Neil O’Brien MP,
Parliamentary Under Secretary of State (Minister for Primary Care and Public Health),
House of Commons,
Menus without calorie information should be available in all restaurants in the UK
Dear Mr O’Brien,
I am writing to you to highlight the demonstrable public health need for menus without calorie information to be available in all restaurants in the UK upon request.
Since April 2022, restaurants and large businesses have been mandated to display calorie information on menus and food labels (Department of Health and Social Care & Churchill, 2021). This was introduced by the previous Public Health Minister, Jo Churchill, as part of an initiative to control the increasing rates of obesity in the United Kingdom, and to mitigate the health implications of unhealthy diets. While the success of including calorie information on lowering levels of obesity is inconclusive (McGeown, 2019, Cantu-Jungles et al., 2017) it has unintentionally caused considerable distress among individuals with eating disorders (Javed, 2022). In light of this, businesses have the option of providing menus without nutritional information to support vulnerable customers (Department of Health and Social Care & Churchill, 2021). However, the availability of such menus is not mandatory and as such, these resources are often unavailable. As this exacerbates the challenges faced by individuals with eating disorders (Haynos & Roberto, 2017), it is an urgent public health matter.
What are eating disorders?
Eating disorders are estimated to affect between 1.25 and 3.4 million people in the UK (Priory, 2023), however many cases go undiagnosed and are not reflected in statistics (Kraeft et al., 2013). Those with eating disorders engage in disordered behaviours, such as bingeing, restricting food, or excessive exercise, as a means to cope with difficult feelings or situations (Beat, 2023, NHS, 2021). These illnesses are characterised by a preoccupation with body shape and weight (NHS, 2021). Sadly, they have the highest mortality rate of all psychiatric disorders (Priory, 2023).
Eating disorders are complex; they are thought to result from an interdependent web of biological, psychological, and socio-cultural factors (Eli & Warin, 2018). However, in the UK, the social context of eating disorders is often overlooked, with treatments primarily focussing on the individual (Fogarty & Ramjan, 2016). This represents a missed opportunity to improve health outcomes by addressing the social aspects associated with eating disorders.
Social factors play a significant role in the development of eating disorders. For example, anthropologist Anne Becker (2004) investigated the association between the introduction of westernised television in Fiji and the subsequent rise in eating disorder behaviours (such as restrictive eating) among the population. She found that rather than the behaviours stemming from a straightforward aspiration for thinness (as is often proposed in scholarship about eating disorders [McCarthy, 1990]), the exposure to western TV influenced ideas of success, promoting the idea that thinness would lead to better career prospects. This led to disordered behaviours that permeated through social groups so that the destructive attitudes towards eating and body image were continually reinstated among peers. In this way, food and eating can take on harmful new meanings through the role they play in social groups and eating disorders become an integral part of the sufferer’s social world. Therefore, effective treatment relies on addressing the social context of the illness combined with approaching the sufferer through individual treatment.
In the UK, individuals with eating disorders face the additional challenge of societal focus on obesity and nutrition, often accompanied by fatphobic undertones. For example, during the COVID-19 pandemic, health messaging was partially focussed on the ‘Quarantine 15’ (15lbs that could be gained during self-isolation) rather than the risk of the coronavirus (Cooper, et al., 2022). This not only demonised weight gain during a global pandemic but placed additional stress on the stigmatisation of fatness in the UK.
This discourse is reinforced by providing calorie information on menus. This approach was criticised at the time for portraying an over-simplified view of obesity and its possible treatments (Talbot & Branley-Bell, 2022). Furthermore it reinstates the incorrect idea that thinner bodies are healthier (Bacon & Aphramor, 2011) – “Restricting food intake is not always the healthier choice” (Talbot & Branley-Bell, 2022:1254). Calorie counting is frequently a distressing aspect of eating disorders that is particularly difficult to overcome (Beat, 2021). Calorie information can be used for harmful behaviours like food restriction (Walsh, 2011) and can contribute to feelings of guilt around food (Frank, 1991). In turn, recovering from an eating disorder involves approaching food in a more holistic way (LaMarre & Rice, 2015) and breaking the “obsessional habit of counting calories” (Hsu et al., 1992:347). In fact, a very important part of recovery is to practice eating at restaurants (Moskowitz, 2022) and eating foods with an unknown calorie content (Shafran, 2002). This is why menus without calories are essential.
The social life of food
Food is used as a powerful indicator of care (Mol, 2010), identity (Petridou, 2001) and heritage (Kishigami, 2002). As such, food has social meanings. Viewing food solely from a nutritional standpoint, without considering its social context, overlooks the “complexities of nourishment that are at the heart of kinship, social life, and caregiving” (Burnett, et al., 2020:1023).
Commensality, or eating together, is an important social activity which also has health implications (Mol, 2010). For example, elderly residents of care homes often eat insufficiently and suffer increased frailty as a consequence. Residents tend to eat more in ‘cosier’ environments, so in these situations the nutritional benefit of the meal is increased. At mealtimes, a cosy atmosphere can be created by allowing residents to eat together as a community at tables set with tablecloths with music playing in the background. Attention to the social context of food in this way improves health outcomes for vulnerable populations. The loss of opportunities for commensality was abundantly clear during the COVID-19 lockdowns. During this time 86% of eating disorders became more severe (Branley-Bell & Talbot, 2020).
Furthermore, adding calorific values to menus may be ineffective as a quantified, nutritional understanding of food (such as macronutrients and calories) doesn’t always align with cultural understandings of food. Anthropologist Emily Yates-Doerr (2014) found that in Guatemala, nutritional advice didn’t translate well into local food ideas. Suggestions such as creating meals with set proportions of key food groups were difficult to prepare in practice. For example, the local women were confused as to how an avocado would fit into this classification system because the Mayan language didn’t support partitioning food into distinct groups. Prioritising a nutritional perspective of food denied the local cultural understandings of food as something than cannot be broken down into proportions of macronutrients, and as such, this approach was ineffective. As a proudly diverse nation, UK health policies must engage with the cultures of everyone whom they seek to help. This requires an acknowledgement of the diverse food practices and meanings of food for different people and incorporating this understanding into health policies.
Social context of eating disorder recovery
The social context plays a crucial role in eating disorder recovery. As with many forms of illness, an alteration in the narrative of the illness experience (changing how people think about their illness) can be vital for the healing process. This is reliant on a reconfiguration of what the illness means to the sufferer in their social context (Bury, 2001). For example: shifting an individual’s perception of themselves from a victim identity to a survivor identity (Figley, 1985:399).
Eating disorders often lead sufferers to view food differently to others. For some, food is seen exclusively in terms of calorific content (Darmon, 2009), while others perceive it as unpleasant textures or sensations (Bradbury, 2020). These perspectives often overshadow the social role of food. For example, a birthday cake may represent a ‘fear food’ (a food someone is particularly afraid of consuming) due to the calorie content or the texture of jam, rather than a treat to celebrate a person’s life. Recovery requires individuals to develop a more relaxed relationship with food, recognising that it is not a threat but something to be enjoyed (Noordenbos, 2011). Providing calories on menus provides an additional obstacle to this process.
Therefore, an important part of recovery is incorporating a sense of social support for recovery (Herrick et al., 2020). This was demonstrated by a research project focussing on TikTok content tagged with #EDrecovery. Creators fostered an ‘eating disorder recovery community’ by making videos that explored the common struggles in eating disorder recovery (such as trying unfamiliar foods or feeling guilty after eating) and providing advice for fellow sufferers. This led to users supporting each other in recovery and encouraging the narrative that recovery is achievable. Eating disorder sufferers were able to make positive change through the social support available through social media.
Some of the #EDrecovery TikTok content took the form of ‘What I eat in a day’ videos, creating a sense of virtual commensality and support for recovery narratives from other users. This is especially significant considering the role of food in mental health recovery. Improved nutrition, when delivered compassionately and acknowledging the social connotations of food, has been shown to benefit individuals with complex health needs beyond what biomedical approaches alone can achieve (Ecks, 2021). Eating disorders, like other mental health issues, require an integrated healthcare approach in which biological, psychological, and social factors of the illness are all addressed. As eating disorder sufferers are often acutely aware of nutritional values of foods, this knowledge can produce fear around particular foods (Cowdrey et al., 2013). Therefore, in order to support the holistic view of food promoted in eating disorder recovery, the social meanings of food should be emphasised and sharing meals is key to this approach. However, providing menus with calorie information may undermine this benefit as it this can trigger fears for eating disorder sufferers that delay recovery.
Ultimately, this government has a duty to promote health among the whole UK population. Access to calorie information on menus is damaging for eating disorder sufferers; their illnesses have been exacerbated as a result of the policy to provide calories on menus (Javed, 2022). The consequences of only considering food as a nutritional object without considering the social meanings are, and will continue to be, severe unless something changes. This unintended consequence can be rectified by providing the permanent and universal option of viewing menus without calorie information to support the needs of the population.
Eating disorders are a subject close to my heart, I know that recovering requires a courageous leap of faith into the advice of others.
This small change will save lives.
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