The influence of recipe modification and nutritional information on restaurant food acceptance and macronutrient intakes

A Meta-Analysis of Food Labeling Effects on Consumer Diet Behaviors and Industry Practices

CONTEXT

The influence of food and beverage labeling (food labeling) on consumer behaviors, industry responses, and health outcomes is not well established.

EVIDENCE ACQUISITION

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Ten databases were searched in 2014 for studies published after 1990 evaluating food labeling and consumer purchases/orders, intakes, metabolic risk factors, and industry responses. Data extractions were performed independently and in duplicate. Studies were pooled using inverse-variance random effects meta-analysis. Heterogeneity was explored with I2, stratified analyses, and meta-regression; and publication bias was assessed with funnel plots, Begg's tests, and Egger's tests. Analyses were completed in 2017.

EVIDENCE SYNTHESIS

From 6,232 articles, a total of 60 studies were identified, including 2 million observations across 111 intervention arms in 11 countries. Food labeling decreased consumer intakes of energy by 6.6% (95% CI= -8.8%, -4.4%, n=31), total fat by 10.6% (95% CI= -17.7%, -3.5%, n=13), and other unhealthy dietary options by 13.0% (95% CI= -25.7%, -0.2%, n=16), while increasing vegetable consumption by 13.5% (95% CI=2.4%, 24.6%, n=5). Evaluating industry responses, labeling decreased product contents of sodium by 8.9% (95% CI= -17.3%, -0.6%, n=4) and artificial trans fat by 64.3% (95% CI= -91.1%, -37.5%, n=3). No significant heterogeneity was identified by label placement or type, duration, labeled product, region, population, voluntary or legislative approaches, combined intervention components, study design, or quality. Evidence for publication bias was not identified.

CONCLUSIONS

From reviewing 60 intervention studies, food labeling reduces consumer dietary intake of selected nutrients and influences industry practices to reduce product contents of sodium and artificial trans fat.

A Meta-Analysis to Determine the Impact of Restaurant Menu Labeling on Calories and Nutrients (Ordered or Consumed) in U.S. Adults

A systematic review and meta-analysis determined the effect of restaurant menu labeling on calories and nutrients chosen in laboratory and away-from-home settings in U.S. adults. Cochrane-based criteria adherent, peer-reviewed study designs conducted and published in the English language from 1950 to 2014 were collected in 2015, analyzed in 2016, and used to evaluate the effect of nutrition labeling on calories and nutrients ordered or consumed. Before and after menu labeling outcomes were used to determine weighted mean differences in calories, saturated fat, total fat, carbohydrate, and sodium ordered/consumed which were pooled across studies using random effects modeling. Stratified analysis for laboratory and away-from-home settings were also completed. Menu labeling resulted in no significant change in reported calories ordered/consumed in studies with full criteria adherence, nor the 14 studies analyzed with ≤1 unmet criteria, nor for change in total ordered carbohydrate, fat, and saturated fat (three studies) or ordered or consumed sodium (four studies). A significant reduction of 115.2 calories ordered/consumed in laboratory settings was determined when analyses were stratified by study setting. Menu labeling away-from-home did not result in change in quantity or quality, specifically for carbohydrates, total fat, saturated fat, or sodium, of calories consumed among U.S. adults.

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.

Reducing calories, fat, saturated fat, and sodium in restaurant menu items: Effects on consumer acceptance

OBJECTIVE

To assess consumer acceptance of reductions of calories, fat, saturated fat, and sodium to current restaurant recipes.

METHODS

Twenty-four menu items, from six restaurant chains, were slightly modified and moderately modified by reducing targeted ingredients. Restaurant customers (n = 1,838) were recruited for a taste test and were blinded to the recipe version as well as the purpose of the study. Overall consumer acceptance was measured using a 9-point hedonic (like/dislike) scale, likelihood to purchase scale, Just-About-Right (JAR) 5-point scale, penalty analysis, and alienation analysis.

RESULTS

Overall, modified recipes of 19 menu items were scored similar to (or better than) their respective current versions. Eleven menu items were found to be acceptable in the slightly modified recipe version, and eight menu items were found to be acceptable in the moderately modified recipe version. Acceptable ingredient modifications resulted in a reduction of up to 26% in calories and a reduction of up to 31% in sodium per serving.

CONCLUSIONS

The majority of restaurant menu items with small reductions of calories, fat, saturated fat, and sodium were acceptable. Given the frequency of eating foods away from home, these reductions could be effective in creating dietary improvements for restaurant diners.

Impact of nutritional labelling on 10-d energy intake, appetite perceptions and attitudes towards food

The purpose of this study was to investigate the impact of nutritional labelling on energy intake, appetite perceptions and attitudes towards food. During a 10-d period, seventy normal-weight (BMI<25 kg/m2) and seventy-one obese women (BMI≥30 kg/m2) were given three meals per d under ad libitum conditions. Participants were randomly assigned to one of three experimental labelling groups in which the only difference was the label posted on lunch meal entrée: (1) low-fat label, (2) energy label (energy content of the entrée and average daily needs) and (3) no label (control). Average energy intake was calculated by weighing all foods before v. after daily consumption. Hunger and fullness perceptions were rated on visual analogue scales immediately before and after each meal. Satiety efficiency was assessed through the calculation of the satiety quotient (SQ). The appreciation and perceived healthiness of the lunch entrées were rated on eight-point Likert scales. There was no difference in energy intake, SQ and attitudes towards food between the three labelling groups. Fasting hunger perception was higher in the low-fat label group compared with the two others groups (P=0·0037). No interactions between labelling groups and BMI categories were observed. In conclusion, although labelling does not seem to influence energy intake, a low-fat label may increase women’s fasting hunger perceptions compared with an energy label or no label.

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.

A randomized trial of calorie labeling on menus

BACKGROUND

Food consumed outside the home accounts for a growing proportion of the North American diet and has been associated with increased obesity.

PURPOSE

To examine the effect of nutrition labeling on menus on awareness, use, and food consumption, including the impact of "traffic light" labeling and adding other nutrients.

METHODS

Blinded, randomized trial with 635 Canadian adults conducted in 2010-2011. Participants ordered a free meal from one of four experimental menus: 1) no nutritional information shown, 2) calorie amounts only, 3) calorie amounts in "traffic lights", and 4) calorie, fat, sodium, and sugar shown in "traffic lights". Recall of nutrition information, knowledge of calorie content and nutrient consumption were assessed.

RESULTS

Participants in the calorie conditions were more likely to recall the calorie content of meals and to report using nutrition information when ordering. The calorie content of meals was not significantly different across conditions; however, calorie consumption was significantly lower among participants in the Calorie-only condition compared to the No information condition (mean=-96 kcal, p=.048).

CONCLUSIONS

Menu labeling increased awareness and use of nutrition information and reduced consumption. Adding "traffic lights", fat, sodium, and sugar amounts to menus had little impact compared to calorie-only labeling.

Evaluating the impact of menu labeling on food choices and intake

OBJECTIVES

We assessed the impact of restaurant menu calorie labels on food choices and intake.

METHODS

Participants in a study dinner (n=303) were randomly assigned to either (1) a menu without calorie labels (no calorie labels), (2) a menu with calorie labels (calorie labels), or (3) a menu with calorie labels and a label stating the recommended daily caloric intake for an average adult (calorie labels plus information). Food choices and intake during and after the study dinner were measured.

RESULTS

Participants in both calorie label conditions ordered fewer calories than those in the no calorie labels condition. When calorie label conditions were combined, that group consumed 14% fewer calories than the no calorie labels group. Individuals in the calorie labels condition consumed more calories after the study dinner than those in both other conditions. When calories consumed during and after the study dinner were combined, participants in the calorie labels plus information group consumed an average of 250 fewer calories than those in the other groups.

CONCLUSIONS

Calorie labels on restaurant menus impacted food choices and intake; adding a recommended daily caloric requirement label increased this effect, suggesting menu label legislation should require such a label. Future research should evaluate menu labeling's impact on children's food choices and consumption.

Rationale and evidence for menu-labeling legislation

Menu-labeling legislation is a proposed public health intervention for poor diet and obesity that requires chain restaurants to provide nutrition information on menus and menu boards. The restaurant industry has strongly opposed menu-labeling legislation. Using scientific evidence, this paper counters industry arguments against menu labeling by demonstrating that consumers want chain restaurant nutrition information to be disclosed; the current methods of providing nutrition information are inadequate; the expense of providing nutrition information is minimal; the government has the legal right to mandate disclosure of information; consumers have the right to know nutrition information; a lack of information reduces the efficiency of a market economy; and menu labeling has the potential to make a positive public health impact.

Effects of calorie labeling and value size pricing on fast food meal choices: results from an experimental trial

BACKGROUND

Although point-of-purchase calorie labeling at restaurants has been proposed as a strategy for improving consumer food choices, a limited number of studies have evaluated this approach. Likewise, little research has been conducted to evaluate the influence of value size pricing on restaurant meal choices.

METHODS

To examine the effect of point-of-purchase calorie information and value size pricing on fast food meal choices a randomized 2 x 2 factorial experiment was conducted in which participants ordered a fast food meal from one of four menus that varied with respect to whether calorie information was provided and whether value size pricing was used. Study participants included 594 adolescents and adults who regularly ate at fast food restaurants. Study staff recorded the foods ordered and consumed by each participant. Participants also completed surveys to assess attitudes, beliefs and practices related to fast food and nutrition.

RESULTS

No significant differences in the energy composition of meals ordered or eaten were found between menu conditions. The average energy content of meals ordered by those randomized to a menu that included calorie information and did not include value size pricing was 842 kcals compared with 827 kcals for those who ordered their meal from a menu that did not include calorie information but had value size pricing (control menu). Results were similar in most analyses conducted stratified by factors such as age, race and education level.

CONCLUSION

Additional research is needed to better evaluate the effects of calorie labeling and value size pricing on fast food meal choices. Studies in which participants are repeatedly exposed to these factors are needed since long term exposure may be required for behavior change.

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

OBJECTIVES

To understand consumer (1) interest in nutrition information on food labels and quick-service restaurant menu boards and (2) reactions to modifying this information to help highlight calories and more healthful choices.

DESIGN

Eight consumer focus groups, using a guide and stimuli.

SETTING

Focus group discussions in 4 US cities.

PARTICIPANTS

A total of 68 consumers, with 7 to 10 per focus group.

ANALYSIS

Authors prepared detailed summaries of discussions based on observation. Video recordings and transcripts were used to cross-check summaries. Data were systematically reviewed, synthesized, and analyzed.

PHENOMENON OF INTEREST

Consumer views on alternative presentations of nutrition information on packaged food items and quick-service restaurant menu boards.

RESULTS

Participants (1) were interested in having nutrition information available, but would not use it at every eating occasion; (2) thought that food products typically consumed at 1 eating occasion should be labeled as a single serving; and (3) indicated that an icon on labels and menu boards that signaled more healthful options could be helpful.

CONCLUSIONS AND IMPLICATIONS

Findings provide a basis for the development of more systematic studies to better understand whether alternative presentations of nutrition information would help consumers.

Comparison of buffet and à la carte serving at worksite canteens on nutrient intake and fruit and vegetable consumption

OBJECTIVE

To evaluate the nutritional composition of worksite canteen lunches and to examine the impact of two meal serving systems on employee intake, i.e. buffet style with a fixed price for a varied number of dishes and à la carte style with a separate price for each item on the menu.

DESIGN

Laboratory technicians observed employees' food selection and collected identical dishes. Food items were weighed separately to calculate the content of fruit and vegetables. The content of protein, fat and ash of each dish was chemically analysed and the carbohydrate and energy content calculated.

SETTING

Fifteen randomly chosen worksite canteens in Denmark: eight canteens serving buffet style and seven canteens with an à la carte line.

SUBJECTS

one hundred and eighty randomly chosen employees having lunch at the worksite canteens.

RESULTS

The average percentage energy from fat was 37 +/- 12 among men and 33 +/- 12 among women. No association was found between the meal serving system and energy intake or macronutrient composition. Eating at canteens serving buffet style, on the other hand, was associated with an increased intake of fruit and vegetables, on average 76 g, and a lower energy density of the food for both genders.

CONCLUSION

The results highlight the possibilities of promoting healthy food choices in the catering sector and the need to identify models of healthy catering practice. Serving buffet style appears to be a promising strategy in order to increase fruit and vegetable consumption in food served away from home.

Portion sizes and the obesity epidemic

The rise in obesity rates over the past 30 y has been paralleled by increases in the portion size of many foods and the prevalence of eating away from home. Foods of particular concern are those that have a high energy density (kJ/g). Many well-controlled, laboratory-based studies have found that large portions of energy-dense foods can lead to excess energy intakes. This influence of large portions on energy intake has been supported by data collected in naturalistic settings. Further research is needed to explore strategies that can be used to moderate the effects of portion size on food consumption. One promising strategy is to reduce the energy density of foods, while maintaining food weight or volume, so that consumers can eat satisfying portions while reducing their energy intakes. There is a need for effective educational messages that not only emphasize limiting the consumption of foods high in energy density, but also encourage the consumption of those with a low energy density, such as fruits and vegetables. The delivery of consistent messages will require more cooperation among the food and restaurant industries, policy makers, and scientists. Effective strategies will also require consumers to understand and accept the importance of eating reasonable portions for better health.

Pros and cons of proposed interventions to promote healthy eating

The increased prevalence and costs associated with the obesity epidemic have made preventive efforts a public health priority. Public health has historically relied on a series of targeted regulations, taxes, and education efforts to curb epidemics, and will rely on similar strategies to combat obesity. We argue that interventions targeted at youth are relatively easy to justify on economic grounds due to the additional protections that this group requires, but that justification for government interventions aimed at curbing obesity among adults requires additional evidence that private markets are not functioning properly. We then present seven proposed intervention strategies to promote healthy eating, and use an economic framework to discuss the relative merits of the interventions. This evaluation will allow policymakers to make more informed decisions concerning the relative merits of these strategies in combating the obesity epidemic.

Effects of repeated exposure and health-related information on hedonic evaluation and acceptance of a bitter beverage

The influence of exposure and information on sensory evaluation and acceptance of bitter flavor was assessed. Following sensory testing in the laboratory, subjects consumed a commercially-available bittersweet beverage once daily for 7days in a setting of their choosing, then returned to the laboratory for post-exposure tests. Hedonic ratings for the beverage increased by 68%, whereas ratings for control stimuli sampled only in the laboratory did not change. Following exposure, relationships of hedonic ratings with intensity and familiarity varied according to the context in which evaluations were made: hedonic ratings were correlated with intensity in a familiar setting and with familiarity in an unfamiliar setting. Health-related information had no effect on perceptual changes that accompanied exposure, but did tend to increase a behavioral measure of acceptability, suggesting that information may have a greater effect on behavior than on hedonics. Together, the data suggest that repeated exposure can enhance hedonic evaluation of a bittersweet beverage, perhaps through a learned association of flavor with post-ingestive consequences. Context may mediate this effect and studies addressing the influence of information on bitter food acceptance should include measures of consumption and evaluate information strategies, as bitter foods may be particularly resistant to cognitively-based appeals.

The Supersizing of America: Portion Size and the Obesity Epidemic

Although we are just beginning to understand how environmental factors such as portion size affect eating behavior, the available data suggest that large portions of energy-dense foods are contributing to the obesity epidemic. Several possible strategies for adjusting portions to bring intake back in line with energy requirements are discussed. The continuing rise in the rates of obesity calls for urgent action.