Estimating the impact of various menu labeling formats on parents’ demand for fast-food kids’ meals for their children: An experimental auction

Perceived effectiveness of added-sugar warning label designs for U.S. restaurant menus: An online randomized controlled trial

Added-sugar consumption in the U.S. exceeds recommended limits. Policymakers are considering requiring restaurants to use menu warning labels to indicate items high in added sugar. We sought to determine whether icon-only and icon-plus-text added-sugar menu labels were (1) perceived as more effective at potentially reducing consumption of items high in added sugar and (2) increased knowledge of menu items' added-sugar content relative to control labels, and if effects differed by label design. A national sample of U.S. adults (n = 1327) participated in an online randomized experiment. Participants viewed menu items with either a control label, 1 of 6 icon-only labels, or 1 of 18 icon-plus-text labels with 3 text variations. For their assigned label, participants provided ratings of perceived message effectiveness (a validated scale of a message's potential to change behavior). Participants were also asked to classify menu items by their added-sugar content. The icon-only and icon-plus-text labels were perceived as more effective than the control label (means: 3.7 and 3.7 vs. 3.1, respectively, on a 5-point scale; p < 0.001). The icon-only and icon-plus-text groups each correctly classified 71% of menu items by added-sugar content vs. 56% in the control group (p < 0.001). All icons and text variations were perceived as similarly effective. In conclusion, relative to a control label, icon-only and icon-plus-text added-sugar menu labels were perceived as effective and helped consumers identify items high in added sugar. Menu warning labels may be a promising strategy for reducing added-sugar consumption from restaurants, but research on behavioral effects in real-world settings is needed. Clinical Trials Identifier:NCT04637412.

Nudging and boosting children’s restaurant menus for healthier food choice: a blinded quasi-randomized controlled trial in a real life setting

Background

Restaurants are ideal settings for implementing food interventions targeted at children. Studies with adults suggest that changes to the physical menu can lead to healthier food choices; online studies with parents indicate that specific menu designs facilitate healthier choices. However, it is unknown whether applying well-established nudging and boosting methods to children’s menus also increases their choice of healthier meals in a real-world restaurant setting.

Methods

The effects of two versions of a restaurant menu on the frequency of choosing a healthy meal (newly created, healthy target dish) were tested in a blinded quasi-randomized controlled trial. The menu in the control condition contained all dishes (including the healthy target dish) in a standardized format. The intervention menu included nudging (e.g. comic character, fun attractive name for the dish) and boosting elements (e.g. information on low calorie density) next to the healthy target dish. Over five months, the control and intervention menus were switched every two weeks and records were made of how often the healthy target dish was ordered.

Results

In total, 607 orders were made from the children’s restaurant menu (57% from the intervention menu). During the intervention phase, 4.2% of all ordered dishes from the children’s menu were the healthy target dish, during the control phase, 4.4% of orders were for the target dish (p=.896).

Conclusions

Contrary to our hypothesis, a modified children’s menu did not lead to a significant increase in the number of orders for a healthy dish compared with a neutral control menu. Importantly, given that parents and children often choose the child’s dish together, particularly boosting methods that focus on social processes and joint decision making could be promising to increase children’s frequency of healthy food choices in restaurants.

Trial registration

DRKS00027039, registered on 11/22/2021, (Retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12365-5.

Sodium menu labelling: priorities for research and policy

OBJECTIVE

To understand the different Na menu labelling approaches that have been considered by state and local policymakers in the USA and to summarise the evidence on the relationship between Na menu labelling and Na content of menu items offered by restaurants or purchased by consumers.

DESIGN

Proposed and enacted Na menu labelling laws at the state and local levels were reviewed using legal databases and an online search, and a narrative review of peer-reviewed literature was conducted on the relationship between Na menu labelling and Na content of menu items offered by restaurants or purchased by consumers.

SETTING

Local and state jurisdictions in the USA.

PARTICIPANTS

Not applicable.

RESULTS

Between 2000 and 2020, thirty-eight laws - eleven at the local level and twenty-seven at the state level - were proposed to require Na labelling of restaurant menu items. By 2020, eight laws were enacted requiring chain restaurants to label the Na content of menu items. Five studies were identified that evaluated the impact of Na menu labelling on Na content of menu items offered by restaurants or purchased by consumers in the USA. The studies had mixed results: two studies showed a statistically significant association between Na menu labelling and reduced Na content of menu items; three showed no effects.

CONCLUSION

Data suggest that Na menu labelling may reduce Na in restaurant menu items, but further rigorous research evaluating Na menu labelling effects on Na content of menu items, as well as on the Na content in menu items purchased by consumers, is needed.

Desert on the menu? What children are served in German full-service restaurants

OBJECTIVES

Prevalence of obesity and overweight among children is rising worldwide. Thus, the importance of restaurants as food environments is also growing. Considering these developments, the present study describes and evaluates menus and meals offered to children in German full-service restaurants.

METHODS

Using quota sampling procedure, a representative sample of German full-service restaurants was identified. The individual meals were then assessed, using the Children's Menu Assessment tool (CMA). A total of 500 restaurants and 1,877 individual meals were analyzed.

RESULTS

On average, every menu included 3.76 ± 1.31 meals for children. The arithmetic mean of the CMA score was 0.73 ± 0.85. Around 80% of all offered meals were limited to eight typical dishes and over 50% included French fries or another form of fried potatoes. Not one of the meals included any nutritional information. Healthy entrees were never marked (e.g. by an optional qualitative information such as healthy food symbol or a healthier choice tag). Eighty-one percent of all the main components in the meals were rated as unhealthy and none of the meals used wholegrain products. The automatic inclusion of a drink and free refill options are both rather unusual in Germany, as well as the use of cartoon characters and product logos or giving away promotional toys. A positive correlation was found between the price of the food and its quality. The majority of dishes feature a high energy density while simultaneously having a low nutrient density.

CONCLUSIONS

Overall, the range of food on offer for children in German restaurants is unhealthy and lacking in variety. There is an urgent need for improvement of both the menus themselves as well as the offered meals. Our study is not only by far the most comprehensive study, but also the study with the worst CMA score values worldwide.

Testing the efficacy of and parents' preferences for nutrition labels on children's menus from a full-service chain restaurant: results of an online experiment

OBJECTIVE

Test the efficacy and perceived effectiveness of nutrition labels on children's menus from a full-service chain restaurant in an online study.

DESIGN

Using a between-groups experiment, parents were randomised to view children's menus displaying one of five children's nutrition labelling conditions: (i) No Nutrition Information (control); (ii) Calories Only; (iii) Calories + Contextual Statement (CS); (iv) Calories, Sodium + CS; or (v) Calories and Sodium in Traffic Lights + CS. Parents hypothetically ordered up to one entrée, side, beverage and dessert for their child, then rated and ranked all five labelling conditions on the level of perceived effectiveness.

SETTING

Online survey.

PARTICIPANTS

998 parents with a 3-12 year old child.

RESULTS

Parents exposed to menus displaying 'Calories, Sodium + CS' selected significantly fewer calories 'overall' (entrées + side + dessert + beverage) compared to parents exposed to the control condition (-53·1 calories, P < 0·05). Parents selected 'entrees' with significantly fewer calories and lower sodium when exposed to menus with 'Calories + CS' (-24·3 calories, P < 0·05); 'Calories, Sodium + CS' (-25·4 calories, -56·1 mg sodium, P < 0·05 for both); and 'Calories and Sodium in Traffic Lights + CS' (-29·1 calories, -58·6 mg sodium, P < 0·05 for both). Parents exposed to menus with 'Calories, Sodium + CS' and 'Calories and Sodium in Traffic Lights + CS' were more likely to notice and understand nutrition information compared to other nuntrition labelling conditions. Parents perceived the menu with 'Calories and Sodium in Traffic Lights + CS' as most effective (P < 0·05).

CONCLUSIONS

Menus disclosing calories, sodium and a contextual statement increased the proportion of parents who noticed and understood nutrition information, and resulted in parents selecting lower calorie and sodium entrées for their children in the hypothetical purchase task.

All Aboard Meal Train: Can Child-Friendly Menu Labeling Promote Healthier Choices in Hospitals?

OBJECTIVE

To evaluate patient meal orders and consumption with a revised menu design that includes child-friendly labeling.

STUDY DESIGN

A randomized controlled trial among hospitalized children was performed over a 1-month period comparing the control menu layout and the intervention menu. The intervention menu contained the same choices but was labeled to encourage healthy eating. Children on a specialized diet, receiving parenteral nutrition, or age <2 years were excluded.

RESULTS

A total of 163 patients (81 males) were included, with a mean age of 9.9 ± 5.1 year, and a mean weight z-score of -0.08 ± 1.3. Children receiving the intervention ordered more "green-light" healthy choices and fewer "red-light" items, with 0.65 lower odds of selecting a red-light item (95% CI, 0.55-0.76) and 1.75 higher odds of selecting a green-light item (95% CI, 1.49-2.04), both at the first meal, but with effects waning over time. There were trends toward increased intake of fruits and vegetables and decreased intake of "foods to limit", but no impact on the consumption of sugar-sweetened beverages. Both intervention and control group consumed their meals in equal proportions.

CONCLUSIONS

The combination of menu labeling techniques targeted to children in the inpatient hospital setting was an effective short-term tool for increasing the intake of healthier foods, although the effect of labeling waned over time.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02692001.

Comparative evidence of the consumption from fast-food restaurants between normal-weight and obese Saudi schoolchildren

OBJECTIVE

To provide an in-depth analysis of the relationship between obesity and fast-food consumption by comparing urban obese and normal-weight Saudi Arabian children.

DESIGN

A multicentre cross-sectional study was conducted from December 2015 to March 2016. Participants were divided into two groups (normal weight and obese) and further stratified by sex. Groups were randomly selected using a multistage stratified cluster-sampling technique. A self-paced questionnaire was used to collect data relating to food consumption. Weight height and waist circumference were measured and bioelectrical impedance analysis was performed in all children.

SETTING

Capital of Saudi Arabia, Riyadh.

SUBJECTS

Children aged 9·00-11·99 years (n 1023).

RESULTS

Compared with normal-weight groups, intake frequency of fast food/week was higher among the obese groups (P<0·001), irrespective of fast-food consumption outside (P<0·001) or inside (P<0·001) the home; and larger portion sizes were preferred in obese groups (P<0·001). Families eating fast-food meals together was a protective factor against obesity (OR; 95 % CI: 2·67; 1·44, 4·96, P<0·001), with similar results for families ordering from a 'healthy meals menu' for their children (1·90; 1·24, 2·90, P=0·002). Taste of fast foods (P=0·021), child-friendly menu (P=0·020) and meal cost (P<0·001) were identified as main reasons why parents took their children to fast-food restaurants; these data were replicated for parents with obese boys, but not girls.

CONCLUSIONS

Development of effective interventions to reduce fast-food consumption in Saudi Arabian schoolchildren requires greater research-based evidence of fast-food consumption habits and practices associated with increased childhood obesity.