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ACTA SCIENTIFIC NUTRITIONAL HEALTH (ISSN:2582-1423)
Volume 5 Issue 2 February 2021 Review Article
Eating Out of Home and Risk for Obesity: An Overview
Rotondo G2, Cazzaniga E1,2* and Palestini P1,2
1School of Medicine and Surgery, University of Milano-Bicocca, Italy
2Master ADA, Nutrition and Dietetics Applied, University of Milano-Bicocca, Italy
*Corresponding Author: Cazzaniga E, School of Medicine and Surgery, University of
Milano-Bicocca, Italy.
Received: December 01, 2020
Published: January 21, 2021
© All rights are reserved by Cazzaniga E.,
et al.
Abstract
Keywords: Obesity; USA; Nutrient
Despite Mediterranean dietary pattern has become a healthy eating standard, even Mediterranean countries such as Italy, show
a progressive disaffection from this diet in parallel to the increasing trend in prevalence of body overweight and obesity and correlate
pathologies.
The causes that led to the explosion of the body overweight and obesity phenomenon and the differences in the prevalence of this
condition among various social groups, are cultural and economic as well as biological and epidemiological.
-
ing attention among cultural and behavioral factors linked to obesity. Indeed, with the rapid development of economy, diet habits
have undergone great changes.
An increasingly number of people, especially in urban settings, is eating out of home not only for working people during their
lunch break, but also at dinnertime. Studies showed that a very high dietary energy content of both full service and fast-food restau-
rant meals is a widespread phenomenon and that there is a positive relationship between the consumption of food away from home
and weight gain.
This has garnered considerable attention from public health experts in formulating national policies and programs designed to
curb the growing trends in obesity. USA, Canada and Australia, proposed calorie-labeling policy that required chain restaurants to
post the calorie content of items on menus. In Europe, there is not such a policy yet. Unfortunately, many studies show that menu
restaurant calories and nutritionallabeling mandatory policies did not have achieved the set goals in guiding consumers throughout
restaurant menu to choose healthier dishes in terms of less calories and nutrients composition.
Probably, educational and information campaigns are factors to put beside calorie and nutrient labeling.
Introduction
Obesity and its comorbidities (i.e. metabolic syndrome, car-
diovascular diseases, diabetes) are an increasing health prob-
lem capable to damage nations due to high hospitalization rates,
treatment costs and impaired quality of life [1-3]. Indeed, from
obesity was observed in both adults and youth in USA where the
prevalence of obesity was 39,8% in adults and 18,5% in young in
2015-2016 [4]. As a consequence, the United States, the only case
among developed countries, is beginning to experience a decline in
life expectancy at birth in some states. A recent study has shown
that in states such as Mississippi, Arkansas, Kentucky, Tennessee,
Oklahoma, Alabama and Louisiana, there is a progressive decrease
in life expectancy, especially of women, among which there are the
Citation: Cazzaniga E., et al. “Eating Out of Home and Risk for Obesity: An Overview". 5.2 (2021): 126-136.
127
Seedlessness in Hybrid Fruits is a Low-input Resource for Canning Industry
higher rates of obesity and smoking. In Mississippi, in particular,
the state with the highest obesity rate, life expectancy is only 67
years for men and 74 years for women [5]. Although Italy had a life
expectancy at birth of 83,244 years in 2017, second in the world
only to Japan, according to data from the World Bank [6], indica-
tors of malnutrition due to food excess and lifestyles changes pre-
dict a reversal of this tendency. Indeed, parallel to USA, the preva-
lence of obesity has tripled since the 1980s in many countries of
the European Region according to the World Health Organization
(WHO) [7]. In Italy the prevalence of obesity was 10,9% and the
prevalence of overweight was 31,6% in the general population in
the time period 20152018 according to the health surveillance
system PASSI of the Italian National Institute of Health (ISS, Isti-
tuto Superiore di Sanità) [8]. Among young and teenagers Italians,
5 to 19 years old, the prevalence of overweight is 37% according to
data from WHO and ISTAT [7,9]. Obesity in young people is a form
of malnutrition known for its association with obesity in adult age
and with the chronic-degenerate pathologies correlated to obesity
[10]. Furthermore, the doubling in average life expectancy in the
last 100 years [11]
percentage of elderly people (older than 65). In Italy, it has in-
creased from 4% in 1900 to 20.6% in 2010 and this percentage
should reach 34% in 2050. The same growth trend in the percent-
age of elderly people is occurring worldwide [12].
In western country, approximately 80% of people over-65 to-
[13].
Often senile diseases are associated with bad dietary habits and
lifestyle already existing at a younger age. It is well established that
both body weight increase due to an excess of calories intake and
an unhealthy diet for quality and nutrients composition acceler-
ate aging and increase risk for or exacerbate a range of diseases
including cancer, stroke, heart disease, diabetes and mental illness
[14-20]. Thus, with the projected increase in global life expectancy
and the concomitant growth in the incidence of chronic diseases
as a direct consequence of the increase of the elderly population,
there is a call from international and national health organizations
and policy makers for implementing actions that would diffuse
awareness on importance of a healthy diet to shift population food
consumption toward healthy habits.
Indeed, the decreasing levels of primary prevention, such as
to obesity could contribute to make the health system economically
unsustainable even for the National Public Health Service (INHS)
of Italy, one of the world’s highest ranked for ability and quality of
healthcare in relationship to the resources invested [21].
Recently, studies have put emphasis on examining the role of
diet in health as a composite of multiple nutrients and foods. We
eat foods, not nutrients, and the combination of foods may be more
-
ent alone [22-24]. According to that, since the study of Ancel Keyes
-
iterranean regions and lower rates of heart disease in the Seven
Countries Study of 1958 [25], the Mediterranean dietary pattern
has become a healthy eating standard transferable world wide to
nonMediterranean countries as well. According to the concept that
-
ily in its synergy among various nutrients and foods rather than on
any individual component, many recent studies have shown that it
is able to prevent a range of chronic diseases and slow down aging
in people having adopted it [26-33]. The Mediterranean diet pat-
tern is more than just a healthy diet in the area where it was cul-
turally born, like the central and south part of Italy. It is a healthy
life style involving a set of skills, knowledge, rituals, symbols and
conservation, processing, cooking, and particularly the sharing and
consumption of food [34], at a point that the Mediterranean diet
was inscribed on the Representative List of the Intangible Cultural
Heritage of Humanity by the United Nations Educational, Sci-
[35]. Despite
that, even Mediterranean countries such as Italy, as well as Greece
and Spain, show a progressive disaffection from the Mediterranean
diet [36-38] in parallel to the increasing trend in prevalence of
body overweight and obesity and correlate pathologies, according
to the data previously described above [7-9].
In this review we have made an overview of the changes in eat-
ing habits in the population, in particular the causes that lead to
the changes. We will try to understand if eating out-of-home causes
Citation: Cazzaniga E., et al. “Eating Out of Home and Risk for Obesity: An Overview". 5.2 (2021): 126-136.
128
Seedlessness in Hybrid Fruits is a Low-input Resource for Canning Industry
weight gain in and if something has been proposed at the level of
programs to curb the growing tendencies towards obesity.
Eating in and eating out of home: habit changes in the popula-
tion food consumption.
The causes that led to the explosion of the body overweight
and obesity phenomenon and the differences in the prevalence
of this condition among various social groups, are cultural and
economic as well as biological and epidemiological [39]. Factors
such as the level of education, income and social position seem to
be crucial to an individual’s likelihood of becoming obese [40]. In
-
tion of foods and beverages out of home, has received increasing
attention among cultural and behavioral factors linked to obesity.
Indeed, with the rapid development of economy, diet habits have
undergone great changes. An increasingly number of people, espe-
cially in urban settings, is eating out of home not only mandatory
for working people during their lunch break, but also increasingly
at dinnertime, with substantial dietary changes with passive over-
consumption of energy despite the neurobiological processes con-
trolling food intake.
The 2015 Nielsen Global Out-of-Home Dining Survey polled
more than 30,000 online respondents in 61 countries to under-
stand consumers’ out-of-home dining behaviors and preferences
[41]. It provides a perspective on the habits of only existing in-
ternet users, not total populations. Thus, in developing markets
where online penetration is still growing, respondents may be
country. Even with these limitations, the trend appears very clear:
global respondents are avid out-of-home diners, with nearly half
(48%) saying they eat out weekly or more often; lunch and din-
ner are the meals that consumers most frequently eat away from
home, but breakfast may represent a growth opportunity in some
markets; quick-service and casual restaurants are the most pre-
ferred eating establishments and food quality and price are the
most important factors when choosing an out-of-home dining es-
tablishment [41]. In Italy, the expenditure on food away from home
is increased of 5.7% between the years 2008 and 2018 reaching
36% of the global food expenditure in 2018. Between 2001 and
2018 the average annual growth rate of demand in the restaurant
industry was 0.6% [42]. A survey research on a sample representa-
tive for the entire Italian population by CATI (Computer Assisted
Telephone Interview) and CAWI (Computer Assisted Web Inter-
view) administered between the 11th of November and the third
of December 2019, shows that 32.7% of the sample cook lunch and
53% cook dinner at home everyday. The 64.3% of the sample de-
clares to get his breakfast out-of-home; 67.6% has his lunch out-of-
home at least twice a month week time and 10.4% says to get lunch
out-of-home every day. More than 27% of respondents claims to
have lunch out-of-home more times in 2019 than in 2018. 62.5%
of respondents claim to have dinner out of home at least twice a
month, with 18.5 % that has dinner 3 or 4 times a week and 5.6 ev-
eryday [42]. In Italy, full day working people have mandatory their
lunch out-of-home during the lunch break at work. According to
welfare index PMI 2018, 8.1% companies have canteens where full
time employees may have their lunch. 8.3% of the companies offer
lunch to their full time employees at outside partner canteens and
restaurant [43]. 10.5% of companies offer meal ticket to their full
time employees. In absolute numbers, 2.4 millions of Italians have
used meal tickets in 2017. 70% of company employees, which re-
and restaurants [44].
Eating out of home. Nutrition characteristics of food choices
and association with weight gain in the population
Healthy diet patterns, as the Mediterranean diet, are easier
implemented at home dining then at out-of-home dining. Great
amounts of studies examine the nutrition characteristics of eating
in a variety of different dining places out of home. Indeed, many
studies seem to associate eating at food outlets and leisure places
and “on the go” with less-healthy food choices and average body
weight gain in the general population [45-48] -
ish study examining the energy content of main meals served in
major UK restaurant chain shows that the average energy content
of main meals served in both fast food and full service restaurants
in the UK is higher than public health recommendations [49]. In
USA, a multisite randomized study came up with the same conclu-
Citation: Cazzaniga E., et al. “Eating Out of Home and Risk for Obesity: An Overview". 5.2 (2021): 126-136.
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Seedlessness in Hybrid Fruits is a Low-input Resource for Canning Industry
sion. Both non-chain restaurants and large-chain restaurants serve
amounts of energy that are typically far in excess of human energy
requirements for single eating occasions [50]. A multi-country
cross sectional study analyzes energy content of frequently pur-
all continents and compare them to USA restaurant meals. This
study shows that a very high dietary energy content of both full
service and fast-food restaurant meals is a widespread phenom-
enon [51]. Foods prepared and/or consumed away from home are
higher in total fat, saturated fat, and trans fatty acids in compari-
son with foods prepared at home [52-54]. Thus, as many studies
in the literature report that eatout-of-home food is usually both
high in energy content and irrespective of reference recommenda-
tion for healthy nutrient intakes, the question is whether or not
eating outside of the home environment on a frequent basis may
be associated with weight gain both in young and adults. Although
many methodological differences among the studies performed up
to date currently limit the ability to make comparisons, majority
of data in the literature suggest there is a positive relationship be-
tween the consumption of food away from home and weight gain.
who consume on average at least 25% of their daily energy out of
the total daily energy intake and the energy density of daily food
consumption are higher for SOH eaters than for non-SOH eaters
[55]-
and young Irish population [52,56]. Data from a study aimed to
compare adult Norwegians SOH with NSOH (non-substantial out-
of-home eaters) regarding to the nutritional quality of their diet,
show SOH eaters had a higher energy intake, a higher percentage
quality of the diet [57]
that eating-out consumers (two times or more per week) have
higher average adjusted weight gain per year then NSOH. These
observations suggest that as a result of recent socio-economic
changes the rapid increase of away-from-home meal consumption,
may play a role in the current obesity epidemic observed in some
Mediterranean countries [58]. A crosssectional analysis in the
context of the European Prospective Investigation into Cancer and
Nutrition study (EPIC- PANACEA study) has examined association
of body mass index (BMI) and weight gain with eating at restau-
rants or eating at work among 10 European countries. The analysis
similar establishments with a higher body mass index among men
[59]. Thus, observational studies seem to indicate a prevalence of
weight gain among SOH eaters both in north European countries
and in Mediterranean ones despite their differences in food culture
se determines the observed average gain in weight. If that is true,
we should record a similar phenomenon all over the world despite
cultural, social and culinary tradition differences among nations
considering that the increase in obesity is a global phenomenon.
Indeed, this seems to be the case. A Chinese longitudinal survey
study analyzes the consequences of Food Away From of Home
(FAFH) consumption rising in rural and urban China. This study
shows that the frequency of meals consumed away from home had
[60]. The ob-
served urban–rural difference are explained as result of a differ-
ent amount of surplus energy due to the different labor intensity
among rural and urban residents. Thus, socio-economics changes
that combine spread of sedentary works and out-of-home food
consumption have an impact on gain of weight and obesity. Indeed,
data showing that eating out is associated to an increase in daily
total energy intake and to a poor diet quality [61]. Conversely, eat-
ing takeaway food or eating at sit-down restaurant seems not be
related to the prevalence of adult obesity in Australian rural com-
munities [62]. In USA, the mean energy content of individual meals
offered by non-chain restaurants, which account for approximately
50% of restaurant locations in the United States, is equivalent to
66% of typical daily energy requirements, with 7,6% of the meals
providing more than 100% of typical daily energy requirements
[50,63]. As a consequence of that, a study on the Wisconsin State
population highlights that participants, who reported eating fre-
quently at either fast-food restaurants or sit-down restaurants,
were more likely to have higher BMIs [64]. Another study focus its
analysis on young American adults with a mean age of about 25
years, that frequently eat out of home, with one third eating food
from a fullservice restaurant, one third from a sandwich shop and
one third from fast-food restaurant. The young adults who fre-
quently eat food from burger-and-fries fast-food restaurants are
at increased risk for overweight/obesity and poor dietary intake
[48] -
ther fast-food or full-service restaurant consumption is associated
with higher daily total energy intake, poorer dietary indicators, and
weight gain [65-71].
Citation: Cazzaniga E., et al. “Eating Out of Home and Risk for Obesity: An Overview". 5.2 (2021): 126-136.
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Seedlessness in Hybrid Fruits is a Low-input Resource for Canning Industry
Policies and programs towards FAFH designed to keep back
the growing obesity trends
Recent shifts in eating patterns favoring eating out compared
to eating at home have garnered considerable attention as public
health experts pursue potential targets for national policies and
programs designed to curb the growing obesity trends [72-75]. En-
vironmental approaches that address sources of excess energy are
a promising option to address the obesity epidemic. Thus, some
-
ed calorie-labeling policy that required chain restaurants to post
the calorie content of items on menus, menu boards, and item tags.
First in USA, the New York City’s Health Department amended the
city Health Code to require the posting of calorie counts by chain
restaurants in 2006. The opposition of restaurants deled its enact-
ment, it was implemented in January 2008. After that, several state
and local jurisdictions passed their own menu labeling laws before
that USA Congress imposed menu-labeling requirements on chain
restaurants as part of the federal health care reform bill signed into
law in March 2010. The U.S. Food and Drug Administration delayed
implementation of the law several times until it went into effect on
May 7, 2018 [76-80]. In Europe, there is not such a policy, neither
at European Union level nor at state level. UK government has en-
couraged catering chains to provide in store kcal information in
2011. But voluntary policies have not resulted in an adequate kcal
labeling in the UK eating out of home sector. Thus, UK government
is considering the introduction of legislation to make kcal labeling
mandatory among catering chains [81].
Policymakers have based decision to enforce calorie-labeling
policy on studies showing that most consumers are unaware of the
high levels of calories, fat, saturated fat, and sodium found in many
menu items [69,82,83]. Thus, provision of nutrition information
on restaurant menus could potentially have a positive impact on
public health by reducing the consumption of less-healthful foods.
At the same time mandatory implementation of calorie-labeling
policy may induce restaurant industry to offer less energy-dense
foods with an increase in overall nutritional quality of items of-
fered [84,85]
menu kcal labeling in NYC, many studies have assessed the impact
of such a policy on guiding consumer choices towards more equili-
-
tion to be examined, it has been the accuracy of stated energy con-
tents of foods purchased in restaurants following implementation
of restaurant menu calorie-labeling policies. One study measured
dietary energy in food from 42 restaurants. The restaurants were
randomly selected from quick-serve and sit-down restaurants in
some USA states between January and June 2010. Authors found
a correspondence between the absolute stated energy contents of
menu items and the absolute measured energy contents for most
of the food items analyzed. However, there was a substantial inac-
curacy for some individual foods [86]. After that studies focused on
assessing effects of mandatory labeling policies on energy content
of food purchased at restaurants by consumers. Some studies de-
tected a positive effect on the energy content of food purchased in
full-service restaurants [87-89] but others studies instead did not
detected any effect in fast-food restaurants [90,91]. Since adoles-
cent tend to often eat out, especially at fast-food restaurants, a study
has focused on gathering qualitative information from adolescents
regarding the use of menu labels when eating out. Although the
majority of participants were knowledgeable about menu labeling,
they reported rarely noticing menu labels at eating establishments.
When they noted it, menu labeling did not affect food purchasing
decisions except for girls from highincome families, pointing out to
the importance of social and cultural factors in successful of menu
labeling policies [92].
Furthermore calorie-labeling menu policy in chain seat-down
restaurants seems not to have had effects on total calories or serv-
ing size of items on the menu both in Canada and Australia [78,93].
In the USA Washington State, it has been reported a modest de-
crease in energy, saturated fat and sodium contents in the entrée
that were on the menu of sit-down restaurant at 18 month follow-
ing the implementation of mandatory menu labeling compared to
6 month. Even if overall levels of energy, saturated fat and sodium
remain excessive [94]. Thus, the evidence regarding menu calorie-
labeling appears to be mixed, showing that labels may reduce the
energy content of food purchased in some contexts, but have little
effect in other contexts. Demographic characteristics and consum-
er preferences are important determinants in the use of posted
calorie information as well as it could be important to change the
presenting calorie information in the form of physical exercise
equivalents [92,95]. Indeed, many restaurant customers may not
be knowledgeable about the correct range of recommended caloric
intake, thus seeing a number of calories next to a food item did not
have any meaning for them.
Future healthy eating actions towards restaurant industry
Many studies show that menu restaurant calories and nutri-
tional-labeling mandatory policies did not have achieved the set
goals in guiding consumers throughout restaurant menu to choose
healthier dishes in terms of less calories and nutrients composi-
tion. Certainly, calories statement needs to be matched with nutri-
tional fact labeling and percentile of calories daily value referred
to the recommended daily calorie intake for greatest effectiveness.
Even so, that further nutritional information could not be enough
to change consumer out-of-home food habit. Educational and in-
Citation: Cazzaniga E., et al. “Eating Out of Home and Risk for Obesity: An Overview". 5.2 (2021): 126-136.
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Seedlessness in Hybrid Fruits is a Low-input Resource for Canning Industry
formation campaigns are factors to put beside calorie and nutrient
labeling. As well as psychological and environmental determinants
that guide restaurant menu items choices need to be taken in ac-
count. Calories and nutrients composition labeling needs to be
studies in the literature have also shown that mandatory restau-
rant menu-labeling policies do not seem to have induced restau-
rant industry to offer less energy-dense foods with an increase
in overall nutritional quality of offered items. In Europe, there is
not such a mandatory calories and nutrition menu-labeling policy
neither at country level nor at European Union level. Neverthe-
less, in Europe the share of people eating out of home is increas-
ing likewise in the countries in which the mandatory policy has
been enforced. Thus, strategies aimed both to promote healthier
food choices among restaurants patrons and to induce restaurants
to improve nutritional quality and to reduce calories amount of
items in their food menu, need to be implemented. Since interven-
tions along these lines need to be adopted voluntary by restaurant
industry, they need to be perceived as marketing improvements
able to enlarge restaurants market by meeting consumers’ needs.
In Mediterranean countries, as Italy, eating pleasure, interest in
regional e local products and cooking recipes as well as an atmo-
sphere of conviviality, are important factors in determining food
healthiness, constraints, weight control and special diets, and as-
pects related to emotions, like taste, pleasure, habits, hunger and
convenience as determinates of consumers food choices [96-98].
Since determinants of food choices are multiple, interrelated and
complex, efforts focused on just communicating about rational de-
terminants of food choices such as health attributes and energy
density of foods, are not enough to change consumers habit as
previously shown with restaurant menu labeling policies. Thus,
nutrition interventions should address this complexity [99]. Some
authors have argued that automatic emotional processes, which
are at the root of food choices, are determining factors in the expe-
rience of eating pleasure [100]. Considering that pleasure seeking
is an important factor in food choice [97,98], social marketing pro-
grams aimed to encourage healthy eating at serving restaurants
need to be integrated with the concept of food pleasure to have
chances to succeed [101]. Up to now the European Union program
Fighting Obesity Through Offer and Demand (FOOD) is the only ten
years (2009-2019) public project that has targeted both consum-
in the restaurant business that plan, cook and serve the food items
in the restaurant menu to promote healthy eating in European countries,
included Italy [102,103] The project FOOD starts from an educational strat-
egy aimed at promoting health eating by tacking actions direct both towards
consumers at work places, who are made aware of healthy and balanced
nutrition principle, and towards restaurants to improve the nutritional qual-
ity of the food offered in their menu [104]. Thus, the FOOD program, being
a public/private initiative, it brings together different stakeholder which is
very important. Building a virtuous cycle between the demand of healthy
food from restaurant and the offer of healthy food by restaurant. A question-
naires survey directed at both target groups, employees and restaurants,
commissioned within the framework of the FOOD program highlights how
the employees/consumers declare they would like to have a restaurant close
to their work places offering balanced food and they would appreciate nu-
tritional information about the menu items easy to understand and to put
in practice. Restaurants owners, managers and chefs, on the other hand, are
aware of the new demand for healthier food and are eager to meet their cus-
tomers’ demand even if restaurant owners have little time and little budget
to take action and chefs are open to suggestions but not to big changes in
composition and preparation of the food items offered [104]. In Italy inter-
view survey conducted by DOXA in 2018, reveals that Italians, who eats out
at least once a month, do it in search of physical and mental wellness, eating
-
ested in the quality and origins of menu items ingredients with a preference
for zero KM organic seasonal ingredients.
Conclusion
The restaurant could develop technological innovations with smart digi-
tal menu at the table able to guide consumers choices throughout the differ-
ent types of displayed dishes according to different personal needs tacking
in account food intolerances and allergies. Thus, customize meals instead to
order items straight from the menu seems to be the new restaurant patrons
demand trend [105].
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