Calorie-labelling in catering outlets: acceptability and impacts on food sales

The impact of fast-food energy posting on college students' food purchases

BACKGROUND

The Patient Protection US Affordable Care Act (ACA) energy posting mandate requires restaurant chains to disclose information on the energy content of their food items. Assessments of the effect of menu energy labeling on dietary choices have reported inconsistent findings.

OBJECTIVES

This study examined the impact of menu energy labeling on food items purchased by college students after the mandate was enacted nationally.

METHODS

Student food sales data from purchases made at 3 fast-food restaurants during the 2017/2018 and 2018/2019 academic years at a university campus were used for the analysis. The total sample included 1662 students on the university meal plan; these students generated 145,295 food transactions at the restaurants over the study period. We utilized a difference-in-differences (DiD) empirical strategy, comparing changes in transaction-level energy purchases at 2 fast-food restaurants B and C (FFRB and FFRC - treatment groups) that posted energy information in the summer of 2018 with another fast-food restaurant A (FFRA - control group) that began posting energy information before the study period.

RESULTS

We observed increases in the mean energy content per transaction after implementing the menu-labeling policy. The DiD estimates found an increase of 20.6 in the mean calories of energy purchased per transaction at the treatment restaurants relative to the control restaurant. In the subgroup analyses, the DiD estimates indicated calories of energy increased: 18.7 for female students, 20.5 for male students, 23.5 for non-Hispanic Black students, 30.2 for students eligible for federal financial aid, and 19.9 for students not eligible for federal financial aid.

CONCLUSIONS

The results suggest that the ACA energy menu-labeling policy led to an increase in the energy content per transaction by students at a public university. This paper highlights the need for more research to better understand the determinants of food choice among college students.

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.

Investigating business outcomes of healthy food retail strategies: A systematic scoping review

Large changes to food retail settings are required to improve population diet. However, limited research has comprehensively considered the business implications of healthy food retail strategies for food retailers. We performed a systematic scoping review to identify types of business outcomes that have been reported in healthy food retail strategy evaluations. Peer-reviewed and grey literature were searched. We identified qualitative or quantitative real-world food or beverage retail strategies designed to improve the healthiness of the consumer nutrition environment (eg, changes to the "marketing mix" of product, price, promotion, and/or placement). Eligible studies reported store- or chain-level outcomes for measures of commercial viability, retailer perspectives, customer perspectives, and/or community outcomes. 11 682 titles and abstracts were screened with 107 studies included for review from 15 countries. Overall item sales, revenue, store patronage, and customer level of satisfaction with strategy were the most frequently examined outcomes. There was a large heterogeneity in outcome measures reported and in favourability for retailers of outcomes across studies. We recommend more consistent reporting of business outcomes and increased development and use of validated and reliable measurement tools. This may help generate more robust research evidence to aid retailers and policymakers to select feasible and sustainable healthy food retail strategies to benefit population health within and across countries.

Types of Interventions Targeting Dietary, Physical Activity, and Weight-Related Outcomes among University Students: A Systematic Review of Systematic Reviews

A plethora of studies aiming to improve dietary, physical activity (PA), and weight-related (WR) outcomes among university students have been implemented and summarized in a series of systematic reviews, with unclear conclusions regarding their effectiveness. This overview aims to identify systematic reviews and meta-analyses of studies aiming to improve health outcomes in university students, to assess their methodological quality, to identify the different types of interventions used and outcomes assessed, and to estimate their overall effect. Four electronic databases were searched until 19 March, 2018 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The identified reviews were described and their methodological quality was rated. The studies of reviews were investigated to identify the different types of interventions used and outcomes assessed. Effectiveness was assessed by measuring the overall number of improved outcomes out of the total number of outcomes reported. As a result, 8 reviews were identified targeting food sales (n = 2), dietary (n = 3), PA (n = 1), WR (n = 1), or all outcomes (n = 1). The methodological quality of the reviews was moderate (n = 5) to low (n = 3). In all, the reviews included 122 studies, of which 36 used an environmental, 51 a face-to-face, 30 an e-intervention, and 5 a combined approach. Environmental interventions improved a moderate number of food sales (32 of 61) and dietary intake (22 of 47) outcomes. Face-to-face interventions improved a high number of dietary cognitive outcomes (15 of 18), a moderate number of dietary intake (28 of 65) and WR (11 of 18) outcomes, and a low number of PA behavioral (22 of 69) and cognitive (2 of 14) outcomes. E-interventions improved a high number of dietary cognitive variables (11 of 16) but had a low effect (≤33%) on the other types of outcomes. In conclusion, face-to-face and e-interventions improved cognitive variables toward diet or PA but were less effective in changing actual behaviors. Environmental interventions favorably changed food sales. Face-to-face and e-interventions moderately affected WR outcomes. Future research should focus on long-term studies.

An evaluation and exploration of Irish food-service businesses' uptake of and attitudes towards a voluntary government-led menu energy (calorie) labelling initiative

OBJECTIVE

To investigate the uptake of and attitudes towards a voluntary government-led energy (calorie) menu labelling initiative in Ireland among a representative sample of food-service businesses and to inform further actions that may need to be undertaken to facilitate successful implementation.

DESIGN

A mixed-methods approach, incorporating a national telephone survey, structured observation visits and semi-structured interviews.

SETTING

Twenty-six counties in the Republic of Ireland.

SUBJECTS

A random selection of food-service businesses (n 604) participated in the telephone survey. Businesses which indicated that they did display calories were selected to participate in structured observation visits (n 42), along with a random sample (n 38) of businesses that did not display calories. A purposive sample of thirteen food-service business owners who participated in the telephone survey participated in semi-structured interviews.

RESULTS

In the telephone survey, 7 % (n 42) of food businesses reported displaying calories and the observation visits revealed that of these businesses, 10 % (n 4) were not displaying calorie information. Three major themes emerged from the semi-structured interviews: uncertainty, impact on business and consumer nutrition knowledge. Participants expressed concerns regarding inaccuracies in the calorie information, cost and time implications, mistrust in the food-service industry and poor nutritional knowledge among consumers. These concerns impeded the implementing of calorie menu labelling.

CONCLUSIONS

A multifactorial approach that incorporates guidance and support (training/tax incentives), practical assistance (user-friendly calorie calculation software), a reasonable legislative structure and a standardised monitoring system is needed to facilitate the successful implementation of calorie menu labelling.

Nutritional labelling for healthier food or non-alcoholic drink purchasing and consumption

BACKGROUND

Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour.

OBJECTIVES

To assess the impact of nutritional labelling for food and non-alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption.

SEARCH METHODS

We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries.

SELECTION CRITERIA

Eligible studies: were randomised or quasi-randomised controlled trials (RCTs/Q-RCTs), controlled before-and-after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non-alcoholic drinks in real-world or laboratory settings.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary.

MAIN RESULTS

We included 28 studies, comprising 17 RCTs, 5 Q-RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28).Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real-world settings, including purchases from vending machines (one cluster-RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q-RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta-analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD -46.72 kcal, 95% CI -78.35, -15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta-analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias.Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta-analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD -50 kcal, 95% CI -104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies.Six laboratory studies (four RCTs and two Q-RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta-analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI -0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies.There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high-energy foods) during a snack or meal. A meta-analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI -0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate.

AUTHORS' CONCLUSIONS

Findings from a small body of low-quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality.Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high-quality research in real-world settings is needed to enable more certain conclusions.Further high-quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status.

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.

Supersize the label: The effect of prominent calorie labeling on sales

OBJECTIVES

Calorie labeling has been suggested as an antiobesity measure; however, evidence on its effects is scarce and formatting guidance not well defined. The aim of this study was to test the effects of prominent calorie labeling on sales of the labeled items.

METHODS

Prominent calorie labels were posted in front of two popular items for a period of 1 mo. Sales were recorded for 2 mo consecutively, before and during labeling.

RESULTS

Muffins sales (the higher-calorie item) fell by 30%, whereas sales of scones rose by 4%, a significant difference (χ² = 10.258; P = 0.0014).

CONCLUSIONS

Calorie labeling is effective when noticed. Wider adoption of calorie labeling for all food businesses and strengthening legislation with formatting guidelines should be the next step in public health policy.

The Effect of Energy Labelling on Menus and a Social Marketing Campaign on Food-Purchasing Behaviours of University Students

Background

This study assessed the impact of kilojoule (kJ) labelling alone or accompanied by a social marketing campaign on food sales and selection of less energy-dense meals by young adults from a university food outlet.

Methods

There were two kJ labelling intervention phases each of five weeks: (1) kJ labelling alone (2) kJ labels with marketing materials (“8700 kJ campaign”). Food sales of labelled items were tracked during each intervention and five weeks after. Food sales during interventions were also compared with historical sales of foods in the same 10-week period in the previous year. A sub sample of young adults (n = 713; aged 19–24) were surveyed during both the interventions to assess awareness, influence, sentiment and anticipated future impact of kJ labels and the social marketing campaign respectively.

Results

There were no differences in sales between the kJ labelling with social marketing and the 5-weeks of labelling before and after. The percentage sale of chicken Caesar burger (3580 kJ, P = 0.01), steak and chips (4000 kJ, P = 0.02) and the grill burger (5500 kJ, P = 0.00) were lower in the year with menu labelling and social marketing campaign. Only 30 % students were initially aware of the kJ labels on the menu but 75 % of students were accepting of kJ labelling, after they were made aware. Respondents viewing the marketing campaign elements and then using kJ values on the menu selected meals with a lower mean energy content; constituting a reduction of 978 kJ (p < 0.01) even though the majority claimed that the 8700 kJ campaign would not impact their food choices.

Conclusions

Point-of-purchase energy labelling may be an effective method to encourage better food choices when eating out among young adults. However, further efforts to increase awareness and provide education about energy requirements to prevent weight gain will be needed.

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.