Adolescents' awareness and use of menu labels in eating establishments: results from a focus group study

Food for thought: Reinforced learning and recall of physical activity calorie equivalent (PACE) and numerical calorie content in an associative learning task

Calorie overconsumption has been proposed as a critical contributing factor to rising obesity rates. To combat this health issue, governments and policymakers have suggested implementing numerical caloric content labels. Alternatively, physical activity calorie equivalent (PACE) labels are being proposed as an easier-to-understand metric, representing the amount of physical activity required to burn off calorie content. This study examined individuals' ability to correctly estimate either the numerical caloric content or the PACE values of food images in an associative learning task. Moreover, it assessed whether this knowledge was learned and retained over time. One hundred and ninety-one participants were instructed to estimate either the numerical caloric content or PACE values of thirty food images. To facilitate learning, feedback on the correct number of calories or PACE values was provided during the first session (Time 1). To assess retention, people re-estimated numerical caloric content or PACE values of the same food pictures three days later (Time 2) and seven days later (Time 3), where feedback was not provided. Results showed that participants in both groups improved their estimations using feedback, with people being consistently more accurate when estimating numerical calorie content. Yet, our results also suggest that participants consolidated their knowledge of PACE values over time. Finally, our findings show that hunger moderates individuals' estimation ability, where hungrier people are less accurate than satiated ones. The results contribute to our understanding of how consumers process, estimate, and learn PACE labels versus numerical caloric content, and provide valuable information for researchers and policymakers to develop and implement nutritional labels as a health strategy.

Examining young people's views and understanding of traffic light and physical activity calorie equivalent (PACE) food labels

BACKGROUND

Childhood obesity is a public health challenge in many countries. Food labelling may help children make healthier food choices. Food is typically labelled using the traffic light label system but this is complex to understand. Physical activity calorie equivalent (PACE) labelling may be easier for children to understand and more appealing because it contextualises the energy content of food/drinks.

METHODS

A cross-sectional online questionnaire was completed by 808 adolescents aged 12-18 years in England. The questionnaire investigated participants' views and understanding of traffic light and PACE labels. Participants were also asked about their understanding of the meaning of calories. The questionnaire explored participants' views about the potential frequency of use of PACE labels and their perceived usefulness in influencing purchasing and consumption decisions. Questions that explored participants' views about the possible implementation of PACE labelling, preferences for food settings and types of food/drinks they may like such labelling implemented, and whether PACE labels would encourage physical activity were included. Descriptive statistics were explored. Analyses assessed associations between variables and tested differences in the proportions of views about the labels.

RESULTS

More participants reported PACE labels as easier to understand than traffic light labels (69% vs 31%). Of participants who had seen traffic light labels, 19% looked at them often/always. Forty-two percent of participants would look at PACE labels often/always. The most common reason why participants never/would never look at food labels is because they are not interested in making healthy choices. Fifty-two percent of participants said PACE labels would make it easier for them to choose healthy food and drinks. Fifty percent of participants reported PACE labels would encourage them to be physically active. It was perceived that PACE labels could be useful in a range of food settings and on a range of food/drinks.

CONCLUSIONS

PACE labelling may be easier for young people to understand and more appealing/useful to them than traffic light labelling. PACE labelling may help young people choose healthier food/drinks and reduce excess energy consumption. Research is now needed to understand the impact of PACE labelling on food choice among adolescents in real eating settings.

Family Facilitators of, Barriers to and Strategies for Healthy Eating among Chinese Adolescents: Qualitative Interviews with Parent-Adolescent Dyads

Healthy eating is vital in preventing obesity and long-term non-communicable diseases. This study explores potential family facilitators of, barriers to and strategies for healthy eating among adolescents in Chinese families to guide the development of effective interventions in the future. Parent-adolescent dyads were purposively sampled by age, gender, fruit and vegetable intake and household income. Key family factors were identified by thematic analysis. Fourteen themes under five domains were identified: family health with (1) illness experienced in the family; parental knowledge of (2) dietary recommendations, (3) the preparation of healthy food and (4) healthy food choice; parental attitudes towards (5) the importance of healthy eating and (6) the priority of family health; socioeconomic factors of (7) time concerns and (8) cost concerns; and food parenting practices in (9) nutritional education, (10) role modeling, (11) food provision, (12) child involvement, (13) parental supervision and (14) the cultivation of food preference. Useful strategies included incorporating healthy ingredients in adolescents' favorite recipes and providing a variety of fruit and vegetables at home. There is a need to empower parents with practical nutrition knowledge, to be more authoritative in food parenting practices, to discuss healthy eating with children and to acquire practical skills related to time- and cost-saving healthy cooking.

Adolescent Knowledge, Attitudes and Practices of Healthy Eating: Findings of Qualitative Interviews among Hong Kong Families

To tackle unhealthy eating among adolescents, it is crucial to understand the dietary knowledge, attitudes, and practices (KAP) on which adolescent eating habits are based. This qualitative study identifies the gaps in KAP by exploring what Chinese adolescents know, perceive, and practice regarding healthy eating to better inform targeted interventions for this important health problem. Parent–adolescent dyads were purposively sampled based on, for example, the dietary intake, age, and gender of the adolescent and household income, and each completed a 30 to 60 min interview. Twelve themes were synthesized: knowledge: (1) dietary recommendations, (2) health outcomes of healthy eating, (3) nutrition content in food, and (4) access to healthy meals; attitudes: (5) outcome expectation for healthy eating, (6) food preferences, and (7) self-efficacy regarding adopting healthy eating; and practices: (8) going grocery shopping for healthy food, (9) eating home-prepared meals. (10) eating out in restaurants or consuming takeaway food, (11) fruit and vegetable consumption, and (12) snacking, perceived unhealthy eating to be low risk, made unhealthy choices regarding snacking and eating out, and had insufficient fruit and vegetable intake. Programs should emphasize the positive short-term health outcomes of healthy eating and empower adolescents to acquire food preparation skills to sustain healthy eating habits.

The Negative Effects of Long Time Physical Activity Calorie Equivalent Labeling on Purchase Intention for Unhealthy Food

(1) Background: Obesity has become a global epidemic that arouse much attention from governments, companies and scholar. Physical activity calorie equivalent (PACE) labels are introduced as a more effective nudge invention on less-calorie ordering. However, the effects of PACE labels are controversial in previous literature, thus, the research objective is to explore the effects of different PACE labels and furtherly to explore the underlying psychological mechanism; (2) Methods: Across four scenario-based experiments, involving potato chips, chocolate and cookies, this study manipulated the three calorie-information labeling (standard calorie label, long time PACE and short time PACE labels). Meanwhile, the mediating mechanism of the effects involving anticipatory guilt and the moderation effects between consumers’ future self-continuity and PACE labels are also measured; (3) Results: Results show that compared with the short time PACE and calorie labels, the longtime PACE labels have more negative influence on consumers’ purchase intention for unhealthy food. What’s more, the anticipatory guilt has negative effect of PACE labels as consumers are often prone to feeling guilty in the process of unhealthy food consumption. In addition, individuals with high future self-continuity have higher self-control and take more consideration of future outcomes, they are reluctant to choose unhealthy food than others; (4) Conclusions: Unhealthy food with a long time PACE label has more negative effect on consumers’ purchase intention rather than a short time PACE label. At the same time, companies that produce healthy foods should actively participate in the movement to label calories through the PACE labels.

Should physical activity calorie equivalent (PACE) labelling be introduced on food labels and menus to reduce excessive calorie consumption? Issues and opportunities

PACE food labelling seeks to provide kilocalorie information with an interpretation of what the kilocalorie content of the food item or meal means for energy expenditure. For example, "the kilocalories in this pizza require 110 minutes of walking to expend". Displaying calorie content in an easily understandable format is important given evidence indicating that the public consistently underestimate the energy content of food when labelling is not provided. Evidence from systematic reviews and trials testing the effects of PACE labelling point to the possible benefits of inclusion on food labels and menus. However, several criticisms of this labelling system have been raised. This commentary explores both the issues and opportunities related to PACE food labelling, arguing that the benefits of implementation outweigh potential unintended consequences.

The Differential Effects of Physical Activity Calorie Equivalent Labeling on Consumer Preferences for Healthy and Unhealthy Food Products: Evidence from a Choice Experiment

Background: Since numerical calorie labels have limited effects on less-calorie food ordering, an alternative called physical activity calorie equivalent (PACE) labels, which exhibit calories using visible symbols and the minutes of exercise to burn off the calories, may be more effective in reducing calories ordered. Methods: By using a choice experiment (CE) approach, the aims of this study were to estimate the effects of PACE labels on consumer preferences for healthy and unhealth food. Red date walnuts and potato chips were used as the representatives of healthy and unhealthy foods respectively in this study. Moreover, future time perspective (FTP) is an individual trait variable of consumers, which has been recognized as a significant driver of healthy behaviors. We also included FTP into the interaction with PACE labels. Results: Firstly, the results were opposite between the healthy and unhealthy food groups. Respondents showed significantly more positive attitudes toward red date walnuts (i.e., healthy food) with PACE labels, while they showed significantly more negative preferences for chips (i.e., unhealthy food) with PACE labels. Secondly, people with higher FTP are preferred red date walnuts with PACE labels, while PACE labels on chips could undermine the preferences of respondents with higher FTP. Thirdly, we found that women (vs. men) were less inclined to choose healthy food with standard calorie labels and labels showing the minutes of running to burn off the calories, as well as that the elderly (vs. younger) people in the healthy food group preferred the labels showing the minutes of running to burn off the calories. People with a higher body mass index (BMI) were reluctant to purchase walnuts with the information about the minutes of walking. Conclusions: Results from this study showed that PACE labels have significant effects on consumers’ preferences for food products.

A Qualitative Study of Parents With Children 6 to 12 Years Old: Use of Restaurant Calorie Labels to Inform the Development of a Messaging Campaign

BACKGROUND

US law mandates that chain restaurants with 20 or more locations post calorie information on their menus to inform consumers and encourage healthy choices. Few qualitative studies have assessed how parents perceive and use this information when ordering for their children and what types of accompanying messages might increase use of calorie labels when ordering food.

OBJECTIVE

We aimed to better understand parents' perceptions and use of calorie labeling and the types of messages that might increase use.

DESIGN

We conducted 10 focus groups (n = 58) and 20 shop-along interviews (n = 20). Focus group participants discussed their hypothetical orders and restaurant experiences when dining with their children, and shop-along participants verbalized their decision processes while ordering at a restaurant. Both groups gave feedback on 4 public service messages aimed to increase healthier ordering for children. All interviews were voice-recorded and transcribed.

PARTICIPANTS/SETTING

Participants were primary caregivers of at least 1 child between 6 and 12 years who reported having less than a college education at the time of screening and who commonly ate at chain restaurants. Focus groups were conducted in a conference room, and shop-alongs were conducted in quick-serve and full-service chain restaurants around Philadelphia between August 2016 and May 2017.

ANALYSES

A modified grounded theory approach was used to extract themes from transcripts.

RESULTS

Thematic analysis of transcripts revealed 5 key themes: (1) parents' use of calorie labels; (2) differences across restaurant settings; (3) nonjudgmental information; (4) financial value and enjoyment of food; and (5) message preferences. These themes suggested that nonjudgmental, fact-based messages that highlight financial value, feelings of fullness, and easy meal component swaps without giving up the treatlike aspect of eating out may be particularly helpful for consumers.

CONCLUSIONS

These findings can inform current US Food and Drug Administration campaign efforts to support consumer use of calorie labels on menus.

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.

Effects of physical activity calorie equivalent food labelling to reduce food selection and consumption: systematic review and meta-analysis of randomised controlled studies

Background

There is limited evidence that nutritional labelling on food/drinks is changing eating behaviours. Physical activity calorie equivalent (PACE) food labelling aims to provide the public with information about the amount of physical activity required to expend the number of kilocalories in food/drinks (eg, calories in this pizza requires 45 min of running to burn), to encourage healthier food choices and reduce disease.

Objective

We aimed to systematically search for randomised controlled trials and experimental studies of the effects of PACE food labelling on the selection, purchase or consumption of food/drinks.

Methods

PACE food labelling was compared with any other type of food labelling or no labelling (comparator). Reports were identified by searching electronic databases, websites and social media platforms. Inverse variance meta-analysis was used to summarise evidence. Weighted mean differences (WMD) and 95% CIs were used to describe between-group differences using a random effects model.

Results

15 studies were eligible for inclusion. When PACE labelling was displayed on food/drinks and menus, significantly fewer calories were selected, relative to comparator labelling (WMD=−64.9 kcal, 95% CI −103.2 to −26.6, p=0.009, n=4606). Presenting participants with PACE food labelling results in the consumption of significantly fewer calories (WMD=−80.4 kcal, 95% CI−136.7 to −24.2, p=0.005, n=486) relative to comparator food labelling.

Conclusion

Based on current evidence PACE food labelling may reduce the number of kilocalories selected from menus and decrease the number of kilocalories/grams of food consumed by the public, compared with other types of food labelling/no labelling.

Trial registration number

CRD42018088567.

Adolescent obesity in the past decade: A systematic review of genetics and determinants of food choice

Background and purpose:

As the incidence of global obesity increases, concerns about adverse health outcomes in adolescents continues to rise. The complexity and expense of this problem require early recognition and specific preventive treatments. Knowledge of genetics and determinants of food choices contributing to adolescent obesity warrants further examination. The primary goal was to appraise the literature from the past decade (2007–2017) on the current state of food choice and genetic determinants of adolescent overweight/obesity in the United States. The secondary goal was to determine trends in the literature and areas for future research.

Methods:

A systematic review of research studies in the United States from 2007 to 2017 was completed. Database searches were conducted using CINAHL, Embase, PsycINFO, PsycArticles, PubMed, Scopus, Academic Search Complete, Web of Science, BIOSIS, and the Cochrane Library. A total of 535 studies were selected. Of these, 283 studies focused on determinants of food choices and 165 studies focused on genetic factors.

Conclusions:

A total of 41 full-text articles included in this literature review contained studies limited exclusively to adolescents. Stress factors related to food choices demonstrated a new trend being explored. The need for precision health, the application of genetic information, could uncover ways food choices affect adolescent obesity.

Implications for practice:

The etiology of adolescent obesity requires that nurses gain knowledge of genetics and food choice determinants to inform personalized treatments for adolescents, which may establish effective interventions that promote healthy weight achievement.

Progress Evaluation for the Restaurant Industry Assessed by a Voluntary Marketing-Mix and Choice-Architecture Framework That Offers Strategies to Nudge American Customers toward Healthy Food Environments, 2006-2017

Consumption of restaurant food and beverage products high in fat, sugar and sodium contribute to obesity and non-communicable diseases. We evaluated restaurant-sector progress to promote healthy food environments for Americans. We conducted a desk review of seven electronic databases (January 2006-January 2017) to examine restaurant strategies used to promote healthful options in the United States (U.S.). Evidence selection (n = 84) was guided by the LEAD principles (i.e., locate, evaluate, and assemble evidence to inform decisions) and verified by data and investigator triangulation. A marketing-mix and choice-architecture framework was used to examine eight voluntary strategies (i.e., place, profile, portion, pricing, promotion, healthy default picks, priming or prompting and proximity) to evaluate progress (i.e., no, limited, some or extensive) toward 12 performance metrics based on available published evidence. The U.S. restaurant sector has made limited progress to use pricing, profile (reformulation), healthy default picks (choices), promotion (responsible marketing) and priming and prompting (information and labeling); and some progress to reduce portions. No evidence was available to assess progress for place (ambience) and proximity (positioning) to promote healthy choices during the 10-year review period. Chain and non-chain restaurants can apply comprehensive marketing-mix and nudge strategies to promote healthy food environments for customers.

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

Introduction:

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

School-Based Interventions to Reduce Obesity Risk in Children in High- and Middle-Income Countries

School-based interventions are relatively new and were first introduced in the United States in the 1990s. Early programs were mainly education based with many of the findings now embedded in school policy in the form of a healthy eating curriculum. More recent school programs have taken education outside the classroom and attempted to engage parents as well as teachers. Environmental changes such as improving the quality of foods available at lunchtime and at other times during the school day are now common. Reviews of evaluations of school-based programs have demonstrated that they are effective and successfully improve dietary quality such as increasing fruit and vegetable intake and decreasing sweet and savory snacks and sweetened drinks; not just in school but over the whole day and particularly in younger school children. School-based interventions are also effective at reducing obesity if components to increase physical activity and reduce sedentary behaviors are also targeted but not if only dietary behaviors are tackled. Most of the high-quality evaluation studies using randomized controlled trials have been carried out in high-income countries as they are costly to run. However, middle-income countries have benefitted from the information available from these evaluation studies and many are now starting to fund and evaluate school-based programs themselves, resulting in unique problems such as concomitant under- and overnutrition being addressed. Action for the future demands more focus on populations most at risk of poor dietary quality and obesity in order to reduce inequalities in health and on adolescents who have not benefited as much as younger children from school-based interventions. This will involve innovative solutions within schools as well as targeting the food environment outside schools such as reducing the density of fast-food outlets and marketing of sweet and savory snacks and drinks.