The effect of energy and traffic light labelling on parent and child fast food selection: a randomised controlled trial

Socioeconomic position and the effect of energy labelling on consumer behaviour: a systematic review and meta-analysis

BACKGROUND

There are well documented socioeconomic disparities in diet quality and obesity. Menu energy labelling is a public health policy designed to improve diet and reduce obesity. However, it is unclear whether the impact energy labelling has on consumer behaviour is socially equitable or differs based on socioeconomic position (SEP).

METHODS

Systematic review and meta-analysis of experimental (between-subjects) and pre-post implementation field studies examining the impact of menu energy labelling on energy content of food and/or drink selections in higher vs. lower SEP groups.

RESULTS

Seventeen studies were eligible for inclusion. Meta-analyses of 13 experimental studies that predominantly examined hypothetical food and drink choices showed that energy labelling tended to be associated with a small reduction in energy content of selections that did not differ based on participant SEP (X2(1) = 0.26, p = .610). Effect estimates for higher SEP SMD = 0.067 [95% CI: -0.092 to 0.226] and lower SEP SMD = 0.115 [95% CI: -0.006 to 0.237] were similar. A meta-analysis of 3 pre-post implementation studies of energy labelling in the real world showed that the effect energy labelling had on consumer behaviour did not significantly differ based on SEP (X2(1) = 0.22, p = .636). In higher SEP the effect was SMD = 0.032 [95% CI: -0.053 to 0.117] and in lower SEP the effect was SMD = -0.005 [95% CI: -0.051 to 0.041].

CONCLUSIONS

Overall there was no convincing evidence that the effect energy labelling has on consumer behaviour significantly differs based on SEP. Further research examining multiple indicators of SEP and quantifying the long-term effects of energy labelling on consumer behaviour in real-world settings is now required.

REVIEW REGISTRATION

Registered on PROSPERO (CRD42022312532) and OSF ( https://doi.org/10.17605/OSF.IO/W7RDB ).

Effects of food nutrition labels on the health awareness of school-age children

BACKGROUND

Overweight and obesity have been described as a global epidemic that seriously affects the health of adults and children. Front of Package (FOP) Nutrition Labeling can increase consumers' awareness of unhealthy foods. The purpose of this study is to find effective deterrence and improve children's health awareness via the FOP.

METHODS

This study examined children's health awareness of snack packaging using the four labels: guideline daily amounts (GDA), traffic light system (TLS), Apple label (designed in this study), and Warning label. This study recruited 343 children in the sixth grade, including 223 children living in cities and 120 children living in rural areas. First, 30 children in grades 3 to 6 selected 8 snacks that they often buy. Then, each snack was synthesized into these four labels according to their nutritional content for a total of 32 samples. Finally, a questionnaire was used to evaluate the health of snack packaging and the visibility of nutrition labels.

RESULTS

Four results can be drawn: (1) GDA, Apple label and TLS can help children determine healthier snack choices, (2) black Warning label cannot induce children to make healthier choices, (3) children who often buy snacks have low health awareness, and (4) rural children have weak health awareness of snack packaging.

CONCLUSIONS

These results can provide a packaging label design, which can effectively improve children's health awareness.

Nutritional and activity recommendations for the child with normal weight, overweight, and obesity with consideration of food insecurity: An Obesity Medical Association (OMA) Clinical Practice Statement 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details nutritional and activity recommendations for the child with normal weight, overweight, and obesity (Appendix A) with consideration of food insecurity. This CPS is intended to provide clinicians with an overview of clinical practices applicable to children and adolescents with body mass indices in the normal range and body mass indices greater than or equal to the 85th percentile for their ages, particularly those with adverse consequences resulting from increased body mass. The information in this CPS is based on scientific evidence, supported by the medical literature, and derived from the clinical experiences of members of the OMA.

Methods

The scientific information and clinical guidance in this CPS is based upon referenced evidence and derived from the clinical perspectives of the authors.

Results

This OMA Clinical Practice Statement details nutritional and activity recommendations for the child with normal weight, overweight, and obesity with consideration of food insecurity. In addition, this CPS addresses nutritional recommendations for complications related to the disease of obesity as well as providing guidance on food insecurity as it impacts children with obesity and their families.

Conclusions

This OMA Clinical Practice Statement on nutritional and activity recommendations for the child with normal weight, overweight, and obesity with consideration of food insecurity is an overview of current recommendations. These recommendations provide a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications.

Body Positivity, but not for everyone: The role of model size in exposure effects on women's mood, body satisfaction, and food choice

Body Positivity (or 'BoPo') social media content may be beneficial for women's mood and body image, but concerns have been raised that it may reduce motivation for healthy behaviours. This study examines differences in women's mood, body satisfaction, and hypothetical food choices after viewing BoPo posts (featuring average or larger women) or a neutral travel control. Women (N = 167, 81.8 % aged 18-29) were randomly assigned in an online experiment to one of three conditions (BoPo-average, BoPo-larger, or Travel/Control) and viewed three Instagram posts for two minutes, before reporting their mood and body satisfaction, and selecting a meal from a hypothetical menu. Women who viewed the BoPo posts featuring average-size women reported more positive mood than the control group; women who viewed posts featuring larger women did not. There were no effects of condition on negative mood or body satisfaction. Women did not make less healthy food choices than the control in either BoPo condition; women who viewed the BoPo images of larger women showed a stronger association between hunger and calories selected. These findings suggest that concerns over BoPo promoting unhealthy behaviours may be misplaced, but further research is needed regarding women's responses to different body sizes.

The effect of energy and fat content labeling on food consumption pattern: a systematic review and meta-analysis

CONTEXT

Consumption of high-energy food has increased globally, thereby leading to an increase in many diseases. One strategy for addressing this is to make people aware of their energy intake through energy and fat labels. However, the effectiveness of this remains debatable.

OBJECTIVE

This review aims to pool the mixed outcomes of recent studies assessing the effect of energy and fat content labeling on food consumption pattern.

DATA SOURCES

Google Scholar, MEDLINE, and Cochrane Library databases were searched. Randomized controlled and quasi-experimental controlled trials published from 2014 to 2019 were included.

DATA EXTRACTION

Two reviewers screened 413 abstracts independently. Qualitative and quantitative data was extracted from 10 articles; meta-analysis was carried out on 6 of those studies.

RESULTS

The majority of the included papers were conducted in the regions of America, the Western Pacific, and Europe. Overall, the 6 studies claimed that labeling did not reduce the consumption of energy or fat. However, meta-analysis showed that fat and energy content labeling of food had a statistically significant effect on consumption. Subgroup analysis showed no difference with respect to types of labels, ie, context labeling vs traffic-light labeling, but energy content labels seemed to be more effective than fat content labels in influencing healthy food choices.

CONCLUSION

Energy and fat content labeling were shown to reduce the consumption of each significantly. However, the outcome was influenced by the study setting and the population concerned. There is a need for research in other regions in order to assess the global effectiveness of nutrition labels on food consumption.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020172675.

Testing the efficacy of and parents' preferences for nutrition labels on children's menus from a full-service chain restaurant: results of an online experiment

OBJECTIVE

Test the efficacy and perceived effectiveness of nutrition labels on children's menus from a full-service chain restaurant in an online study.

DESIGN

Using a between-groups experiment, parents were randomised to view children's menus displaying one of five children's nutrition labelling conditions: (i) No Nutrition Information (control); (ii) Calories Only; (iii) Calories + Contextual Statement (CS); (iv) Calories, Sodium + CS; or (v) Calories and Sodium in Traffic Lights + CS. Parents hypothetically ordered up to one entrée, side, beverage and dessert for their child, then rated and ranked all five labelling conditions on the level of perceived effectiveness.

SETTING

Online survey.

PARTICIPANTS

998 parents with a 3-12 year old child.

RESULTS

Parents exposed to menus displaying 'Calories, Sodium + CS' selected significantly fewer calories 'overall' (entrées + side + dessert + beverage) compared to parents exposed to the control condition (-53·1 calories, P < 0·05). Parents selected 'entrees' with significantly fewer calories and lower sodium when exposed to menus with 'Calories + CS' (-24·3 calories, P < 0·05); 'Calories, Sodium + CS' (-25·4 calories, -56·1 mg sodium, P < 0·05 for both); and 'Calories and Sodium in Traffic Lights + CS' (-29·1 calories, -58·6 mg sodium, P < 0·05 for both). Parents exposed to menus with 'Calories, Sodium + CS' and 'Calories and Sodium in Traffic Lights + CS' were more likely to notice and understand nutrition information compared to other nuntrition labelling conditions. Parents perceived the menu with 'Calories and Sodium in Traffic Lights + CS' as most effective (P < 0·05).

CONCLUSIONS

Menus disclosing calories, sodium and a contextual statement increased the proportion of parents who noticed and understood nutrition information, and resulted in parents selecting lower calorie and sodium entrées for their children in the hypothetical purchase task.

Can sodium warnings modify preferences? A case study with white bread

Several studies have shown that the inclusion of front of pack nutritional warnings is a potentially effective strategy to encourage consumers to avoid products with high content of nutrients associated with non-communicable diseases. In this context, the present work aimed at exploring consumers' reaction towards sodium reduction in the context of the implementation of warnings in three scenarios: package evaluation, tasting and intention to re-purchase the product after tasting, using white bread as case study. A total of 171 consumers participated in the study that encompassed four parts. Firstly, consumers received two bread samples with different salt content (2.00% and 1.38% salt) under blind conditions and were asked to rate their overall liking and to indicate the one they preferred. Then, they were asked to look at four bread packages differing in graphic design and the presence of warnings. They had to rate their expected liking and to indicate the one they would purchase. Finally, consumers were asked to try the bread they had previously chosen, to assess their overall liking and to indicate their willingness to purchase it again. Salt content significantly affected consumer hedonic reaction towards the breads. Two consumer segments with different preference for the salt content in bread were identified: 58% of consumers preferred the bread with 2.00% salt while 42% preferred breads with 1.38% salt. However, when looking at the packages the majority of consumers in both groups selected bread packages that did not feature warnings. In addition, after having tried the bread, most consumers were willing to buy the bread they had previously chosen again, which is promising in terms of reaching sustainable changes towards lower salt levels. Results from the present work suggest that, in the case of bread, nutritional warnings have potential to shift consumers' preferences to lower sodium content, even after trying the products.

Effect of Face-to-Face Education on Knowledge, Attitudes, and Practices Toward "Traffic Light" Food Labeling in Isfahan Society, Iran

Emerging noncommunicable diseases (NCDs) with premature mortality are one of the major concerns in health supervising organizations of the world. High intake of energy, salt, sugar, fat, and trans fatty acids are introduced as dietary risk factors of NCDs. The status of food risk factors is presented in Traffic Light (TL) food labeling through colors of red, yellow, and green as the signs of stop, wait and watch and go, respectively. This stepwise interventional study examined whether TL education can result in choosing healthier food via assessing the impact of face-to-face educational sessions on knowledge, attitudes, and practices of 673 respondents toward TL food labeling through a self-administered and structured questionnaire. Paired t test or alternatively Wilcoxon test was used to evaluate the influence of education in total scores of knowledge, attitudes, and practices in test-retest. Results indicated that before education, the average of the scores for the knowledge, attitudes, and practices was 1.003 ± 0.69, 10.97 ± 1.86, and 1.60 ± 1.84, respectively. After education, the scores were increased to 8.72 ± 3.11, 15.95 ± 2.64, and 8.42 ± 1.69. Significant differences in the scores of the respondents were observed before and after education (p < .05). This study revealed that the intervention of education had positive effect on the knowledge, attitudes, and practices of the studied population. Even though general awareness about the food risk factors of NCDs existed, special education is required to make public TL and food labeling information usage as an actual guidance for every food item in Iran.

The impact of calorie and physical activity labelling on consumer's emo-sensory perceptions and food choices

Providing labelling information is one of the strategies used to help consumers make healthier choices. However, although the type of information has the potential to assist consumers, it is important to evaluate their sensory and emotional perceptions. Therefore, the objective of this study was to evaluate the effect of different labelling information on consumers' sensory and emotional perceptions and their choices, for three different products (potato chips, juice and yogurt). A total of 480 participants were randomly assigned to one of four information conditions (no information (blind), kilocalorie (kcal) information, physical activity (PA) information [duration of walking required to burn the kcal in the product], kcal + PA information). For each information condition, participants were provided with higher kcal and lower kcal equivalent food pairs and were required to choose one. The participants evaluated their overall liking using a 9-point hedonic scale and answered rate-all-that-apply (RATA) questions related to the sensory and emotional characteristics of the products. The results showed no significant impact of calorie and physical activity labelling on consumers' overall liking for juice and yogurt samples and no impact of PA information for chips. Significant differences in overall liking were found when comparing the blind condition with kcal and kcal + PA information, with lower acceptance of the chips samples when this information was presented. Although providing calorie and physical activity labelling had little impact on consumers' sensory and emotional perceptions, consumers perceived unhealthy attributes and negative emotions, such as fatty and guilty, when information was presented. The present work suggests that, although nutrition labelling may be presented as an important strategy to assist consumers, it is important to evaluate consumers' lifestyles, considering that non-dieters and those low and moderate in dietary restraint may not be impacted by this information.

Compared to other front-of-pack nutrition labels, the Nutri-Score emerged as the most efficient to inform Swiss consumers on the nutritional quality of food products

Background

Switzerland, like other high-income countries, is facing a major public health challenge with the increasing burden of non-communicable diseases. Discussions are currently on-going in Switzerland regarding the implementation of a Front-of-Pack nutrition label (FoPL) as a public health measure to guide consumers towards healthier food choices, and the Nutri-Score represents an alternative supported by multiple actors. To date, no studies have investigated the performance of the Nutri-Score among Swiss consumers. This study aimed to compare the response of Swiss consumers to five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes and Warning symbol) in terms of perception and understanding of these labels and effects on food choices.

Methods

In 2019, 1,088 Swiss consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles and then classify the products within the sets according to their nutritional quality. Tasks were performed in situations without a label and then with one of the five FoPLs–depending on the group in which they were randomized–on the pack. Finally, participants were questioned on their perceptions regarding the label to which they were exposed.

Results

All FoPLs were favorably perceived, with marginal differences between FoPLs. The Nutri-Score demonstrated the highest percentage of improvement in food choices and the highest overall performance in helping consumers rank the products according to their nutritional quality.

Conclusion

Overall, the Nutri-Score was the most efficient FoPL in informing Swiss consumers of the nutritional quality of food products, and as such could be a useful tool to improve food choices and reduce the burden of chronic diseases in Switzerland.

The effect of 'Traffic-Light' nutritional labelling in carbonated soft drink purchases in Ecuador

Overweight and obesity have become global concerns in developed and developing countries due to their rise in recent years and their association with the prevalence of non-communicable diseases including diabetes, hypertension and cardiovascular diseases. In fact, it is estimated that roughly 39% of adults worldwide are overweight and 13% are obese. Ecuador is an example of a developing country concerned with the overweight and obesity problem, where it is estimated that 30% of children, 26% of teenagers and 63% of adults are either overweight or obese and where 1 in 4 deaths are attributed to chronic diseases. To address the overweight and obesity problem via the promotion of healthy eating habits, in 2013 the country approved technical regulation for the labelling of packed processed food products. The regulation included a mandatory traffic-light (TL) supplemental nutritional information labelling system to be displayed on the package of all processed foods for sale in the country. This new labelling system displays a traffic light panel for the product content of sugar, fat and salt in addition to the traditional nutrient declaration label. The objective of this paper was to evaluate the effect of the TL supplemental nutritional information on consumers’ buying behavior in Ecuador. More specifically, we concentrated on the purchasing behavior of carbonated soft drinks. For our analysis, we used monthly aggregated purchase data (total expenditures, quantities and average prices) of carbonated soft drinks from January 2013 to December 2015 obtained from Kantar World Panel—Ecuador. We estimated a non-linear Almost Ideal Demand System where we model the demand for high sugar and low sugar carbonated soft drinks. We found that the introduction of the traffic light supplemental nutrition labelling did not have the expected effect of reducing purchases of carbonated soft drinks during its first year of implementation, especially those high in sugar. Additionally, we found that lower income-status households tend to spend more on and consume more calories from CSD than households with higher socio-economic status. Finally, we identified that over time purchases of high sugar soft drinks decreased while purchases of low and no sugar soft drinks increased. Beyond our contribution of evaluating the effect of the traffic light on the purchases of carbonated soft drinks, we also estimated price and income elasticities of carbonated soft drinks which can be useful in the evaluation of fiscal policies.

The Role of Supportive Food Environments to Enable Healthier Choices When Eating Meals Prepared Outside the Home: Findings from Focus Groups of 18 to 30-Year-Olds

Young adults are the highest consumers of food prepared outside home, which has been linked to weight gain. The aim of this qualitative research was to gather opinions from young adults about what influences their food choice when eating out and if they so desired, what might enable healthy choices. Thirty-one adults aged 18 to 30 years participated in four focus groups (females = 24). Predetermined questions were used to guide discussions which were audiotaped then transcribed. The content was organized into themes and sub-themes using NVivo software. Two broad groupings arose—personal behaviors and changes to physical and social food environments. For many, eating out was viewed as a special occasion so that healthy food was not a priority and despite understanding health consequences of poor diets this was not an immediate concern. Price discounts and menu-labelling were suggested and trust in credible organizations and peers’ endorsement of meals and venues expressed. The role of smartphones in the modern food environment emerged as a tool to enable immediate access to many restaurants to order food and access reviews and social media as a source of persuasive food imagery. Current menu-labelling initiatives should continue, food pricing be explored and influence of smartphones on diet further researched. However, these findings may be limited by the high proportion of women and higher socioeconomic status and urban residence of many participants.

Cluster randomised controlled trial of an online intervention to improve healthy food purchases from primary school canteens: a study protocol of the 'click & crunch' trial

INTRODUCTION

School canteens are the most frequently accessed take-away food outlet by Australian children. The rapid development of online lunch ordering systems for school canteens presents new opportunities to deliver novel public health nutrition interventions to school-aged children. This study aims to assess the effectiveness and cost-effectiveness of a behavioural intervention in reducing the energy, saturated fat, sugar and sodium content of online canteen lunch orders for primary school children.

METHODS AND ANALYSIS

The study will employ a cluster randomised controlled trial design. Twenty-six primary schools in New South Wales, Australia, that have an existing online canteen ordering system will be randomised to receive either a multi-strategy behavioural intervention or a control (the standard online canteen ordering system). The intervention will be integrated into the existing online canteen system and will seek to encourage the purchase of healthier food and drinks for school lunch orders (ie, items lower in energy, saturated fat, sugar and sodium). The behavioural intervention will use evidence-based choice architecture strategies to redesign the online menu and ordering system including: menu labelling, placement, prompting and provision of feedback and incentives. The primary trial outcomes will be the mean energy (kilojoules), saturated fat (grams), sugar (grams) and sodium (milligrams) content of lunch orders placed via the online system, and will be assessed 12 months after baseline data collection.

ETHICS AND DISSEMINATION

The study was approved by the ethics committees of the University of Newcastle (H-2017-0402) and the New South Wales Department of Education and Communities (SERAP 2018065), and the Catholic Education Office Dioceses of Sydney, Parramatta, Lismore, Maitland-Newcastle, Bathurst, Canberra-Goulburn, Wollongong, Wagga Wagga and Wilcannia-Forbes. Study results will be disseminated through peer-reviewed publications, reports, presentations at relevant national and international conferences and via briefings to key stakeholders. Results will be used to inform future implementation of public health nutrition interventions through school canteens, and may be transferable to other food settings or online systems for ordering food.

TRIAL REGISTRATION NUMBER

ACTRN12618000855224.

Consumers' Responses to Front-of-Pack Nutrition Labelling: Results from a Sample from The Netherlands

Front-of-pack labels (FoPLs) are efficient tools for helping consumers identify healthier food products. Although discussions on nutritional labelling are currently ongoing in Europe, few studies have compared the effectiveness of FoPLs in European countries, including the Netherlands. This study aimed to compare five FoPLs among Dutch participants (the Health Star Rating (HSR) system, Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RIs), and Warning symbols) in terms of perception and understanding of the labels and food choices. In 2019, 1032 Dutch consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles, and then rank the products within the sets according to their nutritional quality. These tasks were performed with no label and then with one of the five FoPLs on the package, depending on the randomization arm. Finally, participants were questioned on their perceptions regarding the label to which they were exposed. Regarding perceptions, all FoPLs were favorably perceived but with only marginal differences between FoPLs. While no significant difference across labels was observed for food choices, the Nutri-Score demonstrated the highest overall performance in helping consumers rank the products according to their nutritional quality.

All Aboard Meal Train: Can Child-Friendly Menu Labeling Promote Healthier Choices in Hospitals?

OBJECTIVE

To evaluate patient meal orders and consumption with a revised menu design that includes child-friendly labeling.

STUDY DESIGN

A randomized controlled trial among hospitalized children was performed over a 1-month period comparing the control menu layout and the intervention menu. The intervention menu contained the same choices but was labeled to encourage healthy eating. Children on a specialized diet, receiving parenteral nutrition, or age <2 years were excluded.

RESULTS

A total of 163 patients (81 males) were included, with a mean age of 9.9 ± 5.1 year, and a mean weight z-score of -0.08 ± 1.3. Children receiving the intervention ordered more "green-light" healthy choices and fewer "red-light" items, with 0.65 lower odds of selecting a red-light item (95% CI, 0.55-0.76) and 1.75 higher odds of selecting a green-light item (95% CI, 1.49-2.04), both at the first meal, but with effects waning over time. There were trends toward increased intake of fruits and vegetables and decreased intake of "foods to limit", but no impact on the consumption of sugar-sweetened beverages. Both intervention and control group consumed their meals in equal proportions.

CONCLUSIONS

The combination of menu labeling techniques targeted to children in the inpatient hospital setting was an effective short-term tool for increasing the intake of healthier foods, although the effect of labeling waned over time.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02692001.

Food Rating Scale in Food Services: From Development to Assessment of a Strategy for Consumer Healthier Choices

This study aimed to create an easy tool to identify healthier choices for meal assembly in food services (self-service restaurants) and to allow consumers to compose their plates to make healthier choices. It is an interventional study, and the first step was setting healthy food parameters to design a rating scale. The first evaluation criterion was based on energy density (ED) and sodium content (SC) using “traffic light” color in the dishes’ nameplates; the second criterion was based on food groups; the third criterion was based on ingredients of the meals. After using the classification, we assessed the rating scale in a food service and we evaluated the strategy with its consumers. To evaluate the effect of the nutritional intervention, we developed a multiple-choice-questionnaire with eight questions to measure the impact on consumer food choices quantitatively. The dish nameplate allows identification of healthier choices regarding SC and/or ED by colors; ingredients that compose the dish; the food group and the serving size, helping the identification of the amount of food to compose the meal. Banners helped consumers to understand the information. After four weeks, all the consumers (n = 1000) received questionnaires regarding their comprehension of the classification. The questionnaire presented an ICC of 0.71. Most of the preparations (61%) were inadequate based on ED and/or SC at the studied food service. A total of 556 consumers returned questionnaires, and 86.3% of them observed the rating scale as a nutritional strategy. Almost 55% (n = 261) of consumers reported changes in food choice after reading the dishes nameplates. The items with greater impact on consumer change in eating behavior were the use of colors as an indicator of nutritional quality, portion size information and ingredients list. Almost 25% of the consumers that changed their eating behavior noticed more than three items presented on the nameplate.

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.

Can nutritional information modify purchase of ultra-processed products? Results from a simulated online shopping experiment

OBJECTIVE

The aim of the present work was to evaluate the influence of two front-of-pack nutrition information schemes (traffic-light system and Chilean warning system) on consumer purchase of ultra-processed foods in a simulated online grocery store.

DESIGN

Following a between-subjects design, participants completed a simulated weekly food purchase in an online grocery store under one of three experimental conditions: (i) a control condition with no nutrition information, (ii) a traffic-light system and (iii) the Chilean warning system. Information about energy (calories), sugar, saturated fats and salt content was included in the nutrition information schemes.

SETTING

Participants were recruited from a consumer database and a Facebook advertisement.

SUBJECTS

People from Montevideo (Uruguay), aged 18-77 years (n 437; 75 % female), participated in the study. All participants were in charge of food purchase in the household, at least occasionally.

RESULTS

No significant differences between experimental conditions were found in the mean share of ultra-processed foods purchased by participants, both in terms of number of products and expenditure, or in the mean energy, sugar, saturated fat and salt content of the purchased items. However, the Chilean warning system decreased intended purchase of sweets and desserts.

CONCLUSIONS

Results from this online simulation provided little evidence to suggest that the traffic-light system or the Chilean warning system in isolation could be effective in reducing purchase of ultra-processed foods or improving the nutritional composition of the purchased products.

Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years

BACKGROUND

Child and adolescent overweight and obesity has increased globally, and can be associated with significant short- and long-term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages.

OBJECTIVES

To assess the effects of diet, physical activity and behavioural interventions (behaviour-changing interventions) for the treatment of overweight or obese children aged 6 to 11 years.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour-changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta-analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty-five trials compared a behaviour-changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour-changing intervention. Sixty-four trials were parallel RCTs, and four were cluster RCTs. Sixty-four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2.Primary analyses demonstrated that behaviour-changing interventions compared to no treatment/usual care control at longest follow-up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was -0.53 kg/m2 (95% confidence interval (CI) -0.82 to -0.24); P < 0.00001; 24 trials; 2785 participants; low-quality evidence. MD in BMI z score was -0.06 units (95% CI -0.10 to -0.02); P = 0.001; 37 trials; 4019 participants; low-quality evidence and MD in weight was -1.45 kg (95% CI -1.88 to -1.02); P < 0.00001; 17 trials; 1774 participants; low-quality evidence.Thirty-one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour-changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health-related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI -12.88 to -0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all-cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta-analysed.As the meta-analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post-intervention follow-up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post-intervention was no longer evident at follow-up at less than six months, which has to be investigated in further trials.

AUTHORS' CONCLUSIONS

Multi-component behaviour-changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short-term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour-changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour-changing interventions on health-related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer-term follow-up and further research on the most appropriate forms of post-intervention maintenance in order to ensure intervention benefits are sustained over the longer term.

Warnings as a directive front-of-pack nutrition labelling scheme: comparison with the Guideline Daily Amount and traffic-light systems

Objective

Warnings have recently been proposed as a new type of directive front-of-pack (FOP) nutrition labelling scheme to flag products with high content of key nutrients. In the present work, this system was compared with the two most common FOP nutrition labelling schemes (Guideline Daily Amounts (GDA) and traffic-light system) in terms of goal-directed attention, influence on perceived healthfulness and ability to differentiate between products.

Design/Setting/Subjects

Goal-directed attention to FOP labels was evaluated using a visual search task in which participants were presented with labels on a computer screen and were asked to indicate whether labels with high sodium content were present or absent. A survey with 387 participants was also carried out, in which the influence of FOP labels on perceived healthfulness and ability to identify the healthful alternative were evaluated.

Results

Warnings improved consumers’ ability to correctly identify a product with high content of a key nutrient within a set of labels compared with GDA and received the highest goal-directed attention. In addition, products with high energy, saturated fat, sugar and/or sodium content that featured warnings on the label were perceived as less healthful than those featuring the GDA or traffic-light system. Warnings and the traffic-light system performed equally well in the identification of the most healthful product.

Conclusions

Results from the present work suggest that warnings have potential as directive FOP nutrition labels to improve consumer ability to identify unhealthful products and highlight advantages compared with the traffic-light system.

Cluster randomised controlled trial of a consumer behaviour intervention to improve healthy food purchases from online canteens: study protocol

INTRODUCTION

School canteens represent an opportune setting in which to deliver public health nutrition strategies given their wide reach, and frequent use by children. Online school canteen ordering systems, where students order and pay for their lunch online, provide an avenue to improve healthy canteen purchases through the application of consumer behaviour strategies that impact on purchasing decisions. The aim of this study is to assess the efficacy of a consumer behaviour intervention implemented in an online school canteen ordering system in reducing the kilojoule, saturated fat, sugar and sodium content of primary student lunch orders.

METHODS AND ANALYSIS

The study will employ a cluster randomised controlled trial design. Approximately 1040 students (aged 5-12 years) from 10 primary schools in New South Wales, Australia, currently using an online canteen ordering system will be invited to participate. Schools will be randomised in a 1:1 ratio to receive either the intervention (enhanced system) or control (standard online ordering only). The intervention will include evidence-based strategies shown to influence healthy food purchasing (strategies targeting availability, menu labelling, placement and prompting). The primary outcomes of the trial will be the mean content per student online lunch order of (1) energy (kJ), (2) saturated fat (g), (3) sugar (g) and (4) sodium (mg). The impact of the intervention will be determined by between-group assessment of the nutritional content of lunch purchases over a 2-month period postintervention initiation.

ETHICS AND DISSEMINATION

The study was approved by the Hunter New England Human Research Ethics Committee, University of Newcastle Human Research Ethics Committee and New South Wales Department of Education and School Communities. Study findings will be disseminated widely through peer-reviewed publications and relevant presentations in international conferences and to stakeholders.

TRIAL REGISTRATION NUMBER

ACTRN12616000499482.

The influence of menu labelling on food choices among children and adolescents: a systematic review of the literature

Introduction:

Childhood obesity is a serious public health concern internationally, and population-level interventions are needed to support healthy food choices. Existing reviews of menu labelling have focused predominantly on adults. However, childhood and adolescence are distinct periods of development during which longer term eating behaviours and food preferences are established. Although some studies have examined the effect of menu labelling among children and adolescents, no reviews have synthesised this evidence.

Objective:

To assess whether menu labelling influences the amount of calories ordered by children and adolescents (or parents on behalf of youth) in food outlets including restaurants and cafeterias.

Methods:

Comprehensive literature searches were conducted in Medline, Scopus, PsycINFO, CINAHL, SocINDEX and Embase databases. Eleven relevant studies were identified from an initial search yielding 1,682 results. Studies were assessed using a validated quality assessment tool.

Results:

Examinations of hypothetical food purchases in artificial environments suggest that menu labelling may be efficacious in reducing calories purchased for or by children and adolescents. Real-world studies are less supportive, although school-based studies were generally positive. It is unclear whether contextual or interpretive menu-labelling formats are more effective compared to numeric calorie information alone.

Conclusion:

Evidence supporting the impact of menu labelling on lowering the energy content of restaurant and cafeteria food choices made for or by children or adolescents is limited. There remains a need for high-quality studies conducted in real-world settings.

Effect of calorie or exercise labels on menus on calories and macronutrients ordered and calories from specific foods in Hispanic participants: a randomized study

The effect of menu labels on food choices is unknown in Hispanics. This study evaluated the impact of menu labels on calories and macronutrients ordered in Hispanics. 372 Hispanics (18-65 years) were randomly assigned to menus with no labels (NL) (n=127), rank-ordered calorie labels plus a statement on energy needs per meal (CL) (n=123), or rank-ordered exercise labels showing minutes of brisk walking necessary to burn the food calories (EL) (n=122). The menus had identical food choices. Participants were instructed to select foods from the assigned menu as if having lunch in a fast food restaurant. One-way analysis of variance found no difference in calories ordered (median (25th and 75th centiles)) by menu condition (NL: 785.0 (465.0, 1010.0) kcal; CL: 790.0 (510.0, 1020.0) kcal; EL: 752.5 (520.0, 1033.8) kcal; p=0.75). Calories from specific foods and macronutrient intake were not different by menu condition. Menu label use was 26.8% in the CL and 25.4% in the EL condition. Calories ordered were not different between those who used and those who did not use the labels. Regression analysis showed that perception of being overweight (p=0.02), selecting foods based on health value (p<0.0001), and meeting exercise guidelines (p<0.0001) were associated with fewer calories ordered. Logistic regression showed that selecting foods based on health value (p=0.01) was associated with higher food label use. Menu labels did not affect food choices in Hispanic participants. Future studies should determine if nutrition, exercise, and weight perception counseling prior to menu labels intervention would result in better food choices.

TRIAL REGISTRATION NUMBER

NCT02804503; post-results.

Parental Nutrition Knowledge Rather Than Nutrition Label Use Is Associated With Adiposity in Children

OBJECTIVE

Determine how parental nutrition label use, label literacy, and nutrition knowledge may be associated with cardiovascular health in parents and their children.

DESIGN AND SETTING

Cross-sectional analyses of 2006 data from the Healthy Heart Project in Montreal, Canada.

PARTICIPANTS

Among community recruited families, parents were predominantly mothers (n = 127 [80%]; mean age, 45.0 years) and half of their children were female (44%; mean age, 12.5 years).

MAIN OUTCOME MEASURES

Blood pressure, lipids, and weight. Nutrition label use, label literacy, and nutrition knowledge among parents were collected using existing scales.

ANALYSES

Multivariable linear regression models.

RESULTS

Among parents, nutrition label use was associated with lower total cholesterol (B[SE] = -.53 [.20]; P = .009), lower low-density lipoprotein (B[SE] = -.57 [.21]; P = .007), and lower total cholesterol/high-density lipoprotein cholesterol ratio (B[SE] = -.82 [.30]; P = .008) but was not associated with adiposity. Among children, greater parental nutrition knowledge was associated with lower body mass index percentiles (B[SE] = -3.6 [1.49]; P = .02), lower waist circumference (B[SE] = -1.27 [.55]; P = .02), and lower percent body fat (B[SE] = -1.28 [.47]; P = .008). Parental nutrition label use or nutrition knowledge was not associated with children's lipids.

CONCLUSIONS AND IMPLICATIONS

Parents with greater nutrition label use had more favorable lipids, but children's lipids were unaffected. Children of parents with greater nutrition knowledge had lower adiposity. Further research on the correlates of label use and health is needed.

Motives Underlying Food Choice for Children and Perception of Nutritional Information Among Low-Income Mothers in a Latin American Country

OBJECTIVE

The aim of the present study was to investigate the influence of nutritional information on how low-income mothers select food for their children.

DESIGN

Five focus groups, each consisting of 5-10 participants, were conducted.

PARTICIPANTS

Women, older than 18 years, mothers of young children who were beneficiaries of one of the national food stamps programs in Uruguay.

PHENOMENON OF INTEREST

Focus group discussions were held around motives underlying food choices for children and perception of labeling systems.

ANALYSIS

Transcripts of the focus group discussions were analyzed using inductive coding.

RESULTS

Forty-two women, aged between 18 and 40 years, participated in 5 focus groups. Results showed that low-income mothers do not consider nutritional information when selecting food their children. Traditional nutritional labeling was perceived as complex, difficult to find, and difficult to understand. Participants stressed that they relied on the nutrition claims included on labels for assessing the healthfulness of food products. Semi-directive and directive front-of-pack labels were positively evaluated in terms of ease of interpretation. Participants preferred the traffic light system over other alternatives.

CONCLUSIONS AND IMPLICATIONS

Results suggest the need to implement simplified nutritional labeling and to regulate the use of nutrition claims on products targeted at children.

Food ordering for children in restaurants: multiple sources of influence on decision making

OBJECTIVE

Restaurants are playing an increasingly important role in children's dietary intake. Interventions to promote healthy ordering in restaurants have primarily targeted adults. Much remains unknown about how to influence ordering for and by children. Using an ecological lens, the present study sought to identify sources of influence on ordering behaviour for and by children in restaurants.

DESIGN

A mixed-methods study was conducted using unobtrusive observations of dining parties with children and post-order interviews. Observational data included: child's gender, person ordering for the child and server interactions with the dining party. Interview data included: child's age, restaurant visit frequency, timing of child's decision making, and factors influencing decision making.

SETTING

Ten independent, table-service restaurants in San Diego, CA, USA participated.

SUBJECTS

Complete observational and interview data were obtained from 102 dining parties with 150 children (aged 3-14 years).

RESULTS

Taste preferences, family influences and menus impacted ordering. However, most children knew what they intended to order before arriving at the restaurant, especially if they dined there at least monthly. Furthermore, about one-third of children shared their meals with others and all shared meals were ordered from adult (v. children's) menus. Parents placed most orders, although parental involvement in ordering was less frequent with older children. Servers interacted frequently with children but generally did not recommend menu items or prompt use of the children's menu.

CONCLUSIONS

Interventions to promote healthy ordering should consider the multiple sources of influence that are operating when ordering for and by children in restaurants.

Menu labelling and food choice in obese adults: a feasibility study

Background

To date research examining the benefits of menu labelling in the UK is sparse. The aim of the present study was to examine the impact of menu labelling in a UK obese population.

Methods

Using a repeated measures design, 61 patients at a tier 3 weight management service completed four questionnaires to assess their food choice (control) and behaviour change when presented with 3 menu labelling formats (calorie content; nutrient content; and energy expenditure).

Results

All three forms of labelling increased participants weight control concerns compared to the control condition. There was a significant difference in content of food ordered in the three menu labelling formats compared to the control condition. The calorie condition had the largest percentage decrease in calories selected followed by energy expenditure and nutrient content. However, no difference was observed between the three conditions in the desire for menu labelling in restaurants to be introduced in the UK.

Conclusions

The findings suggest that menu labelling should be enforced in the UK as it is both beneficial to promoting healthy eating and in demand. This study is the first to examine menu labelling in a UK obese population using energy expenditure equivalents to provide nutritional information.

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.

Beyond positivism: Understanding and addressing childhood obesity disparities through a Critical Theory perspective

PURPOSE

We apply Critical Theory to examine menu labeling with the aim of uncovering important implications for nursing practice, research, and policy.

CONCLUSIONS

Our critical analysis uncovers barriers to menu labeling's effectiveness, particularly for vulnerable populations. Nurses must work to minimize the impact of these barriers and optimize the effectiveness of menu labeling, in order to strengthen the fight against obesity.

PRACTICE IMPLICATIONS

We suggest changes, guided by this critical analysis, which can be implemented by nurses working in clinical practice, research, and policy.

Comparison of the nutrient content of children's menu items at US restaurant chains, 2010-2014

Objective

To determine changes in the nutritional content of children’s menu items at U.S. restaurant chains between 2010 and 2014.

Methods

The sample consisted of 13 sit down and 16 fast-food restaurant chains ranked within the top 50 US chains in 2009. Nutritional information was accessed in June-July 2010 and 2014. Descriptive statistics were calculated for nutrient content of main dishes and side dishes, as well as for those items that were added, removed, or unchanged during the study period.

Results

Nutrient content of main dishes did not change significantly between 2010 and 2014. Approximately one-third of main dishes at fast-food restaurant chains and half of main dishes at sit down restaurant chains exceeded the 2010 Dietary Guidelines for Americans recommended levels for sodium, fat, and saturated fat in 2014. Improvements in nutrient content were observed for side dishes. At sit down restaurant chains, added side dishes contained over 50 % less calories, fat, saturated fat, and sodium, and were more likely to contain fruits/vegetables compared to removed sides (p < 0.05 for all comparisons). Added side dishes at fast-food restaurant chains contained less saturated fat (p < 0.05).

Conclusions

The majority of menu items, especially main dishes, available to children still contain high amounts of calories, fat, saturated fat, and sodium. Efforts must be made by the restaurant industry and policy makers to improve the nutritional content of children’s menu items at restaurant chains to align with the Dietary Guidelines for Americans. Additional efforts are necessary to help parents and children make informed choices when ordering at restaurant chains.

Hip Hop HEALS: Pilot Study of a Culturally Targeted Calorie Label Intervention to Improve Food Purchases of Children

OBJECTIVES

We explored the effect of a culturally targeted calorie label intervention on food purchasing behavior of elementary school students.

METHOD

We used a quasi-experimental design with two intervention schools and one control school to assess food purchases of third through fifth graders at standardized school food sales before and after the intervention (immediate and delayed) in schools. The intervention comprised three 1-hour assembly-style hip-hop-themed multimedia classes.

RESULTS

A mean total of 225 children participated in two baseline preintervention sales with and without calorie labels; 149 children participated in immediate postintervention food sales, while 133 children participated in the delayed sales. No significant change in purchased calories was observed in response to labels alone before the intervention. However, a mean decline in purchased calories of 20% (p < .01) and unhealthy foods (p < .01) was seen in immediately following the intervention compared to baseline purchases, and this persisted without significant decay after 7 days and 12 days.

CONCLUSION

A 3-hour culturally targeted calorie label intervention may improve food-purchasing behavior of children.

Smart food policies for obesity prevention

Prevention of obesity requires policies that work. In this Series paper, we propose a new way to understand how food policies could be made to work more effectively for obesity prevention. Our approach draws on evidence from a range of disciplines (psychology, economics, and public health nutrition) to develop a theory of change to understand how food policies work. We focus on one of the key determinants of obesity: diet. The evidence we review suggests that the interaction between human food preferences and the environment in which those preferences are learned, expressed, and reassessed has a central role. We identify four mechanisms through which food policies can affect diet: providing an enabling environment for learning of healthy preferences, overcoming barriers to the expression of healthy preferences, encouraging people to reassess existing unhealthy preferences at the point-of-purchase, and stimulating a food-systems response. We explore how actions in three specific policy areas (school settings, economic instruments, and nutrition labelling) work through these mechanisms, and draw implications for more effective policy design. We find that effective food-policy actions are those that lead to positive changes to food, social, and information environments and the systems that underpin them. Effective food-policy actions are tailored to the preference, behavioural, socioeconomic, and demographic characteristics of the people they seek to support, are designed to work through the mechanisms through which they have greatest effect, and are implemented as part of a combination of mutually reinforcing actions. Moving forward, priorities should include comprehensive policy actions that create an enabling environment for infants and children to learn healthy food preferences and targeted actions that enable disadvantaged populations to overcome barriers to meeting healthy preferences. Policy assessments should be carefully designed on the basis of a theory of change, using indicators of progress along the various pathways towards the long-term goal of reducing obesity rates.

Exposure to ‘healthy’ fast food meal bundles in television advertisements promotes liking for fast food but not healthier choices in children

Due to regulatory changes, fast food companies often depict healthy foods in their television advertisements to children. The present study examined how exposure to advertising for ‘healthy’ meal bundles to children influenced the selection of food in children. A total of fifty-nine children (thirty-seven males) aged 7–10 years (8·8 (sd0·9) years) took part in the present study. The within-participant, counterbalanced design had two conditions: control (exposure to ten toy adverts across two breaks of five adverts each) and experimental (the middle advert in each break replaced with one for a McDonald's Happy Meal®depicting the meal bundle as consisting of fish fingers, a fruit bag and a bottle of mineral water). Following viewing of the adverts embedded in a cartoon, children completed a hypothetical menu task that reported liking for McDonald's food and fast food, in general. Nutritional knowledge, height and weight of the children were measured. There was no significant difference between the two advert conditions for the nutritional content of the meal bundles selected. However, children's liking for fast food, in general, increased after exposure to the food adverts relative to control (P= 0·004). Compared to children with high nutritional knowledge, those with low scores selected meals of greater energy content (305 kJ) after viewing the food adverts (P= 0·016). Exposure to adverts for ‘healthy’ meal bundles did not drive healthier choices in children, but did promote liking for fast food. These findings contribute to debates about food advertising to children and the effectiveness of related policies.