Act would face hefty fines.

According to government spokesperson David Jensen, the Bill was motivated by the reality that “dining out has become part of the typical diet for Canadians and…people typically underestimate calories” of restaurant meals.

In 2001, Canadians prepared 70% of their meals at home, but by 2008, that number had dropped to 65%, according to the Canadian Restaurant and Food Services Association. But many don’t recognize, for example, that a large fry at McDonald’s has 560 calories, without fulfilling protein or vitamin needs. Even items that may appear healthy might not be; a crispy chicken pecan salad at Boston Pizza clocked in at 1,150 calories. The recommended total daily intake for a somewhat active man aged 31 to 50 is 2,600 calories; for a somewhat active woman of the same age, it’s 2,000.

Currently, numerous major chains, including the Keg, Tim Hortons and McDonald’s, have taken part in a voluntary program to disclose nutritional indicators, including trans fat, sugar and protein content as well as some vitamin and mineral levels. But the information is available on brochures, not on the menus themselves, and a review of the program in BC found only 2% of customers requested the brochures before purchasing food.

Yet, 95% of Ontarians state they would like to see calorie information on fast food menus, according to a recent Ipsos Reid poll. Health experts, unsurprisingly, also support Ontario’s legislation. Virtually all major health organizations, including the Canadian Diabetes Association, the College of Family Physicians of Canada, the Canadian Stroke Network and dozens more, support nutritional information on menus. And the reasoning is simple. “It’s estimated 65,000 Canadians die prematurely every year from unhealthy eating. It’s driving obesity, hypertension, dyslipidemia, diabetes and many cancers,” says Norm Campbell, a professor of medicine at the University of Calgary and chair of the Heart and Stroke Foundation of Canada’s Hypertension Prevention and Control Initiative.

Still, previous bills proposing menu labelling have failed to be enacted. France Gélinas, a member of parliament with the New Democratic Party, has put forward two such bills. According to Campbell, “the industry on the other side is fighting tooth and nail, lobbying the government and undermining efforts to improve the situation.”

James Rilett, vice president for Ontario at Restaurants Canada, said his members would prefer the voluntary program to a mandatory one, but also said restaurant owners go out of their way to respond to nutritional transparency requests from the public. “They want customers to be happy,” he explained.

The evidence behind restaurant menu labelling

The restaurant industry’s main argument against menu labelling is that it’s expensive and ineffective. “We have never seen any proof that menu labeling works,” says Rilett, pointing to several studies that found people don’t order fewer calories, on average, when nutritional information is displayed.

Generally, however, the evidence suggests menu labelling does prompt customers to order slightly fewer calories. “The larger and better designed, more controlled studies do show decreases in calories purchased per transaction,” says Kate Comeau, a dietitian and spokesperson with Dietitians Canada.

The biggest study to date, at over 200 Starbucks locations in New York City, found consumers purchased almost 6% fewer calories from food in the 11 months following the introduction of a menu labeling program. Supposing one quarter of those calories came from chain restaurants, a 6% reduction wouldn’t significantly impact obesity, the researchers note.

But looking at averages can miss the effect menu labelling can have on individuals. Loyalty card data in the Starbucks study suggested those who order more calories were more influenced by calorie information. Those who previously bought items totalling more than 250 calories ordered 26% fewer calories per transaction after the calorie information was posted.

As well, mandatory calorie labelling may prompt restaurants to offer healthier choices. A study of 37 restaurant chains in Washington State found that six months after menu labelling was introduced, menu items contained, on average, 41 fewer calories compared with 18 months prior to the introduction of labelling. (It’s possible, however, that the restaurants chose to offer lower calorie options for other reasons than concern about posted numbers.)

Sodium should be added to menus, say experts

Many health experts argue that sodium, in addition to calories, should be flagged on menus. Researcher Mary L’Abbé at the University of Toronto surveyed 20 sit-down and 65 fast-food restaurants across Canada, and found the average dish contained 1455 mg of sodium, almost equivalent to what is considered adequate for most people for an entire day. Currently, it’s estimated Canadians consume 3500mg of sodium per day, and research shows halving that that would prevent up to 11,500 cardiovascular disease events, including strokes and heart attacks, per year.

High salt intake can lead to hypertension, which puts one at a higher risk of heart disease and stroke. “About two million Canadians have hypertension related to high dietary sodium. If we were able to reduce this, there would be tremendous cost savings to our health care system,” says Campbell.

Gélinas says she’ll advocate for the inclusion of sodium on menus when the current bill goes to Committee later this spring. At this stage, members of the public are also invited to provide input on the bill.

Jensen didn’t rule out the inclusion of sodium at a later date. “The proposed legislation includes regulation-making authority that would allow the government to require the posting of other nutrients at a later date, if desired,” he explained in an email.

Numbers alone aren’t enough

Many sources explained that part of the reason the research on menu labelling is underwhelming is that calorie and sodium numbers alone don’t resonate with individuals. Moreover, basing a decision solely on calories can lead to poor choices, says Comeau. “If I’m a consumer and I’m trying to decide between plain yoghurt with blueberries at 150 calories and a cookie at 100 calories, the risk is that I’m going to pick the cookie…when in fact the blueberries and yoghurt would have been more nourishing,” she says.

David Hammond, a professor in public health at the University of Waterloo, says calorie numbers can be effective if they’re “leveraged for a broader conversation” – one that underlines the concepts of daily calorie intake, the Food Guide and the importance of ensuring most of the calories one does consume are nutritious.

Research by Hammond and others show a single number is less meaningful to consumers in comparison to a number that is described as high or low. This could be indicated through a colour-coding system, or by listing the average person’s total recommended daily calorie intake. Hammond argues a “traffic light” type of approach, with green indicating a healthy choice and red indicating a high-calorie or high-sodium choice, would be most effective. However, the adoption of such systems is hampered by lobbying by the restaurant industry “because they’re more negative,” says Hammond.

Heidi Bates, director of the Integrated Dietetic Internship at the University of Alberta thinks menu labels should be accompanied by an educational campaign, which would ideally include multiple platforms such as infographic posters in restaurants, television and radio messaging and classroom education for school-age children.

Campbell compared menu labels to labels on cigarette packages, explaining labels “are a win,” but need to be accompanied with a host of other policies. Such policies could include offering incentives for healthy food stores to set up in neighbourhoods with high obesity rates (as is done in the US), the provision of free fruits in schools (as is done in the UK), or the requirement for vending machine snacks to meet criteria on fat and sugar levels (as is the case for government premises in Bermuda).

Whatever information is given, it needs to ‘click in’ quickly. “People don’t have an hour to stand in the restaurant line trying to decipher the nutritional information. Convenience is king,” says Bates.