Helping consumers make more healthful food choices: consumer views on modifying food labels and providing point-of-purchase nutrition information at quick-service restaurants

Qualitative menu labelling in university restaurants and its influence on food choices: A systematic review and synthesis without meta-analysis

Qualitative menu labelling can be defined as descriptive or non-numerical interpretive labels (e.g. traffic light labelling, healthy food symbols, messages or ingredient lists). Qualitative information seems to have a positive influence on consumers' food choices, particularly in institutional food service establishments, such as in universities. The aim of this systematic review was to assess the influence of different formats of qualitative menu labelling on food choices in university restaurants. This systematic review was guided by the Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) and Synthesis Without Meta-Analysis (SWiM) and conducted vote counting of studies based on the direction of effect. Studies were retrieved from Cochrane Library, Scopus, MEDLINE, LILACS, SciELO and Web of Science databases and reference lists of selected articles. Experimental and quasi-experimental studies were included. Two independent researchers searched and extracted the data and assessed the methodological quality using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. From the initial search (460 records), four papers were selected, plus one paper identified in a previous study and a further six from an update search, totalling 11 included studies, reporting 14 different interventions (n = 499 174). Types of interventions included the use of symbols and the inclusion of traffic light labelling. Outcomes of interest were food choice, expressed as mean, median or percent healthy food choices or purchases. Qualitative menu labels increased healthy food choices and/or purchase behaviour, with 10 of 12 interventions favouring the intervention (83%; 95%CI 55-95%; p = 0.0386). Most of the studies favouring the intervention used healthy food symbols for healthier foods or food components, alone or in association with another intervention and were of moderate and weak quality. These findings may serve as a basis for the implementation of nutrition information policies in university restaurants.

The effects of nutrition and health claims on the nutrient composition of single and subsequent meal servings

Nutrition and health claims (NHCs) can help individuals make better food choices. While NHCs have been found to influence consumer perceptions and consumption, there has been less focus on how claims influence the nutritional composition of servings. There has also been little attention paid to longer term or compensatory effects of claims on subsequent food selection. This manuscript details two studies considering these matters. Study 1 (n = 60) was a within-subjects experiment to measure the impact of NHCs on food selection and nutritional composition at single meal servings. Participants served from three fake food buffet meal stations (breakfast, hot meal, snacks) with NHCs present or absent. Study 2 (n = 55) was a within-subjects experiment to examine the impact of NHCs on food selection and nutritional composition at a subsequent meal. Participants served from a fake food buffet breakfast with or without NHCs followed by a lunch without NHCs. In study 1, while results varied for different meals, the presence of claims was found to significantly reduce the amount of energy, fat, saturated fat, sugar, carbohydrates, and sodium, and increase the amount of protein in meals that were served. Results for fibre were mixed. In addition, NHCs increased the quantity of food served in the snacks condition. There was no evidence of claims at breakfast impacting the nutritional composition of subsequent lunch servings in study 2. Despite claims potentially increasing serving quantities, the nutritional composition of chosen servings was more encouraging and claims may help individuals to meet recommended nutritional daily guidelines. These findings have wider implications in terms of government policy, food reformulation, and the continuing debate around the use of nutrient profiling regulations for products carrying claims.

Current use of nutrition facts tables and attitudes towards new red and green front-of-package labels among Israeli consumers

Front-of-package labels (FOPL) are designed to simplify nutrition information and to help consumers make healthier food choices. The Israeli government has implemented new regulations requiring mandatory red warning FOPL for high levels of sodium, sugar, or saturated fats. A voluntary green positive FOPL for products fitting the national nutritional recommendations was concurrently encouraged. In order to characterise adult consumers' current use of Nutrition Facts Tables (NFT) and their attitudes towards the new FOPL, a nationally representative cross-sectional telephone survey was conducted. Most of the 1,042 survey respondents reported frequent NFT use (76.2%) and intentions to purchase fewer red-labelled (81.1%) and more green-labelled products (85.0%). Consumers with higher BMI and lower education expressed higher intentions to use the new FOPL, but not higher current use of NFT. This finding suggests that these high-risk groups, which the new labels are meant to target, may indeed benefit from the new policy.

How Is Functional Food Advertising Understood? An Approximation in University Students

In functional food advertising, messages are not always easily understandable for the target audience. Current European legislation, enforced through Regulation 1924/2006, specifies that such messages should be clear and precise so as not to mislead the consumer. The objective of this study was to observe consumers' understanding of messages in functional food advertisements. The methodology used was a self-administered survey filled out by 191 students enrolled in a Degree in Advertising and Public Relations at the University of Alicante (Spain). The results suggest that a large number of students do not know what functional food is and obtain information about these products mainly from labelling/packaging. The major means of communication through which they learn about health benefits via advertising is the internet, followed by television. Most respondents indicated that they understood related advertisements and found it helpful to be given additional information on health benefits. Worthy of note, the greater their level of understanding of the messages, the higher their level of distrust of advertising messages, which they considered to be deceptive or misleading.

Does labelling of healthy foods on menus using symbols promote better choices at the point-of-purchase?

OBJECTIVE

Take-away foods account for a significant proportion of dietary intake among young adults (18-35 years). Young adults want nutrition information at the point-of-purchase (POP); however, it is either unavailable, perceived as ineffective or difficult to use. The present study examined whether symbols on university food outlet menus identifying healthier options would increase their sales and consumer's awareness of these symbols, purchasing factors and barriers to eating healthy foods.

DESIGN

Repeated-measures, comparison group, quasi-experimental study.

SETTING

Two carefully matched university food outlets were analysed to determine the targeted items. Tick symbols ✓ were placed next to the targeted items in the experimental outlet. No changes were made at the comparison outlet. Customers were surveyed at the experimental outlet. Food sales were collected for 4 weeks from both outlets at baseline and during the intervention. Food sales were also collected from the experimental outlet 10 weeks later.

PARTICIPANTS

Food outlet patrons.

RESULTS

Significant increases in food sales were observed during observation 3 compared with observation 1 (P = 0·0004) and observation 2 (P = 0·0002). Sixty-eight per cent of respondents noticed the symbols, and of that, 30 % reported being influenced. Taste was the most common purchasing factor, and people were less likely to select taste as a factor if they were influenced by the symbols (P = 0·04).

CONCLUSIONS

Identifying healthier options with a symbol at the POP increased sales over time. Several purchasing factors (price, taste and healthy food availability) need to be addressed to improve the food selection of young adults.

The response to nutritional labels: Evidence from a quasi-experiment

This paper evaluates a UK policy that aimed to improve dietary information provision by introducing nutrition labelling on retailers' store-brand products. Exploiting the differential timing of the introduction of Front-of-Pack nutrition labels as a quasi-experiment, our findings suggest that labelling led to a reduction in the quantity purchased of labelled store-brand foods, and an improvement in their nutritional composition. More specifically, we find that households reduced the total monthly calories from labelled store-brand foods by 588 kcal, saturated fats by 14 g, sugars by 7 g, and sodium by 0.8 mg.

Analyzing app-based food information services: the case of Olive Oil sector

Purpose

The provision of information about food to consumers is well recognized to be problematic and complex. Novel approaches tend to adopt app-based services as a way for consumers to get better food information. Potentially, these services could provide relevant information to consumers because they could address particular needs by leveraging on context-awareness, ubiquity and pervasiveness. Do current app-based services actualize these potentialities? The purpose of this paper is twofold: to propose a methodological approach that can be easily adapted to conduct reviews of app-based services and provide consumers with information about food and to answer this question on a specified food information domain (namely, olive oil).

Design/methodology/approach

A literature review was performed to investigate characteristics of food information services under a consumer’s value perspective. Then, a qualitative framework was built, which allowed a multidimensional analysis of the food information provided by a service through a mobile app. Moreover, an application of that framework on “olive oil” mobile apps was carried out, with the twofold objective of providing an example of application of the proposed framework in a real context and analyzing the role of mobile apps in reducing consumers’ information and knowledge gap in this particular domain. The review covers commercial applications on “olive oil,” available on the Apple App Store and Google Play Store.

Findings

A framework of multidimensional analysis of the two-way information flow in the interaction between a consumer/user and a food app-based service is proposed. The framework represents a useful tool to analyze the offer of mobile-based services in a given sector. The framework is then applied to perform a situation analysis of app-based services in the olive oil market. The analysis highlights that olive oil information providers do not seem to fully exploit recent advances in “Internet of food” technologies. Hence, results from our survey suggest some direction to conceive and develop innovative mobile olive oil apps that better exploit mobiquitous technology features.

Practical implications

Consumers perceive a growing need of information about food. This need is mainly due to recent cases of adulterations, allegations of fraud and subterfuges that have invested food sector (in particular, olive oil sector). This research provides a useful framework to analyze some aspects of management of food information provision through mobile apps. Such a framework represents a practical tool that provides fruitful insights for the design of a new generation of food-app based services within the so-called “internet of food” domain.

Originality/value

Although there are countless mobile apps aimed to assist consumers with their everyday food practices, little research has been devoted to investigate the impact of mobiquitous technologies on the management of food information provision to consumers. The available research lacks in defining an approach capable to analyze the relevance of information provided to targeted audiences by mobile food apps. This paper tries to fill this knowledge gap by proposing a framework that is based on a characterization of food information flows in terms of categorization, source and service features.

Serving Size and Nutrition Labelling: Implications for Nutrition Information and Nutrition Claims on Packaged Foods

The presentation of nutrition information on a serving size basis is a strategy that has been adopted by several countries to promote healthy eating. Variation in serving size, however, can alter the nutritional values reported on food labels and compromise the food choices made by the population. This narrative review aimed to discuss (1) current nutrition labelling legislation regarding serving size and (2) the implications of declared serving size for nutrition information available on packaged foods. Most countries with mandatory food labelling require that serving size be presented on food labels, but variation in this information is generally allowed. Studies have reported a lack of standardisation among serving sizes of similar products which may compromise the usability of nutrition information. Moreover, studies indicate that food companies may be varying serving sizes as a marketing strategy to stimulate sales by reporting lower values of certain nutrients or lower energy values on nutrition information labels. There is a need to define the best format for presenting serving size on food labels in order to provide clear and easily comprehensible nutrition information to the consumer.

Menu labels, for better, and worse? Exploring socio-economic and race-ethnic differences in menu label use in a national sample

Menu calorie labeling aims to empower customers to make healthier food choices, but researchers have questioned whether labels will empower those with greater health literacy, literacy or numeracy more, possibly reinforcing race-ethnic or socioeconomic inequalities in obesity. The goal of this study was to investigate differences in seeing and using restaurant menu calorie labels and whether differences have compounded over time. Using data from three rounds of the National Health and Nutrition Examination Survey covering the period 2007-2014, we investigate race-ethnic and socio-economic differences in menu label usage over time adjusting for sex, age and body weight. While menu label usage increased over time, not all groups increased their use equally. While we find that Blacks and Hispanics use labels more than Whites in sit-down restaurants, more educated individuals, higher income groups and Whites each increased the degree to which they saw and/or used labels in certain settings compared with other groups. This study reinforces concerns that menu-calorie labeling may exacerbate socio-economic and certain race-ethnic obesity differences. As menu labeling policy moves forward to be implemented federally, more attention may need to be diverted to educational campaigns accompanying the implementation and improving the labels so the information is easier to use.

Reported Influences on Restaurant-Type Food Selection Decision Making in a Grocery Store Chain

OBJECTIVE

To examine food decision-making priorities for restaurant-type foods at grocery stores and determine whether adding calorie information, as required by federal menu labeling laws, affected decision-making priorities.

DESIGN

Natural experiment: intervention and control groups with baseline and follow-up.

SETTING

Regional grocery store chain with 9 locations.

PARTICIPANTS

Participants (n = 393; mean age, 54.8 ± 15.1 years) were primarily women (71%) and Caucasian (95%).

INTERVENTION

Data were collected before and after calorie information was added to restaurant-type foods at 4 intervention locations.

MAIN OUTCOME MEASURE(S)

Primary influencers of food selection decision making for restaurant-type foods and frequency of use of nutrition information.

ANALYSIS

Quantitative analysis examined the top 3 influencers of food selections and chi-square goodness of fit test determined whether the calorie labeling intervention changed food decision-making priorities. Qualitative data were used to describe responses.

RESULTS

Taste, cost, and convenience were the most frequently reported influencers of restaurant-type food selections; 20% of participants rated calories as influential. Calorie labeling did not affect food selection decision making; 16% of participants in intervention stores noticed calorie labels. Qualitative explanations confirmed these findings.

CONCLUSIONS AND IMPLICATIONS

Menu labeling laws increase access to calorie information; however, use of this information is limited. Additional interventions are needed to encourage healthier restaurant-type food selections in grocery stores.

Influence of menu labeling on food choices in real-life settings: a systematic review

CONTEXT

Evidence that menu labeling influences food choices in real-life settings is lacking. Reviews usually focus on calorie counts without addressing broader issues related to healthy eating.

OBJECTIVE

This systematic review assessed the influence of diverse menu-labeling formats on food choices in real-life settings.

DATA SOURCES

Several databases were searched: Cochrane Library, Scopus, MEDLINE, Web of Science, Food Science and Technology Abstracts, Biological Abstracts, CAB Abstracts, EconLit, SciELO, and LILACS.

STUDY SELECTION

Articles reporting experiments, quasi-experiments, and observational studies using control or preintervention groups were selected blindly by two reviewers.

DATA EXTRACTION

Data was extracted using a standard form. Analyses differentiated between foodservice types. The quality of the 38 included studies was assessed blindly by two reviewers.

DATA ANALYSIS

The results were mixed, but a partial influence of menu labeling on food choices was more frequent than an overall influence or no influence. Menu labeling was more effective in cafeterias than in restaurants. Qualitative information, such as healthy-food symbols and traffic-light labeling, was most effective in promoting healthy eating. In general, the studies were of moderate quality and did not use control groups.

CONCLUSIONS

Calorie labeling in menus is not effective to promote healthier food choices. Further research in real-life settings with control groups should test diverse qualitative information in menu labeling.

Preferences for menu labelling formats of young adults in Brazil and in the United Kingdom

ABSTRACT Objective This pilot study was aimed at exploring preferences of young adults in two different contexts on restaurant menu labelling formats. Methods Five focus groups were conducted with 36 participants, two focus groups with 11 participants in Brazil and three focus groups with 25 in the United Kingdom. Themes originating from the content analysis of the transcriptions were organised around four possible menu labelling formats: 1) numerical information on calories; 2) numerical information on calories and nutrients; 3) traffic light system plus Guideline Daily Amounts; 4) food information with ingredients list plus highlighted symbols. Results In both countries, participants preferred the ingredients list plus symbols format, considered more comprehensive and useful to make an informed food choice. Organic food and vegetarian symbols were the ones considered most important to appear on restaurant menu labels with ingredients list. However, most participants in Brazil and in the United Kingdom rejected the information restricted to calories and calories plus nutrients formats, saying that these would not influence their own choices. Conclusion This is the first multicultural qualitative study exploring preferences of people living in different countries with different eating habits, but where menu labelling is voluntary. Results evidenced similarities in participants’ likes and dislikes for menu labelling formats in these two different contexts. Discussions showed participants in both countries prefer qualitative information than numerical information, suggesting that ingredients list and symbols provide information that people want to see on the menu.

Wholegrain Food Acceptance in Young Singaporean Adults

Previous epidemiological evidence suggests that habitual consumption of whole grains is associated with reduction of disease risk. While wholegrain food consumption appears to be increasing in Singapore, it is still low, with more infrequent consumption noted in younger Singaporeans. Therefore, the primary objective of this study is to determine the knowledge of whole grains and barriers to consumption of wholegrain foods. Thirty participants (age range 21–26 year, 19 females) took part in two focus groups separated by a 2-week period in which participants trialled a range of wholegrain foods. Barriers towards whole grain consumption and experiences of products during this familiarization period were discussed during the focus groups and knowledge of whole grains was assessed by questionnaire. Potential barriers such as personal factors, product-specific factors and external factors were identified with sensory and habitual being stronger barriers. The whole grain familiarization period did not alter the taste expectations of the consumers but it did manage to increase acceptance for four of the wholegrain products tested (muesli, cookies, granola bars and wholewheat pasta). These findings suggest existing barriers to wholegrain food consumption should be considered by public health agencies and manufacturing companies.

Consumer use and understanding of labelling information on edible marijuana products sold for recreational use in the states of Colorado and Washington

BACKGROUND

In 2014, the states of Colorado and Washington began allowing retail sales of marijuana for recreational use. The regulatory agencies in these states have implemented specific labelling requirements for edible marijuana products sold for recreational use to help address concerns such as delayed activation time, accidental ingestion, and proper dosing.

METHODS

We conducted 12 focus groups with 94 adult consumers and nonconsumers of edibles in Denver and Seattle to collect information on their use and understanding of labelling information on edible marijuana products sold for recreational use. Specifically, we asked participants about the usefulness, attractiveness, ease of comprehension, relevancy, and acceptability of the label information.

RESULTS

Some focus group participants look for and read specific information, such as the potency profile and serving size statement, but do not read or were unfamiliar with other labelling features. The focus groups revealed that participants have some concerns about the current labelling of edibles. In particular, participants were concerned that there is too much information on the labels so consumers may not read the label, there is no obvious indication that the product contains marijuana (e.g., a Universal Symbol), and the information on consumption advice is not clear. Participants in both locations suggested that education in a variety of formats, such as web- and video-based education, would be useful in informing consumers about the possible risks of edibles.

CONCLUSION

The focus group findings suggest that improvements are needed in the labelling of edibles to prevent unintentional ingestion among adult nonusers and help ensure proper dosing and safe consumption among adult users. These findings, along with lessons learned from Colorado and Washington, can help inform the labelling of edibles as additional states allow the sale of edibles for recreational use.

Health Representations, Perceived Valence, and Concept Associations for Symbols as Food Cues: A Mixed-Methods Approach

Researchers have experimented with a range of point-of-purchase (PoP) interventions in supermarkets, restaurants, and cafeterias. In general, these interventions have employed written materials. This research tested symbols to visually summarize information about the (un)healthiness of food. Study one explored health representations and valence associated with the image of a heart, a bathroom scale, and a running shoe using qualitative field interviews (N = 1200). Study two explored accessibility of a priori concept associations for two of those images, stratified by valence, in a computerized response latency task (N = 40). Study one indicted that the heart was best linked to its intended theme "heart health." Concerning valence, the heart was seen as both positive and negative whereas the scale was less likely to be viewed as positive relative to the running shoe. In study two, the heart was linked to five of the six a priori concepts and there was evidence that three of these were more accessible. Overall, the heart was better linked to positive poles than negative ones. A heart symbol may be useful to prompt heart healthy choices at the PoP. There was evidence that a scale may bias choice away from undesirable foods.

Effects of an icon-based menu labelling initiative on consumer food choice

Aims:

The purpose of this study was to examine the impact of an icon-based menu labelling initiative on consumer buying behaviour.

Methods:

This quasi-experimental study recruited a convenience sample of eight food service establishments, all with at least one menu item meeting the heart healthy criteria. Data from sales of all menu items sold over an 8-week period were collated 4 weeks prior to and 4 weeks during the display of information icons related to healthy food choices on menus.

Results:

The absolute change in menu item sales showed a non-significant trend towards an increase in healthier menu item selections. Furthermore, there was no association between the type of food service establishment and the percentage change in labelled menu item sales.

Conclusion:

The study did not find a statistically significant influence of the icon-based menu labels on consumer food choice. Given the limited amount of research that examines alternative menu labelling formats in real-world settings, more studies are necessary to confirm these results. Further research is needed to identify the optimal format, content and impact of menu labels on consumer behaviour.

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.

Exploring enhanced menu labels' influence on fast food selections and exercise-related attitudes, perceptions, and intentions

Labeling restaurant menus with calorie counts is a popular public health intervention, but research shows these labels have small, inconsistent effects on behavior. Supplementing calorie counts with physical activity equivalents may produce stronger results, but few studies of these enhanced labels have been conducted, and the labels' potential to influence exercise-related outcomes remains unexplored. This online study evaluated the impact of no information, calories-only, and calories plus equivalent miles of walking labels on fast food item selection and exercise-related attitudes, perceptions, and intentions. Participants (N = 643) were randomly assigned to a labeling condition and completed a menu ordering task followed by measures of exercise-related outcomes. The labels had little effect on ordering behavior, with no significant differences in total calories ordered and counterintuitive increases in calories ordered in the two informational conditions in some item categories. The labels also had little impact on the exercise-related outcomes, though participants in the two informational conditions perceived exercise as less enjoyable than did participants in the no information condition, and trends following the same pattern were found for other exercise-related outcomes. The present findings concur with literature demonstrating small, inconsistent effects of current menu labeling strategies and suggest that alternatives such as traffic light systems should be explored.

Consumers' responses to front-of-pack labels that vary by interpretive content

Previous research has shown that front-of-pack labels (FoPLs) can assist people to make healthier food choices if they are easy to understand and people are motivated to use them. There is some evidence that FoPLs providing an assessment of a food's health value (evaluative FoPLs) are easier to use than those providing only numerical information on nutrients (reductive FoPLs). Recently, a new evaluative FoPL (the Health Star Rating (HSR)) has been introduced to Australia and New Zealand. The HSR features a summary indicator, differentiating it from many other FoPLs being used around the world. The aim of this study was to understand how consumers of all ages use and make sense of reductive FoPLs and evaluative FoPLs including evaluative FoPLs with and without summary indicators. Ten focus groups were conducted in Perth, Western Australia with adults (n = 50) and children aged 10-17 years (n = 35) to explore reactions to one reductive FoPL (the Daily Intake Guide), an existing evaluative FoPL (multiple traffic lights), and a new evaluative FoPL (the HSR). Participants preferred the evaluative FoPLs over the reductive FoPL, with the strongest preference being for the FoPL with the summary indicator (HSR). Discussions revealed the cognitive strategies used when interpreting each FoPL (e.g., using cut offs, heuristics, and the process of elimination), which differed according to FoPL format. Most participants reported being motivated to use the evaluative FoPLs (particularly the HSR) to make choices about foods consumed as part of regular daily meals, but not for discretionary foods consumed as snacks or deserts. The findings provide further evidence of the potential utility of evaluative FoPLs in supporting healthy food choices and can assist policy makers in selecting between alternative FoPL formats.

The effects of increased serving sizes on consumption

The US Food and Drug Administration recently revealed that it is considering modifying the Nutrition Facts Panels required on packaged foods. One proposed change is increasing serving sizes included on labels, which has two potential implications. Larger serving sizes could increase consumption if consumers use the serving sizes displayed as a reference point for their own consumption (McFerran et al., 2010). Alternatively, larger serving sizes that depict increased values of negative nutrients (e.g. calories) could lead consumers to perceive foods as less healthy, thereby reducing consumption (Russo et al., 1986). In study 1 (Online sample, N = 208, Mage = 32, SDage = 12), participants saw pictures of packaged food items and nutrition labels. The labels, depicted either the existing or larger serving size. Across all foods, larger serving sizes led to lower health perceptions. Labels with larger serving sizes were rated as more representative of typical consumption. Study 2 (Online sample, N = 347, Mage = 31, SDage = 10) used the same design as study 1, but required participants to virtually portion foods. While serving sizes did not impact the amount of food consumers portioned, those who saw labels with larger serving sizes estimated that they portioned out more calories. In study 3 (Student sample, N = 198, Mage = 20, SDage = 1), participants were given M&Ms to eat, paired with a nutritional label depicting either the current or a larger serving size, while participating in unrelated surveys. Participants presented with the larger serving size label consumed less than those presented with the current serving size label. Together, the results suggest that the proposed increase in serving sizes on Nutrition Facts Panels could lower consumption of high-calorie foods.

College Students Must Overcome Barriers to Use Calorie Labels in Fast-Food Restaurants

OBJECTIVE

To explore predictors of intention of college students to use calorie labels on fast-food menus and differences in calories ordered after viewing calorie information.

DESIGN

Quasi-experimental design. Participants selected a meal from a menu without calorie labels, selected a meal from the same menu with calorie labels, and completed a survey that assessed demographics, dietary habits, Theory of Planned Behavior constructs, and potential barriers to use of calorie labeling.

SETTING

A southern university.

PARTICIPANTS

Undergraduate university students (n = 97).

MAIN OUTCOME MEASURES

Predictors of intention to use calorie labels and whether calories selected from the nonlabeled menu differed from the labeled menu.

ANALYSIS

Confirmatory factor analysis, exploratory factor analysis, multiple regression, and paired t tests.

RESULTS

Participants ordered significantly fewer calories (P = .02) when selecting from the labeled menu vs the menu without labels. Attitudes (P = .006), subjective norms (P < .001), and perceived behavioral control (P = .01) predicted intention to use calorie information but did not predict a difference in the calories ordered. Hunger (P = .03) and cost (P = .04) were barriers to using the calorie information.

CONCLUSIONS AND IMPLICATIONS

If students can overcome barriers, calorie labeling could provide information that college students need to select lower-calorie items at fast-food restaurants.

The growing role of front-of-pack nutrition profile labeling: a consumer perspective on key issues and controversies

Nutrition-related diseases, such as some cancers, heart diseases, and obesity, belong to the most challenging health concerns of our time. Communicating intuitive and simple nutrition information by means of front-of-pack (FOP) nutrition profile signpost labeling is increasingly seen as an essential tool in efforts to combat unhealthy food choices and improve public health. Consequently, much attention in policy and research is given to nutrient profiling methods and the determination of optimal nutrition criteria. Although consumer research on nutrition signpost labeling is now gradually appearing in the literature, the value and meaning of these labeling systems for consumers have received less attention. In the current debate a concise overview is lacking of the consumer perspective, including relevant psychological phenomena, in relation to much debated controversies surrounding these labels and their further development, such as the most effective type of signpost labeling system and varying stakeholder interests. Therefore, this paper aims to critically review the literature in the consumer domain of FOP nutrition labeling in order to illustrate the strengths and weaknesses of this form of nutrition education from a consumer perspective.

Perceptions of university students regarding calories, food healthiness, and the importance of calorie information in menu labelling

This study investigated Brazilian university students' perceptions of the concept of calories, how it relates to food healthiness, and the role of calorie information on menus in influencing food choices in different restaurant settings. Focus groups were conducted with 21 undergraduate students from various universities. Transcriptions were analysed for qualitative content, by coding and grouping words and phrases into similar themes. Two categories were obtained: Calorie concept and connection to healthiness; and Calorie information and food choices in restaurants. Calories were understood as energy units, and their excessive intake was associated with weight gain or fat gain. However, food healthiness was not associated to calorie content, but rather to food composition as a whole. Calorie information on restaurant menus was not considered enough to influence food choices, with preferences, dietary restrictions, food composition, and even restaurant type mentioned as equally or more important. Only a few participants mentioned using calorie information on menus to control food intake or body weight. Students' discussions were suggestive of an understanding of healthy eating as a more complex issue than calorie-counting. Discussions also suggested the need for more nutrition information, besides calorie content, to influence food choices in restaurants.

Improving the design of nutrition labels to promote healthier food choices and reasonable portion sizes

Accurate and easy-to-understand nutrition labeling is a worthy public health goal that should be considered an important strategy among many to address obesity and poor diet. Updating the Nutrition Facts Panel on packaged foods, developing a uniform front-of-package labeling system and providing consumers with nutrition information on restaurant menus offer important opportunities to educate people about food's nutritional content, increase awareness of reasonable portion sizes and motivate consumers to make healthier choices. The aims of this paper were to identify and discuss: (1) current concerns with nutrition label communication strategies; (2) opportunities to improve the communication of nutrition information via food labels, with a specific focus on serving size information; and (3) important future areas of research on nutrition labeling as a tool to improve diet. We suggest that research on nutrition labeling should focus on ways to improve food labels' ability to capture consumer attention, reduce label complexity and convey numeric nutrition information in simpler and more meaningful ways, such as through interpretive food labels, the addition of simple text, reduced use of percentages and easy-to-understand presentation of serving size information.

Transparency for Food Consumers: Nutrition Labeling and Food Oppression

Transparency for consumers through nutrition labeling should be the last, not the first, step in a transformative food policy that would reduce dramatic health disparities and raise the United States to the health standards of other nations with similar resources. Nonetheless, transparency in the food system is a key focal point of efforts to improve health by providing consumers with necessary information to make good nutritional choices, as well as to achieve sustainable food chains and ensure food safety and quality. In fact, nutrition labeling on packaging and in restaurants is the centerpiece of policy designed to decrease obesity, a condition many health advocates consider to be the most urgent public health crisis of the twenty-first century. The resulting increased transparency about food ingredients has led to some changes in industry practices and allowed many middle- and upper-income consumers to make informed choices about the products they purchase and consume. Unfortunately, however, research reveals that increased nutritional information does not improve health.

Reducing sugar-sweetened beverage consumption by providing caloric information: how Black adolescents alter their purchases and whether the effects persist

OBJECTIVES

We examined the ways in which adolescents altered the type and size of their purchases of sugar-sweetened beverages (SSBs), together with whether the effects persisted after removing caloric information signs in stores.

METHODS

We used a case-crossover design with 6 stores located in low-income Black neighborhoods in Baltimore, Maryland, from 2012 to 2013. The intervention used 1 of 4 randomly posted signs with caloric information: absolute calories, number of teaspoons of sugar, and number of minutes of running or miles of walking necessary to burn off a beverage. We collected data for 4516 purchases by Black adolescents, including both baseline and postintervention periods with no signs posted.

RESULTS

We found that providing caloric information significantly reduced the number of total beverage calories purchased, the likelihood of buying an SSB, and the likelihood of buying an SSB greater than 16 ounces (P < .05). After removing the signs, the quantity, volume, and number of calories from SSB purchases remained lower than baseline (P < .05).

CONCLUSIONS

Providing caloric information was associated with purchasing a smaller SSB, switching to a beverage with no calories, or opting to not purchase a beverage; there was a persistent effect on reducing SSB purchases after signs were removed.

Restaurant menu labelling: Is it worth adding sodium to the label?

OBJECTIVE

Several provincial and federal bills have recommended various forms of menu labelling that would require information beyond just calories; however, the additional benefit of including sodium information is unknown. The objective of this study was to determine whether sodium information on menus helps consumers make lower-sodium choices and to understand what other factors influence the effect of menu labelling on consumers' meal choices.

METHODS

A total of 3,080 Canadian consumers completed an online survey that included a repeated measures experiment in which consumers were asked to select what they would typically order from four mock-restaurant menus. Subsequently, consumers were randomly allocated to see one of three menu-labelling treatments (calories; calories and sodium; or calories, sodium and serving size) and were given the option to change their order.

RESULTS

There was a significant difference in the proportion of consumers who changed their order, varying from 17% to 30%, depending on the restaurant type. After participants had seen menu labelling, sodium levels decreased in all treatments (p&lt;0.0001). However, in three of the four restaurant types, consumers who saw calorie and sodium information ordered meals with significantly less sodium than consumers who saw only calorie information (p&lt;0.01). Consumers who saw sodium labelling decreased the sodium level of their meal by an average of 171-384 mg, depending on the restaurant. In the subset of consumers who saw sodium information and chose to change their order, sodium levels decreased by an average of 681-1,360 mg, depending on the restaurant. Sex, intent to lose weight and the amount of calories ordered at baseline were the most important predictors of who used menu labelling. Eighty percent of survey panelists wanted to see nutrition information when dining out.

CONCLUSION

Including sodium information alongside calorie information may result in a larger decrease in the amount of sodium ordered by restaurant-goers.

The influence of menu labeling on calories selected or consumed: a systematic review and meta-analysis

Recent menu labeling initiatives in North America involve posting the calorie content of standard menu items, sometimes with other nutrients of public health concern, with or without contextual information (such as the recommended daily caloric intake for an average adult) or interpretive information (such as traffic light symbols). It is not clear whether this is an effective method to convey nutrition information to consumers wanting to make more-informed food choices. Of particular concern are those consumers who may be limited in their food and health literacy skills to make informed food choices to meet their dietary needs or goals. The purpose of this systematic review was to determine whether the provision of menu-based nutrition information affects the selection and consumption of calories in restaurants and other foodservice establishments. A secondary objective was to determine whether the format of the nutrition information (informative vs contextual or interpretive) influences calorie selection or consumption. Several bibliographic databases were searched for experimental or quasiexperimental studies that tested the effect of providing nutrition information in a restaurant or other foodservice setting on calories selected or consumed. Studies that recruited generally healthy, noninstitutionalized adolescents or adults were included. When two or more studies reported similar outcomes and sufficient data were available, meta-analysis was performed. Menu labeling with calories alone did not have the intended effect of decreasing calories selected or consumed (-31 kcal [P=0.35] and -13 kcal [P=0.61], respectively). The addition of contextual or interpretive nutrition information on menus appeared to assist consumers in the selection and consumption of fewer calories (-67 kcal [P=0.008] and -81 kcal [P=0.007], respectively). Sex influenced the effect of menu labeling on selection and consumption of calories, with women using the information to select and consume fewer calories. The findings of this review support the inclusion of contextual or interpretive nutrition information with calories on restaurant menus to help consumers select and consume fewer calories when eating outside the home. Further exploration is needed to determine the optimal approach for providing this menu-based nutrition information, particularly for those consumers who may be limited in their food and health literacy skills.

Efficacy and consumer preferences for different approaches to calorie labeling on menus

OBJECTIVE

To evaluate the efficacy and consumer preferences of calorie labeling on menus.

DESIGN

Between-group experiment. Participants were randomized to view menu items according to 1 of 4 experimental conditions: no calorie information, calorie-only information, calorie plus health statement (HS), and calorie plus the Physical Activity Scale. Participants selected a snack and then rated menus from all conditions on the level of understanding and perceived effectiveness.

SETTING

University of Waterloo, Canada.

PARTICIPANTS

A total of 213 undergraduate university students recruited from classrooms.

MAIN OUTCOME MEASURES

The calorie amount of menu selection and ratings of understandability and perceived effectiveness.

ANALYSIS

Linear regression models and chi-square tests.

RESULTS

Participants who selected items from menus without calorie information selected snacks with higher calorie amounts than participants in the calorie-only condition (P = .002) and the calorie plus HS condition (P = .001). The calorie plus HS menu was perceived as most understandable and the calorie plus calorie plus Physical Activity Scale menu was perceived as most effective in helping to promote healthy eating.

CONCLUSIONS AND IMPLICATIONS

Calorie labeling on menus may assist consumers in making healthier choices, with consumer preference for menus that include contextual health statements.

What types of nutrition menu labelling lead consumers to select less energy-dense fast food? An experimental study

This study assessed whether the inclusion of kilojoule labelling alone or accompanied by further nutrition information on menus led adults to select less energy-dense fast food meals. A between-subjects experimental design was used with online menu boards systematically varied to test the following labelling conditions: none (control); kilojoule; kilojoule+percent daily intake; kilojoule+traffic light; and kilojoule+traffic light+percent daily intake. Respondents were 1294 adults aged 18-49 in Victoria, Australia who had purchased fast food in the last month and were randomly assigned to conditions. Respondents in the no labelling condition selected meals with the highest mean energy content and those viewing the kilojoule and kilojoule+traffic light information selected meals with a significantly lower mean energy content, that constituted a reduction of around 500kJ (120kcal). Respondents most commonly reported using the traffic light labels in making their selections. These findings provide support for the policy of disclosure of energy content on menus at restaurant chains. Given the magnitude of the reduction in energy density reported, and the prevalence of fast food consumption, this policy initiative has the potential to yield health benefits at the population level.

Associations Between a Voluntary Restaurant Menu Designation Initiative and Patron Purchasing Behavior

Background. Restaurant initiatives provide an efficient opportunity to impact large numbers of patrons. The purpose of this study is to measure patron purchasing behaviors during the ¡Por Vida! menu designation initiative. Method. This study used a cross-sectional design and survey data to assess 23 restaurants throughout Bexar County and 152 restaurant patrons. The Patron Awareness Questionnaire assessed if patrons noticed the logo; believed nutrition, cost, and taste were important in making purchasing decisions; and purchased a ¡Por Vida! item. Descriptive statistics, Spearman correlations, and logistic regression were used to analyze the data. Results. Most (93.4%) patrons considered taste very important when deciding what to eat. Cost was very important to 63.8% and nutrition was very important to 55.9% of the sample. The strongest predictors of purchasing a ¡Por Vida! item were the patrons’ ages being between 18 and 35 years (odds ratio = 1.474; confidence interval = 0.017, 0.812; p < .05) and if patrons saw the logo (odds ratio = 4.327; confidence interval = 1.696-11.036; p < .01). Discussion/Conclusion. Menu logo designation initiatives can potentially influence patron purchasing behaviors among a segment of the population when the logo is visible.

Potential effect of physical activity based menu labels on the calorie content of selected fast food meals

In this study we examined the effect of physical activity based labels on the calorie content of meals selected from a sample fast food menu. Using a web-based survey, participants were randomly assigned to one of four menus which differed only in their labeling schemes (n=802): (1) a menu with no nutritional information, (2) a menu with calorie information, (3) a menu with calorie information and minutes to walk to burn those calories, or (4) a menu with calorie information and miles to walk to burn those calories. There was a significant difference in the mean number of calories ordered based on menu type (p=0.02), with an average of 1020 calories ordered from a menu with no nutritional information, 927 calories ordered from a menu with only calorie information, 916 calories ordered from a menu with both calorie information and minutes to walk to burn those calories, and 826 calories ordered from the menu with calorie information and the number of miles to walk to burn those calories. The menu with calories and the number of miles to walk to burn those calories appeared the most effective in influencing the selection of lower calorie meals (p=0.0007) when compared to the menu with no nutritional information provided. The majority of participants (82%) reported a preference for physical activity based menu labels over labels with calorie information alone and no nutritional information. Whether these labels are effective in real-life scenarios remains to be tested.

Evaluation of consumer understanding of different front-of-package nutrition labels, 2010-2011

Introduction

Governments throughout the world are using or considering various front-of-package (FOP) food labeling systems to provide nutrition information to consumers. Our web-based study tested consumer understanding of different FOP labeling systems.

Methods

Adult participants (N = 480) were randomized to 1 of 5 groups to evaluate FOP labels: 1) no label; 2) multiple traffic light (MTL); 3) MTL plus daily caloric requirement icon (MTL+caloric intake); 4) traffic light with specific nutrients to limit based on food category (TL+SNL); or 5) the Choices logo. Total percentage correct quiz scores were created reflecting participants’ ability to select the healthier of 2 foods and estimate amounts of saturated fat, sugar, and sodium in foods. Participants also rated products on taste, healthfulness, and how likely they were to purchase the product. Quiz scores and product perceptions were compared with 1-way analysis of variance followed by post-hoc Tukey tests.

Results

The MTL+caloric intake group (mean [standard deviation], 73.3% [6.9%]) and Choices group (72.5% [13.2%]) significantly outperformed the no label group (67.8% [10.3%]) and the TL+SNL group (65.8% [7.3%]) in selecting the more healthful product on the healthier product quiz. The MTL and MTL+caloric intake groups achieved average scores of more than 90% on the saturated fat, sugar, and sodium quizzes, which were significantly better than the no label and Choices group average scores, which were between 34% and 47%.

Conclusion

An MTL+caloric intake label and the Choices symbol hold promise as FOP labeling systems and require further testing in different environments and population subgroups.

Consumer attitudes toward information displayed at food buffets in commercial restaurants

This study aimed to evaluate the attitude of consumers towards information about dishes in a commercial restaurant. This research was conducted from January to April 2009 in a restaurant in the city of Santa Maria (RS), Brazil. Food information including the name of the dish, ingredients, health benefits and warnings, and calorie value was displayed. After providing this nutritional information, a questionnaire was applied to 300 consumers at the restaurant to observe their attitudes towards the food information. It was found that 10.57% of the respondents reported allergy or intolerance to some kinds of food and that 10.98% of the respondents reported having diseases that require moderate consumption and/or total restriction on the consumption of those foods. However, 84.96% of the respondents did not restrict consumption of any food, even though those foods may have posed a risk to their health, and 58.54% of the respondents consumed some food due to the potential benefits to their health. With regard to the respondents' level of satisfaction concerning the food information provided, 72.76% considered the information provided as very good. The respondents had a tendency to change their behavior towards consumption after having access to information about the dishes displayed.

Counting calories: resident perspectives on calorie labeling in New York City

OBJECTIVE

The present study investigates consumer responses to New York City's 2008 calorie labeling regulation in 2 lower-income neighborhoods of New York City.

METHODS

Focus groups were conducted, and 34 fast-food consumers participated. Group summaries and descriptive and analytic depictions of group responses and interactions were developed based on a thorough examination of the notes and tapes.

RESULTS

Findings included that there is support for the regulation, as well as skepticism regarding the potency of calorie posting as a behavior change tool. In addition, there were strong beliefs about both parental responsibility for children's eating habits as well as the role of poverty, hunger, and lack of education in food selection.

CONCLUSIONS AND IMPLICATIONS

Calorie labeling is one avenue for educating consumers about nutrition; however, given competing factors in food choice decisions as well as the realities of hunger and poverty, more proactive measures are needed.

Calorie postings in chain restaurants in a low-income urban neighborhood: measuring practical utility and policy compliance

Current strategies for combating obesity include recent federal legislation mandating calorie count postings in chain restaurants. This study describes the current practice of menu board calorie postings in a low-income urban neighborhood, identifies the extent to which current practice complies with existing policy, and evaluates the practical utility of menu boards to consumers. We conclude that although most postings were legally compliant, they did not demonstrate utility. Menu postings for individual servings are easily understood, but complex math skills are needed to interpret meals designed to serve more than one person. In some items, calories doubled depending on flavor and the calorie posting did not give enough information to make healthier selections. We identified specific strategies to improve practical utility and provide recommendations for policy implementation.

Consumers’ knowledge of food label information: an exploratory investigation in Potchefstroom, South Africa

Objective

To determine the ability of consumers to: locate and manipulate food label information; assess the accuracy of nutrient content claims and which health/nutrient claims are allowed; and identify symbols on food labels. Associations pertaining to use and knowledge regarding food label information were also determined for consumers from different demographic and related groups.

Design

An exploratory descriptive study was undertaken, employing a face-to-face survey focusing on demographic information, shopping behaviour, nutrition is important beliefs, label use, label knowledge and label preference and information sources.

Setting

Selected public locations in Potchefstroom in the North West Province of South Africa.

Subjects

Respondents (n 229) complying with set inclusion criteria were recruited through purposive sampling.

Results

The results indicated respondents’ general health and label awareness, as most of them (>80 %) could locate label information and identify symbols and specific nutrient content claims although only 53 % were able to calculate the number of servings. Nevertheless, an inability was found to assess the accuracy of some nutrient content claims and permissible health/nutrient claims. More educated, younger, Afrikaans- and English-speaking respondents seemed to be more knowledgeable regarding food label information.

Conclusions

Respondents who were informed about nutrition were also informed about label information, while label reading practices resulted in label-influenced purchasing decisions. Educational programmes on food labels should start with nutritional background that could be implemented by consumers during label reading and purchasing decisions.

The science on front-of-package food labels

Objective

The US Food and Drug Administration and Institute of Medicine are currently investigating front-of-package (FOP) food labelling systems to provide science-based guidance to the food industry. The present paper reviews the literature on FOP labelling and supermarket shelf-labelling systems published or under review by February 2011 to inform current investigations and identify areas of future research.

Design

A structured search was undertaken of research studies on consumer use, understanding of, preference for, perception of and behaviours relating to FOP/shelf labelling published between January 2004 and February 2011.

Results

Twenty-eight studies from a structured search met inclusion criteria. Reviewed studies examined consumer preferences, understanding and use of different labelling systems as well as label impact on purchasing patterns and industry product reformulation.

Conclusions

The findings indicate that the Multiple Traffic Light system has most consistently helped consumers identify healthier products; however, additional research on different labelling systems’ abilities to influence consumer behaviour is needed.

The effect of a mindful restaurant eating intervention on weight management in women

OBJECTIVE

To evaluate the effect of a Mindful Restaurant Eating intervention on weight management.

DESIGN

Randomized control trial.

SETTING

Greater metropolitan area of Austin, Texas.

PARTICIPANTS

Women (n = 35) 40-59 years old who eat out at least 3 times per week.

INTERVENTION

The intervention, using 6 weekly 2-hour, small group sessions, focused on reducing calorie and fat intake when eating out through education, behavior change strategies, and mindful eating meditations.

MAIN OUTCOME MEASURES

Weight, waist circumference, self-reported daily calorie and fat intake, self-reported calories and fat consumed when eating out, emotional eating, diet related self-efficacy, and barriers to weight management when eating out.

ANALYSIS

General linear models examined change from baseline to final endpoint to determine differences in outcomes between the intervention and control group.

RESULTS

Participants in the intervention group lost significantly more weight (P =.03), had lower average daily caloric (P = .002) and fat intake (P = .001), had increased diet-related self-efficacy (P = .02), and had fewer barriers to weight management when eating out (P = .001).

CONCLUSIONS AND IMPLICATIONS

Mindful Restaurant Eating intervention was effective in promoting weight management in perimenopausal women.

Nutrition labeling and portion size information on children's menus in fast-food and table-service chain restaurants in London, UK

OBJECTIVE

To investigate meals, price, nutritional content, and nutrition and portion size information available on children's menus in fast-food and table-service chain restaurants in London, since the United Kingdom does not currently require such information but may be initiating a voluntary guideline.

METHODS

Children's menus were assessed in 22 chain restaurants for portion size information, nutrition information, and price. The most healthful available meal was purchased and analyzed for nutritional content and portion size.

RESULTS

Nutrition and portion size information was not provided in 67% of the restaurants. Fast-food restaurants were significantly cheaper, had smaller portion sizes than table-service restaurants, and provided fewer portions of fruit, vegetables, iron, and vitamin C.

CONCLUSIONS AND IMPLICATIONS

Not all restaurants provided nutrition or portion size information. Differences in portion size and nutritional content between fast-food and table-service restaurants were established, and both were below recommendations. In the future, nutrition labeling in restaurants in the United Kingdom may provide consumers with the nutrition and portion size information necessary to help make appropriate choices.

Consumer perceptions of trans fats in 2009 show awareness of negative effects but limited concern regarding use in snack foods

The purpose of this study was to determine consumers' perceptions of industrially produced trans fats. A cross-sectional study was conducted in Regina at 3 different grocery store chains located in 3 different regions. A 21-item survey was administered in English by 3 research assistants at the grocery stores over a 5-day period. Of 498 potential respondents who were approached, 211 completed the survey, for a 42% response rate. The majority of respondents were female and over 61 years of age. When respondents were asked if they looked for information on food packages while grocery shopping, none of the respondents indicated that they looked for trans fat on the food label. Ninety-six percent of respondents identified that trans fat is found in processed foods, whereas 42% of respondents incorrectly identified trans fat as being found in nonhydrogenated margarines. More female respondents self-reported that they had made dietary changes to decrease trans fat intake as compared with male respondents (p < 0.05). Those participants who made dietary changes to decrease trans fat intake had higher mean knowledge scores than did those who did not make changes (p < 0.043). Sixty-three percent of respondents indicated that they would not make dietary changes to their snack food selections even if their selections contained trans fat. Consumers know a little about trans fats and consider them to be a concern. However, consumers are reluctant to make dietary changes to limit these fats in their snack food selections.