Rationale and evidence for menu-labeling legislation

The impact of nutritional labeling on adult snack choices: A controlled field experiment in a non-commercial professional setting

Each year, 2.8 million people die because of comorbidities associated with being overweight. Snacking substantially contributes to people's calorie intake. One way to nudge consumers towards healthier alternatives is the implementation of nutritional labeling. This study reports on a controlled field experiment that evaluates the effect of two nutritional labels on free snack choices (n = 739). Participants at a conference could choose between nuts, cookies, and candy bars as a snack, presented at the bar at six different locations across 2 bar counters. The labels were set up in front of each snack in three conditions: no labeling (control), a calorie label, or a traffic light label (i.e., the Nutri-Score). The location of the snacks on the counter (Either side of the counter; Center, Right, Left) and the time-of-day (Morning (=reference) vs Afternoon) were statistically controlled for. The results show that calorie labels could not successfully nudge consumers toward healthier snack choices (nuts instead of candy bars or cookies). In contrast, the Nutri-Score label significantly increased the probability of choosing nuts over candy bars. The Nutri-Score also increased the chance of choosing nuts over cookies, but the difference was not significant. No prior studies to our knowledge have directly compared calorie labels to the Nutri-Score. This study suggests that the Nutri-Score label can be a more successful intervention than calorie labels to nudge consumers towards healthier choices in situations were free snacks are offered, like many modern workplaces. Changing snacking behavior is challenging and naturalistic field experiments like this one are needed to translate the theory from previous laboratory studies to real-life settings.

Menu Labeling and Calories Purchased in Restaurants in a US National Fast Food Chain

Importance

Menu labeling has been implemented in restaurants in some US jurisdictions as early as 2008, but the extent to which menu labeling is associated with calories purchased is unclear.

Objective

To estimate the association of menu labeling with calories and nutrients purchased and assess geographic variation in results.

Design, Setting, and Participants

A cohort study was conducted with a quasi-experimental design using actual transaction data from Taco Bell restaurants from calendar years 2007 to 2014 US restaurants with menu labeling matched to comparison restaurants using synthetic control methods. Data were analyzed from May to October 2023.

Exposure

Menu labeling policies in 6 US jurisdictions.

Main Outcomes and Measures

The primary outcome was calories per transaction. Secondary outcomes included total and saturated fat, carbohydrates, protein, sugar, fiber, and sodium.

Results

The final sample included 2329 restaurants, with menu labeling in 474 (31 468 restaurant-month observations). Most restaurants (94.3%) were located in California. Difference-in-differences model results indicated that customers purchased 24.7 (95% CI, 23.6-25.7) fewer calories per transaction from restaurants in the menu labeling group in the 3- to 24-month follow-up period vs the comparison group, including 21.9 (95% CI, 20.9-22.9) fewer calories in the 3- to 12-month follow-up period and 25.0 (95% CI, 24.0-26.1) fewer calories in the 13- to 24-month follow-up period. Changes in the nutrient content of transactions were consistent with calorie estimates. Findings in California were similar to overall estimates in magnitude and direction; yet, among restaurants outside of California, no association was observed in the 3- to 24-month period. The outcome of menu labeling also differed by item category and time of day, with a larger decrease in the number of tacos vs other items purchased and a larger decrease in calories purchased during breakfast vs other times of the day in the 3- to 24-month period.

Conclusions and Relevance

In this quasi-experimental cohort study, fewer calories were purchased in restaurants with calorie labels compared with those with no labels, suggesting that consumers are sensitive to calorie information on menu boards, although associations differed by location.

Relationship between Food Insecurity and Nutritional Risk among Older Adults in Poland-A Preliminary Study

Aging populations may be associated with increased nutritional risk, malnutrition, and food insecurity. This study aims to examine the relationship between food insecurity and nutritional risk, taking into account selected characteristics of the study group, and factors describing nutritional risk. It was conducted between May and July 2021, among 417 people aged 60 and older, in two regions of Poland. Questions from the SCREEN-14 questionnaire were used to assess nutritional risk. Selected questions from the HFSS questionnaire (U.S. Household Food Security Survey Module) concerning the elderly were used to assess food insecurity. A K-means cluster analysis was used to separate homogeneous clusters into food security indicators and nutritional risk factors. The Mann-Whitney U test and Kruskal-Wallis test were used to compare mean values between groups, and the Chi-square test was used to verify the differences. Two clusters were distinguished: I-"low food security and high nutritional risk" and II-"high food security and low nutritional risk". Cluster I included people aged 60-65, and over 75, living in urban areas, living alone or with family, with unfavorable economic situations and family relationships. Cluster II was composed of people aged 71-75, who were rural residents, living with a partner, with favorable economic situations and family relations. The vast majority of nutritional risk factors were found in Cluster I and among those at high nutritional risk. The largest number of people were affected by such nutritional risk factors such as difficulty in chewing or biting, loss in appetite, skipping meals, and perceiving one's weight as abnormal. Moreover, the group of people most significantly affected by high nutritional risk were in unfavorable economic situations, had poor family relationships, lived alone or with family, rated their health as worse than their peers, were overweight and obese, had metabolic disease, or impeding mobility. The results obtained can be applied to the planning of social and health policies for the elderly in Poland.

What Is on the Menu?-A Quantitative Analysis on Label Format among (Potential) Restaurant Guests and Restaurant Owners

About 20% of energy intake in the Netherlands is consumed out-of-home. Eating out-of-home is associated with higher energy intake and poorer nutrition. Menu labeling can be considered a promising instrument to improve dietary choices in the out-of-home sector. Effectiveness depends on the presentation format of the label and its attractiveness and usability to restaurant guests and restaurant owners. This exploratory study investigated which menu labeling format would be mostly appreciated by (a) (potential) restaurant guests (n386) and (b) the uninvestigated group of restaurant owners (n41) if menu labeling would be implemented in Dutch full-service restaurants. A cross-sectional survey design was used to investigate three distinct menu labeling formats: a simple health logo; (star) ranking and calorie information. Questionnaires were used as study tool. Ranking has been shown to be the most appreciated menu labeling format by both (potential) restaurant guests and owners. Statistical analysis showed that label preference of potential restaurant guests was significantly associated with age, possibly associated with level of education, and not associated with health consciousness. In summary, we found that ranking is the most appreciated menu label format according to both (potential) restaurant guests and restaurant owners, suggesting it to be a promising way to improve healthy eating out-of-home.

Dietary policies and programs in the United States: A narrative review

•

School-based and youth targeted programs and policies were most frequently studied.

•

Research has rather neglected older adult, Asian, Native Hawaiian and American Indian populations.

•

Despite existing research indicating effectiveness, faith-based were understudied.

Prior reviews describing approach, methodological quality and effectiveness of dietary policies and programs may be limited in use for practitioners seeking to introduce innovative programming, or academic researchers hoping to understand and address gaps in the current literature. This review is novel, assessing the “where, who, and in whom” of dietary policies and programs research in the United States over the past decade – with results intended to serve as a practical guide and foundation for innovation. This study was conducted from October 2018 to March 2019. Papers were selected through a tailored search strategy on PubMed as well as citation searches, to identify grey literature. A total of 489 papers were relevant to our research objective. The largest proportion of papers described school-based strategies (31%) or included economic incentives (19%). In papers that specified demographics, the study populations most often included children, adults and adolescents (54%, 46%, and 42% respectively); and White, Black and Hispanic populations (77%, 76% and 70%, respectively). Results highlight opportunities for future research within workplace and faith-based settings, among racial/ethnic minorities, and older adults.

Regulating the Fast-Food Landscape: Canadian News Media Representation of the Healthy Menu Choices Act

With the rapid rise of fast food consumption in Canada, Ontario was the first province to legislate menu labelling requirements via the enactment of the Healthy Menu Choice Act (HMCA). As the news media plays a significant role in policy debates and the agenda for policymakers and the public, the purpose of this mixed-methods study was to clarify the manner in which the news media portrayed the strengths and critiques of the Act, and its impact on members of the community, including consumers and stakeholders. Drawing on data from Canadian regional and national news outlets, the major findings highlight that, although the media reported that the HMCA was a positive step forward, this was tempered by critiques concerning the ineffectiveness of using caloric labelling as the sole measure of health, and its predicted low impact on changing consumption patterns on its own. Furthermore, the news media were found to focus accountability for healthier eating choices largely on the individual, with very little consideration of the role of the food industry or the social and structural determinants that affect food choice. A strong conflation of health, weight and calories was apparent, with little acknowledgement of the implications of menu choice for chronic illness. The analysis demonstrates that the complex factors associated with food choice were largely unrecognized by the media, including the limited extent to which social, cultural, political and corporate determinants of unhealthy choices were taken into account as the legislation was developed. Greater recognition of these factors by the media concerning the HMCA may evoke more meaningful and long-term change for health and food choices.

Perspective: Public Health Nutrition Policies Should Focus on Healthy Eating, Not on Calorie Counting, Even to Decrease Obesity

Calorie-focused policies, such as calorie menu labeling, seem to result in minor shifts toward healthier choices and public health improvement. This paper discusses the (lack of) relations between energy intake and healthy eating and the rationale for shifting the focus of public health nutrition policies to healthier foods and meals. We argue that the benefits of reducing caloric intake from low-quality foods might not result from the calorie reduction but rather from the reduced consumption of low-quality foods. It is better to consume a given number of calories from high-quality foods than a smaller number of calories from low-quality foods. It is not possible to choose a healthy diet solely based on the caloric value of foods because calories are not equal; they differ in nutritional quality according to their source. Foods are more than just a collection of calories and nutrients, and nutrients interact differently when presented as foods. Different subtypes of a macronutrient, although they have the same caloric value, are metabolized and influence health in different ways. For instance, industrial trans fats increase lipogenesis and the risk of heart diseases, whereas monounsaturated fats have the opposite effect. Food processing and cooking methods also influence the nutritional value of foods. Thus, public health nutrition policies should stop encouraging people to focus mainly on calorie counting to fight noncommunicable diseases. Instead, policies should focus on ingredients, dietary sources, and food processing and cooking methods.

What is the impact of increasing the prominence of calorie labelling? A stepped wedge randomised controlled pilot trial in worksite cafeterias

Background

Calorie labelling may help to reduce energy consumption, but few well-controlled experimental studies have been conducted in real world settings. In a previous randomised controlled pilot trial we did not observe an effect of calorie labelling on energy purchased in worksite cafeterias. In the present study we sought to enhance the effect by making the labels more prominent, and to address the operational challenges reported previously by worksites.

Methods

Three worksite cafeterias were randomised in a stepped wedge design to start the intervention at one of three fortnightly periods between March and July 2018. The intervention comprised introducing prominent calorie labelling for all cafeteria products for which calorie information was available (on average 87% of products offered across the three sites were labelled). Calorie content was displayed in bold capitalised Verdana typeface with a minimum font size of 14 e.g.120 CALORIES. Feasibility and acceptability were assessed using post-intervention surveys with cafeteria patrons and semi-structured interviews with managers. Effectiveness was assessed using total daily energy (kcal) purchased from intervention items across the three sites, analysed using semi-parametric GAMLSS models.

Results

Recruitment and retention of worksite cafeterias proved feasible: all three randomised sites successfully completed the study. Post-intervention feedback suggested high levels of intervention acceptability: 87% of responding patrons wanted calorie labelling to remain in place. No effect of the intervention on daily energy purchased was observed: −0.6% (95%CI -2.5 to 1.2, p = .487). By-site analyses showed similar null effects at each of the three sites, all ps > .110.

Conclusions

There was no evidence that prominent calorie labelling changed daily energy purchased across three English-based worksite cafeterias. The intervention was feasible to implement and acceptable to patrons and managers.

Effects of health star labelling on the healthiness of adults' fast food meal selections: An experimental study

The addition of Health Star Rating (HSR) labelling to menus at fast food outlets is feasible, however how this would impact consumer menu selection remains unclear. The aim of this study was to test whether the addition of HSR labelling to kilojoule (kJ) labelling on menus at fast food outlets would prompt consumers to select healthier meals. Using a between-subjects experimental design, 1007 adults aged 18-49 were allocated to one of four menu labelling conditions: (i) no labelling; (ii) kilojoule labelling; (iii) HSR labelling; and (iv) kilojoule + HSR labelling. Respondents were presented with their assigned menu online and instructed to select an evening meal as they would at a fast food restaurant. The main analyses tested differences by menu labelling condition in the total mean kilojoule content and Nutrient Profiling Score (NPS) of respondents' evening meal selections using one-way ANOVA. The mean kilojoule content of meals did not differ significantly by menu labelling condition. However, respondents in the kilojoule + HSR labelling condition selected healthier meals (lower mean NPS) than those who viewed menu boards with kilojoule labelling only (M = 2.88 cf. M = 3.78, p = 0.046). In addition, in a post hoc per-protocol analysis of respondents who reported using menu labelling to assist their meal selection, respondents shown kilojoule + HSR menu labelling selected meals with a significantly lower kilojoule content compared to those shown HSR labelling only (4751 kJ cf. 5745 kJ, p = 0.038). Findings provide evidence that adding HSRs to kilojoule labelling on menu boards at fast food outlets has the potential to assist adults to make healthier evening meal selections.

Understanding the Density and Distribution of Restaurants in Los Angeles County to Inform Local Public Health Practice

INTRODUCTION

To describe the potential reach of restaurant-based strategies that seek to improve the healthfulness of menu options, it is important to understand the local restaurant environment, including the extent to which restaurants subject to policy mandates are located in communities disproportionately affected by diet-related diseases.

METHODS

This cross-sectional study examined the restaurant environment in Los Angeles County, a large jurisdiction with diverse geographic and socioeconomic characteristics, specifically 1) the number and characteristics of restaurants; 2) the association between neighborhood sociodemographics and restaurant density; and 3) the association between neighborhood sociodemographics and restaurant characteristics, including chain status (large chain, small chain, independent restaurant). Data sources were 1) industry data on restaurant location and characteristics (N = 24,292 restaurants) and 2) US Census data on neighborhood sociodemographics (N = 247 neighborhoods). We conducted descriptive and bivariate analyses at the restaurant and neighborhood level.

RESULTS

Countywide, only 26.5% of all restaurants were part of a large chain (a chain with ≥20 locations). We found positive associations between restaurant density and neighborhood proportions of non-Hispanic white residents and residents with more than a high school education. We found limited support to suggest a greater density of large chains in neighborhoods with lower socioeconomic status.

CONCLUSION

Results highlight the potentially limited reach of strategies targeting chain restaurants and point to the importance of including small chain restaurants and independent restaurants in public health efforts to improve the healthfulness of restaurants. Understanding where restaurants are in relation to priority populations is a critical step to planning strategies that address diet-related disparities.

Barriers and facilitators to implementation of menu labelling interventions to support healthy food choices: a mixed methods systematic review protocol

BACKGROUND

Menu labelling is continuing to gather public and legislative support as one of the potential environmental strategies for addressing the obesity pandemic. However, issues relating to implementation have been reported in countries where menu labelling has been introduced on a voluntary or mandatory basis. The aim of this mixed methods systematic review is to synthesise the empirical evidence on the barriers and facilitators to implementation of menu labelling interventions to support healthy food choices.

METHODS

This review will use the 'best fit' framework synthesis approach to synthesise qualitative, quantitative and mixed methods evidence. Peer-reviewed publications will be accessed through PubMed, EMBASE, CINAHL, PsycINFO, Web of Science and Scopus. Grey literature will be accessed through Google Scholar, OpenGrey, RIAN, EThOS, ProQuest, WorldCat, Networked Digital Library of Theses and Dissertations, Open Access Theses and Dissertations, and public health organisation websites. Screening reference lists, citation chaining and contacting authors of all included studies will be undertaken. There will be no restriction on menu labelling scheme or format, publication year or language; however, only primary research studies relevant to supply-side stakeholders will be eligible for inclusion. Study quality will be assessed using the Mixed Methods Appraisal Tool. At least two independent reviewers will perform study selection, data extraction and quality appraisal; if consensus is required, another independent reviewer will be consulted. A combination of deductive coding, using the Consolidated Framework for Implementation Research as the a priori framework, and inductive analysis, using secondary thematic analysis, will be used. The overall process will assist in the construction of a new evidence-based conceptual model regarding the implementation of menu labelling interventions. The new model will be assessed for bias and a sensitivity analysis performed.

DISCUSSION

Given the growing consensus that a systemic, sustained portfolio of obesity prevention strategies, delivered at scale, is needed to address the obesity epidemic, greater understanding of the practical issues relating to implementation of such strategies is required. Findings from this review will be used to develop a set of best-practice guidelines to enhance the adoption, implementation and sustainability of menu labelling interventions across countries worldwide.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017083306.

Compliance in 2017 With Federal Calorie Labeling in 90 Chain Restaurants and 10 Retail Food Outlets Prior to Required Implementation

OBJECTIVES

To examine early compliance with the delayed federal calorie labeling regulation that requires posting calories on menus and menu boards at retail food chains with 20 or more establishments nationally.

METHODS

We explored implementation of calorie labeling at 90 of the largest US chain restaurants and the 10 highest-grossing supermarket chains from May to December 2017. We contacted corporate offices and at least 2 locations for each chain, made site visits when possible, and supplemented these efforts with targeted Internet searches.

RESULTS

Overall, 71 (79%) restaurant chains partially or fully implemented labeling, as did 9 (90%) supermarket chains. Fast-food and fast-casual restaurants fully implemented labeling at a modestly higher rate than did full-service restaurants.

CONCLUSIONS

Most of the retail food chains we assessed implemented calorie labeling policies in advance of the May 2018 compliance date. Public Health Implications. Although implementation of federal calorie labeling has been delayed repeatedly in the 8 years since the passage of the legislation, retail food chains have demonstrated a high rate of compliance with calorie labeling in advance of the required May 2018 implementation date. Despite reports from some retail food industries that compliance will be difficult, current implementation shows the feasibility of complying.

Correlates of Reported Use and Perceived Helpfulness of Calorie Information in Restaurants Among U.S. Adults

PURPOSE

This study reports correlates in reported use and helpfulness of calorie information, when available, in restaurants on a national scale in the United States for demographic behavioral and health-related conditions.

DESIGN

This study is a secondary data analysis of the 2013 National Cancer Institute's Health Information National Trends Survey data.

SETTING

United States.

SUBJECTS

Adults (n = 3407).

MEASURES

Menu labeling use and helpfulness; behavior change attempts; reported fruit, vegetable, and soda consumption; weight status; and chronic health conditions.

ANALYSIS

Trends were identified in weighted logistic and linear regression models.

RESULTS

U.S. adults who intended to lose weight (odds ratio [OR] = 5.01 [95% confidence interval 2.96, 8.46]), increase fruit (OR = 1.10 [.66, 1.84]) or vegetable consumption (OR = 2.25 [1.32, 3.83]), or reduce soda consumption (OR = 1.67 [1.11, 2.51]) were more likely to report using menu-labeling information when available. More women reported calorie information was helpful when ordering (p < .05). Racial/ethnic and socioeconomic status disparities were identified in use (non-Hispanic [NH] blacks vs. NH whites OR = .43 [.25, .74]) and helpfulness (NH blacks vs. NH whites β = -.06 [-.44, .32]).

CONCLUSION

Findings highlight potential subgroups to target for communication and education efforts regarding use of calorie information in restaurants. Following publication of final rules for federal menu-labeling legislation and implementation, further surveillance of public response to this information may inform message framing and educational interventions to promote use of calorie information on menu boards.

A Systematic Review of Calorie Labeling and Modified Calorie Labeling Interventions: Impact on Consumer and Restaurant Behavior

OBJECTIVE

Evidence on the effects of restaurant calorie labeling on consumer and restaurant behavior is mixed. This paper examined: (1) consumer responses to calorie information alone or compared to modified calorie information and (2) changes in restaurant offerings following or in advance of menu labeling implementation.

METHODS

Searches were conducted in PubMed, Web of Science, Policy File, and PAIS International to identify restaurant calorie labeling studies through October 1, 2016, that measured calories ordered, consumed, or available for purchase on restaurant menus. The reference lists of calorie labeling articles were also searched.

RESULTS

Fifty-three studies were included: 18 in real-world restaurants, 9 in cafeterias, and 21 in laboratory or simulation settings. Five examined restaurant offerings.

CONCLUSIONS

Because of a lack of well-powered studies with strong designs, the degree to which menu labeling encourages lower-calorie purchases and whether that translates to a healthier population are unclear. Although there is limited evidence that menu labeling affects calories purchased at fast-food restaurants, some evidence demonstrates that it lowers calories purchased at certain types of restaurants and in cafeteria settings. The limited data on modified calorie labels find that such labels can encourage lower-calorie purchases but may not differ in effects relative to calorie labels alone.

Nutritional quality and marketing strategies of fast food children's combo meals in Guatemala

BACKGROUND

Overweight and obesity prevalence in children is now on the rise in low/middle-income countries, including Guatemala. Fast food consumption is a recognized contributing factor to this rise. Fast food restaurants use health claims, toy giveaways, price incentives and fast service to promote children's combo meals. This study sought to assess the use of toy giveaways, time to delivery and price incentives as marketing strategies in fast food chain restaurants in Guatemala. In addition, we sought to compare nutritional quality of combo meals with and without health claims.

METHODS

We visited one restaurant from each of the 8 major fast food chains in Guatemala and purchased all children's combo meals to assess the prevalence of toy giveaways, health claims, and difference in delivery time and price between the combo meal and each meal item purchased separately. Each item was then classified as "healthy" or "less healthy" using the UK Nutrition Profile Model. Nutrition information was collected on-site, from the restaurant website, or by calling the customer service phone number.

RESULTS

We found 114 combo meals, 21 (18.4%) of which were children's combo meals. Five (24%) had nutrition information, all were classified by our analysis as "less healthy", and three had a health claim. On average, combo meals were US$1.93 less expensive than purchasing children's meal items individually (p = 0.01). Time to delivery was 1.44 min faster for combo meals compared to purchasing meal items individually (p = 0.19).

CONCLUSIONS

Children's fast food combo meals in Guatemala were promoted using several marketing strategies that encourage consumption, including offering toy giveaways and price incentives. In addition, nutrition information is lacking in fast food chain restaurants. Public health advocates in Guatemala should consider a comprehensive approach to encourage healthier choices within fast food restaurants including policies that require fruit and vegetable options for meal side dishes, accessible and easy to read nutrition information, and restrict the use of toy giveaways.

Food, health, and complexity: towards a conceptual understanding to guide collaborative public health action

BACKGROUND

What we eat simultaneously impacts our exposure to pathogens, allergens, and contaminants, our nutritional status and body composition, our risks for and the progression of chronic diseases, and other outcomes. Furthermore, what we eat is influenced by a complex web of drivers, including culture, politics, economics, and our built and natural environments. To date, public health initiatives aimed at improving food-related population health outcomes have primarily been developed within 'practice silos', and the potential for complex interactions among such initiatives is not well understood. Therefore, our objective was to develop a conceptual model depicting how infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy can be linked via shared drivers, to illustrate potential complex interactions and support future collaboration across public health practice silos.

METHODS

We developed the conceptual model by first conducting a systematic literature search to identify review articles containing schematics that depicted relationships between drivers and the issues of interest. Next, we synthesized drivers into a common model using a modified thematic synthesis approach that combined an inductive thematic analysis and mapping to synthesize findings.

RESULTS

The literature search yielded 83 relevant references containing 101 schematics. The conceptual model contained 49 shared drivers and 227 interconnections. Each of the five issues was connected to all others. Obesity and food insecurity shared the most drivers (n = 28). Obesity shared several drivers with food allergy (n = 11), infectious foodborne illness (n = 7), and dietary contamination (n = 6). Food insecurity shared several drivers with infectious foodborne illness (n = 9) and dietary contamination (n = 9). Infectious foodborne illness shared drivers with dietary contamination (n = 8). Fewer drivers were shared between food allergy and: food insecurity (n = 4); infectious foodborne illness (n = 2); and dietary contamination (n = 1).

CONCLUSIONS

Our model explicates potential interrelationships between five population health issues for which public health interventions have historically been siloed, suggesting that interventions targeted towards these issues have the potential to interact and produce unexpected consequences. Public health practitioners working in infectious foodborne illness, food insecurity, dietary contaminants, obesity, and food allergy should actively consider how their seemingly targeted public health actions may produce unintended positive or negative population health impacts.

Restaurant Menu Labeling Policy: Review of Evidence and Controversies

In response to high rates of obesity in the USA, several American cities, counties, and states have passed laws requiring restaurant chains to post labels identifying the energy content of items on menus, and nationwide implementation of menu labeling is expected in late 2016. In this review, we identify and summarize the results of 16 studies that have assessed the impact of real-world numeric calorie posting. We also discuss several controversies surrounding the US Food and Drug Administration's implementation of federally mandated menu labeling. Overall, the evidence regarding menu labeling is mixed, showing that labels may reduce the energy content of food purchased in some contexts, but have little effect in other contexts. However, more data on a range of ong-term consumption habits and restaurant responses is needed to fully understand the impact menu labeling laws will have on the US population's diet.

Menu labelling is effective in reducing energy ordered and consumed: a systematic review and meta-analysis of recent studies

Objective

Menu labelling is a practical tool to inform consumers of the energy content of menu items and help consumers make informed decisions in the eating-out environment, and the volume of studies published recently regarding its effects is expanding, both quantitatively and geographically. The aim of the present review and meta-analysis is to consider the most recent evidence which assesses the effect of menu labelling regarding changes in energy consumed, ordered or selected in both real-world and experimental settings.

Design

The review included fifteen peer-reviewed, full-text articles published between 2012 and 2014. Pertinent methodological information was extracted from each of the included studies and a quality assessment scheme was applied to classify the studies, after which systematic across-study comparisons were conducted. A meta-analysis was conducted including twelve of the fifteen studies, and stratified according to type of research setting and outcome: energy consumed, ordered or selected.

Results

The rating yielded studies categorized by study quality: good (n 3), fair (n 9) and weak (n 3). Overall nine studies showed statistically significant reductions in energy consumed, ordered or selected. Three articles reported no effect of menu labelling. The meta-analysis showed statistically significant effects of menu labelling: overall energy consumed was reduced by a mean of 419·5 kJ (100·2 kcal) and energy ordered in real-world settings decreased by a mean of 325·7 kJ (77·8 kcal).

Conclusions

The review supports that menu labelling can effectively reduce energy ordered and consumed in the away-from-home food environment.

Nutrition and the science of disease prevention: a systems approach to support metabolic health

Progress in nutritional science, genetics, computer science, and behavioral economics can be leveraged to address the challenge of noncommunicable disease. This report highlights the connection between nutrition and the complex science of preventing disease and discusses the promotion of optimal metabolic health, building on input from several complementary disciplines. The discussion focuses on (1) the basic science of optimal metabolic health, including data from gene-diet interactions, microbiome, and epidemiological research in nutrition, with the goal of defining better targets and interventions, and (2) how nutrition, from pharma to lifestyle, can build on systems science to address complex issues.

Food for thought: obstacles to menu labelling in restaurants and cafeterias

Menu labelling is recommended as a policy intervention to reduce obesity and diet-related disease. The present commentary considers the many challenges the restaurant industry faces in providing nutrition information on its menus. Barriers include lack of nutrition expertise, time, cost, availability of nutrition information for exotic ingredients, ability to provide accurate nutrition information, libel risk, customer dissatisfaction, limited space on the menu, menu variations, loss of flexibility in changing the menu, staff training and resistance of employees to change current practice. Health promotion specialists and academics involved in fieldwork must help restaurateurs find solutions to these barriers for menu labelling interventions to be widely implemented and successful. Practical support for small independent restaurants such as free or subsidised nutrition analysis, nutrition training for staff and menu design may also be necessary to encourage voluntary participation.

Menu label accuracy at a university's foodservices. An exploratory recipe nutrition analysis

The increase in the weight of American adults and children has been positively associated with the prevalence of the consumption of food-away-from-home. The objective was to assess the accuracy of claimed nutritional information of foods purchased in contracted foodservices located on the campus of an institution of higher education. Fifty popular food items were randomly collected from five main dining outlets located on a selected campus in the northeastern United States. The sampling was repeated three times on separate occasions for an aggregate total of 150 food samples. The samples were then weighed and assessed for nutrient composition (protein, cholesterol, fiber, carbohydrates, total fat, calories, sugar, and sodium) using nutrient analysis software. Results were compared with foodservices' published nutrition information. Two group comparisons, claimed and measured, were performed using the paired-sample t-test. Descriptive statistics were used as well. Among the nine nutritional values, six nutrients (total fat, sodium, protein, fiber, cholesterol, and weight) had more than 10% positive average discrepancies between measured and claimed values. Statistical significance of the variance was obtained in four of the eight categories of nutrient content: total fat, sodium, protein, and cholesterol (P < .05). Significance was also reached in the variance of actual portion weight compared to the published claims (P < .001). Significant differences of portion size (weight), total fat, sodium, protein, and cholesterol were found among the sampled values and the foodservices' published claims. The findings from this study raise the concern that if the actual nutritional information does not accurately reflect the declared values on menus, conclusions, decisions and actions based on posted information may not be valid.

Systematic review and meta-analysis of the impact of restaurant menu calorie labeling

We conducted a systematic review and meta-analysis evaluating the relationship between menu calorie labeling and calories ordered or purchased in the PubMed, Web of Science, PolicyFile, and PAIS International databases through October 2013. Among 19 studies, menu calorie labeling was associated with a -18.13 kilocalorie reduction ordered per meal with significant heterogeneity across studies (95% confidence interval = -33.56, -2.70; P = .021; I(2) = 61.0%). However, among 6 controlled studies in restaurant settings, labeling was associated with a nonsignificant -7.63 kilocalorie reduction (95% confidence interval = -21.02, 5.76; P = .264; I(2) = 9.8%). Although current evidence does not support a significant impact on calories ordered, menu calorie labeling is a relatively low-cost education strategy that may lead consumers to purchase slightly fewer calories. These findings are limited by significant heterogeneity among nonrestaurant studies and few studies conducted in restaurant settings.

Small, medium, large or supersize? The development and evaluation of interventions targeted at portion size

In the past decades, portion sizes of high-caloric foods and drinks have increased and can be considered an important environmental obesogenic factor. This paper describes a research project in which the feasibility and effectiveness of environmental interventions targeted at portion size was evaluated. The studies that we conducted revealed that portion size labeling, offering a larger variety of portion sizes, and proportional pricing (that is, a comparable price per unit regardless of the size) were considered feasible to implement according to both consumers and point-of-purchase representatives. Studies into the effectiveness of these interventions demonstrated that the impact of portion size labeling on the (intended) consumption of soft drinks was, at most, modest. Furthermore, the introduction of smaller portion sizes of hot meals in worksite cafeterias in addition to the existing size stimulated a moderate number of consumers to replace their large meals by a small meal. Elaborating on these findings, we advocate further research into communication and marketing strategies related to portion size interventions; the development of environmental portion size interventions as well as educational interventions that improve people's ability to deal with a 'super-sized' environment; the implementation of regulation with respect to portion size labeling, and the use of nudges to stimulate consumers to select healthier portion sizes.

Changes in awareness and use of calorie information after mandatory menu labeling in restaurants in King County, Washington

OBJECTIVES

We examined population-level impact on customer awareness and use and explored potential disparities in outcomes regarding the King County, Washington, regulation requiring chain restaurants to provide calorie information.

METHODS

We analyzed 2008 to 2010 Behavioral Risk Factor Surveillance System data from 3132 English-speaking King County residents aged 18 years and older who reported eating at a regulated chain. We used regression models to assess changes in calorie information awareness and use from prepolicy to postpolicy implementation by customer demographics, health status, and restaurant type.

RESULTS

Calorie information awareness and use increased significantly from 2008 to 2010. Unadjusted analyses indicated that the proportion who saw and used calorie information tripled, from 8.1% to 24.8%. Fully adjusted analyses confirmed significant increases. After policy implementation, White, higher income, and obese respondents had greater odds of seeing calorie information. Women, higher income groups, and those eating at a fast-food versus a sit-down chain restaurant were more likely to use this information.

CONCLUSIONS

Significant increases in calorie information awareness and use following regulation support the population-wide value of this policy. However, improvements varied across race, income, and gender.

Does providing nutrition information at vending machines reduce calories per item sold?

In 2010, the United States (US) enacted a restaurant menu labeling law. The law also applied to vending machine companies selling food. Research suggested that providing nutrition information on menus in restaurants might reduce the number of calories purchased. We tested the effect of providing nutrition information and 'healthy' designations to consumers where vending machines were located in college residence halls. We conducted our study at one university in Southeast US (October-November 2012). We randomly assigned 18 vending machines locations (residence halls) to an intervention or control group. For the intervention we posted nutrition information, interpretive signage, and sent a promotional email to residents of the hall. For the control group we did nothing. We tracked sales over 4 weeks before and 4 weeks after we introduced the intervention. Our intervention did not change what the residents bought. We recommend additional research about providing nutrition information where vending machines are located, including testing formats used to present information.

Solid fat and added sugar intake among U.S. children: The role of stores, schools, and fast food, 1994-2010

BACKGROUND

Little is known about the role of location in U.S. children's excess intake of energy from solid fat and added sugar, collectively referred to as SoFAS.

PURPOSE

The goal of this study was to compare the SoFAS content of foods consumed by children from stores, schools, and fast-food restaurants and to determine whether trends from 1994 to 2010 differ across these locations.

METHODS

Children aged 2-18 years (N=22,103) from five nationally representative surveys of dietary intake from 1994 to 2010 were studied. SoFAS content was compared across locations for total intake and key foods. Regression models were used to test and compare linear trends across locations. Data were analyzed in 2012.

RESULTS

The mean percentage of total energy intake consumed from each location that was provided by SoFAS remained above recommendations, despite significant improvements between 1994 and 2010 at stores (1994, 38.3%; 2004, 33.2%); schools (1994, 38.7%; 2004, 31.2%); and fast-food restaurants (1994, 34.6%; 2004, 34.6%). For each key food, SoFAS content decreased significantly at stores and schools, yet progress at schools was comparatively slower. Milk was higher in SoFAS at schools compared to stores because of shifts toward flavored milk at schools. Schools provided french fries that were higher in solid fat than store-bought versions and pizza that was not significantly different in SoFAS content than fast-food pizza. However, schools made significantly greater progress for sugar-sweetened beverages, as lower-sugar beverages replaced regular sodas. Key fast foods showed little improvement.

CONCLUSIONS

These findings can inform future strategies targeted to the specific locations and foods where continued progress is needed to reduce children's SoFAS consumption.

Relationships among grocery nutrition label users and consumers' attitudes and behavior toward restaurant menu labeling

In the United States (US), based on the 2010 Affordable Care Act, restaurant chains and similar retail food establishments with 20 or more locations are required to begin implementing calorie information on their menus. As enacting of the law begins, it is important to understand its potential for improving consumers' healthful behaviors. Therefore, the objective of this study was to explore relationships among users of grocery nutrition labels and attitudes toward restaurant menu labeling, along with the caloric content of their restaurant menu selection. Study participants were surveyed and then provided identical mock restaurant menus with or without calories. Results found that participants who used grocery nutrition labels and believed they would make healthy menu selections with nutrition labels on restaurant menus made healthier menu selections, regardless of whether the menu displayed calories or not. Consumers' nutrition knowledge and behaviors gained from using grocery nutrition labels and consumers' desire for restaurants to provide nutrition menu labels have a positive effect on their choosing healthful restaurant menu items.

Reading nutrition labels is associated with a lower risk of metabolic syndrome in Korean adults: the 2007-2008 Korean NHANES

BACKGROUND AND AIMS

Several studies demonstrated that reading nutrition labels was associated with healthier food choices, despite some controversy. This study investigated the association between the use of nutrition labels and metabolic syndrome (MetS) in Korean adults.

METHODS AND RESULTS

This cross-sectional study included 7756 individuals who participated in the 2007-2009 Korean National Health and Nutrition Examination Survey (KNHANES). A self-reported questionnaire was used to determine participant's awareness of nutrition labels. Modified Asian criteria based on a harmonizing definition of MetS were adopted. Individuals in the group that read nutrition labels (the Reading Group) were youngest and leanest, but their daily caloric intake fell between that of the group that did not read nutrition labels (the Non-Reading Group) and the group that did not know about them (the Not-Knowing Group). The prevalence of MetS was 16.8% in the Reading Group, 27.2% in the Non-Reading Group, and 47.3% in the Not-Knowing Group. In comparison to participants in the Reading Group, the odds ratios (95% confidence interval) for MetS in the participants in the Non-Reading Group and Not-Knowing Group were 1.85 (1.60-2.14) and 4.44 (3.79-5.20), respectively, when not adjusted. The relationship between the use of nutrition labels and MetS remained statistically significant even after adjusting for covariates such as age, sex and socioeconomic status including household income and education level [1.27 (1.05-1.53) in the Non-Reading Group and 1.34 (1.05-1.70) in the Not-Knowing Group].

CONCLUSION

Reading nutrition labels appeared to be associated with a lower prevalence of MetS in a nationally representative sample of Korean adults.

Calorie estimation accuracy and menu labeling perceptions among individuals with and without binge eating and/or purging disorders

Menu labeling is a public health policy that requires chain restaurants in the USA to post kilocalorie information on their menus to help consumers make informed choices. However, there is concern that such a policy might promote disordered eating. This web-based study compared individuals with self-reported binge eating disorder (N = 52), bulimia nervosa (N = 25), and purging disorder (N = 17) and those without eating disorders (No ED) (N = 277) on restaurant calorie information knowledge and perceptions of menu labeling legislation. On average, people answered 1.46 ± 1.08 questions correctly (out of 6) (25%) on a calorie information quiz and 92% of the sample was in favor of menu labeling. The findings did not differ based on eating disorder, dieting, or weight status, or race/ethnicity. The results indicated that people have difficulty estimating the calories in restaurant meals and individuals with and without eating disorders are largely in favor of menu labeling laws.

Would You Like Fries (380 Calories) With That? Menu Labeling Mitigates the Impact of Weight-Based Stereotype Threat on Food Choice

Policies that focus on self-regulation are being implemented to reduce obesity. One policy is menu labeling, the provision of calorie information on restaurant menus, which has evidenced mixed results. To illuminate the role of psychological processes, we examined the effect of weight-based stereotype threat on food choice as a function of body mass index (BMI). In Study 1, participants under stereotype threat ordered food containing more calories from a conventional menu that did not present calorie information as BMI increased, whereas no association between BMI and calories was found in the control (no threat) condition. In Study 2, participants under stereotype threat ordered more calories from a conventional menu as BMI increased, whereas no association between BMI and calories was found among participants who ordered from a calorie menu, demonstrating that menu labeling eliminated the stereotype threat effect. Theoretical and practical implications for stereotype threat and policy interventions are discussed.

Ready for policy? Stakeholder attitudes toward menu labelling in Toronto, Canada

OBJECTIVES

The purpose of this research was to assess key stakeholder attitudes regarding menu labelling in Toronto, the largest municipality in Canada. Menu labelling is a population health intervention where food-labelling principles are applied to the eating-out environment through disclosure of nutrient content of food items on restaurant menus at the point of sale. Menu-labelling legislation has been implemented in the United States, but has yet to be adopted in Canada. As provincial voluntary programs and federal analyses progress, municipal jurisdictions will need to assess the feasibility of moving forward with parallel interventions.

METHODS

Data were collected and analyzed in late 2011 to early 2012, including: a consumer eating-out module incorporated into a public health surveillance telephone survey (n=1,699); an online survey of independent restaurant operators (n=256); in-depth key informant interviews with executives and decision makers at chain restaurants (n=9); and a policy consultation with local restaurant associations.

RESULTS

Toronto residents, particularly men, younger adults, and those with higher income or education, frequently eat out. A majority indicated that nutrition information is important to them; 69% note that they currently use it and 78% reported they would use it if it were readily available. Resistance to menu-labelling requirements at the municipal level was articulated by franchise/chain restaurant executives and industry associations. Despite overall low interest among independent restaurant operators, 57% reported feeling some responsibility to provide nutrition information and 50% believed it could be good for business.

CONCLUSIONS

This research supports earlier literature that indicates strong public support for menu labelling alongside perceived barriers among the restaurant and foodservices sector. Leverage points for effective operator engagement for menu-labelling adoption were identified, nonetheless, highlighting the need for public health support.

Assessment of the dining environment on and near the campuses of fifteen post-secondary institutions

OBJECTIVE

The present study evaluated the restaurant and dining venues on and near post-secondary campuses varying in institution size.

DESIGN

The Nutrition Environment Measures Survey for Restaurants (NEMS-R) was modified to evaluate restaurants as fast food, sit down and fast casual; and campus dining venues as dining halls, student unions and snack bar/cafe´s. ANOVA with post hoc Tukey’s B and T tests were used to distinguish differences between dining venues and associated institutions by size.

SETTING

The study was conducted at fifteen US post-secondary institutions, 2009–2011.

SUBJECTS

Data presented are from a sample of 175 restaurants and sixty-eight on-campus dining venues.

RESULTS

There were minimal differences in dining halls by institution size, although medium-sized institutions as compared with small-sized institutions offered significantly more healthful side dish/salad bar items. Dining halls scored significantly higher than student unions or snack bar/cafe´s on healthful entre´es, side dish/salad bar and beverages offerings, but they also had the most barriers to healthful dietary habits (i.e. all-you-can-eat). No differences were found by restaurant type for NEMS-R scores for total restaurant dining environment or healthful entre´es and barriers. Snack bars had more healthful side dishes (P50?002) and fast-food restaurants had the highest level of facilitators (i.e. nutrition information; P50?002).

CONCLUSIONS

Based on this evaluation in fifteen institutions, the full campus dining environment provides limited support for healthy eating and obesity prevention. The quality of campus dining environments can be improved via healthful offerings, providing nutrition information and other supports to facilitate healthy eating and prevent unwanted weight gain.

Does food marketing need to make us fat? A review and solutions

Food marketing is often singled out as the leading cause of the obesity epidemic. The present review examines current food marketing practices to determine how exactly they may be influencing food intake, and how food marketers could meet their business objectives while helping people eat healthier. Particular attention is paid to the insights provided by recently published studies in the areas of marketing and consumer research, and those insights are integrated with findings from studies in nutrition and related disciplines. The review begins with an examination of the multiple ways in which 1) food pricing strategies and 2) marketing communication (including branding and food claims) bias food consumption. It then describes the effects of newer and less conspicuous marketing actions, focusing on 3) packaging (including the effects of package design and package-based claims) and 4) the eating environment (including the availability, salience, and convenience of food). Throughout, this review underscores the promising opportunities that food manufacturers and retailers have to make profitable "win-win" adjustments to help consumers eat better.

Applying a common-sense approach to fighting obesity

The obesity epidemic is a threat to the health of millions and to the economic viability of healthcare systems, governments, businesses, and nations. A range of answers come to mind if and when we ask, "What can we, health professionals (physicians, nurses, nutritionists, behavioral psychologists), do about this epidemic?" In this paper, we describe the Common-Sense Model of Self-Regulation as a framework for organizing existent tools and creating new tools to improve control of the obesity epidemic. Further, we explain how the Common-Sense Model can augment existing behavior-change models, with particular attention to the strength of the Common-Sense Model in addressing assessment and weight maintenance beyond initial weight loss.

Personal responsibility and obesity: a constructive approach to a controversial issue

The concept of personal responsibility has been central to social, legal, and political approaches to obesity. It evokes language of blame, weakness, and vice and is a leading basis for inadequate government efforts, given the importance of environmental conditions in explaining high rates of obesity. These environmental conditions can override individual physical and psychological regulatory systems that might otherwise stand in the way of weight gain and obesity, hence undermining personal responsibility, narrowing choices, and eroding personal freedoms. Personal responsibility can be embraced as a value by placing priority on legislative and regulatory actions such as improving school nutrition, menu labeling, altering industry marketing practices, and even such controversial measures as the use of food taxes that create healthier defaults, thus supporting responsible behavior and bridging the divide between views based on individualistic versus collective responsibility.

Obesity and health system reform: private vs. public responsibility

Obesity is a particularly vexing public health challenge, since it not only underlies much disease and health spending but also largely stems from repeated personal behavioral choices. The newly enacted comprehensive health reform law contains a number of provisions to address obesity. For example, insurance companies are required to provide coverage for preventive-health services, which include obesity screening and nutritional counseling. In addition, employers will soon be able to offer premium discounts to workers who participate in wellness programs that emphasize behavioral choices. These policies presume that government intervention to reduce obesity is necessary and justified. Some people, however, argue that individuals have a compelling interest to pursue their own health and happiness as they see fit, and therefore any government intervention in these areas is an unwarranted intrusion into privacy and one's freedom to eat, drink, and exercise as much or as little as one wants. This paper clarifies the overlapping individual, employer, and social interest in each person's health generally to avoid obesity and its myriad costs in particular. The paper also explores recent evidence on the impact of government interventions on obesity through case studies on food labeling and employer-based anti-obesity interventions. Our analysis suggests a positive role for government intervention to reduce and prevent obesity. At the same time, we discuss criteria that can be used to draw lines between government, employer, and individual responsibility for health, and to derive principles that should guide and limit government interventions on obesity as health reform's various elements (e.g., exchanges, insurance market reforms) are implemented in the coming years.