In April 2022 mandatory calorie labelling in the Out of Home Food Sector (OHFS) was implemented in England as part of the UK government’s strategy to tackle obesity. The policy was designed to provide the public with the information ‘to make healthier decisions’ and requires businesses with 250 or more employees selling food for immediate consumption to display the energy content of unpackaged food and non-alcoholic drinks in kilocalories (kcal), alongside contextual kcal reference information [1].

Previously mandatory calorie labelling on menus has been introduced in the OHFS in parts of the US, Canada and Australia between 2018 and 2019. Calorie labelling is likely to have modest effects on consumer behaviour in terms of kcal purchased [2]. Calorie labelling may also promote product reformulation, with one meta-analysis finding calorie labelling in the OHFS was associated with a statistically significant reduction in kcal (-15kcal) per dish [2].

An Office for Health Improvements and Disparities survey of the general public reported that the inclusion of calories on menus in the OHFS was supported by 79% of the UK population [3]. However, calorie labelling has received some criticism since its implementation. For example, an analysis of Twitter responses to the introduction of calorie labelling found that 71.4% of 276 respondents expressed a negative sentiment towards the policy [4]. This in part reflected public concern about the impact of the policy on people with eating disorders (EDs). Calorie labelling policy has been criticised by BEAT, the UK’s leading ED charity. It has been suggested that the policy increases the vulnerability of those at risk from an ED, exacerbates ED symptoms for those already diagnosed, and perpetuates weight stigma [5].

What does the research say about the potential influence of calorie labelling on people with an ED? Until recently there has been a lack of studies addressing this, but a small number of new studies have attempted to answer this question. Four studies have examined the opinions and experiences of people with EDs using qualitative methods (see Table 1). Recurrent themes describe how calories on menus: can lead to a hyper-fixation on calories, restrict food freedom (meals are chosen for their calorific value rather than what was actually wanted or appropriate for hunger levels), reduce eating out opportunities, increase feelings of anxiety, guilt and shame around food choices, and inhibit ED recovery. Some participants in these studies expressed anger over the messaging from ‘trusted’ public health authorities on the normalisation of calorie counting, because calorie counting had played a pivotal role in the development of their ED [6, 7]. Although these qualitative studies predominantly list negative impacts on those with EDs, some positive themes were also identified: calorie labelling can increase feelings of reassurance, control and accountability of food eaten [7, 8], and for some, the information provided may help to reduce overconsumption and the subsequent guilt [9]. Although for others, this element of control was seen as negative, as it reinforced disordered eating behaviours [7].

Table 1 Studies reporting qualitative and quantitative data relating to participants experiences and support vs. opposition for calorie labelling.
Full size table

In these recent studies, quantitative data suggest some support towards the policy; with the one study that measured policy support finding 43% of participants with diagnosed eating disorders agreed with policy implementation (Table 1). When specifically asked about ED symptomatology, 55% (of 583 participants with EDs) reported that calorie labelling may worsen their ED symptoms [8] and 91% (of 399 participants) stated that they had experienced challenges because of calories on menus [7].

But what about measured objective changes to ED symptoms as a result of calorie labelling? To date, there is very limited evidence, however one study attempted to examine negative outcomes from calorie labelling in 2015. In a sample of 299 undergraduate females, considered as at high risk from eating pathologies, Lillico et al. [10] measured eating disturbance scores, affective reactions (anxiety and body image satisfaction), unhealthy weight-related behaviours (binging, restricting calories, exercising excessively) and calorie consumption, before and after calorie labelling was introduced in a university cafeteria. They found no significant differences across all measures when calorie labels were absent or present, and concluded that there were no adverse effects of calorie labels on those at risk of EDs. However, it must be noted that although these participants were considered at high risk of eating pathologies due to their age and sex, they were stratified by Eating Attitudes Test scores rather than a formal ED diagnosis. Further research on the impact of calories on menus is therefore needed to see if these findings translate to those with diagnosed EDs. Likewise, there is now a need for more studies to develop the very minimal evidence base outlined in Table 1, including further research on impacts among those living with obesity and an ED, and understanding impacts among those with different types of ED (including binge eating disorder, anorexia nervosa and bulimia nervosa (see Fig. 1).

Fig. 1
figure 1

Key research priorities on the impact of calorie labelling on EDs.

Full size image

The UK government calorie labelling guidance does acknowledge that those with EDs may find seeing calorie information on menus challenging and permits that businesses provide a menu without calories on request, ‘at the business’s discretion’ [1]. However, anecdotal experiences of those with EDs suggests that menus without calories are not always available [11], with a recent observational study finding just 12% of 90 food outlets had a calorie-free menu available on request [12]. Furthermore, the very act of requesting may be distressing for those with an ED by drawing further attention to their ED [11]. Perhaps the best solution would be for all establishments to mandatorily provide menus with and without calories, either online or via QR code [7] and thus eliminate the need to publicly request a menu without calories.

EDs are complex mental health conditions. Many people with EDs also have obesity, and having obesity is also a risk factor for developing an ED [5]; thus large numbers of people that are the ‘target’ of calorie labelling are at risk of harm. Yet despite the perceived negative impacts of calories on menus, many people living with an ED understand the need to address population-level obesity and a significant proportion support calorie labelling. However, this should not be at the detriment of their own health, and should not increase weight stigma or encourage restrictive eating. As with every public health policy, we should aim to ‘first do no harm’. Based on studies conducted to date, we propose it should be mandatory for businesses to provide calorie free menus alongside menus with calories.