An observational study of consumers' accessing of nutrition information in chain restaurants

Menu labeling, calories, and nutrient density: Evidence from chain restaurants

The Food and Drug Administration's menu labeling rule requires chain restaurants to prominently display calories, while leaving other nutritional information (e.g., fat, sodium, sugar) to the request of consumers. We use rich micronutrient data from 257 large chain brands and 24,076 menu items to examine whether calories are correlated with widely used "nutrient profile" scores that measure healthfulness based on nutrient density. We show that calories are indeed statistically significant predictors of nutrient density. However, as a substantive matter, the correlation is highly attenuated (partial R2 < 0.01). Our findings (a) suggest that the promise of calorie labeling to improve nutrient intake quality at restaurants is limited and (b) clarify the basis for transparency of nutrient composition beyond calories to promote healthy menu choices.

Development of menu board media for information on sugar, salt and fat related health messages at a senior high school cafeteria in Depok City, Indonesia

Purpose

The purpose of this paper is to produce informative menu board media to show sugar, salt and fat (SSF) related health messages in a Senior High School canteen.

Design/methodology/approach

The research model included stages of needs analysis, design, product development and product evaluation. The data were collected from material experts, media experts and 186 high school students. Data were analyzed by descriptive qualitative and statistical analysis.

Findings

The C and D menu boards were selected for their content information and health messages that received higher scores.

Originality/value

There are four stages required in the development of menu board media: needs analysis, menu board design, product development and product evaluation. Further research would be needed to develop the menu boards into a simpler model.

Health and nutrition content claims on Australian fast-food websites

OBJECTIVE

To determine the extent that Australian fast-food websites contain nutrition content and health claims, and whether these claims are compliant with the new provisions of the Australia New Zealand Food Standards Code ('the Code').

DESIGN

Systematic content analysis of all web pages to identify nutrition content and health claims. Nutrition information panels were used to determine whether products with claims met Nutrient Profiling Scoring Criteria (NPSC) and qualifying criteria, and to compare them with the Code to determine compliance.

SETTING

Australian websites of forty-four fast-food chains including meals, bakery, ice cream, beverage and salad chains.

SUBJECTS

Any products marketed on the websites using health or nutrition content claims.

RESULTS

Of the forty-four fast-food websites, twenty (45 %) had at least one claim. A total of 2094 claims were identified on 371 products, including 1515 nutrition content (72 %) and 579 health claims (28 %). Five fast-food products with health (5 %) and 157 products with nutrition content claims (43 %) did not meet the requirements of the Code to allow them to carry such claims.

CONCLUSIONS

New provisions in the Code came into effect in January 2016 after a 3-year transition. Food regulatory agencies should review fast-food websites to ensure compliance with the qualifying criteria for nutrition content and health claim regulations. This would prevent consumers from viewing unhealthy foods as healthier choices. Healthy choices could be facilitated by applying NPSC to nutrition content claims. Fast-food chains should be educated on the requirements of the Code regarding claims.

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

Introduction:

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Menu labelling is effective in reducing energy ordered and consumed: a systematic review and meta-analysis of recent studies

Objective

Menu labelling is a practical tool to inform consumers of the energy content of menu items and help consumers make informed decisions in the eating-out environment, and the volume of studies published recently regarding its effects is expanding, both quantitatively and geographically. The aim of the present review and meta-analysis is to consider the most recent evidence which assesses the effect of menu labelling regarding changes in energy consumed, ordered or selected in both real-world and experimental settings.

Design

The review included fifteen peer-reviewed, full-text articles published between 2012 and 2014. Pertinent methodological information was extracted from each of the included studies and a quality assessment scheme was applied to classify the studies, after which systematic across-study comparisons were conducted. A meta-analysis was conducted including twelve of the fifteen studies, and stratified according to type of research setting and outcome: energy consumed, ordered or selected.

Results

The rating yielded studies categorized by study quality: good (n 3), fair (n 9) and weak (n 3). Overall nine studies showed statistically significant reductions in energy consumed, ordered or selected. Three articles reported no effect of menu labelling. The meta-analysis showed statistically significant effects of menu labelling: overall energy consumed was reduced by a mean of 419·5 kJ (100·2 kcal) and energy ordered in real-world settings decreased by a mean of 325·7 kJ (77·8 kcal).

Conclusions

The review supports that menu labelling can effectively reduce energy ordered and consumed in the away-from-home food environment.

Nutrition and the science of disease prevention: a systems approach to support metabolic health

Progress in nutritional science, genetics, computer science, and behavioral economics can be leveraged to address the challenge of noncommunicable disease. This report highlights the connection between nutrition and the complex science of preventing disease and discusses the promotion of optimal metabolic health, building on input from several complementary disciplines. The discussion focuses on (1) the basic science of optimal metabolic health, including data from gene-diet interactions, microbiome, and epidemiological research in nutrition, with the goal of defining better targets and interventions, and (2) how nutrition, from pharma to lifestyle, can build on systems science to address complex issues.

Availability, Location, and Format of Nutrition Information in Fast-food Chain Restaurants in Ontario, Canada

PURPOSE

To assess the availability, location, and format of nutrition information in fast-food chain restaurants in Ontario.

METHODS

Nutrition information in restaurants was assessed using an adapted version of the Nutrition Environment Measures Study for Restaurants (NEMS-R). Two raters independently visited 50 restaurants, 5 outlets of each of the top-10 fast-food chain restaurants in Canada. The locations of the restaurants were randomly selected within the Waterloo, Wellington, and Peel regions in Ontario, Canada. Descriptive results are presented for the proportion of restaurants presenting nutrition information by location (e.g., brochure), format (e.g., use of symbols), and then by type of restaurant (e.g., quick take-away, full-service).

RESULTS

Overall, 96.0% (n = 48) of the restaurants had at least some nutrition information available in the restaurant. However, no restaurant listed calorie information for all items on menu boards or menus, and only 14.0% (n = 7) of the restaurants posted calorie information and 26.0% (n = 13) of restaurants posted other nutrients (e.g., total fat) for at least some items on menus boards or menus.

CONCLUSIONS

The majority of the fast-food chain restaurants included in our study provided at least some nutrition information in restaurants; however, very few restaurants made nutrition information readily available for consumers on menu boards and menus.

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.

Use of psychology and behavioral economics to promote healthy eating

Understanding the psychology of how people make decisions can shed light on important factors contributing to the cause and maintenance of public health problems like obesity. This knowledge can and should inform the design of government and private-sector public health interventions. Several insights from psychology and behavioral economics that help explain why people are particularly vulnerable to the current food environment are discussed. These insights fall into the following categories: the influence of starting points (status quo bias and anchoring effects); communicating health information (simplicity and framing); and unintended consequences of policy interventions (compensation, substitution, and the peanuts effect). The paper discusses opportunities for improving the design of food policies and interventions by altering default options, providing the public with simple and meaningful nutrition information, carefully constructing the framing of public health messages, and designing food policies to minimize unintended consequences, such as compensation and substitution.

Price, promotion, and availability of nutrition information: a descriptive study of a popular fast food chain in New York City

Legislation in NYC requires chain restaurants to post calorie information on menu boards in an effort to help consumers make more informed decisions about food and beverage items they are purchasing. While this is a step in the right direction in light of the current obesity epidemic, there are other issues that warrant attention in a fast food setting, namely the pricing of healthy food options, promotional strategies, and access to comprehensive nutrition information. This study focused on a popular fast-food chain in NYC. The study’s aims were threefold: (1) to determine the cost differential between the healthiest meal item on the chain’s general menu and meal items available specifically on a reduced cost menu for one dollar (US$1.00); (2) to identify and describe the promotions advertised in the windows of these restaurants, as well as the nutrition content of promoted items; and (3) to ascertain availability of comprehensive nutrition information to consumers within the restaurants. We found the healthiest meal item to be significantly higher in price than less nutritious meal items available for $1.00 (t = 146.9, p < .001), with the mean cost differential equal to $4.33 (95% CI $4.27, $4.39). Window promotions generally advertised less healthful menu items, which may aid in priming customers to purchase these versus more healthful options. Comprehensive nutrition information beyond calorie counts was not readily accessible prior to purchasing. In addition to improving access to comprehensive nutrition information, advertising more of and lowering the prices of nutritious options may encourage consumers to purchase healthier foods in a fast food setting. Additional research in this area is needed in other geographic locations and restaurant chains.

Supplementing menu labeling with calorie recommendations to test for facilitation effects

OBJECTIVES

We examined the effect on food purchases of adding recommended calorie intake per day or per meal to the mandated calorie information posted on chain restaurant menus.

METHODS

Before and after New York City implemented calorie posting on chain restaurant menus in 2008, we provided daily, per-meal, or no calorie recommendations to randomized subsets of adult lunchtime customers (n = 1121) entering 2 McDonald's restaurants, in Manhattan and Brooklyn, and collected receipts and survey responses as they exited. In linear and logistic regressions, with adjustment for gender, race, age, and day, we tested for simple differences in calories consumed and interactions between variables.

RESULTS

Posting calorie benchmarks had no direct impact, nor did it moderate the impact of calorie labels on food purchases. The recommendation appeared to promote a slight increase in calorie intake, attributable to increased purchases of higher-calorie entrées.

CONCLUSIONS

These results do not support the introduction of calorie recommendations as a means of enhancing the impact of posted calorie information or reducing the contribution of restaurant dining to the obesity epidemic.

What types of nutrition menu labelling lead consumers to select less energy-dense fast food? An experimental study

This study assessed whether the inclusion of kilojoule labelling alone or accompanied by further nutrition information on menus led adults to select less energy-dense fast food meals. A between-subjects experimental design was used with online menu boards systematically varied to test the following labelling conditions: none (control); kilojoule; kilojoule+percent daily intake; kilojoule+traffic light; and kilojoule+traffic light+percent daily intake. Respondents were 1294 adults aged 18-49 in Victoria, Australia who had purchased fast food in the last month and were randomly assigned to conditions. Respondents in the no labelling condition selected meals with the highest mean energy content and those viewing the kilojoule and kilojoule+traffic light information selected meals with a significantly lower mean energy content, that constituted a reduction of around 500kJ (120kcal). Respondents most commonly reported using the traffic light labels in making their selections. These findings provide support for the policy of disclosure of energy content on menus at restaurant chains. Given the magnitude of the reduction in energy density reported, and the prevalence of fast food consumption, this policy initiative has the potential to yield health benefits at the population level.

Associations Between a Voluntary Restaurant Menu Designation Initiative and Patron Purchasing Behavior

Background. Restaurant initiatives provide an efficient opportunity to impact large numbers of patrons. The purpose of this study is to measure patron purchasing behaviors during the ¡Por Vida! menu designation initiative. Method. This study used a cross-sectional design and survey data to assess 23 restaurants throughout Bexar County and 152 restaurant patrons. The Patron Awareness Questionnaire assessed if patrons noticed the logo; believed nutrition, cost, and taste were important in making purchasing decisions; and purchased a ¡Por Vida! item. Descriptive statistics, Spearman correlations, and logistic regression were used to analyze the data. Results. Most (93.4%) patrons considered taste very important when deciding what to eat. Cost was very important to 63.8% and nutrition was very important to 55.9% of the sample. The strongest predictors of purchasing a ¡Por Vida! item were the patrons’ ages being between 18 and 35 years (odds ratio = 1.474; confidence interval = 0.017, 0.812; p < .05) and if patrons saw the logo (odds ratio = 4.327; confidence interval = 1.696-11.036; p < .01). Discussion/Conclusion. Menu logo designation initiatives can potentially influence patron purchasing behaviors among a segment of the population when the logo is visible.

Changes in energy content of lunchtime purchases from fast food restaurants after introduction of calorie labelling: cross sectional customer surveys

OBJECTIVE

To assess the impact of fast food restaurants adding calorie labelling to menu items on the energy content of individual purchases.

DESIGN

Cross sectional surveys in spring 2007 and spring 2009 (one year before and nine months after full implementation of regulation requiring chain restaurants' menus to contain details of the energy content of all menu items). Setting 168 randomly selected locations of the top 11 fast food chains in New York City during lunchtime hours.

PARTICIPANTS

7309 adult customers interviewed in 2007 and 8489 in 2009.

MAIN OUTCOME MEASURES

Energy content of individual purchases, based on customers' register receipts and on calorie information provided for all items in menus.

RESULTS

For the full sample, mean calories purchased did not change from before to after regulation (828 v 846 kcal, P = 0.22), though a modest decrease was shown in a regression model adjusted for restaurant chain, poverty level for the store location, sex of customers, type of purchase, and inflation adjusted cost (847 v 827 kcal, P = 0.01). Three major chains, which accounted for 42% of customers surveyed, showed significant reductions in mean energy per purchase (McDonald's 829 v 785 kcal, P = 0.02; Au Bon Pain 555 v 475 kcal, P<0.001; KFC 927 v 868 kcal, P<0.01), while mean energy content increased for one chain (Subway 749 v 882 kcal, P<0.001). In the 2009 survey, 15% (1288/8489) of customers reported using the calorie information, and these customers purchased 106 fewer kilocalories than customers who did not see or use the calorie information (757 v 863 kcal, P<0.001).

CONCLUSION

Although no overall decline in calories purchased was observed for the full sample, several major chains saw significant reductions. After regulation, one in six lunchtime customers used the calorie information provided, and these customers made lower calorie choices.

Consumer awareness of fast-food calorie information in New York City after implementation of a menu labeling regulation

OBJECTIVES

We assessed consumer awareness of menu calorie information at fast-food chains after the introduction of New York City's health code regulation requiring these chains to display food-item calories on menus and menu boards.

METHODS

At 45 restaurants representing the 15 largest fast-food chains in the city, we conducted cross-sectional surveys 3 months before and 3 months after enforcement began. At both time points, customers were asked if they had seen calorie information and, if so, whether it had affected their purchase. Data were weighted to the number of city locations for each chain.

RESULTS

We collected 1188 surveys pre-enforcement and 1229 surveys postenforcement. Before enforcement, 25% of customers reported seeing calorie information; postenforcement, this figure rose to 64% (P < .001; 38% and 72%, weighted). Among customers who saw calorie information postenforcement, 27% said they used the information, which represents a 2-fold increase in the percentage of customers making calorie-informed choices (10% vs 20%, weighted; P < .001).

CONCLUSIONS

Posting calorie information on menu boards increases the number of people who see and use this information. Since enforcement of New York's calorie labeling regulation began, approximately 1 million New York adults have seen calorie information each day.

Evaluation of a voluntary menu-labeling program in full-service restaurants

OBJECTIVES

We assessed whether labeling restaurant menus with information on the nutrient content of menu items would cause customers to alter their ordering patterns.

METHODS

Six full-service restaurants in Pierce County, Washington, added nutrition information to their menus, and they provided data on entrée sales for 30 days before and 30 days after the information was added. We assessed the prelabeling versus postlabeling difference in nutrient content of entrées sold, and we surveyed restaurant patrons about whether they noticed the nutrition information and used it in their ordering.

RESULTS

The average postlabeling entrée sold contained about 15 fewer calories, 1.5 fewer grams of fat, and 45 fewer milligrams of sodium than did the average entrée sold before labeling. Seventy-one percent of patrons reported noticing the nutrition information; 20.4% reported ordering an entrée lower in calories as a result, and 16.5% reported ordering an entrée lower in fat as a result.

CONCLUSIONS

The concentration of calorie reduction among 20.4% of patrons means that each calorie-reducing patron ordered about 75 fewer calories than they did before labeling. Thus, providing nutrition information on restaurant menus may encourage a subset of restaurant patrons to significantly alter their food choices.

An observational study of consumer use of fast-food restaurant drive-through lanes: implications for menu labelling policy

Objective

Some versions of restaurant menu labelling legislation do not require energy information to be posted on menus for drive-through lanes. The present study was designed to quantify the number of customers who purchase fast food through drive-in windows as a means of informing legislative labelling efforts.

Design

This was an observational study.

Setting

The study took place at two McDonald’s and Burger King restaurants, and single Dairy Queen, Kentucky Fried Chicken, Taco Bell and Wendy’s restaurants.

Subjects

The number of customers entering the chain restaurants and purchasing food via the drive-through lane were recorded. A total of 3549 patrons were observed.

Results

The percentage of customers who made their purchases at drive-throughs was fifty-seven. The overall average (57 %) is likely a conservative estimate because some fast-food restaurants have late-night hours when only the drive-throughs are open.

Conclusions

Since nearly six in ten customers purchase food via the drive-through lanes, menu labelling legislation should mandate the inclusion of menu labels on drive-through menu boards to maximise the impact of this public health intervention.

Evaluating the impact of menu labeling on food choices and intake

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rationale and evidence for menu-labeling legislation

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