In April 2022, the UK government mandated calorie labelling on menus for large businesses, as part of the government’s strategy to tackle obesity. Large businesses, including restaurants, cafes, and takeaway establishments, must by law display the calorie information of non-pre-packaged food and soft drinks on menus, third party apps, food delivery platforms, and food labels at the point of choice. In addition, menus must include daily recommended calorie needs. The public health minister at the time, Maggie Throup, said:

As part of our efforts to tackle disparities and level up the nation’s health, these measures are an important building block to making it as easy as possible for people to make healthier food choices. (Department of Health and Social Care, 2022)

Similar strategies have been introduced in Canada, the United States, and Australia. However, doubts about the efficacy of this kind of legislation are growing. A Cochrane review demonstrated that only a small number of low-quality studies suggest that calorie information on menus lowers calories ordered or purchased (Crockett et al. 2018). Concerns about the harm these measures will have for people with an eating disorder (ED) are rising. For example, the leading UK charity for EDs, Beat, documented concerns about the legislation, and an online petition to halt the plans reached over 29,000 signatures.

Considering that EDs affect around 1 in 5 women and around 1 in 8 men (NHS, 2020), there is a need to research the impact of calorie labelling on menus for people with EDs. The authors of the current paper explored the perceived impact of calorie labelling on menus on this vulnerable population (Frances et al., 2023).

Methods

An online survey was developed and shared via social media and through the mailing lists of organisations or services in contact with people with lived experience of an ED. The survey included multiple open-ended questions, exploring the experiences, challenges, management strategies, potential positive impacts, and broader relationship/societal effects associated with calorie labelling. Participants were included if they were 16 or over and had self-reported experience with a current or past ED.

Reflexive thematic analysis was used to analyse the data, from a critical realist perspective (i.e., there are no singular ‘truths’, but multiple truths coexist which are socially constructed and contextualised; Fletcher, 2017).

Results

399 participants completed the survey. 91% of those who gave demographic information reported being female and of a white racial background, and 39% identified as LGBTQIA+. Participants had experience of anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), otherwise specified feeding and eating disorder (OSFED), avoidant restrictive food intake disorder (ARFID), and rumination disorder.

The following six themes were developed from the coding of the survey responses.

• Impacts on relationships
  • Dining out is usually by nature a social activity. As such, respondents felt that calorie information on menus had impacted their friendships and relationships in that when they required support from close others, this caused strain on the relationship.
  • Respondents also felt responsible for causing worry and upset to people they dined with, which produced feelings of guilt, shame, and sadness.
• Exclusion and increased isolation
  • Respondents felt that the new legislation had increased isolation and induced ‘enforced exclusion’; where participants had worked hard and progressed towards dining out, the legislation led respondents to feel they had no choice but to avoid the experience as it did not feel safe.
• Restricted freedom
  • Respondents felt unable to make what they felt were free choices when dining out.
  • An inner conflict emerged, where participants felt that although calorie information might sometimes reduce anxiety, it ultimately restrained their freedom. The authors refer to this as an illusion of safety and control, where although calorie information provides a sense of control, it may trap individuals in decision-making dominated by numbers.
  • Worryingly, some respondents felt that they had been triggered by the legislation and were more likely to engage in ED behaviours.
• Dis/embodiment
  • Participants felt torn between what they wanted and listening to their body, and making choices based on calorie content. As such, choices often did not satiate their hunger and therefore did not reflect their body’s needs.
• Anger and frustration at the perpetuation of diet culture
  • The legislation has stirred anger due to perceived lack of scientific support, concerns about promoting disordered eating, frustration with the government’s neglect of broader societal issues that drive poor health, and the potential reinforcement of a culture of shame around food and weight, which would disproportionately affect those already harmed by weight stigma.
• We are all responsible for ourselves
  • A few respondents viewed the legislation positively, seeing it as a tool to stay accountable to food choices aligned with their recovery.
  • They perceived the information as a means to exert control, make informed decisions, and even challenge themselves, though acknowledging this could be part of ED thoughts.

Conclusions

The authors conclude that the majority of those with experience of an eating disorder (ED) find that calorie labelling legislation has led to increased isolation and feelings of guilt and shame.

Feelings of guilt and shame, and isolation are core features of having an ED. Therefore, these experiences shed light on how EDs can be made worse by the new legislation. Whereas a minority might find the legislation helpful in some way, this could be an illusion of control and safety.

Ultimately, these qualitative experiences bolster concerns that the legislation may be dangerous for people with an ED and add to the empirical evidence base that weight-centred policies can cause harm.

Strengths and limitations

This qualitative study provides a rich understanding of the impact of new legislation to display calorie information on menus to those with experience of an ED. The study also benefits from a large sample (N = 399), representing hundreds of viewpoints and experiences, and amplifying the voices of those with EDs. However, incomplete survey responses were not included in the final analysis. There is a small possibility that there was a common reason for not completing the survey, and that these respondents’ data would have added something new or different to the analysis.

The researchers discuss their role as ‘inside researchers’, nodding to their own lived experience of having an ED. Within reflexive thematic analysis, reflexivity refers to the process of understanding how the subjective experiences and positioning of the researcher can shape data analysis (Braun and Clarke, 2023). Therefore, it is important to carefully understand how the researchers’ lived experience may have shaped the analysis and results. For example, if the researchers were already unfavourable towards the legislation before starting their analysis. However, their positioning and lived experience arguably adds a deeper understanding of and sensitivity to the survey responses, and amplifies respondents’ difficulties.

A limitation is that the sample was overwhelmingly white and female, although roughly only 74% and 71% participants gave information on their gender and racial and ethnic background, respectively. This brings into question how representative the views on calorie labelling presented here are.

It is important, and would be useful to understand, the experiences of men who have EDs and body image concerns. Body image concerns experienced by men often include muscle-enhancing goals and the assessment of calories and the macro-nutritional content of food (Nagata et al., 2021). ED behaviours more unique to men may include cycles of ‘bulking’ (weight lighting; consuming large amounts of protein) and ‘cutting’ (reducing calorie and specific macronutrient intake to decrease body fat; Forrest et al., 2019). As such, further research is needed to understand men’s views and experiences with calorie labelling on menus.

Implications for practice

The implications of this research are highly important. Recent NHS statistics demonstrate that EDs, which have the potential to greatly derail a young person’s life, are not a small-scale problem. Survey statistics examining probable mental disorders in young people found that 12.5% of 17 to 19-year-olds, and 5.9% of 20 to 25-year-olds had an ED in 2023. Rates for 17 to 19-year-old women were 20.8% (up from 1.6% in 2017) and were 5.1% for men. The survey also found that EDs were identified in 11 to 16-year-olds had rates that were four times higher in girls (4.3%) than boys (1.0%) (Newlove-Delgado et al., 2023).

There is subsequently an urgent need to review this legislation if we are to create a safe dining-out environment for those with EDs, especially for young people. Health policy legislation of this kind requires meaningful consultation and involvement of those with lived experience of EDs. Despite concerns being expressed by the All-Party Parliamentary Group on Eating Disorders prior to the move to calorie labelling, the legislation was pushed ahead.

As someone with past experience of disordered eating, I also felt the legislation was disappointing. The respondents of this survey suggest that menus without calories should be the primary option available, and that calorie information could be available on request or via some other option for those who want it or might find it helpful (e.g., QR code). There could be limitations to this approach. For example, in the instances where, out of curiosity, I have requested for a menu without calories, I have been told that this option is not available. Therefore, it’s hard to know whether both options would be reliably available across restaurants.

As said by participants in this survey, there are key systemic issues that need addressing as a priority. Food insecurity (a lack of economic, social or physical means to ensure a sufficient supply of nutritionally appropriate food; Purdam et al., 2016) is at an all-time high in the UK and greatly affects those with EDs (Hazzard et al., 2023; Kuehne et al., 2023). Introducing measures that contribute to a culture of shame and anxiety around food will exacerbate the guilt and shame already experienced by those affected by food insecurity and eating disorders. Adding calorie information on menus feels like an extra cruel addition to the hostile environment those recovering from an ED already find themselves in. As the authors put it in the title of the article, it is an extra fight we didn’t ask for.

The cold hard truth is that the risk of obesity in those from lower socioeconomic backgrounds is not going to be fixed with calorie labelling, but by making healthy food cheaper and more convenient, and by solving poverty. (Yeo, 2022, p. 454)

Statement of interests

No conflict of interest to declare.

Links

Primary paper

Frances, T., O’Neill, K., & Newman, K. (2023). ‘An extra fight I didn’t ask for’: A qualitative survey exploring the impact of calories on menus for people with experience of eating disorders. British Journal of Health Psychology.

Other references

Braun, V., Clarke, V., Hayfield, N., Davey, L., Jenkinson, E. (2022). Doing Reflexive Thematic Analysis. In: Bager-Charleson, S., McBeath, A. (eds) Supporting Research in Counselling and Psychotherapy. Palgrave Macmillan.

Department of Health and Social Care. (2022, April 6). New calorie labelling rules come into force to improve nation’s health. GOV.UK.

Fletcher, A. J. (2017). Applying critical realism in qualitative research: methodology meets method. International Journal of Social Research Methodology, 20(2), 181-194.

Forrest, L. N., Perkins, N. M., Lavender, J. M., & Smith, A. R. (2019). Using network analysis to identify central eating disorder symptoms among men. International Journal of Eating Disorders, 52(8), 871-884.

Hazzard, V. M., Williams, B. M., & Levinson, C. A. (2023). Introduction to the special issue on food insecurity and disordered eating. Eating Behaviors, 50, 101781-101781.

Department of Health and Social Care (2022) New Calorie Labelling Rules come into force to improve nation’s health, GOV.UK. Available at: (Accessed: 29 November 2023).

Kuehne, C., Hemmings, A., Phillips, M., İnce, B., Chounkaria, M., Ferraro, C., … & Schmidt, U. (2023). A UK-wide survey of healthcare professionals’ awareness, knowledge and skills of the impact of food insecurity on eating disorder treatment. Eating Behaviors, 49, 101740.

Nagata, J. M., Ganson, K. T., & Murray, S. B. (2020). Eating disorders in adolescent boys and young men: an update. Current Opinion in Pediatrics, 32(4), 476–481.

Newlove-Delgado T, Marcheselli F, Williams T, Mandalia D, Dennes M, McManus S, Savic M, Treloar W, Croft K, Ford T. (2023). Mental Health of Children and Young People in England, 2023. NHS England, Leeds.

Purdam, K., Garratt, E. A., & Esmail, A. (2016). Hungry? Food insecurity, social stigma and embarrassment in the UK. Sociology, 50(6), 1072-1088.

Yeo, G. S. (2022). Is calorie labelling on menus the solution to obesity? Nature Reviews Endocrinology, 18(8), 453–454.

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