Supplementing menu labeling with calorie recommendations to test for facilitation effects

Prevalence of menu label use and its association with calorie intake among US adults

The 2018 Federal Menu Labeling regulations require restaurants and similar retail food establishments that are part of a chain with 20 or more locations to provide calorie and other nutrition information for standard menu items. In this study, we describe the sociodemographic correlates of prevalence of menu label use at Food-Away-From-Home (FAFH) establishments and estimate the association between menu label use and calorie intake. We use nationally representative data spanning the years 2007-2018 and multivariable logit regression and ordinary least squares regression models. For FAFH establishments, we find that female respondents have about 26% (95% CI = [1.14, 1.39]) higher odds of using menu labels. Respondents with high school degree have 51 percent higher odds (95% CI = [1.24, 1.85]), respondents with some college education have 107 percent higher odds (95% CI = [1.74, 2.47]) of seeing menu labels. Higher income is associated with 12% (95% CI = [1.08, 1.15]) greater odds of seeing menu labels. Hispanic respondents have 29% (95% CI = [0.62, 0.81]) lower odds of seeing and 79% (95% CI = [1.41, 2.29]) higher odds of using menu labels. Black respondents have 54% (95% CI = [1.35,1.75] higher odds of seeing menu labels at sit-down restaurants. Menu label users at fast-food restaurants reported consuming 202 kcal (95% CI = [-252,-153]) fewer total calories than nonusers and menu label users at sit-down restaurants reported using 181 kcal (95% CI = [-256,-106]) fewer total calories than nonusers. Our findings highlight the sociodemographic disparities in menu label use and provide baseline estimates for future studies evaluating the federal menu labeling regulation.

Menu Labeling and Calories Purchased in Restaurants in a US National Fast Food Chain

Importance

Menu labeling has been implemented in restaurants in some US jurisdictions as early as 2008, but the extent to which menu labeling is associated with calories purchased is unclear.

Objective

To estimate the association of menu labeling with calories and nutrients purchased and assess geographic variation in results.

Design, Setting, and Participants

A cohort study was conducted with a quasi-experimental design using actual transaction data from Taco Bell restaurants from calendar years 2007 to 2014 US restaurants with menu labeling matched to comparison restaurants using synthetic control methods. Data were analyzed from May to October 2023.

Exposure

Menu labeling policies in 6 US jurisdictions.

Main Outcomes and Measures

The primary outcome was calories per transaction. Secondary outcomes included total and saturated fat, carbohydrates, protein, sugar, fiber, and sodium.

Results

The final sample included 2329 restaurants, with menu labeling in 474 (31 468 restaurant-month observations). Most restaurants (94.3%) were located in California. Difference-in-differences model results indicated that customers purchased 24.7 (95% CI, 23.6-25.7) fewer calories per transaction from restaurants in the menu labeling group in the 3- to 24-month follow-up period vs the comparison group, including 21.9 (95% CI, 20.9-22.9) fewer calories in the 3- to 12-month follow-up period and 25.0 (95% CI, 24.0-26.1) fewer calories in the 13- to 24-month follow-up period. Changes in the nutrient content of transactions were consistent with calorie estimates. Findings in California were similar to overall estimates in magnitude and direction; yet, among restaurants outside of California, no association was observed in the 3- to 24-month period. The outcome of menu labeling also differed by item category and time of day, with a larger decrease in the number of tacos vs other items purchased and a larger decrease in calories purchased during breakfast vs other times of the day in the 3- to 24-month period.

Conclusions and Relevance

In this quasi-experimental cohort study, fewer calories were purchased in restaurants with calorie labels compared with those with no labels, suggesting that consumers are sensitive to calorie information on menu boards, although associations differed by location.

A multi-country comparison of jurisdictions with and without mandatory nutrition labelling policies in restaurants: analysis of behaviours associated with menu labelling in the 2019 International Food Policy Study

OBJECTIVE

To examine differences in noticing and use of nutrition information comparing jurisdictions with and without mandatory menu labelling policies and examine differences among sociodemographic groups.

DESIGN

Cross-sectional data from the International Food Policy Study (IFPS) online survey.

SETTING

IFPS participants from Australia, Canada, Mexico, United Kingdom and USA in 2019.

PARTICIPANTS

Adults aged 18-99; n 19 393.

RESULTS

Participants in jurisdictions with mandatory policies were significantly more likely to notice and use nutrition information, order something different, eat less of their order and change restaurants compared to jurisdictions without policies. For noticed nutrition information, the differences between policy groups were greatest comparing older to younger age groups and comparing high education (difference of 10·7 %, 95 % CI 8·9, 12·6) to low education (difference of 4·1 %, 95 % CI 1·8, 6·3). For used nutrition information, differences were greatest comparing high education (difference of 4·9 %, 95 % CI 3·5, 6·4) to low education (difference of 1·8 %, 95 % CI 0·2, 3·5). Mandatory labelling was associated with an increase in ordering something different among the majority ethnicity group and a decrease among the minority ethnicity group. For changed restaurant visited, differences were greater for medium and high education compared to low education, and differences were greater for higher compared to lower income adequacy.

CONCLUSIONS

Participants living in jurisdictions with mandatory nutrition information in restaurants were more likely to report noticing and using nutrition information, as well as greater efforts to modify their consumption. However, the magnitudes of these differences were relatively small.

Inducing consumers to use calorie information: a multinational investigation

OBJECTIVE

We identify individuals who set daily intake budgets and examine if an intervention making people estimate their calorie intake up to a certain point in the day helps those setting daily budgets to regulate their calorie intake for the remainder of the day, after high prior consumption.

DESIGN

We conducted an online experiment in five countries: Australia, China, Germany, India, and the UK (n = 3,032) using a 2 (setting calorie budget: yes vs. no, measured) x 2 (intervention: intake reminder vs. control, manipulated) between-subjects design, with the amount of prior consumption measured. Participants were contacted in the afternoon. Those in the intervention condition were asked to estimate their prior calorie intake on that day.

MAIN OUTCOME MEASURES

We measured the individual characteristics of those who set daily calorie budgets and the intended calorie intake for the remainder of the day.

RESULTS

Among people who set daily calorie budgets, the intervention reduced intended calorie intake for the remainder of the day by 176 calories if they had already consumed a high amount of calories that day.

CONCLUSION

A timely intervention to estimate one's calorie intake can lower additional intended calorie intake among those who set daily calorie budget.

The Impact of Nutrition Labelling on Customer Buying Intention and Behaviours in Fast Food Operations: Some Implications for Public Health

This research examines customers’ intention to buy depending on their use of nutrition labelling (NL) in fast food operations (FFOs) and their intention to visit and recommend these FFOs with nutrition-labelled menus. The research model draws on the theory of planned behaviour (TPB) to examine customers’ intentions to buy from nutrition-labelled menus and their behaviour of visiting and recommending to others FFOs with nutrition-labelled menus. To achieve this purpose, a self-administrated questionnaire was distributed to and collected from a random sample of customers at FFOs in Greater Cairo, Egypt, i.e., McDonald’s and Subway. The results from the structural equation modelling (SEM) using AMOS software indicated positive and direct significant paths from the constructs of the TPB, except for customers’ attitude, to customer intention to buy nutrition-labelled menu items. The results also showed a positive significant impact of customers’ intention on their behaviour of visiting and recommending FFOs featuring nutrition-labelled menus. The findings showed that there is an awaking of nutritional awareness among fast-food customers and that providing nutritional information on fast-food menus will affect their purchasing intention in the future by encouraging them to make healthy food choices. Theoretical implications for scholars and managerial implications for FFOs, especially in relation to public health in general and healthy food choices in particular, are explained and discussed.

Systematic review of clinician-directed nudges in healthcare contexts

OBJECTIVE

Nudges are interventions that alter the way options are presented, enabling individuals to more easily select the best option. Health systems and researchers have tested nudges to shape clinician decision-making with the aim of improving healthcare service delivery. We aimed to systematically study the use and effectiveness of nudges designed to improve clinicians' decisions in healthcare settings.

DESIGN

A systematic review was conducted to collect and consolidate results from studies testing nudges and to determine whether nudges directed at improving clinical decisions in healthcare settings across clinician types were effective. We systematically searched seven databases (EBSCO MegaFILE, EconLit, Embase, PsycINFO, PubMed, Scopus and Web of Science) and used a snowball sampling technique to identify peer-reviewed published studies available between 1 January 1984 and 22 April 2020. Eligible studies were critically appraised and narratively synthesised. We categorised nudges according to a taxonomy derived from the Nuffield Council on Bioethics. Included studies were appraised using the Cochrane Risk of Bias Assessment Tool.

RESULTS

We screened 3608 studies and 39 studies met our criteria. The majority of the studies (90%) were conducted in the USA and 36% were randomised controlled trials. The most commonly studied nudge intervention (46%) framed information for clinicians, often through peer comparison feedback. Nudges that guided clinical decisions through default options or by enabling choice were also frequently studied (31%). Information framing, default and enabling choice nudges showed promise, whereas the effectiveness of other nudge types was mixed. Given the inclusion of non-experimental designs, only a small portion of studies were at minimal risk of bias (33%) across all Cochrane criteria.

CONCLUSIONS

Nudges that frame information, change default options or enable choice are frequently studied and show promise in improving clinical decision-making. Future work should examine how nudges compare to non-nudge interventions (eg, policy interventions) in improving healthcare.

Response of the public and restaurant owners to the mandatory menu energy-labelling implementation in restaurants in Saudi Arabia

OBJECTIVE

Mandatory menu energy-labelling policy in restaurants has received increasing attention worldwide as a useful tool for promoting balanced energy intake and encouraging healthier food selection to reduce obesity prevalence. Therefore, we aimed to evaluate the knowledge, views and observations of the public and restaurant owners towards the mandatory menu energy-labelling policy (introduced in August 2018) in restaurants in Saudi Arabia.

DESIGN

In February 2019, we conducted a cross-sectional study using an electronic questionnaire.

SETTING

Saudi Arabia.

PARTICIPANTS

Saudi individuals (n 1228) aged 18-80 years and forty-one restaurant owners.

RESULTS

Most participants identified the correct daily energetic requirements for moderately active men (51 %) and women (69 %), but not for inactive adults (36 %). Although 40 % reported adequate knowledge to select low-energetic meals and 55 % perceived the policy as useful, 51 % reported they would be less likely to eat at restaurants displaying energy. Most participants (76 %) mentioned they would choose lower-energetic meals, and 79 % would feel guilty after consuming high-energetic meals. Moreover, 62 % of participants reported that the new labelling policy affected their food selections, prompting them to order different food items, eat less, change restaurants or eat at restaurants less frequently. Among restaurant owners, half were aware of the reason for the implementation of this policy and supported this measure. However, they did not consider modifying recipes to reduce energy. Sales of low- and high-energetic meals increased and decreased in 44 % and 39 % of restaurants, respectively.

CONCLUSIONS

This policy may be an effective public health tool for promoting balanced energy intake and encouraging healthier food selection in Saudi Arabia.

A review of nutrition labeling and food choice in the United States

A proliferation of processed food and labeling claims motivated the Nutrition Labeling and Education Act of 1990, which mandated the Nutrition Facts Label. Providing nutrition information is often put forth as a way to change food choice; however, despite efforts to provide dietary information using nutrition labeling, more than a third of the US has obesity and portions of the population continue to under consume vital nutrients. There has been progress beyond the Nutrition Facts Label in recent years with front-of-package labeling and menu labeling, which is crucial given changes in consumption trends for food-away-from-home. Additionally, changes were recently made to the Nutrition Facts Label due to lack of awareness, understanding, and ability to effectively improve diet quality. This paper explores the literature to track the evolution of knowledge about attention to nutrition information and how nutrition information affects dietary choices.

Improving Cardiovascular Health through Nudging Healthier Food Choices: A Systematic Review

Obesity and metabolic syndrome are considered major public health problems, and their negative impact on cardiovascular disease (CVD) and diabetes mellitus type 2 (DM2) is profound. Targeting modifiable risk factors such as dietary habits is therefore of great importance. Many of today’s health challenges with overweight and obesity may have behavioral roots, and traditional methods such as regulations and campaigns are often insufficient to improve dietary choices. Nudging or choice architecture might be a viable tool to influence people’s everyday choices and behaviors to better outcomes. This paper reviews the current state of the rapidly expanding number of experimental field studies that investigate the effects/associations of nudging on healthy food choices. A systematic literature search was conducted in PubMed, where 142 citations were identified. Based on selection criteria, six randomized controlled trials and 15 non-randomized controlled trials were ultimately included. The results of this systematic review show that many of the studies included traffic-light labeling, which may be a promising strategy. The reviewed findings, however, also highlight the challenges that confront experimental studies examining the impact of nudging on diet.

The effect of ingredient-specific calorie information on calories ordered

Providing calorie labeling is a widely used strategy to combat obesity. However, there is little evidence that the availability of calorie information at food-away-from-home establishments has an effect on food choices. Listing calorie information for each ingredient, though, may allow customers to avoid high-calorie items that add little to their enjoyment. Data from a natural experiment were used to compare total calories ordered before and after the provision of per-ingredient versus for build-your-own sandwiches, and per-sandwich for pre-defined sandwiches, at a supermarket sandwich counter.

Sandwich order slips from a Lincoln, Neb. supermarket were collected from December 15, 2016 to February 4, 2018. In June 2017, calorie information was introduced. A total of 1134 build-your-own orders and 559 pre-defined orders were collected.

Calories ordered before and after the provision of calorie information were examined for build-your-own and pre-defined sandwiches using two-sample t-tests. Orders post-calorie information were split into three periods to examine whether responses to information changed over time. Ingredients ordered were also examined before and after information was provided.

Customers decrease calories ordered by 7.8% for build-your-own sandwiches when per-ingredient calorie information is introduced. There is no significant change in calories ordered for pre-defined sandwiches. Calorie reduction appears to result from substitution away from some higher calorie items, e.g., mayonnaise, towards lower calorie ingredients, like mustard. Despite low calorie content, customers did not increase the number of vegetables ordered. Finally, there is no attenuation of the effect of calorie information over time.

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Per-ingredient calorie information of sandwiches yields a significant decrease in calories ordered.

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Calorie decreases in per-ingredient orders persist over time.

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Customers substitute away from some high-calorie ingredients like mayo.

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Customers did not increase the number of vegetables ordered despite low calorie content.

Behavioral economics and diabetic eye exams

Diabetic retinopathy is a common microvascular complication of diabetes mellitus and is the leading cause of new blindness among working-age adults in the United States. Timely intervention to prevent vision loss is possible with early detection by regular eye examinations. Unfortunately, adherence to recommended annual diabetic eye exams is poor. Public health interventions have targeted traditional barriers to care, such as cost and transportation, with limited success. Behavioral economics provides an additional framework of concepts and tools to understand low screening rates and to promote regular diabetic eye exams for populations at risk. In particular, behavioral economics outlines biases and heuristics that affect decision-making and underlie pervasive barriers to care, such as not viewing diabetic eye exams as a priority or perceiving oneself as too healthy to need an examination. In this review, we examine the literature on the use of behavioral economics interventions to promote regular diabetic eye exams. From the results of the included studies, we outline how concepts from behavioral economics can improve eye examination rates. In particular, the default bias, present bias, and self-serving bias play a significant role in precluding regular diabetic eye examinations. Potential tools to mitigate these biases include leveraging default options, using reminder messages, providing behavioral coaching, applying commitment contracts, offering financial incentives, and personalizing health messages. When combined with traditional public health campaigns, insights from behavioral economics can improve understanding of pervasive barriers to care and offer additional strategies to promote regular preventive eye care for patients with diabetes.

The Effect of Graphic Warnings on Sugary-Drink Purchasing

Governments have proposed text warning labels to decrease consumption of sugary drinks-a contributor to chronic diseases such as diabetes. However, they may be less effective than more evocative, graphic warning labels. We field-tested the effectiveness of graphic warning labels (vs. text warning labels, calorie labels, and no labels), provided insight into psychological mechanisms driving effectiveness, and assessed consumer sentiment. Study 1 indicated that graphic warning labels reduced the share of sugary drinks purchased in a cafeteria from 21.4% at baseline to 18.2%-an effect driven by substitution of water for sugary drinks. Study 2 showed that graphic warning labels heighten negative affect and prompt consideration of health consequences. Study 3 indicated that public support for graphic warning labels can be increased by conveying effectiveness information. These findings could spur more effective labeling policies that facilitate healthier choices, do not decrease overall beverage purchases, and are publicly accepted.

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.

Parents' meal choices for their children at fast food and family restaurants with different menu labeling presentations

BACKGROUND/OBJECTIVES

This study examined the effect of nutrition labeling formats on parents' food choices for their children at different restaurant types.

SUBJECTS/METHODS

An online survey was conducted with 1,980 parents of children aged 3-12 years. Participants were randomly assigned to fast food or family restaurant scenarios, and one of four menu stimuli conditions: no labeling, low-calorie symbol (symbol), numeric value (numeric), and both low-calorie symbol and numeric value (symbol + numeric). Participants selected menu items for their children. Menu choices and total calories were compared by nutrition labeling formats in each type of the restaurant.

RESULTS

Low-calorie item selections were scored and a two-way analysis of variance (ANOVA) was conducted for an interaction effect between restaurant and labeling type. In the fast food restaurant group, parents presented with low-calorie symbols selected the lowest calorie items more often than those not presented with the format. Parents in the symbol + numeric condition selected significantly fewer calories (653 kcal) than those in the no labeling (677 kcal) or numeric conditions (674 kcal) (P = 0.006). In the family restaurant group, no significant difference were observed among different labeling conditions. A significant interaction between restaurant and labeling type on low-calorie selection score (F = 6.03, P < 0.01) suggests that the effect of nutrition labeling format interplays with restaurant type to jointly affect parents' food choices for their children.

CONCLUSIONS

The provision of easily interpretable nutritional information format at fast food restaurants may encourage healthier food choices of parents for their children; however, the effects were negligible at family restaurants.

A Systematic Review of Calorie Labeling and Modified Calorie Labeling Interventions: Impact on Consumer and Restaurant Behavior

OBJECTIVE

Evidence on the effects of restaurant calorie labeling on consumer and restaurant behavior is mixed. This paper examined: (1) consumer responses to calorie information alone or compared to modified calorie information and (2) changes in restaurant offerings following or in advance of menu labeling implementation.

METHODS

Searches were conducted in PubMed, Web of Science, Policy File, and PAIS International to identify restaurant calorie labeling studies through October 1, 2016, that measured calories ordered, consumed, or available for purchase on restaurant menus. The reference lists of calorie labeling articles were also searched.

RESULTS

Fifty-three studies were included: 18 in real-world restaurants, 9 in cafeterias, and 21 in laboratory or simulation settings. Five examined restaurant offerings.

CONCLUSIONS

Because of a lack of well-powered studies with strong designs, the degree to which menu labeling encourages lower-calorie purchases and whether that translates to a healthier population are unclear. Although there is limited evidence that menu labeling affects calories purchased at fast-food restaurants, some evidence demonstrates that it lowers calories purchased at certain types of restaurants and in cafeteria settings. The limited data on modified calorie labels find that such labels can encourage lower-calorie purchases but may not differ in effects relative to calorie labels alone.

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.

Targeted Calorie Message Promotes Healthy Beverage Consumption Better than Charity Incentive

OBJECTIVE

Sugar-sweetened beverage (SSB) consumption is cited as a major contributor to the U.S. obesity epidemic. The objective of this paper was to leverage insights from behavioral economics to examine whether nudges would entice college students to save meal calories by choosing water over SSBs.

METHODS

Three message-based nudge interventions, with washout periods between, were used during the 7-week study. Calorie savings (self-interest), charity (prosocial), or charity-plus-calorie message posters were displayed in a college-based food franchise. Multilevel logistic regressions compared the proportions of students choosing water during three experimental conditions. This study assessed whether the frequency of dining establishment visits over the study period moderated effects of the experimental conditions on beverage choices. Multiple data points from the same customer were treated as repeated measures.

RESULTS

A total of 2,393 unique students purchased 6,730 meals. Posters displaying calorie information increased water choice relative to washout periods, while the poster without calorie information (charity only) had no effect. Controlling for fixed effects produced the same results. The calorie message poster influenced less frequent diners more than frequent diners.

CONCLUSIONS

Food-service operations can nudge college students to substitute water for SSBs with a simple calorie-based message to save hundreds of calories per meal.

Nudges that fail

Why are some nudges ineffective, or at least less effective than choice architects hope and expect? Focusing primarily on default rules, this essay emphasizes two reasons for this. The first involves strong antecedent preferences on the part of choosers. The second involves successful “counternudges,” which persuade people to choose in a way that confounds the efforts of choice architects. Nudges might also be ineffective, and less effective than expected, for five other reasons: (1) some nudges produce confusion in the target audience; (2) some nudges have only short-term effects; (3) some nudges produce “reactance” (though this appears to be rare); (4) some nudges are based on an inaccurate (though initially plausible) understanding on the part of choice architects of what kinds of choice architecture will move people in particular contexts; and (5) some nudges produce compensating behavior, resulting in no net effect. When a nudge turns out to be insufficiently effective, choice architects have three potential responses: (1) do nothing; (2) nudge better (or differently); and (3) fortify the effects of the nudge, perhaps through counter-counternudges, or perhaps through incentives, mandates, or bans.

The impact of interventions to promote healthier ready-to-eat meals (to eat in, to take away or to be delivered) sold by specific food outlets open to the general public: a systematic review

INTRODUCTION

Ready-to-eat meals sold by food outlets that are accessible to the general public are an important target for public health intervention. We conducted a systematic review to assess the impact of such interventions.

METHODS

Studies of any design and duration that included any consumer-level or food-outlet-level before-and-after data were included.

RESULTS

Thirty studies describing 34 interventions were categorized by type and coded against the Nuffield intervention ladder: restrict choice = trans fat law (n = 1), changing pre-packed children's meal content (n = 1) and food outlet award schemes (n = 2); guide choice = price increases for unhealthier choices (n = 1), incentive (contingent reward) (n = 1) and price decreases for healthier choices (n = 2); enable choice = signposting (highlighting healthier/unhealthier options) (n = 10) and telemarketing (offering support for the provision of healthier options to businesses via telephone) (n = 2); and provide information = calorie labelling law (n = 12), voluntary nutrient labelling (n = 1) and personalized receipts (n = 1). Most interventions were aimed at adults in US fast food chains and assessed customer-level outcomes. More 'intrusive' interventions that restricted or guided choice generally showed a positive impact on food-outlet-level and customer-level outcomes. However, interventions that simply provided information or enabled choice had a negligible impact.

CONCLUSION

Interventions to promote healthier ready-to-eat meals sold by food outlets should restrict choice or guide choice through incentives/disincentives. Public health policies and practice that simply involve providing information are unlikely to be effective.

The influence of calorie and physical activity labelling on snack and beverage choices

BACKGROUND

Much research suggests nutrition labelling does not influence lower energy food choice. This study aimed to assess the impact of physical activity based and kilocalorie (Kcal) based labels on the energy content of snack food and beverage choices made.

METHODS

An independent-groups design, utilizing an online questionnaire platform tested 458 UK adults (87 men), aged 18-64 years (mean: 30 years) whose BMI ranged from 16 to 41 kg/m² (mean: 24 kg/m²). Participants were randomized to one of four label information conditions (no label, Kcal label, physical activity label [duration of walking required to burn the Kcal in the product], Kcal and physical activity label) and were asked to choose from higher and lower energy options for a series of items.

RESULTS

Label condition significantly affected low vs. high-energy product selection of snack foods (p < 0.001) and beverages (p < 0.001). The physical activity label condition resulted in significantly lower energy snack and beverage choices than the Kcal label condition (p < 0.001). This effect was found across the full sample and persisted even when participants' dietary restraint, BMI, gender, socioeconomic status, habitual physical activity, calorie and numerical literacy were controlled.

CONCLUSION

The provision of physical activity information appeared most effective in influencing the selection of lower Kcal snack food and beverage items, when compared with no information or Kcal information. These findings could inform the debate around potential legislative policies to facilitate healthier nutritional choices at a population level.

The effects of restaurant nutrition menu labelling on college students' healthy eating behaviours

OBJECTIVE

According to the US Affordable Care Act, restaurant chains are required to provide energy (calorie) and other nutrition information on their menu. The current study examined the impact of menu labelling containing calorie information and recommended daily calorie intake, along with subjective nutrition knowledge, on intention to select lower-calorie foods prior to the implementation of the Affordable Care Act.

DESIGN

Full factorial experimental design with participants exposed to four variants of a sample menu in a 2 (presence v. absence of calorie information) ×2 (presence v. absence of recommended daily calorie intake).

SETTING

Large, public university in the Southwest USA.

SUBJECTS

Primarily undergraduate college students.

RESULTS

Majority of participants were 19-23 years of age (mean 21·8 (sd 3·6) years). Menu information about calorie content and respondents' subjective nutrition knowledge had a significantly positive impact on students' intention to select lower-calorie foods (β=0·24, P<0·001 and β=0·33, P<0·001, respectively); however, recommended daily calorie intake information on the menu board did not influence students' intention to select lower-calorie foods (β=0·10, P=0·105). Gender played a significant role on purchase intent for lower-calorie menu items, with females more affected by the calorie information than males (β=0·37, P<0·001).

CONCLUSIONS

Findings support the role menu labelling can play in encouraging a healthier lifestyle for college students. College students who are Generation Y desire healthier menu options and accept nutritional labels on restaurant menus as a way to easily and expediently obtain nutrition information.

The incidence of calorie labeling on fast food choices: A comparison between stated preferences and actual choices

In order to test the effect of calorie information on fast food choices, we conducted a questionnaire employing two types of stated preferences methods (the best-worst-scaling and intentional questions) and a follow-up randomized field experiment in a sample of 119 participants. This combined approach allowed us to test the internal validity of preferences for fast food meals across elicitation scenarios. The results showed that calorie information reduces the probability of selecting high calorie meals only in the questionnaire, while it did not have any significant impact on actual purchasing behavior in the field experiment. Thus, the findings show that there is a clear difference between the role of calorie information on immediate stated preference choices, and the relatively low level of responsiveness in real choices in a restaurant. We believe that the current results are quite suggestive, indicating the limits of predicting actual fast food behavior, and may open the way to using data sources that combine stated methods with field experiments.

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.

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

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

TRIAL REGISTRATION NUMBER

NCT02804503; post-results.

Restaurant Menu Labeling Policy: Review of Evidence and Controversies

In response to high rates of obesity in the USA, several American cities, counties, and states have passed laws requiring restaurant chains to post labels identifying the energy content of items on menus, and nationwide implementation of menu labeling is expected in late 2016. In this review, we identify and summarize the results of 16 studies that have assessed the impact of real-world numeric calorie posting. We also discuss several controversies surrounding the US Food and Drug Administration's implementation of federally mandated menu labeling. Overall, the evidence regarding menu labeling is mixed, showing that labels may reduce the energy content of food purchased in some contexts, but have little effect in other contexts. However, more data on a range of ong-term consumption habits and restaurant responses is needed to fully understand the impact menu labeling laws will have on the US population's diet.

Food for thought: obstacles to menu labelling in restaurants and cafeterias

Menu labelling is recommended as a policy intervention to reduce obesity and diet-related disease. The present commentary considers the many challenges the restaurant industry faces in providing nutrition information on its menus. Barriers include lack of nutrition expertise, time, cost, availability of nutrition information for exotic ingredients, ability to provide accurate nutrition information, libel risk, customer dissatisfaction, limited space on the menu, menu variations, loss of flexibility in changing the menu, staff training and resistance of employees to change current practice. Health promotion specialists and academics involved in fieldwork must help restaurateurs find solutions to these barriers for menu labelling interventions to be widely implemented and successful. Practical support for small independent restaurants such as free or subsidised nutrition analysis, nutrition training for staff and menu design may also be necessary to encourage voluntary participation.

Systematic review and meta-analysis of the impact of restaurant menu calorie labeling

We conducted a systematic review and meta-analysis evaluating the relationship between menu calorie labeling and calories ordered or purchased in the PubMed, Web of Science, PolicyFile, and PAIS International databases through October 2013. Among 19 studies, menu calorie labeling was associated with a -18.13 kilocalorie reduction ordered per meal with significant heterogeneity across studies (95% confidence interval = -33.56, -2.70; P = .021; I(2) = 61.0%). However, among 6 controlled studies in restaurant settings, labeling was associated with a nonsignificant -7.63 kilocalorie reduction (95% confidence interval = -21.02, 5.76; P = .264; I(2) = 9.8%). Although current evidence does not support a significant impact on calories ordered, menu calorie labeling is a relatively low-cost education strategy that may lead consumers to purchase slightly fewer calories. These findings are limited by significant heterogeneity among nonrestaurant studies and few studies conducted in restaurant settings.

Behaviourally designed treatments that increase willingness to treatment from families with children suffering from autism spectrum disorder

BACKGROUND

Autism spectrum disorder is a lifelong disability that is not well known by the general population and tends to be associated with social stigma; also, because it involves children, it may get highly emotionally charged. These stylised facts engender a number of possible heuristics and biases at the moment of deciding on following a treatment or looking for a diagnosis, which should be considered in the presentation of information. Using insights from Behavioural Economics, three treatments are designed to present the information regarding possible therapies.

METHODS

Between-subjects design with one level of variation. Interviews were performed with a convenience sample of 154 households from the metropolitan area of Bogotá (Colombia). The treatments include: use of default option, use of professional interviewer to illustrate the therapy and emotionally charged presentation.

RESULTS

Kruskal-Wallis test of the intention to be treated rejects the null hypothesis (χ(2)=22.14, p=0.00). The cognitive processing of the information is not a determinant, supporting the claim that genuine framing effects shape the choice. The strongest effect of the treatment with a professional suggests a key role for asymmetry of the information, which is confirmed indirectly through the postexperiment questionnaire.

CONCLUSIONS

Bad healthcare decisions are not necessarily driven by lack of information. Asymmetric information (eg, delegating the decision to a professional) improves choices, especially when social stigma is involved. Cognitive processing of information seems to be less relevant than the framing effect.

Using traffic light labels to improve food selection in recreation and sport facility eating environments

Many recreation and sports facilities have unhealthy food environments, however managers are reluctant to offer healthier foods because they perceive patrons will not purchase them. Preliminary evidence indicates that traffic light labeling (TLL) can increase purchase of healthy foods in away-from-home food retail settings. We examined the effectiveness of TLL of menus in promoting healthier food purchases by patrons of a recreation and sport facility concession, and among various sub-groups. TLL of all menu items was implemented for a 1-week period and sales were assessed for 1-week pre- and 1-week post-implementation of TLL (n = 2101 transactions). A subset of consumers completed a survey during the baseline (n = 322) and intervention (n = 313) periods. We assessed change in the proportion of patrons' purchases that were labeled with green, yellow and red lights from baseline to the TLL intervention, and association with demographic characteristics and other survey responses. Change in overall revenues was also assessed. There was an overall increase in sales of green (52.2% to 55.5%; p < 0.05) and a reduction in sales of red (30.4% to 27.2%; p < 0.05) light items from baseline to the TLL period. The effectiveness of TLL did not differ according to any of the demographic or other factors examined in the survey. Average daily revenues did not differ between the baseline and TLL periods. TLL of menus increased purchase of healthy, and reduced purchase of unhealthy foods in a publicly funded recreation and sport facility, with no loss of revenue. Policymakers should consider extending menu labeling laws to public buildings such as recreation and sports facilities to promote selection of healthier items.

The influence of calorie labeling on food orders and consumption: a review of the literature

Obesity is a challenging public health problem that affects millions of Americans. Increasingly policy makers are seeking environmental and policy-based solutions to combat and prevent its serious health effects. Calorie labeling mandates, including the provision in the 2010 Patient Protection and Affordable Care Act that is set to begin in 2014, have been one of the most popular and most studied approaches. This review examines 31 studies published from January 1, 2007 through July 19, 2013. It builds on Harnack and French's 2008 review and assesses the evidence on the effectiveness of calorie labeling at the point of purchase. We find that, while there are some positive results reported from studies examining the effects of calorie labeling, overall the best designed studies (real world studies, with a comparison group) show that calorie labels do not have the desired effect in reducing total calories ordered at the population level. Moving forward, researchers should consider novel, more effective ways of presenting nutrition information, while keeping a focus on particular subgroups that may be differentially affected by nutrition policies.

How calorie-focused thinking about obesity and related diseases may mislead and harm public health. An alternative

Prevailing thinking about obesity and related diseases holds that quantifying calories should be a principal concern and target for intervention. Part of this thinking is that consumed calories – regardless of their sources – are equivalent; i.e. ‘a calorie is a calorie’. The present commentary discusses various problems with the idea that ‘a calorie is a calorie’ and with a primarily quantitative focus on food calories. Instead, the authors argue for a greater qualitative focus on the sources of calories consumed (i.e. a greater focus on types of foods) and on the metabolic changes that result from consuming foods of different types. In particular, the authors consider how calorie-focused thinking is inherently biased against high-fat foods, many of which may be protective against obesity and related diseases, and supportive of starchy and sugary replacements, which are likely detrimental. Shifting the focus to qualitative food distinctions, a central argument of the paper is that obesity and related diseases are problems due largely to food-induced physiology (e.g. neurohormonal pathways) not addressable through arithmetic dieting (i.e. calorie counting). The paper considers potential harms of public health initiatives framed around calorie balance sheets – targeting ‘calories in’ and/or ‘calories out’ – that reinforce messages of overeating and inactivity as underlying causes, rather than intermediate effects, of obesity. Finally, the paper concludes that public health should work primarily to support the consumption of whole foods that help protect against obesity-promoting energy imbalance and metabolic dysfunction and not continue to promote calorie-directed messages that may create and blame victims and possibly exacerbate epidemics of obesity and related diseases.

Out of control mortality matters: the effect of perceived uncontrollable mortality risk on a health-related decision

Prior evidence from the public health literature suggests that both control beliefs and perceived threats to life are important for health behaviour. Our previously presented theoretical model generated the more specific hypothesis that uncontrollable, but not controllable, personal mortality risk should alter the payoff from investment in health protection behaviours. We carried out three experiments to test whether altering the perceived controllability of mortality risk would affect a health-related decision. Experiment 1 demonstrated that a mortality prime could be used to alter a health-related decision: the choice between a healthier food reward (fruit) and an unhealthy alternative (chocolate). Experiment 2 demonstrated that it is the controllability of the mortality risk being primed that generates the effect, rather than mortality risk per se. Experiment 3 showed that the effect could be seen in a surreptitious experiment that was not explicitly health related. Our results suggest that perceptions about the controllability of mortality risk may be an important factor in people's health-related decisions. Thus, techniques for adjusting perceptions about mortality risk could be important tools for use in health interventions. More importantly, tackling those sources of mortality that people perceive to be uncontrollable could have a dual purpose: making neighbourhoods and workplaces safer would have the primary benefit of reducing uncontrollable mortality risk, which could lead to a secondary benefit from improved health behaviours.

Relationship Between Nutritional Knowledge and the Amount of Sugar-Sweetened Beverages Consumed in Los Angeles County

Although consumption of sugar-sweetened beverages (SSBs) is associated with many negative health outcomes, including obesity, diabetes, and cardiovascular disease, the relationship between consumer nutritional knowledge and the amount consumed is poorly understood. The objective of this study was to examine the relationship between knowledge of daily calorie recommendations and the amount of SSBs consumed in a large, economically and racially diverse sample of adults recruited at selected Metro subway and bus shelters in Los Angeles County. In June 2012, the Los Angeles County Department of Public Health conducted street intercept surveys to assess food attitudes and consumption behaviors and public opinions related to a recent 8-week health marketing campaign targeting SSB consumption. Descriptive and comparative analyses were conducted, including a negative binomial regression model, to examine the relationship between knowledge of the daily calorie recommendations and the amount of SSBs consumed. Among survey respondents ( n = 1,041), less than one third correctly identified the daily calorie recommendations for a typical adult. After controlling for sociodemographics and weight status, respondents who correctly identified recommended calorie needs reported, on average, drinking nine fewer SSBs per month than respondents who did not. Results suggest that efforts to reduce SSB consumption might benefit from the inclusion of educational interventions that empower consumers to make healthy choices.