• Jason P Block, Suzanne K Condon, Ken Kleinman, Jewel Mullen, Stephanie Linakis, Sheryl Rifas-Shiman, and Matthew W Gillman.
• Obesity Prevention Program, Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, Boston, MA 02215, USA. jason_block@harvardpilgrim.org
• BMJ. 2013 Jan 1;346:f2907.

ObjectiveTo investigate estimation of calorie (energy) content of meals from fast food restaurants in adults, adolescents, and school age children.DesignCross sectional study of repeated visits to fast food restaurant chains.Setting89 fast food restaurants in four cities in New England, United States: McDonald's, Burger King, Subway, Wendy's, KFC, Dunkin' Donuts.Participants1877 adults and 330 school age children visiting restaurants at dinnertime (evening meal) in 2010 and 2011; 1178 adolescents visiting restaurants after school or at lunchtime in 2010 and 2011.Main Outcome MeasureEstimated calorie content of purchased meals.ResultsAmong adults, adolescents, and school age children, the mean actual calorie content of meals was 836 calories (SD 465), 756 calories (SD 455), and 733 calories (SD 359), respectively. A calorie is equivalent to 4.18 kJ. Compared with the actual figures, participants underestimated calorie content by means of 175 calories (95% confidence interval 145 to 205), 259 calories (227 to 291), and 175 calories (108 to 242), respectively. In multivariable linear regression models, underestimation of calorie content increased substantially as the actual meal calorie content increased. Adults and adolescents eating at Subway estimated 20% and 25% lower calorie content than McDonald's diners (relative change 0.80, 95% confidence interval 0.66 to 0.96; 0.75, 0.57 to 0.99).ConclusionsPeople eating at fast food restaurants underestimate the calorie content of meals, especially large meals. Education of consumers through calorie menu labeling and other outreach efforts might reduce the large degree of underestimation.

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