Changes in awareness and use of calorie information after mandatory menu labeling in restaurants in King County, Washington

Adults Noticing Calorie Counts on Restaurant Menus: Evidence From Nationally Representative Data, 2022

INTRODUCTION

Since May 2018, federal restaurant menu labeling regulations have required large U.S. chain restaurants to disclose calorie counts on menus. This study estimates the share of U.S. adults who notice calorie information on fast-food and sit-down restaurant menus and identifies the consumer characteristics that predict noticing calorie labels.

METHODS

Using a nationally representative sample of 5,185 U.S. adults aged 18 and older from the 2022 Health Information National Trends Survey (HINTS), linear regression models were estimated to predict the likelihood of noticing calorie labels the last time adults ordered food in a fast-food or sit-down restaurant. The 2022 HINTS data were publicly released in April 2023 and these public-use and de-identified data were analyzed in October 2023.

RESULTS

In 2022, about 1 in 2 U.S. adults (49.7%, 95% CI=47.6%, 51.8%) reported noticing calorie labels during their last restaurant visit. The likelihood of noticing calorie information was significantly lower among men, lower income households, unpartnered adults, residents of the Northeast Census Region, and residents of rural areas.

CONCLUSIONS

Approximately half of U.S. adults reported seeing calorie labels when they last ordered food in a fast-food or sit-down restaurant in 2022. Sex, income, marital status, and residential location influenced the likelihood of noticing calorie counts posted on restaurant menus.

Developing Effective Strategies for Obesity Prevention

Nutrition policies can work with clinical treatments to address the obesity epidemic. The United States has passed beverage taxes at the local level and calorie labeling mandates at the federal level to encourage healthier consumption. Nutritional changes to federal nutrition programs have been either implemented or suggested; evidence shows that the changes that have been implemented have resulted in improvements in diet quality and are cost-effective in decreasing the increase in obesity prevalence. A comprehensive policy agenda that addresses risk of obesity on multiple levels of the food supply will have meaningful long-term effects on obesity prevalence.

Is the effect of menu energy labelling on consumer behaviour equitable? A pooled analysis of twelve randomized control experiments

Menu energy labelling has been implemented as a public health policy to promote healthier dietary choices and reduce obesity. However, it is unclear whether the influence energy labelling has on consumer behaviour differs based on individuals' demographics or characteristics and may therefore produce inequalities in diet. Data were analysed from 12 randomized control trials (N = 8508) evaluating the effect of food and drink energy labelling (vs. labelling absent) on total energy content of food and drink selections (predominantly hypothetical) in European and US adults. Analyses examined the moderating effects of participant age, sex, ethnicity/race, education, household income, body mass index, dieting status, food choice motives and current hunger on total energy content of selections. Energy labelling was associated with a small reduction (f2 = 0.004, -50 kcal, p < 0.001) in total energy selected compared to the absence of energy labelling. Participants who were female, younger, white, university educated, of a higher income status, dieting, motivated by health and weight control when making food choices, and less hungry, tended to select menu items of lower energy content. However, there was no evidence that the effect of energy labelling on the amount of energy selected was moderated by any of the participants' demographics or characteristics. Energy labelling was associated with a small reduction in energy content of food selections and this effect was similar across a range of participants' demographics and characteristics. These preliminary findings suggest that energy labelling policies may not widen existing inequalities in diet.

U.S. adults noticing and using menu calorie information: Analysis of the National Cancer Institute's Health Information National Trends Survey Data

FDA's Menu Labeling Final Rule requires covered establishments provide calorie information on menus or menu boards, among other requirements. This study describes correlates of noticing and using menu calorie information in a nationally representative sample of U.S. adults before implementation of the Final Rule in May 2018. Data from the 2018 National Cancer Institute Health Information National Trends Survey was used to assess noticing menu calorie information, using menu calorie information to change menu ordering behavior, and knowledge of daily calorie needs. Regression analysis of weighted data tested associations between individual characteristics and noticing and using menu calorie information. Nearly half of adults (44%) reported noticing menu calorie information. Women, younger individuals, those who seek health information, individuals with a BMI ≥ 30, and those with higher education or higher income were more likely to report noticing menu calorie information. Among adults who reported noticing menu calorie information, three-quarters responded by ordering less (e.g., fewer calories), which equates to about one-third of the population. About 36% of women and 42% of men lacked calorie knowledge. Men with, versus without, calorie knowledge were twice as likely to report noticing menu calorie information (adjusted OR 2.23 95% CI 1.51, 3.29). Findings suggest behavioral response to menu calorie information varies and most individuals who notice the information respond by ordering less in ways that could reduce caloric intake. Future analyses could compare noticing and using menu calorie information before and after menu labeling implementation to assess the effect of policy on population behaviors.

Perceived Effect of Calorie Count Display on Customers' Eating Behaviors in Food Facilities of Eastern Province, Saudi Arabia: A Mixed Method Study

Background

As the Saudi Food and Drug Authority (SFDA) has recently requested all food facilities to display the calorie count on their menus, this study aimed to identify the perceived changes in costumers’ eating behaviours in response to the calorie count display (CCD) policy in the Eastern Province.

Methods

This was a mixed methods study. The first being quantitative, using a cross-sectional questionnaire which included 400 customers of both genders, aged 10 years and older, and was collected at food facilities from three cities in the Eastern Province. Customers completed a self-administered questionnaire and handed their registered receipts. Collected receipts were used to calculate the total calories ordered per customer. The second method is a qualitative in-depth interview with food facility managers.

Results

Customers who reported checking the CCD were 30.5% of the total sample, and 58.2% of them changed their order accordingly. The mean calories ordered were 36 kcal less in customers checking the CCD than those who do not (P=0.674). Customers who exhibit healthy lifestyle habits calculate their daily consumed calories, knowledgeable of the recommended daily caloric intake (RDCI), dining in a dine-in restaurant, and have an educational level of above high school were more likely to check the CCD. This study found that customers who cared to check the CCD were more likely to change their eating behavior. It has been found that only a small percentage (12% to 18%) of customers were knowledgeable regarding the RDCI. After the implementation of the policy, restaurant managers reported a positive change in customers eating behavior, which was more profound in females and athletes.

Conclusion

There is a significant association between checking the CCD and positive behavioral changes in customers’ eating behaviors. The results of this study suggest that further enforcement and awareness raising are crucial to increase the number of customers checking and using the CCD.

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.

Ethical Considerations for Food and Beverage Warnings

Several countries have implemented warnings on unhealthy foods and beverages, with similar policies under consideration in the U.S. and around the world. Research demonstrating food warnings' effectiveness is emerging, but limited scholarship has evaluated the ethics of food warning policies. Using a public health ethics framework for evaluating obesity prevention policies, we assessed the ethical strengths and weaknesses of food warnings along multiple dimensions: 1) Health behaviors and physical health, 2) Psychosocial well-being, 3) Social and cultural values, 4) Informed choice, 5) Equality, 6) Attributions of responsibility, 7) Liberty, and 8) Privacy. Our analysis identifies both ethical strengths and weaknesses of food warnings, including that: 1) warnings are likely to generate important benefits including increased consumer understanding and informed choice, healthier purchases, and potential reductions in obesity prevalence; 2) warnings evoke negative emotional reactions, but these reactions are an important mechanism through which food warnings encourage healthier behaviors and promote informed choice; 3) warnings appear unlikely to have ethically unacceptable effects on social and cultural values, attributions of responsibility, liberty, or privacy. Current research suggests we continue to pursue food warnings as a policy option for improving public health while simultaneously conducting additional research on the ethics of these policies. Future research is especially needed to clarify warnings' effects on stigma and to characterize the balance and distribution of costs of and benefits from implementing warning policies.

Evaluation of the impact of calorie labeling on McDonald's restaurant menus: a natural experiment

Background

The long-term effect of calorie labeling on fast-food purchases is unclear. McDonald’s voluntarily labeled its menus with calories in 2012, providing an opportunity to evaluate this initiative on purchases.

Methods

From 2010 to 2014, we collected receipts from and administered questionnaires to 2971 adults, 2164 adolescents, and 447 parents/guardians of school-age children during repeated visits to 82 restaurants, including McDonald’s and five control chains that did not label menus over the study period in four New England cities. In 2018, we analyzed the data by using difference-in-differences analyses to estimate associations of calorie labeling with calories purchased (actual and estimated) and predicted probability of noticing calorie information on menus.

Results

Calorie labeling at McDonald’s was not associated with changes in calories purchased in adults (change = − 19 cal pre- vs. post-labeling at McDonald’s compared to control chains, 95% CI: − 112, 75), adolescents (change = − 49 cal, 95% CI: − 136, 38), or children (change = 13 cal, 95% CI: − 108, 135). Calorie labeling generally increased the predicted probability of noticing calorie information, but did not improve estimation of calories purchased.

Conclusions

Calorie labeling at McDonald’s was not associated with changes in calories purchased in adults, adolescents, or children. Although participants were more likely to notice calories on menus post-labeling, there was no improvement in ability to accurately estimate calories purchased.

Healthy eating and restaurants. A review of recent evidence in the literature

Food environments influence food consumption and population health. This study sought to establish the outstanding themes in recent scientific literature about healthy eating and restaurants. Studies about the topic published from 2011 to 2016 in seven recognized databases were reviewed systematically. From 999 titles, 20 articles were selected. Content analysis through an inductive method by two independent investigators was performed using Nvivo 10.0. Three dominant subjects were identified: Food supply modifications, promotion of healthy choices and barriers against healthy eating promotion. The findings describe research opportunities in the area, particularly in the Latin American context. It is necessary to make interventions that result in healthy food environments given the impact on collective health.

The influence of sex and self-control on the efficacy of nudges in lowering the energy content of food during a fast food order

An experiment aimed at reducing calorie content of a food order was performed by introducing interventions at the fast food ordering screen on a tablet computer. Modifications included a virtual order assistant, a color-coded system and highlighting low-calorie choices. Participants of the study were 401 university students. Before starting an order, participants were asked to indicate their calorie goal. Our results show that the order assistant is the only intervention that leads to significantly fewer calories in the fast food order. The effect is due to women ordering fewer high-calorie dishes. Men, in contrast, are unresponsive to changes in the choice context regarding calories ordered. Results indicate that the level of self-control moderates the impact of the feature highlighting choices so that higher levels of self-control lead to lower calorie intake for both sexes. This research highlights the importance of gender and self-control for designing choice environments aimed at decreasing calorie intake.

A quasi-experimental study of a mandatory calorie-labelling policy in restaurants: Impact on use of nutrition information among youth and young adults in Canada

In 2017, Ontario became the first Canadian province to require calorie amounts on menus/menu boards of chain restaurants. The province of British Columbia (BC) implemented a voluntary nutrition information initiative in which calorie and sodium information were available upon request. A quasi-experimental design was used to examine the use of nutrition information in Ontario (mandatory calorie labelling), compared to BC (voluntary policy) and three other provinces with no formal menu labelling policy ('control'). Data were collected from youth and young adults (16-30 years) in all provinces pre- (fall 2016; n = 2929) and post- (fall 2017; n = 968) implementation of Ontario's calorie-labelling policy in January 2017. Generalized estimating equations tested differences between provinces over time in noticing and impact of nutrition information and support of mandatory calorie labelling. Noticing of nutrition information in restaurants increased in Ontario significantly more than in BC (+25.1% vs. +1.6%; AOR = 4.26, 95% CI = 2.39-7.61) and control provinces (+6.5%; AOR = 3.00, 95% CI = 1.91-4.73). Ontario respondents were significantly more likely to report that the nutrition information influenced their order than those in BC (+12.9% vs. +2.2%; AOR = 3.53, 95%CI = 1.61-7.76) and control provinces (+2.0%; AOR = 3.71, 95%CI = 1.87-7.36). Policy support increased in all groups at follow-up, with a significantly greater increase in Ontario than control provinces (+12.9% vs. +5.7%; AOR = 1.57, 95%CI = 1.06-2.34). Socio-demographic differences were also observed. Findings suggest that the mandatory menu labelling policy implemented in Ontario has increased noticing and use of nutrition information, with no evidence to support the effectiveness of voluntary policies that require consumers to request nutrition information.

Methods for Evaluating Natural Experiments in Obesity: A Systematic Review

BACKGROUND

Given the obesity pandemic, rigorous methodological approaches, including natural experiments, are needed.

PURPOSE

To identify studies that report effects of programs, policies, or built environment changes on obesity prevention and control and to describe their methods.

DATA SOURCES

PubMed, CINAHL, PsycINFO, and EconLit (January 2000 to August 2017).

STUDY SELECTION

Natural experiments and experimental studies evaluating a program, policy, or built environment change in U.S. or non-U.S. populations by using measures of obesity or obesity-related health behaviors.

DATA EXTRACTION

2 reviewers serially extracted data on study design, population characteristics, data sources and linkages, measures, and analytic methods and independently evaluated risk of bias.

DATA SYNTHESIS

294 studies (188 U.S., 106 non-U.S.) were identified, including 156 natural experiments (53%), 118 experimental studies (40%), and 20 (7%) with unclear study design. Studies used 106 (71 U.S., 35 non-U.S.) data systems; 37% of the U.S. data systems were linked to another data source. For outcomes, 112 studies reported childhood weight and 32 adult weight; 152 had physical activity and 148 had dietary measures. For analysis, natural experiments most commonly used cross-sectional comparisons of exposed and unexposed groups (n = 55 [35%]). Most natural experiments had a high risk of bias, and 63% had weak handling of withdrawals and dropouts.

LIMITATION

Outcomes restricted to obesity measures and health behaviors; inconsistent or unclear descriptions of natural experiment designs; and imperfect methods for assessing risk of bias in natural experiments.

CONCLUSION

Many methodologically diverse natural experiments and experimental studies were identified that reported effects of U.S. and non-U.S. programs, policies, or built environment changes on obesity prevention and control. The findings reinforce the need for methodological and analytic advances that would strengthen evaluations of obesity prevention and control initiatives.

PRIMARY FUNDING SOURCE

National Institutes of Health, Office of Disease Prevention, and Agency for Healthcare Research and Quality. (PROSPERO: CRD42017055750).

Parental Characteristics and Reasons Associated With Purchasing Kids' Meals for Their Children

PURPOSE

Characteristics of parents who purchased kids' meals, reasons for the purchase, and desire for healthy options were examined.

DESIGN

Quantitative, cross-sectional study.

SETTING

National.

PARTICIPANTS

The SummerStyles survey data of 1147 parents (≥18 years).

MEASURES

Self-reported outcome variables were purchase of kids' meals (yes/no), reasons for the purchase (13 choices), and desire for healthy options (yes/no).

ANALYSIS

We used multivariable logistic regression to estimate odds ratios (ORs) for purchasing kids' meals based on parental sociodemographic and behavioral characteristics.

RESULTS

Over half (51%) of parents reported purchasing kids' meals in the past month. The adjusted OR of purchasing kids' meals were significantly higher among younger parents (OR = 3.44 vs ≥50 years) and among parents who consumed sugar-sweetened beverages (SSBs) daily (OR = 2.70 vs none). No differences were found for race/ethnicity, income, and education. Parents who purchased kids' meals reported that the top 3 reasons for purchase were (1) because their children asked for kids' meals, (2) habit, and (3) offering of healthier sides such as fruits or fruit cups. Thirty-seven percent of parents who did not purchase kids' meals expressed willingness to purchase kids' meals if healthy options were available; this willingness was highest among younger parents (47%; P < .05).

CONCLUSIONS

Kids' meal purchases were somewhat common. Our findings on characteristics of parents who frequently bought kids' meals (ie, younger parents and SSB consumers), common reasons for purchasing kids' meals, and willingness to buy healthier kids' meal can be used to inform intervention efforts to improve quality of kids' meals.

Policies to Prevent Obesity and Promote Healthier Diets: A Critical Selective Review

BACKGROUND

Obesity has risen dramatically in recent decades in the US and most other countries of the world. This has led to a search for public policies and other interventions that can prevent obesity and improve diets. However, there remain considerable uncertainty and confusion about the effectiveness of many potential policies.

CONTENT

This review assesses the strength of the research evidence for 4 commonly proposed policies to prevent obesity and improve diets: (a) taxes on sugar-sweetened beverages (SSBs); (b) calorie labels on restaurant menus; (c) restricting food advertising to youth; and (d) excluding energy-dense foods from the Supplemental Nutrition Assistance Program (SNAP).

SUMMARY

The existing literature has many limitations. Often, the research designs are weak, with small nonrepresentative samples and only short-run follow-up. However, a number of studies are of sufficiently high quality to be informative, and on the basis of that evidence, there appears to be no magic bullet to prevent and reduce obesity. Thus, a suite of these policies may be needed for a meaningful impact.

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.

Improving food environments and tackling obesity: A realist systematic review of the policy success of regulatory interventions targeting population nutrition

Background

This systematic review (PROSPERO: CRD42015025276) employs a realist approach to investigate the effect of “real-world” policies targeting different aspects of the food environment that shape individual and collective nutrition.

Objectives

We were interested in assessing intermediate outcomes along the assumed causal pathway to “policy success”, in addition to the final outcome of changed consumption patterns.

Data sources

We performed a search of 16 databases through October 2015, with no initial restriction by language.

Study eligibility criteria

We included all publications that reported the effect of statutory provisions aimed at reducing the consumption of energy-dense foods and beverages in the general population. We allowed all methodological approaches that contained some measure of comparison, including studies of implementation progress.

Study appraisal and synthesis methods

We reviewed included studies using the appraisal tools for pre-post and observational studies developed by the National Heart, Lung, and Blood Institute. Given the considerable heterogeneity in interventions assessed, study designs employed, and outcome measures reported, we opted for a narrative synthesis of results.

Results and implications

Results drawn from 36 peer-reviewed articles and grey literature reports demonstrated that isolated regulatory interventions can improve intermediate outcomes, but fail to affect consumption at clinically significant levels. The included literature covered six different types of interventions, with 19 studies reporting on calorie posting on chain restaurant menus. The large majority of the identified interventions were conducted in the US. Early results from recent taxation measures were published after the review cut-off date but these suggested more favorable effects on consumption levels. Nevertheless, the evidence assessed in this review suggests that current policies are generally falling short of anticipated health impacts.

Low parental awareness about energy (calorie) recommendations for children's restaurant meals: findings from a national survey in the USA

OBJECTIVE

To assess parental awareness of per-meal energy (calorie) recommendations for children's restaurant meals and to explore whether calorie awareness was associated with parental sociodemographic characteristics and frequency of eating restaurant food.

DESIGN

Cross-sectional online survey administered in July 2014. Parents estimated calories (i.e. kilocalories; 1 kcal=4·184 kJ) recommended for a child's lunch/dinner restaurant meal (range: 0-2000 kcal). Responses were categorized as 'underestimate' (600 kcal). Confidence in response was measured on a 4-point scale from 'very unsure' to 'very sure'. Logistic regressions estimated the odds of an 'accurate' response and confident response ('somewhat' or 'very sure') by parental sociodemographic characteristics and frequency of eating from restaurants. Sampling weights based on demographics were incorporated in all analyses.

SETTING

USA.

SUBJECTS

Parents (n 1207) of 5-12-year-old children.

RESULTS

On average, parents estimated 631 (se 19·4) kcal as the appropriate amount for a 5-12-year-old child's meal. Thirty-five per cent answered in the accurate range, while 33·3 and 31·8 % underestimated and overestimated, respectively. Frequent dining at restaurants, lower income and urban geography were associated with lower odds of answering accurately. Parents' confidence in their estimates was low across the sample (26·0 % confident) and only 10·1 % were both accurate and confident.

CONCLUSIONS

Parent education about calorie recommendations for children could improve understanding and use of menu labelling information in restaurants. Targeted strategies are recommended to ensure that such efforts address, rather than exacerbate, health disparities.

Consumer underestimation of sodium in fast food restaurant meals: Results from a cross-sectional observational study

Restaurants are key venues for reducing sodium intake in the U.S. but little is known about consumer perceptions of sodium in restaurant foods. This study quantifies the difference between estimated and actual sodium content of restaurant meals and examines predictors of underestimation in adult and adolescent diners at fast food restaurants. In 2013 and 2014, meal receipts and questionnaires were collected from adults and adolescents dining at six restaurant chains in four New England cities. The sample included 993 adults surveyed during 229 dinnertime visits to 44 restaurants and 794 adolescents surveyed during 298 visits to 49 restaurants after school or at lunchtime. Diners were asked to estimate the amount of sodium (mg) in the meal they had just purchased. Sodium estimates were compared with actual sodium in the meal, calculated by matching all items that the respondent purchased for personal consumption to sodium information on chain restaurant websites. Mean (SD) actual sodium (mg) content of meals was 1292 (970) for adults and 1128 (891) for adolescents. One-quarter of diners (176 (23%) adults, 155 (25%) adolescents) were unable or unwilling to provide estimates of the sodium content of their meals. Of those who provided estimates, 90% of adults and 88% of adolescents underestimated sodium in their meals, with adults underestimating sodium by a mean (SD) of 1013 mg (1,055) and adolescents underestimating by 876 mg (1,021). Respondents underestimated sodium content more for meals with greater sodium content. Education about sodium at point-of-purchase, such as provision of sodium information on restaurant menu boards, may help correct consumer underestimation, particularly for meals of high sodium content.

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 Sugar-Sweetened Beverage Warnings: A Randomized Trial of Adolescents' Choices and Beliefs

INTRODUCTION

California, New York, and the cities of San Francisco and Baltimore have introduced bills requiring health-related warning labels for sugar-sweetened beverages. This study measures the extent to which these warning labels influence adolescents' beliefs and hypothetical choices.

DESIGN

Participants completed an online survey in which they chose a beverage in a hypothetical vending machine task, rated perceptions of different beverages, and indicated interest in coupons for beverages. Data were collected and analyzed in 2015.

SETTING/PARTICIPANTS

A total of 2,202 demographically diverse adolescents aged 12-18 years completed the online survey.

INTERVENTION

Participants were randomly assigned to one of six conditions: (1) no warning label; (2) calorie label; (3-6) one of four text versions of a warning label (e.g.

, SAFETY WARNING

Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay).

MAIN OUTCOME MEASURES

Hypothetical choices, perceptions of beverages, interest in coupons, and endorsement of warning label policies were assessed.

RESULTS

Controlling for frequency of beverage purchases, significantly fewer adolescents chose a sugar-sweetened beverage in three of the four warning label conditions (65%, 63%, and 61%) than in the no label (77%) condition. Adolescents in the four warning label conditions chose fewer sugar-sweetened beverage coupons and believed that sugar-sweetened beverages were less likely to help them lead a healthy life and had more added sugar compared with the no label condition.

CONCLUSIONS

Health-related warning labels on sugar-sweetened beverages improved adolescents' recognition of the sugar content of such beverages and reduced hypothetical choices to buy sugar-sweetened beverages.

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.

Factors Associated with Self-Reported Menu-Labeling Usage among US Adults

BACKGROUND

Menu labeling can help people select foods and beverages with fewer calories and is a potential population-based strategy to reduce obesity and diet-related chronic diseases in the United States.

OBJECTIVE

The aim of this cross-sectional study was to examine the prevalence of menu-labeling use among adults and its association with sociodemographic, behavioral, and policy factors.

METHODS

The 2012 Behavioral Risk Factor Surveillance System data from 17 states, which included 100,141 adults who noticed menu labeling at fast-food or chain restaurants ("When calorie information is available in the restaurant, how often does this information help you decide what to order?") were used. Menu-labeling use was categorized as frequent (always/most of the time), moderate (half the time/sometimes), and never. Multinomial logistic regression was used to examine associations among sociodemographic, behavioral, and policy factors with menu-labeling use.

RESULTS

Overall, of adults who noticed menu labeling, 25.6% reported frequent use of menu labeling, 31.6% reported moderate use, and 42.7% reported that they never use menu labeling. Compared with never users, frequent users were significantly more likely to be younger, female, nonwhite, more educated, high-income, adults who were overweight or obese, physically active, former- or never-smokers, less than daily (<1 time/day) consumers of sugar-sweetened beverage, and living in states where menu-labeling legislation was enacted or proposed.

CONCLUSIONS

Menu labeling is one method that consumers can use to help reduce their calorie consumption from restaurants. These findings can be used to develop targeted interventions to increase menu-labeling use among subpopulations with lower use.

The Influence of Nutrition Label Placement on Awareness and Use among College Students in a Dining Hall Setting

BACKGROUND

Nutrition labels may be important predictors of dietary selections among college students; however, awareness and use are not well understood in this population.

OBJECTIVE

The aim of this work was to investigate the influence of label placement on label awareness and use, including influences over time. We also aimed to identify predictors of awareness and use, preferred label information, and reasons for label nonuse.

DESIGN

Cross-sectional surveys were administered in three 1-week waves over 3 months.

PARTICIPANTS/SETTING

Two thousand seven hundred twenty-nine students aged 18 years or older in four university dining halls.

INTERVENTION

Nutrition labels were placed on sneeze guards in two dining halls and directly in front of food in two comparator dining halls.

MAIN OUTCOME MEASURES

Label awareness and use were measured using 5-point Likert scales. Reasons for label nonuse and preferred types of information were assessed by response frequencies.

STATISTICAL ANALYSIS PERFORMED

Logistic regression was used to determine predictors of label awareness and use. To test for differences in information preferences between label users and nonusers, χ(2) tests were used.

RESULTS

Nutrition label awareness and use did not vary by label placement or over time. Awareness was related to being obese, having higher perceived stress, taking nutrition classes, having good/excellent eating habits, eating breakfast, tracking food intake, and exercising five or more times per week. Use was related to being a woman, being overweight, having higher perceived stress, having good/excellent eating habits, eating breakfast, tracking food intake, and exercising three or more times per week. Information preferences differed by use, but calories, fat, and protein were the most preferred pieces of information overall. Not caring, already having a good idea about nutrition information, and not having time were the top reasons for label nonuse.

CONCLUSIONS

Label awareness and use did not change with label placement or over time. Making labels easy to read and including preferred information may encourage greater awareness and use.

The Influence of Sugar-Sweetened Beverage Health Warning Labels on Parents' Choices

BACKGROUND AND OBJECTIVES

US states have introduced bills requiring sugar-sweetened beverages (SSBs) to display health warning labels. This study examined how such labels may influence parents and which labels are most impactful.

METHODS

In this study, 2381 demographically and educationally diverse parents participated in an online survey. Parents were randomly assigned to 1 of 6 conditions: (1) no warning label (control); (2) calorie label; or (3-6) 1 of 4 text versions of a warning label (eg, Safety Warning: Drinking beverages with added sugar[s] contributes to obesity, diabetes, and tooth decay). Parents chose a beverage for their child in a vending machine choice task, rated perceptions of different beverages, and indicated interest in receiving beverage coupons.

RESULTS

Regression analyses controlling for frequency of beverage purchases were used to compare the no warning label group, calorie label group, and all warning label groups combined. Significantly fewer parents chose an SSB for their child in the warning label condition (40%) versus the no label (60%) and calorie label conditions (53%). Parents in the warning label condition also chose significantly fewer SSB coupons, believed that SSBs were less healthy for their child, and were less likely to intend to purchase SSBs. All P values <.05 after correcting for multiple comparisons. There were no consistent differences among different versions of the warning labels.

CONCLUSIONS

Health warning labels on SSBs improved parents' understanding of health harms associated with overconsumption of such beverages and may reduce parents' purchase of SSBs for their children.

Moving Beyond "Food Deserts": Reorienting United States Policies to Reduce Disparities in Diet Quality

Jason Block and S. V. Subramanian explore avenues for improving the health of Americans through reducing dietary inequalities and look at whether concern over "food deserts" has been taken too far.