HHS COMMITTEE #1 July 24, 2017 MEMORANDUM. July 20, Health and Human Services Committee. Linda McMillan, Senior Legislative Analyst~

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1 HHS COMMITTEE #1 July 24, 2017 MEMORANDUM July 20, 2017 TO: FROM: SUBJECT: Health and Human Services Committee Linda McMillan, Senior Legislative Analyst~ Update from Center for Science in the Public Interest (CSPI) on Restaurant Children's Meal and Menu Labeling Expected for this session: Dr. Margo G. Wootan, D.Sc., Director of Nutrition Policy for the Center for Science in the Public Interest (CSPI) Melvin R. Thompson, Senior Vice President for Governmental Affairs and Public Policy for the Restaurant Association of Maryland Restaurant Children's Meals The Committee last heard from CSPI on this issue in 2013 at which time it reviewed the report "Kids' Meals: Obesity on the Menu." The report looked at the nutritional quality of children's meal combinations at 41 chain restaurants. Because different items can be selected, there were 3,494 combinations. The report said that: 97% of the meal combinations do not meet the expert nutrition standards for children's meals. 91 % of the meal combinations do not meet the National Restaurant Association's Kids LiveWell standards. 56% of the chains do not have any meals that meet the expert nutrition standards. 26% of the chains do not have any meals that meet the Kids Live Well standards. Calories for meals varied from 30 to % of the meal combinations had more than 430 calories and 50% had more than 600 calories Sodium content varied from 25mg to 1,820mg

2 On a positive note, from 2008 to 2012, the number of meal combinations that meet the expert standard went from 7% to 14% and the number that meet the sodium standard went from 15% to 34% An April 2017 brief, "The National Movement to Improve Restaurant Children's Meals," from CSPI is attached at 1-2 and it indicates further improvement, noting that in 2013, McDonald's became the first major chain to stop listing sugary beverages on its children's menu. It has been followed by several other restaurants. However, 74% of top chains still have sugary drinks on the children's menu. It also notes that McDonald's and Disney theme parks have changes the default sides that come with their meals. Attached at 3-9, is the CSPI brief, "Serve Kids Better, Healthy Restaurant Children's Meals Improve Children's Diets and Health." The brief notes that a 2015 report found 89% of parents reported making a purchase from a fast food restaurant for their children in the previous week. This emphasizes the importance of healthier food choices since there is a high likelihood that children will eat fast food at some point during a given week and that, according to a 2016 survey, parents are more likely to order a fast food kids' meal for a younger child (age 2-5) compared to an older child ( age 6-11 ). FDA Delay in Menu Labeling Requirements Dr. Wootan will also discuss with the Committee the delay in the federal requirements for menu labeling. The implementation of these rules was to take effect May 5, 2017 after previous delay. A brief article on the delay from the National Law Review is attached at 10, from the National Association of Convenience Stores at 11, and the statement from HHS Secretary Tom Price at 13. An article from The Consumerist that discusses CSPI's complaint about the FDA action is attached at Because Montgomery County has implemented local menu labeling requirements, the impact of this last-minute delay does not change the requirements for restaurants in Montgomery County (that have more than 20 locations in the United States). However, the delay means that establishments exempt from County law (grocery stores, convenience stores, and movie theaters) will still not have requirements to show calorie and other information. A summary of the County requirements is attached at F:\MCMILLAN\HHS\Children's Meals in Restaurants July 2017.doc 2

3 CENTER FOR Science IN THE Public Interest April 2017 The National Movement to Improve Restaurant Children's Meals National organizations including the American Heart Association/ American Cancer Society,2 Center for Science in the Public Interest, Interfaith Center for Corporate Responsibility,3 and MomsRising4 are encouraging improvements to restaurant children's meals at the local, state, and national level. Although leading restaurant companies and local jurisdictions have made some progress in recent years, much more is needed. Many of the biggest restaurants nationwide are improving their children's menus. In 2013, McDonald's became the first major restaurant chain to agree to stop listing sugary beverages on its children's menus. 5 Since then, Burger King, Wendy's, Dairy Queen, Applebee's, and Jack in the Box have made similar commitments, responding to public health concerns that sugary beverage consumption adversely affects children's health. 6 As a result, fewer restaurants had sugary beverages-soda, lemonade, and fruit punch-on their children's menus in 2016 than in 2012 and However, the majority of top chains (74%) still have sugary drinks on children's menus.7 Public health organizations are encouraging Chili's, 8 Bojangles' (a regional chain popular in the southeast),9 and other major restaurant chains 10 to stop using their children's menus to push sales of sugary drinks. Some restaurants are also improving the 20 nutritional quality of the foods they offer. 10 McDonald's and Walt Disney theme parks have changed the default sides that come Soda and other wgu-, drinks with their children's meals. Over the first 12 years that it has served apples in Happy Meals, McDonald's served 2 billion packages of apples. 11 Disney's healthy defaults resulted in 21 percent fewer calories compared to meals with unhealthy side dish and beverage defaults Restaurants Offering Sugary Drinks on Children's Menus Nationwide, more than 100 companies participate in the National Restaurant Association's Kids LiveWell program, which is designed to encourage healthy options on restaurant children's menus. 13 Participating restaurants offer one meal combination and one side dish that provide a positive contribution to children's nutrition (by including a fruit or vegetable, for example) and are moderate in calories, saturated fat, and sodium. 14 However, among the 50 largest restaurants nationwide, the proportion of children's meals that are healthy only rose from 1 percent to 3 percent from 2008 to % 83% 74% Center for Science in the Public Interest j 1220 L Street, NW, Suite 300, Washington, DC I cspinet.org

4 Communities across the nation are championing healthy restaurant children's meal policies. Five cities in California have passed ordinances to improve the nutritional quality of restaurant children's meals. The cities of Davis, Stockton, and Perris require that restaurants in their jurisdictions offer only healthier beverages as the defaults that come with children's meals. 16 All three ordinances passed by unanimous vote, 17 with the support of city officials and residents. 18 Additionally, San Francisco and Santa Clara County have laws that set nutrition standards for restaurant children's meals that are sold with toys. 19 As of March 2017, healthy kids' meal bills are pending before the Vermont2 and New York 21 state legislatures and the New York City Council. 22 Additional kids' meal bills are expected in localities in California, Colorado, Illinois, Kentucky, and Maryland. Technical assistance is available to communities that would like to implement restaurant children's meal policies. For more information, please contact the Center for Science in the Public Interest at 1 American Heart Association Voices for Healthy Kids. Community. 2 American Cancer Society Cancer Action Network. Improve Nutrition in Kid's Restaurant Meals. 3 Interfaith Center for Corporate Responsibility, MomsRising, Center for Science in the Public Interest. Wendy's Removes Soda from Kids' Meals. 4 Id. 5 Center for Science in the Public Interest and Voices for Healthy Kids' Action Center. Six Down, Many to Go. Available at food marketing.org/wp-content/uploads/2016/11 /six_down_many_to_go_print_ version. pdf. 6 1d. 7 Ribakove S, Almy J, Wootan MG. Soda on the Menu: Improvements Seen but More Change Needed for Beverages on Restaurant Children's Menus (in press). Available at down_many_to_go_print_version.pdf. 8 Center for Science in the Public Interest. Ask Chili's to Drop Sugary Drinks. campaign.id=5g Center for Science in the Public Interest. Improve Bojangles' Kids' Meals. campaign.id= Center for Science in the Public Interest. Please Urge Restaurants to Take Soda Off the Kids' Menu. action?ea.client.id=1927&ea.campaign.id= McDonald's. "What Happens When You Take Something Good for Kids and Make It Fun? Billions of Things!" May 18, Available at 12 Peters J, Beck J, Lande J, Pan Z, Cardel M, Ayoob K, Hill J. "Using Healthy Defaults in Walt Disney World Restaurants to Improve Nutrition." The Behavioral Science of Eating 2016, vol. 1, pp National Restaurant Association. Kids UveWe/1 Program. Available at Kids-UveWell-Program. 14 Kids UveWell requires that kids' meals (entree, side, and beverage) contain two or more food groups and have no more than 600 calories, 35% of calories from total fat, 10% of calories from saturated fat, 0.5 grams artificial trans fat, 35% of calories from total sugars, and 770 mg of sodium. The program also has standards for side dishes. 15 Batada A, Wootan MG. Kids' Meals II: Obesity and Poor Nutrition on the Menu. Washington, D.C.: Center for Science in the Public Interest, March Available at 16 Davis Municipal Code ch.. 17, art (2015); Stockton Municipal Code ch, 5.70 (2016); Perris Ordinance 1340 (2017) (to be codified as Chapter 7.46). 17 Davis City Council, Meeting Minutes for June 2, 2015, CouncilMeetings/Minutes/2015/Minutes City-Council-Meeting.pdf; Stockton City Council, Meeting Minutes for June 7, 2016, Perris City Council, Recorded Meeting of March 15, 2017, 18 See, e.g., Voices for Healthy Kids Action Center, Stockton, CA Passes "Healthy-by-Default" Kids' Meal Beverage Ordinance June 16, 2016, (quoting Stockton Vice Mayor Christina Fugazi); Veronica Rocha, "City of Davis Sours on Sweet Drinks for Kids' Meals in Restaurants," Los Angeles Times November 14, Accessed at lanow/la-me-ln-davis-sweet-drinks-kids-meals story.html. 19 San Francisco Health Code art (2010): Santa Clara County Ordinance Code ch. 22, A A (2010). 20 Vermont Gen. Assembly, S.70, H.264 (2017). 2 1 N.Y. S.1074, A.3375 (2017). 22 N.Y.C. Council Intro (2014). Center for Science in the Public Interest j 1220 L Street, NW, Suite 300, Washington, DC I cspinet.org

5 Healthy Restaurant Children's Meals Improve Children's Diets and Health Some children as young as eight have detectable early warning signs of heart disease,1 and the prevalence of type 2 diabetes in children and youth is increasing and disproportionately affects children of color. 2 While parents are primarily responsible for feeding their children healthfully, they cannot always prepare meals at home. Restaurants and communities should support parents' efforts to feed their children well. Improving the nutritional quality of restaurant children's meals can help improve diet quality and cultivate lifelong healthy eating behaviors, which can help children grow up at a healthy weight. The Nutritional Quality of Restaurant Meals Matters to Children's Diets Children frequently eat at restaurants. In 2012, USDA estimated that children 2 to 19 years old, on average, consume one-quarter of their calories from restaurants and other food-service establishments. 3 In 2015, the National Center for Health Statistics estimated that about 10 percent of children and adolescents obtain 25 to 40 percent of daily calories from fast food, and 12 percent obtain more than 40 percent of daily calories from fast food percent of parents report making a purchase from a fast-food restaurant for their children in the previous week, according to the Rudd Center for Food Policy and Obesity. 5 A 2012 analysis reported that 33 percent of children eat foods or beverages from fast-food restaurants and 12 percent from full-service restaurants on a typical day. 6 A 2015 study concluded that almost half (49.7%) of children ages 3 to 5 had eaten at one or more fast-food restaurants in the past week and one-third (34%) had eaten at McDonald's, in a study in New Hampshire. McDonald's consumption was similar regardless of race or household income.7 Restaurants are a top marketer to children. According to the Federal Trade Commission, fast-food restaurants spent $583 million on marketing directed to children in 2009 (the latest year for which data are available). 8 Restaurants advertise their overall brand to children, often showing a healthier meal only fleetingly. McDonald's, for example, commits to highlight healthier meals in its advertising to children, 9 but children viewing its ads often recall only the promotional theme or movie character tie-in and not the meal visually displayed in the commercial. 10 In 2012, the Federal Trade Commission reported that quick service restaurant chains spend $341 million per year on toys to promote their children's meals. 11 CEl\TER FOR Science 1N Tl n: Public Interest oe... ==-'d I Voices r,""'o cr""'ro"""""'= for Healthy Kid(3,)

6 In 2015, researchers reported that after controlling for parental fast-food consumption and demographics, children ages 3 to 5 are more likely to have eaten McDonald's in the past week if they usually know what toys were offered by fast-food restaurants. 12 Marketing particular foods to children by designating them as "kids' menu items" and by bundling them together as meals establishes food norms for children, which could affect their preferences in other settings. 13 The meals promoted as children's meals are consumed by the youngest kids. Among four common fast-food restaurants, parents surveyed are more likely to order a kids' meal for younger kids (aged 2-5) than for older kids (aged 6-11 years). 14 Data on the overall proportion of parents who order from children's menus vary. In one on line sample of parents, 52 percent of the parents reported ordering a kids' meal for their children at their last visit. 15 (The proportion for children under age 6 was higher, at 64 percent.) Studies show a link between eating out and poor nutrition. Eating out by children has been associated with higher consumption of calories, sugary drinks, saturated fat, and total sugars and with lower diet quality compared to meals at home Researchers have estimated that eating fast food is associated with children eating 126 more calories a day, while eating at a full-service restaurant increases children's calorie intake by 160 calories a day on average. 18 In 2009, researchers reported that frequent consumption of restaurant meals is associated with risk factors for chronic health conditions, including heart disease, and high insulin levels. 19 A recent analysis found that 34 percent of parents purchased a soda or other sugary drink with their child's kids' meal at four common fast-food restaurants. 20, 21 o o o Soda and other sugary drinks are the top source of added sugars in the American diet 22 and account for nearly half of the added sugars consumed by Americans. 23 Excessive consumption of added sugars contributes to an increased risk of developing heart disease and obesity. 24 An extra-small (ten ounce, child-size) cola contains approximately 33 grams of added sugars, 25 which exceeds the 25 grams of added sugars that the American Heart Association (AHA) has established as the daily upper limit for children and teenagers. 26 The AHA recommends that children consume no more than eight ounces of sugary drinks per week; 27 kid-sized beverages vary across restaurants, but are usually six to twelve ounces. 28 C:C1'TER FOR Science 11\ 11 JE Public lmerest ~-,...._ ~~- """ /'1.o~ ce~ v ~. ''""' = ro, =- for Healthy K ~

7 Voluntary improvements by restaurants are slow. In 2016, the majority of kids' meal combinations at fast-food and full-service restaurants exceeded 770 mg of sodium; a majority of kids' meals at full-service restaurants also exceeded saturated fat standard limits. 29 A 2013 analysis concluded that the top fast-food chain children's menus do not offer ample amounts of fruits, vegetables, and whole grains as assessed by the Healthy Eating lndex. 30 In addition, a separate analysis concluded that only ~O percent of the top fast-food and 20 percent of full-service restaurants always include a fruit or vegetable as the default side dish. 31 Among the top-so restaurant chains that included beverages as part of their children's meals in 2016, three-quarters include sugary drinks on their children's menus. 32 Restaurants have made some progress improving children's meals and the National Restaurant Association has formed its Kids LiveWell program to help restaurants increase healthful options for children. 33 However, progress has been modest and slow. Between 2008 and 2012, the percentage of restaurant children's meals that met nutrition standards increased from 1 to 3 percent. 34 Chili's Kids' Burger Bites II 11 --~ ~i. - - _1 700 Calories 600 Calories 9.5 g Saturated Fat 8 g Saturated Fat 1,405 mg Sodium 670 mg Sodium 27 g Sugar 12 g Sugar Healthier Restaurant Children's Meals Support Healthier Eating by Children Changing the offerings on children's menus, including changing defaults, can affect what children eat. Evidence from a wide range of fields (including retirement plans, organ donation, health care, and food/nutrition) shows that people tend to stick with defaults and that setting beneficial defaults has high rates of acceptability (defaults are the option people automatically receive if they do not choose something else). 35 A 2015 study reported that more than half the children ages 8 to 12 surveyed who order children's meals said that they would be somewhat or very likely to order a children's meal that came with vegetables (56.2%) or fruits (78.9%). 36 When a large fast-food restaurant changed the default sides for its children's meals by reducing the size of the fries and adding apple slices automatically, the calories in the average children's meal purchased decreased by 19 percent. 37 CENTER FOR Science 1N Tl 11: Public Interest ve.. ~~ I Voices r ~ o =ro,...,,obe$/ty for Healthy Kid~

8 Children's meals with healthier defaults at Walt Disney theme parks resulted in 21 percent fewer calories compared to meals with unhealthy defaults. 38 In this same study, parents stuck with healthy side dishes 48 percent of the time and healthier beverages 66 percent of the time. 39 A 2015 study reported that sales of strawberry and vegetable sides, and milk increased and sales of french fries and soda decreased after a regional chain restaurant implemented a healthier children's menu. 40 According to an independent verification firm, "McDonald's USA sold 21 million more low-fat and fat-free milk jugs and 100% apple juice boxes in the first 11 months in Happy Meals and ala carte after removing the listing of sodas on the Happy Meal section of menu boards compared to the same period a year earlier (July 2014 to May 2015)." 41 Changing children's meals sends a positive message and models healthy eating for children. Food marketing influences children's food preferences, 42 and restaurants spend more than any other segment marketing food to children. 43 This marketing, including through television, Internet, toys, and which foods are promoted as children's meals, should be used to promote healthier options to children, rather than encouraging nutrition-poor options. Removing sugary drinks from children's menus can send a signal that they are not appropriate everyday beverages for children. The vast majority of children consume more calories from added sugars than is recommended for good health, 44 and the number one source of added sugars in the American diet is sugary beverages. 45 Using toys to promote only healthy meals could change consumption patterns. One study estimated that children are three times more likely to select healthier meal options if toy premiums are used to promote only the healthier meals. 46 The public health community supports improving restaurant children's meals. The 2015 Dietary Guidelines Advisory Committee recommended that restaurants make healthy options the default choice by, for example, offering fat-free or low-fat milk instead of soda or other sugary drinks, and fruit and non-fried vegetables as side dishes in children's meals. 47 The American Heart Association, Center for Science in the Public Interest, and Change Lab Solutions support the adoption of the RAND Performance Standards for Restaurants. 48 The RAND standards for restaurant children's meals are consistent with the Dietary Guidelines for Americans and recommend restaurant children's meals include at least two sources of fruits, vegetables, whole grains, lean protein, or lower fat dairy, and limit fat (including trans and saturated fat), sugars, and sodium, and do not include a sugary drink. The RAND standards align closely with the National Restaurant Association's Kids LiveWell nutrition standards for restaurant children's meals. 49 C[l\ TER for Science 1~ THE Public Imerest

9 1 Jing L, Binkley CM, Suever JD, Umasankar N, Haggerty CM, Rich J, Wehner GJ, Hamlet SM, Powell DK, Radulescu A, Kirchner HL, Epstein FH, Formwalt BK. "Cardiac Remodeling and Dysfunction in Childhood Obesity: A Cardiovascular Magnetic Resonance Study." Journal of Cardiovascular Magnetic Resonance 2016, vol. 18, pp Benjamin EJ, et al. "Heart Disease and Stroke Statistics-2017 Update A Report From the American Heart Association." Circulation 2017, vol. 135, pp. el-e458. Available at /01/25/CI R fu 11. pdf. - 3 Lin B, Morrison RM. "Food and Nutrient Intake Data: Taking a Look at the Nutritional Quality of Foods Eaten at Home and Away From Home." Amber Waves 2012, vol. 10(2), pp Available at a ves/2012/i u n e/ data-feature-food-and-nut ri ent-i nta ke-data/. 4 Vikraman S, Fryar CD, Ogden CL. "Caloric Intake from Fast Food Among Children and Adolescents in the United States, " NCHS Data Brief No. 213, September Available at 5 Schwartz MB. "Have Kids' Meals Become Healthier? Progress and Public Relations." Presentation at the American Public Health Association Annual Meeting, Boston, MA (Nov. 5, 2013). Available at FastFoodFACTS APHAPresentation.pdf. 6 Powell LM, Nguyen BT, Han E. "Energy Intake from Restaurants: Demographics and Socioeconomics, " American Journal of Preventative Medicine 2012, vol. 43, pp Longacre MR, Drake KM, Titus LI, Cleveland LP, Langeloh G, Hendricks K, Dalton MA. "A Toy Story: Association between Young Children's Knowledge of Fast Food Toy Premiums and Their Fast Food Consumption." Appetite 2016, vol. 96, pp Federal Trade Commission (FTC). A Review of Marketing Food to Children and Adolescents: Follow-Up Report. Washington, D.C.: Federal Trade Commission, Accessed at 9 McDonald's USA. Council of Better Business Bureaus Children's Food and Beverage Advertising Initiative: McDonald's USA Support, Updated January Available at v1-mcdona1d s usa food pledge ian 2016.pdf. 10 Bernhardt AM, Wilking C, Gilbert-Diamond D, Emond JA, Sargent JD. "Children's Recall of Fast Food Television Advertising-Testing the Adequacy of Food Marketing Regulation." PLoS One 2015, vol. 10(3), e Available at http ://io u rna Is. plos.org/ploso ne/a rticle?id=l0.1371/iou rna I. pone Federal Trade Commission (FTC). A Review of Marketing Food to Children and Adolescents: Follow-Up Report. Washington, D.C.: Federal Trade Commission, Accessed at food ma rketi ngreport. pdf. 12 Longacre MR, Drake KM, Titus LI, Cleveland LP, Langeloh G, Hendricks K, Dalton MA. "A Toy Story: Association between Young Children's Knowledge of Fast Food Toy Premiums and Their Fast Food Consumption." Appetite 2016, vol. 96, pp Anzman-Frasca S, Dawes F, Sliwa S, Dolan PR, Nelson ME, Washburn K, Economos CD. "Healthier Side Dishes at Restaurants: An Analysis of Children's Perspectives, Menu Content, and Energy Impacts." International Journal of Behavioral Nutrition and Physical Activity 2014, vol. 11, pp Available at https ://i jbn pa. biomedcentra I.com/articles / / Harris JL (2016). Parent Survey of Fast Food Purchasing Patterns. Unpublished raw data (collected in 2016). 15 Harris JL (2016). Parent Survey of Fast Food Purchasing Patterns. Unpublished raw data (collected in 2016). CEr<TER for Science 1~ THE Public ~:::-~ / Voices "'"NoACTJONroPREVENTomnv for Healthy Kid~

10 16 Powell LM, Nguyen BT. "Fast-Food and Full-Service Restaurant Consumption Among Children and Adolescents." Archives of Pediatric and Adolescent Medicine, published on line Nov 5, 2012, El-E7. 17 Mancino L, Todd JE, Guthrie J, Lin BH. How Food Away from Home Affects Children's Diet Quality. Washington, D.C.: USDA, Economic Research Service, ERS Report Number 104, October Powell LM, Nguyen BT. "Fast-Food and Full-Service Restaurant Consumption among Children and Adolescents." Archives of Pediatric and Adolescent Medicine, published on line Nov 5, 2012, El-E7. 19 Fulkerson JA, Farbakhsh K, Lytle L, Hearst MO, Dengel DR, Pasch KE, Kubik MY. "Away-from-Home Family Dinner Sources and Associations with Weight Status, Body Composition, and Related Biomarkers of Chronic Disease among Adolescents and Their Parents." Journal of the American Dietetic Association 2011, vol. 111, pp ; see also Center for Science in the Public Interest, Research Review: Effects of Eating Out on Nutrition and Body Weight. Washington, D.C.: CSPI, October rev-eating out and obesity.pdf. 20 Harris JL (2016). Parent Survey of Fast Food Purchasing Patterns. Unpublished raw data (collected in 2016). 21 Cantor J, Breck A, Eibel 8. "Correlates of Sugar-Sweetened Beverages Purchased for Children at Fast-Food Restaurants." American Journal of Public Health 2016, vol. 106, pp (finding 1 in 3 in New York and New Jersey). 22 U.S. Department of Agriculture (USDA), U.S. Department of Health and Human Services. Dietary Guidelines for Americans Washington, D.C.: U.S. Government Printing Office, December Available at https ://hea Ith.gov/ d ieta rygu idelines/2015/reso u rces/ Dietary Guidelines. pdf. 23 Ibid. 24 Johnson RK, et al. "Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement From the American Heart Association." Circulation 2009, vol. 120, pp Available at ci re.aha iou rna ls.org/ content/ ci rcu lationa h a/120/11/1011. fu 11. pdf. 25 McDonald's, Nutrition for Coca-Cola, nutrition.beverages.520. cocacola-classic-small.html (33 grams of added sugars in an extra-small Coca-Cola). 26 Vos MB, Kaar JL, Welsh JA, Van Horn LV, Feig DI, Anderson CAM, Patel MJ, Cruz Munos J, Krebs NF, Xanthakos SA, Johnson RK. "Added Sugars and Cardiovascular Disease Risk in Children: A Scientific Statement from the American Heart Association." Circulation 2016, vol. 134, published ahead of print at 08/22/CIR Ibid. 28 CSPI, Unpublished Review of Sugary Beverage Offerings on Top-20 Restaurants' Kids' Menus, November Sliwa S, Anzman-Frasca S, Lynskey V, Washburn K, Economos C. "Accessing the Availability of Healthier Children's Meals at Leading Quick-Service and Full-Service Restaurants." Journal of Nutrition Education and Behavior 2016, vol. 38, pp Kirkpatrick SI, Reedy J, Kahle LL, Harris JL, Ohri-Vachaspati P, Krebs-Smith SM. "Fast-food Menu Offerings Vary in Dietary Quality, but Are Consistently Poor." Public Health Nutrition 2014, vol. 17(4), pp Anzman-Frasca S, Dawes F, Sliwa S, Dolan PR, Nelson ME, Washburn K, Economos CD. "Healthier Side Dishes at Restaurants: An Analysis of Children's Perspectives, Menu Content, and Energy Impacts." International Journal of Behavioral Nutrition and Physical Activity 2014, vol. 11, Available at https :/Iii bnpa. biomedcentra I. com/a rticles/ / Ribakove S, Almy J, Wootan MG. "Soda on the Menu: Top Restaurants Continue to Push Sugary Drinks on Kids" (unpublished data). 33 National Restaurant Association. Kids LiveWe/1 Program. Available at mpact/food-hea lthy-livi ng/kids-livewel 1-P rogra m. Cl]\TER FCl2. Science!N rn;: Public Interest ve-. :::::;::~ / Voices r,""'o cno roprevento= for Healthy Kid

11 34 Batada A, Wootan MG. Kids' Meals II: Obesity and Poor Nutrition on the Menu. Washington, D.C.: CSPI, March Available at 35 Wootan MG. "Children's Meals in Restaurants: Families Need More Help to Make Healthy Choices." Childhood Obesity 2012, vol. 8, pp Anzman-Frasca S, Dawes F, Sliwa S, Dolan PR, Nelson ME, Washburn K, Economos CD. "Healthier Side Dishes at Restaurants: An Analysis of Children's Perspectives, Menu Content, and Energy Impacts." International Journal of Behavioral Nutrition and Physical Activity 2014, vol. 11, pp Available at https ://i jbn pa. biomedcentra I.com/a rticl es/ / Wansink B, Hanks A. "Calorie Reductions and Within-Meal Calorie Compensation in Children's Meal Combos." Obesity Journal 2013, vol. 22, pp Peters J, Beck J, Lande J, Pan Z, Cardel M, Ayoob K, Hill J. "Using Healthy Defaults in Walt Disney World Restaurants to Improve Nutrition." The Behavioral Science of Eating 2016, vol. 1, pp Ibid. 40 Anzman-Frasca S, Mueller MP, Lynskey VM, Harelick L, Economos CD. "Orders of Healthier Children's Items Remain High More than Two Years after Menu Changes at a Regional Restaurant Chain." Health Affairs 2015, vol. 11, McDonald's, Alliance for a Healthier Generation."McDonald's and Alliance for a Healthier Generation Announce Progress on Commitment to Promote Balanced Food and Beverage Choices," June 25, Available at 42 Institute of Medicine. Food Marketing to Children: Threat or Opportunity? Washington, D.C.: National Academies Press, Available at Youth-Th reat-or-opportun ity.aspx/ 43 Federal Trade Commission (FTC). A Review of Marketing Food to Children and Adolescents: Follow-Up Report. Washington, D.C.: Federal Trade Commission, Available at os/2012/12/ foodmarketi ngreport. pdf. 44 Vos MB, Kaar JL, Welsh JA, Van Horn LV, Feig DI, Anderson CAM, Patel MJ, Cruz Munos J, Krebs NF, Xanthakos SA, Johnson RK. "Added Sugars and Cardiovascular Disease Risk in Children: A Scientific Statement from the American Heart Association." Circulation 2016, vol. 134, published ahead of print at ci re. a ha jou rna ls.org/ content/ ea rly/2016/08/22/ci R U.S. Department of Agriculture (USDA), U.S. Department of Health and Human Services. Dietary Guidelines for Americans Washington, D.C.: U.S. Government Printing Office, December Available at Dietary Guidelines.pdf. 46 Hobin E, Hammond D, Daniel S, Hanning R. "The Happy Meal Effect: The Impact oftoy Premiums on Healthy Eating Among Children in Ontario, Canada." Canadian Public Health Association 2012, vol. 103, pp Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Available at https ://hea Ith.gov/ d ieta rygu ideli nes/2015-scientific-report/06-cha pter-1/d 1-4. asp. 48 Cohen D, Bhatia R, Story MT, et al. (2013). Performance Standards for Restaurants: A New Approach to Addressing the Obesity Epidemic. Available at proceedings /CF300/CF313/RAND CF313.pdf. 49 National Restaurant Association. Kids livewe/1 Program: About. Available at C[\:TI:R for Science I'\ Tiff Public Interest ve:l.:. ~~ / Voices ruo =ro,,..,."'oses/7y for Healthy Kids (9)

12 FDA Delays Menu Labeling Rule article/fda-delays-menu-labelin... Published on The National Law Review ( FDA Delays Menu Labeling Rule Article By: Food and Drug Law at Keller and Heckman As previously covered on this blog, over the past few years, FDA has been in the process of implementing menu labeling provisions added to the Federal Food, Drug, and Cosmetic Act by the Affordable Care Act. Under the new requirements, restaurants or similar retail food establishments (in chains of 20 or more locations doing business under the same name and selling substantially similar menu items) must provide calorie and other nutrition information for standard menu items. Although the menu labeling requirements were originally scheduled to take effect on December 1, 2015, enforcement was later delayed to December 1, Enforcement was subsequently delayed to May 5, Yesterday, the FDA submitted an interim final rule (IFR) to the Office of Management and Budget (0MB) seeking an "Extension of Compliance Date". The IFR is entitled "Food Labeling; Nutrition Labeling of Standard Menu Items in Restaurants and Similar Retail Food Establishments; Extension of Compliance Date; Request for Comments." It appears that FDA is extending the compliance date for menu labeling to allow interested parties to submit additional comments - potentially on specific issues raised by the National Association of Convenience Stores (NACS) and the National Grocers Association (NGA) in their citizen petition filed on April 5, 2017 (available here). The NACS/NGA citizen petition did not request a specific amount of time industry needs to comply, but rather contested the validity of the scope of the regulation and requested a stay until outstanding issues have been resolved). It is unclear when the IFR will be published, but given that the menu labeling compliance date, May 5, is a week from today, and the fact that a delayed compliance date, potentially leading to less burdensome requirements for industry, are in keeping with the stated goals of the Trump administration, we expect 0MB will do its best to fast-track publication Keller and Heckman LLP Source URL: https :/ / 1 of 7/?0/17 'J A!I Pl\Jf

13 '7 /'")fl/1 '7 FDA Delays Menu-Labeling Rule I NACS Online - Media -Press R... Contact Conexxus Terms of Advertise NACS Fuels About Institute Privacy Suppliers NACS 1600 Duke Street Related Policy Copyright 2017 NACS Alexandria, Va Foundation Associations Glossary Use For THE ASSOCIATION FOR CONVENIENCE & FUEL RETAILING ADVOCACY YOUR BUSINESS SOLUTIONS RESEARCH EVENTS NACSShow JOIN MEDIA Member Directory Store NACS Online/ Media/ Press Releases/ 2017 / FDA Delays Menu-Labeling Rule In this Section 2017 Convenience Store Sales Grow in 2016, Retailers Very Optimistic for 2017 Consumers Enter 2017 Quite Optimistic Despite Rising Gas Prices Nidia Reyes Joins NACS as Accounting Manager NACS Calls for Rapid Action on Menu Labeling Legislation U.S. Convenience Stores Continue Growth Consumer Optimism Remains Strong as Gas Prices Fall Amanda FDA DELAYS MENU-LABELING RULE 4/27/ WASHINGTON - Today, the U.S Food and Drug Administration submitted an interim final rule to the White House Office of Management and Budget that signals a delay in the agency's final menulabeling rule set to take effect on May 5. While FDA announced the submission that has yet to be published, we expect to see the final rule later today and will share more details in tomorrow's NAGS Daily. Earlier this month, NAGS and the National Grocers Association submitted a petition to the FDA asking the agency to delay the final rule's effective date. According to Politico Pro, the "apparent change in course" follows the collective efforts by NAGS and NGA. Initially released on November 25, 2014, the rule establishes menu-labeling requirements for chain restaurants and "similar retail food establishments." Generally, establishments that are covered by the rule must post calories for standard menu items on menus or menu boards or, for self-service items and foods on display, on signs adjacent to the items, as well as provide additional written nutrition information to consumers upon request. NAGS has and continues to maintain that the menu-labeling regulations established by the FDA do not account for the varying approaches to foodservice between big-chain restaurants, convenience stores, grocery stores and delivery operations such as pizza chains. The FDA's regulations add unfair costs and compliance barriers to establishments with offerings that do not appear on a centralized "menu" board, and establishments that may have multiple coffee, frozen drink and food islands as opposed to the central ordering point in a traditional fast-food restaurant. The regulations also place a store or restaurant at risk for criminal penalties if it gives some customers larger servings than they expected based on the calorie information provided. To provide a more practical and flexible approach among the various foodservice and retail establishments affected by the menu-labeling rule, NAGS supports legislation introduced in both the previous and current Congress, the Common Sense Nutrition Disclosure Act (H.R 772/S. 261).

14 FDA Delays Menu-Labeling Rule I NACS Online - Media - Press R... _ Releases/2017 /Pages/PRO... Appelbaum Joins The Fuels Institute as Director of Research Economic Optimism Hits Record High Despite Rise in Gas Prices NACS Publishes Community Toolkit NGA Aligns Its Fall Leadership Meetings with the NACS Show Americans Increasingly Choose Fueling Locations Based on Quality of Food NACS will continue to with Congress and the administration to help ensure that the rules are revised so that they work for everyone. Stay tuned to NACS Daily as more details are revealed. Sales Surge Expected to Continue in Q for Convenience Stores Jeff McQuilkin Joins NACS as Exhibit Sales & Services Manager Americans Say that Low Gas Prices Are Good for the Economy Convenience Stores Hit Record In- Store Sales in 2016 Refresh, Refuel, Reduce and Recycle at Your Local Convenience Store NACS Fights Renewed Efforts to Repeal Pro- Competition, Pro- -#=##- NACS advances the role of convenience stores as positive economic, social and philanthropic contributors to the communities they serve. The U.S. convenience store industry, with more than 154,000 stores nationwide selling fuel, food and merchandise, serves 160 million customers daily-half of the U.S. population-and has sales that are 10.8% of total U.S. retail and food service sales. NACS has 2,100 retailer and 1,750 supplier members from more than 50

15 HHS Secretary Tom Price, M.D. Praises FDA Delay of Menu Labeli... HHS. av U.S. Department of Health & Human SeNices FOR IMMEDIATE RELEASE May 1, 2017 Contact: HHS Press Office HHS Secretary Tom Price, M.D. Praises FDA Delay of Menu Labeling Regulations Health and Human Services Secretary Tom Price, M.D., issued the following statement on the Food and Drug Administration's actions to delay the implementation of its proposed Menu Labeling Rule until May 7, 2018: "The FDA has made the right decision to delay a rule that would have essentially dictated how every food service establishment in America with more than 20 locations - movie theaters, and more - writes and displays their menus. restaurants, grocery stores, "HHS believes strongly in promoting sound nutrition through public health efforts. Tackling childhood obesity is one of our top three stated clinical priorities. We should do this by helping families gain the information they need to make their own choices. Imposing burdensome rules that leave business managers and owners worried about harsh potential penalties and less able to serve their customers is unwise and unhelpful. "Under President Trump, our department will focus on promoting public health in ways that work for American consumers. Toward that end, the FDA is asking for feedback about how to make the Menu Labeling Rule more flexible and less burdensome while still providing useful information to consumers. We look forward to working with all involved to find the right balance." #l#f. Note: All HHS press releases, fact sheets and other news materials are available at Like HHS on Facebook r?il, follow HHS and sign up for HHS Updates. Last revised: May 1,

16 Did FDA Illegally Delay Menu Labeling Rules? - Consumerist /consumerist.com/20 l 7 /06/07 /did-fda-illegally-delay-menu-lab... W TWEET f SHARE Did FDA Illegally Delay Menu Labeling Rules? June 7, :44pm EDT By Mary Beth Quirk MAKE IT HAPPEN FDA MENU LA BELi NG Last month, the Food and Drug Administration announced that it would be delaying the implementation of a rule requiring calorie counts and other nutritional information on the menus of many restaurants for the third time. That decision didn't sit well with some consumer advocates, including two groups that have filed a lawsuit challenging the delay. In the complaint [PDF] filed today in U.S. district court in Washington, D.C., the Center for Science in the Public Interest and the National Consumer League claim that the delay of the menu labeling FOOD AND DRUG ADMINISTRATION requirement - one day before the rule was NUTRITION supposed to take effect - is illegal and must be CALORIE COUNTS vacated. The groups note that when the FDA issued the Nutrition Labeling Rule as part of the Affordable Care Act, the agency recognized that these IMAGE COURTESY OF COYOTY I of5

17 Did FDA Illegally Delay Menu Labeling Rules? - Consumerist /06/07 /did-fda-illegally-delay-menu-lab... requirements "give consumers much needed access to essential nutrition information for a large and growing number of the foods they purchase and consume." According to the lawsuit, the FDA's decision violated the Administrative Procedure Act - which requires agencies to publish a notice of proposed rule making in the Federal Register and provide an opportunity for public comment before formulating, amending, or repealing a rule - by "departing from its prior interpretation of the Affordable Care Act and its prior conclusions about the importance of nutrition labeling without providing a rational explanation." In addition, the complaint claims that the agency violated the APA by issuing a delay rule - a final agency action with legally binding effect - "without complying with mandatory rule making procedures, including advance notice and an opportunity for public comment before the Delay Rule took effect." The plaintiffs are requesting that the court hold the delay rule to be "arbitrary, capricious, an abuse of discretion, and otherwise not in accordance with law, and to have been published without observance of legally required procedure, in violation of the APA." They also seek an order vacating the delay rule, and declaring that compliance with the menu labeling rule is required within 15 days of the court's order. The FDA told Consumerist that it does not comment on pending litigation.

18 Did FDA Illegally Delay Menu Labeling Rules? - Consumerist /consumerist.com/2017 /06/07 /did-fda-illegally-delay-menu-lab... "The recent delay in the rule is yet another example of the Trump administration's willingness to accommodate even unfounded and partial industry opposition to the detriment of the health and welfare of people and families across the country," said Peter Lehner, the Earthjustice senior attorney handling the lawsuit. "There are monitors that can tell us exactly how many steps we take in a day and how much sleep we get at night, but we are denied the basic right to know how many calories are served at a restaurant," he said. The groups say that since the food industry was ready to comply before the delay, it can promptly comply with the rule once it's reinstated. Indeed, despite the rule's delay, some restaurant chains have already put calorie counts on their menus, including major chains like McDonald's, Panera, and Subway. Other chains will likely refrain from doing anything until they absolutely have to: The American Pizza Community - a coalition of pizza companies, regional chains, small business franchise owners, suppliers, and others in the business of pizza - applauded the FDA's decision to delay compliance last month, saying that the "previous approach threatened to impose excessive burdens on thousands of small businesses without achieving meaningful improvements in educating consumers." June 7, 2017 By Mary Beth Quirk 1 n,.,,...o,..-

19 HHS - Environmental Health - Menu Labeling MontgomeryCountyMD.ecfe, Montgomery County Government f You 18 m Food & Facilities Licensing Environmental Health Health Care Facilities Licensing Services Food and Facilities Licensing Environmental Health - Menu Labeling What You Need to Know to Comply with MC Code Chapter 15 - Nutrition Labeling Law What Is Montgomery County's menu labeling law? The Montgomery County Council, acting as the Board of health, adopted Resolution (Montgomery County Code Chapter 15, Section 15-1 Sa) which requires an eating and drinking establishment to post nutritional information for any standardized menu item by July 1, Regulation 7-10 identifies the criteria for complying with Resolution Click here for a copy of the Resolution. When must an establishment comply with the Resolution? An establishment must submit to Licensure & Regulatory Services, no later than September 15, 2010, a written implementation plan indicating when compliance is expected to be achieved. Compliance is mandatory no later than January 1, What establishments must comply with the law? Any eating or drinking establishment located in Montgomery County that is part of a chain with at least 20 locations in the United States offering substantially the same menu items and doing business under the same trade name, regardless of individual ownership. What establishments are exempt from the law? Grocery stores, convenience stores and movie theaters. What is a standard menu item? A standard menu item is a food or drink item as usually prepared and offered for sale. A standardized menu item does NOT include food or drink that Appears on a menu for less than 60 cumulative days per calendar

20 HHS - Environmental Health - Menu Labeling Is not listed on a menu or menu board (for example, condiments, spices or sweeteners placed on a table or counter for general use without charge) Is a test market item that appears on the menu for less than 90 cumulative days per calendar year, or Is a daily special. What food items are exempt from the law? Condiments, garnishes and self-service commercially packaged items that already contain the complete nutritional labeling. What is a "menu" or "menu board"? A "menu" or "menu board" is the primary writing of an eating and drinking establishment from which a consumer makes an order selection. This includes menus or menu boards posted at a drive-thru, on a children's placemat, for delivery or carryout, or as a table tent at a bar or on a dining table. Menus mailed or dropped off to a business or private residence must also comply with the law. Advertisements such as coupons and window posters are not included. What information must be posted on each menu or menu board? The number of calories for any standardized menu item posted next to that menu item and in a manner that is clear and conspicuous to the consumer. A statement as to the current suggested daily caloric intake determined by the U.S.. Department of Health and Human Services. An example of an approved statement is: "A 2,000 calorie diet is used as the basis for general nutrition advice. However, individual caloric needs may vary. Visit for more information." A statement that additional nutrition information is available in writing upon request. What additional nutrition information must be available in writing? Calories, calories from fat, total fat, saturated fat, cholesterol,- sodium, total carbohydrates, sugars, fiber and protein must be provided per serving or, when the menu item is offered as a single unit (such as a bagel or muffin), per menu item from a self service unit or display case. Does the law allow for rounding the amount of calories and additional nutrition information? Yes, in accordance with the menu labeling regulations. Refer to the Code of Federal Regulations (CFR) Titles 9 and 21 for additional information on rounding nutritional values. What is the required font size for the number of calories or the required statements? The printing must be clear and conspicuous to the consumer, such that a person may read the information when standing at the ordering counter or from the menu or food tag. The information must be easily located on the menu, menu board, self-service unit or display case and clearly associated with that menu item. Can an eating and drinking establishments use an abbreviation for the word "calorie" or for the additional nutrition information? ;An eating or drinking establishment may propose an alternative designation for the term "calorie" or for any other term in the additional nutrition information.