Local policies related to restaurant menu labeling: Barriers, facilitating factors, and the role of local health departments

1
Local policies related to restaurant menu
labeling Barriers, facilitating factors, and
the role of local health departments

• A thesis presentation by
• Elizabeth Payne, MPH candidate
• Committee
• Donna Johnson, PhD, RD (Chair)
• Barbara Bruemmer, PhD, RD
• University of Washington, Nutritional Sciences
• February 25th, 2011

2
Introduction

• Obesity and related chronic disease rates
  increasing despite decades of targeted individual
  level interventions1-7
• Obesity approach that mirrors successful
  anti-tobacco work, focusing on environmental
  factors 1, 3, 8
• Nutrition policies based on anti-tobacco work
• change social norms to make unhealthy food less
  accessible, less desirable and less acceptable1

3
IntroductionThe restaurant food environment

• Meals away from home increased with obesity
  rates, now account for 1/3 of calories
  consumed9,10
• 3/4 of restaurant visits at fast-food other
  chain restaurants11
• Fast-food associated with higher intake of
  calories saturated fat, higher BMI, increased
  risk of obesity, type 2 diabetes1-3
• Hard to accurately estimate calories in
  meals15-17
• Not voluntarily reducing portion sizes, or
  displaying nutrient information4-6

4
IntroductionMenu Labeling Policies

• The restaurant industry has opposed attempts to
  regulate the provision of nutrition
  information7,8
• Menu labeling legislation passed in many
  jurisdictions, NYC 1st in 2008 12,18, 20
• In March 2010, passage of the Patient Protection
  and Affordable Health Care Act, made restaurant
  menu labeling federal law.18, 19

5
BackgroundThe effect of menu labeling unclear
Experimental studies Milich et al. 1976 Workplace cafeteria, modest effect
Experimental studies Cinciripini et al. 1984 University cafeteria, mixed effect
Experimental studies Mayer et al. 1987 Workplace cafeteria, no effect
Experimental studies Balfour et al. 1996 Workplace cafeteria, modest effect
Experimental studies Yamamoto et al. 2005 Adolescents, mixed effect
Experimental studies Burton et al. 2006 Mail survey, mixed effect
Experimental studies Harnek et al. 2008 Adolescents, modest effect
Experimental studies Roberto et al. 2010 RCT, significant effect
Studies in real-world situations Bassett et al. 2007 Subway restaurants, effect in some customers
Studies in real-world situations Dumanovsky et al. 2010 NYC post enforcement, 2-fold increase in reported use
Studies in real-world situations Elbel et al. 2009, 2011 NYC regulation, no effect
Studies in real-world situations Pulos et al. 2010 Pierce Co voluntary program, minimal effect
Studies in real-world situations Finkelstein et al. 2011 King Co regulation, no effect
6
Background1st menu labeling policy

• Lessons from NYCs menu labeling
  regulation12,20,29
• 1st passed 2006
• BOH criticized for not including NYSRA
• Big push-back from NYSRA
• 1st lawsuit decided in NYSRAs favor
• Revised regulation went into effect 2008
• 2nd NYSRA lawsuit not successful

7
Background
3 counties in Washington State working to
improve the restaurant food environment using
different approaches to menu labeling
King
Pierce
Thurston
8
BackgroundThree menu labeling cases in
Washington State

• 2nd jurisdiction to pass menu labeling
  regulation
• Intense push-back from industry
• Regulation went into effect Jan 2009
• 1st study to date no impact on calories
  ordered30

King County
9
BackgroundThree menu labeling cases in
Washington State

• SmartMenu voluntary, non-chain restaurants
• Help w/ menus recipes, free nutrient analysis,
  advertising
• 2 studies to date small impact on purchasing
  behavior31, incredibly resource intensive32

Pierce County
10
BackgroundThree menu labeling cases in
Washington State

• NEA showed need for focus on kids meals
• 2009 RWJF HE grant
• Collaborative study w/ local franchise owner
• 1st phase- add healthier items
• 2nd phase- test marketing

Thurston County
11
Need for current study

• Need more studies on policy process
• Public health literature on policy development
  often lacks theoretical framing33, 34
• Applying theories of policy change to real-world
  policy situations needed35
• Opportunity to study interactions between local
  public health departments and industry

12
Study Purpose Aims

• To determine the roles, relationships and
  barriers related to working with restaurants and
  to identify strategies that health departments
  can use to facilitate nutrition policy
  development.

13
Study Purpose Aims

• Specific Aims
• Examine the interactions among restaurant owners,
  the Washington Restaurant Association, and local
  health departments to determine political and
  contextual factors that are barriers or enablers
  to the provision of nutrition information in
  restaurants
• Describe the role of local health departments in
  developing and implementing restaurant nutrition
  information policies

14
The Advocacy Coalition Framework
15
The Advocacy Coalition Framework
16
The Advocacy Coalition Framework

• Relatively Stable Parameters
• system-wide parameters, stable over long periods
  of time
• Governmental, legal and economic systems
• Attributes of policy issue that are enduring and
  frame the policy debate36

17
The Advocacy Coalition Framework
18
The Advocacy Coalition Framework

• External Events
• dynamic factors external to the policy subsystem
• changes in
• socioeconomic conditions
• technology
• public opinion
• political power (i.e. critical elections)
• and the impact of other policy decisions
  subsystems36

19
The Advocacy Coalition Framework
20
The Advocacy Coalition Framework
21
The Advocacy Coalition Framework
Policy Subsystem comprised of the set of actors
involved with a given policy issue subsystem
actors form advocacy coalitions based on shared
values or beliefs36
22
The Advocacy Coalition Framework
23
The Advocacy Coalition Framework
Policy Subsystem- beliefs overarching driver for
policy actors Deep core beliefs - deeply held
personal beliefs, unchangeable Policy core
beliefs - fundamental policy positions of an
advocacy coalition, resistant to change Secondary
beliefs - related to the administration and
implementation of policy, most susceptible to
change36
24
The Advocacy Coalition Framework

• Policy-oriented learning
• occurs as a result of
• direct challenge to an advocacy coalition
  (opponent challenge or external events)
• accumulated experience, the so-called
  enlightenment function of policy process that can
  take up to a decade or more36

25
Methods

• Multiple-case, replication study design
• Data collection
• written documentation from each county
• key informant interviews
• public health employees, Board of Health members,
  restaurant owners, Washington Restaurant
  Association representative
• Interviews by phone, and oral consent was
  obtained using procedures approved by the
  University of Washington Institutional Review
  Board in January 2010.
• The interviews ranged from 20 to 100 minutes in
  length and were recorded to ensure complete data
  collection

26
Methods
Plus one interview with a Washington Restaurant
Association Representative
27
MethodsData Analysis

• Interview transcripts reviewed for key concepts
  and themes
• Coding structure developed, based on the
  constructs of the ACF
• Atlas.ti qualitative data analysis software used
  to code and manage data37
• Coded data explored both within and across cases,
  looking for patterns and linkages
• Data from each case used to assess the fit to the
  Advocacy Coalition Framework

28
Results

• Constraints and resources (barriers/enablers)
• Relatively stable parameters
• External events
• Policy subsystem
• Relationships
• Beliefs- role of Health Department

29
Results- constraints and resources

• Respondents in each county
• obesity rates something must be done
• increases in meals eaten away from home made
  restaurant environment an obvious choice
• Its a given that restaurants are focused on
  profit, public health objectives often at odds

Relatively Stable Parameters Obesity rates Increased eating away from home Restaurants need to be profitable
30
Results- constraints and resources

• ACF Construct King Pierce Thurston

External Events
King Political climate BOH Precedent policy in NYC Support from national organization
Pierce Economic recession Political climate BOH Industry push-back in NYC, King Co Federal legislation
Thurston Funding Political climate BOH Industry push-back in NYC, King Co
31
Results- constraints and resources

• ACF Construct King Pierce
• BOH played central role in development of menu
  labeling policy, very progressive, leader in
  obesity prevention for years
• The BOH voted unanimously in favor of the menu
  labeling regulation
• The BOH was united. We knew that there were
  objections coming forward from the restaurant
  industry. But we had very strong support from the
  community, and from the BOH and from the medical
  community. - BOH member

King Political climate/BOH Precedent policy in NYC Support from national organization
32
Results- constraints and resources

• ACF Construct King Pierce Thurston
• NYC regulation, lawsuits helped guide policy
  development
• Support of Center for Science in the Public
  Interest (CSPI)
• Respondents recalled that after Margo Wootan,
  Nutrition Policy Director at CSPI presented on
  menu labeling, moved forward with policy
• So she gave that presentation and everything
  kind of changed. The BOH was quite taken with the
  information and presentation, so was David
  Flemming, Public Health Director and from there
  we started having meetings- PH employee

King Political climate/BOH Precedent policy in NYC Support from national organization
33
Results- constraints and resources

• ACF Construct King Pierce
• Economy in recession
• Health department impacted
• restructuring, loss of champion
• requiring restaurants to take on additional costs
  would not play well politically

Pierce Economic recession Political climate/BOH Industry push-back in NYC, King Co Federal legislation
34
Results- constraints and resources

• BOH generally supportive and progressive
• Supportive of voluntary approach, less
  enthusiastic about the idea of passing menu
  labeling regulation
• One BOH member described a BOH that is
  politically divided, with some members who are
  pretty conservative and the less government the
  better types

Pierce Economic recession Political climate/BOH Industry push-back in NYC, King Co Federal legislation
35
Results- constraints and resources
Pierce Economic recession Political climate/BOH Industry push-back in NYC, King Co Federal legislation

• Concern about objections from industry was one
  reason didnt want to mandate menu labeling
• BOH members described how the push-back from
  industry in King County and New York City helped
  shape their approach
• Number one we didn't want to lose the support of
  industry. We also wanted to make sure that we
  werent seen as pushing something on the
  restaurants that the public would see as
  invasive. - BOH member

36
Results- constraints and resources

• Large-scale cut backs, re-prioritization of
  tasks and time for new leadership to get up to
  speed on the work
• By the time ready to move forward with policy,
  preemption by federal legislation was a concern

Pierce Economic recession Political climate/BOH Industry push-back in NYC, King Co Federal legislation
37
Results- constraints and resources

• 100 grant funded budget
• Robert Wood Johnson Foundation (RWJF) grant to
  work
• on healthy kids menus- research project

Thurston Funding Political climate/BOH Industry push-back in NYC, King Co
38
Results- constraints and resources

• Respondents described the BOH as very committed
  to
• using a collaborative approach with industry
• Advancing a menu labeling policy was never even
  on the
• agenda
• No way would our county commissioners or BOH
  basically support something like that menu
  labeling regulation either. It wouldnt even be
  an option here to do something like that. That's
  not how they look at it - PH employee

Thurston Funding Political climate/BOH Industry push-back in NYC, King Co
39
Results- constraints and resources

• BOH is 3 county commissioners, elections every 4
  years
• Thurstons population just over 250,000. One
  public health
• employee said,
• Even though were a pretty Democratic
  county, we have a mix- a very Republican mix,
  lots of military families lots of different
  things like that. You have to really be careful
  in terms of thinking through how people look at
  individualism and individual choices.- PH
  employee

Thurston Funding Political climate/BOH Industry push-back in NYC, King Co
40
Results- constraints and resources

• Cautious in approach, didnt want WRA to think
  they were going for a policy
• But, may have changed industry receptivity
• when you call and say I want to talk about this
  healthy dining thing- they get right back to you!
  Which makes it easier to partner, have the
  conversation. What was going on in other places
  got their attention and they were more attentive
  to our discussions. - PH employee

Thurston Funding Political climate/BOH Industry push-back in NYC, King Co
41
Results- Policy Subsystem

• ACF Construct King Pierce
• HEAL- Healthy Eating Active Living

Policy Subsystem Actors
King Leaders Board of Health, Public Health DirectorStaff HEAL, environmental healthIndustry restaurant owners (chains), WRACommunity health organizations advocatesCenter for Science in the Public Interest
Pierce Leaders BOH, former HD manager, PH Director Staff HEAL, environmental health Industry owners (local, non-chain), WRA
Thurston Leaders BOH, senior HD leadership Staff HEAL, environmental health Industry local franchise owner, WRA
42
Results- Policy Subsystem

• Advocacy Coalitions in King Co
• 1st Phase contentious relationships
• BOH members invite WRA to meetings, vote to pass
  regulation
• WRA, restaurant owners feel ignored
• There was no real open dialogue. It wasn't what
  do you guys think? It was this is what we want
  to do and we hope that youll get onboard. Well,
  how do we have the ownership, or how do we feel
  like this is the best way to go if we cant even
  comment? - WRA rep

43
Results- Policy Subsystem

• Advocacy Coalitions in King Co
• 2nd Phase changing relationships
• HD starts stakeholder process
• restaurant owners initially angry
• Trust, relationships get re-built
• By the time of last stakeholder process, went
  from a really adversarial, angry first meeting to
  people who were hugging goodbye, saying how good
  they felt about the process. - PH employee

44
Results- Policy Subsystem

• Advocacy Coalitions in King Co
• 2nd Phase changing relationships
• WRA attempts statewide preemption
• BOH fights for the policy
• WA state legislature- compromise

45
Results- Policy Subsystem

• WRA representative describes the process,
• We ran a statewide labeling bill that would have
  created a consistent statewide standard. King
  County fought us the whole way through that, and
  so unfortunately that was very combative there.
  Through that though we got them to come to the
  table and sit down with us and talk through our
  concernsAnyway, out of that fortunately we
  turned into a relationship that became sort of
  positive. We continued working with them and we
  found an ordinance that our folks could agree
  upon.

46
Results- Policy Subsystem

• Advocacy Coalitions in King Co
• Evidence of policy-oriented learning
• Result of direct challenge by opposing coalition
• Pro-menu labeling coalition compromised on
  implementation strategies (secondary beliefs) in
  order to preserve the regulation (policy core
  beliefs)
• We had to compromise, but we got the
  menu-labeling regulation so it was worth it! -PH
  employee

47
Results- Policy Subsystem
Policy Core Beliefs appropriate role of government, priority of regulation
King Unanimously endorsed the belief that it is an appropriate role of public health to use regulation when necessary to protect the health of the community
Pierce BOH and PH employees less united on the question of using regulation, role of PH to educate vs. role is to safeguard public health and regulation is appropriate
Thurston Role of public health is to ensure that people have choices, regulation only as last resort
48
Results- Policy Subsystem

• ACF Advocacy coalitions form around shared
  policy core beliefs
• Evidence of shared beliefs that favor public
  health policy development in King County
• Beliefs in Pierce less unified
• Thurston unified around beliefs that favor
  partnerships with industry rather than public
  health policy development

49
Results- key factors King Co

• Policy Subsystem
• Advocacy coalitions formed around shared policy
  beliefs
• Pro-menu labeling coalition beliefs role of HD
  is to protect PH and use regulation as needed
• Opposition coalition beliefs (data not shown)
  freedom from regulation priority
• Evidence of policy oriented learning

• Relatively stable parameters
• obesity rates
• meals away from home
• restaurants need to be profitable

Constraints Resources

• External events
• Political climate supportive of regulation
• NYC precedent policy
• Support from CSPI

50
Results- key factors Pierce Co

• Relatively stable parameters
• obesity rates
• meals away from home
• restaurants need to be profitable

• Policy Subsystem
• HD restructure, loss of champion, new leadership
• BOH, PH employees different beliefs about role
  of PH, use of regulation
• BOH more supportive of voluntary program
• Policy development process stalled by threat of
  preemption, new priorities

Constraints Resources

• External events
• Economic recession
• Political climate not supportive of regulation
• Push-back from industry in NYC, King CO
• Federal legislation

51
Results- key factors Thurston Co

• Relatively stable parameters
• obesity rates
• meals away from home
• restaurants need to be profitable

• Policy Subsystem
• Grant driven funding limits strategies
• BOH favors collaboration with industry
• Role of HD is to provide choice
• Policy development was never an option

Constraints Resources

• External events
• Funding
• Political climate not supportive of regulation
• Push-back from industry in NYC, King CO

52
Discussion

• Results of this research suggest that key factors
  influencing the policy process include
• the need for industry to be profitable
• the impact of economic conditions both on
  industry and health departments
• the presence of precedent or role-model policy
• support from national groups
• the political climate
• leadership support for policy

53
DiscussionUsefulness of ACF

• Findings are constant with other studies that
  have examined public health policy process and
  found the political climate, economic context and
  leadership to be important factors5, 7, 12
• The Advocacy Coalition Framework has primarily
  been used to examine and describe anti-tobacco
  policy processes, but given the interest in using
  tobacco policy to develop new approaches to
  obesity using the ACF to understand what happened
  in each of these three counties is especially
  relevant33

54
Discussion

• Implications for practice
• Building an advocacy coalition aligned around
  shared beliefs helps weather inevitable push-back
  from policy opponents
• Leadership support, policy-mentors and the
  support of other (national) organizations are key
• Prepared policy advocates will look for favorable
  conditions and be ready to move on policy when
  the context shifts in their favor

55
Discussion

• Limitations
• Key informants who were not interviewed
• Differences in interview process (King)
• Time frame too short to see policy changes as
  described by ACF

56
Discussion

• Recommendations for future research
• Apply ACF to other policy initiatives for
  improving the food environment in restaurants
  (sodium, SSB)
• Will likely involve many of the same factors and
  policy subsystem actors
• Changes over time, decade or more

57
Conclusion

• Environmental and policy approaches are an
  important part of the public health response to
  reduce obesity and related chronic diseases.
• Food environments that make healthy food more
  accessible, acceptable and desirable make it
  easier for individuals to make healthy choices.
• The menu labeling policy process in King County
  demonstrates that local health departments can
  advance public health aims through the formation
  of advocacy coalitions, making the most of the
  constraints and resources of the policy subsystem
  and building on leadership support.

58
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Acknowledgments

• Thesis Committee
• Donna Johnson
• Barb Bruemmer
• Steering Committee
• Kirsten Frandsen- Tacoma-Pierce County Health
  Dept
• Deborah Allen- Thurston County Public Health
  Social Services Dept
• Donna Oberg- Public Health-Seattle King County
• Molly McNees- Public Health-Seattle King County
• Friends and family

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