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

Comparing the impact of simple and educational point-of-decision messages on nutritional choice outcomes

Emerging evidence suggests that point-of-decision messages may be an effective way to promote healthy food choices. Previous studies show improvements in overall nutritional quality, as well as increases in underconsumed food categories, such as fruits and vegetables, and underconsumed nutrients of public health concern, like dietary fiber. However, there have been multiple approaches used for delivering point-of-decision messages, including very brief messages that remind individuals to consider health during choice, as well as longer messages providing educational information about health benefits. While both approaches have demonstrated positive impacts on outcomes, there is no comparative evidence of the messages' effectiveness. In this study, we examine the impact of four messages on two nutritional attributes of cereals selected in a two-round pre- and post-message breakfast cereal choice exercise with numerous (n = 33) breakfast cereals available. Data were collected via an online survey of adult US residents recruited from the Prolific consumer panel. Three of the messages were simple reminder messages (taste, health, fiber), while there was additionally a longer fiber-focused messaging detailing the health benefits of fiber. Findings show that the simple messages outperformed the longer educational message, though there were some trade-offs between general health and fiber messages. The simple dietary fiber-focused message resulted in significantly higher dietary fiber content in cereals chosen than in any other messaging condition, while the general health message did not result in significantly higher measures of nutritional quality than the simple fiber message. The results of the study suggest that simpler messages may be more effective at increasing the nutritional quality of food choices. Additionally, messages focused on specific nutrients lead to significantly greater increases in the content of those nutrients.

Nutritional Calorie Labeling and Menu Ordering Practices Among US Adults With Chronic Illnesses

BACKGROUND

The relationship between diet and the management of chronic illnesses is well established. However, it is unknown the extent to which people with chronic illnesses pay attention to nutritional information and act upon the information obtained. We evaluated the menu ordering practices of adults with chronic illnesses.

METHODS

We analyzed the 2018 Health Information National Trends Survey (HINTS 5 Cycle 2). Our analytic cohort included 3,154 respondents (weighted population size=228,464,822) who answered questions regarding a personal history of diabetes, hypertension, heart disease, and obesity. They also answered questions about their nutritional habits regarding whether they noticed caloric information at fast-food or sit-down restaurants and how that information influenced their dietary choices.

RESULTS

Among respondents with these chronic illnesses, only obese patients were significantly more likely to pay attention to caloric information (OR=1.56; 95%CI: 1.06-2.31). However, noticing the calorie information was not associated with ordering less calories among all categories of respondents with chronic illnesses.

CONCLUSION

US adults with chronic illnesses do not pay sufficient attention to the calorie information of their diet. Furthermore, awareness of the calorie information did not influence their dietary choices. Healthcare professionals should incorporate dietary counseling into the management of chronic illnesses of their patients.

Front-of-Package-Label-Style Health Logos on Menus-Do Canadian Consumers Really Care about Menu Health Logos?

Public health policies have been widely utilized to improve population nutrition, such as the newly announced front-of-pack labels (FOPLs) that will be applied to Canadian prepackaged foods to help consumers make healthier selections. However, research on similar health logos in the food service sector has been limited. This study explores the potential application of FOPL-style health logos in the food service sector and its impact on consumer behaviors. A survey was conducted among 1070 Canadians to assess their awareness, perception, and support for health logos on restaurant menus. The results indicate that while participants value healthy food options when dining out, taste, price, and convenience remain the primary factors influencing their choices. Most participants were unaware of existing FOPL policies and demonstrated mixed responses regarding the influence of similar health logos on their restaurant selection. However, a majority expressed a desire to see FOPL-style health logos on menus, and nutrient profile ratings and logos indicating nutrient limitations or encouragements were listed as preferred health logos. Notably, females indicated higher supportiveness for FOPL-style health logos on menus and individuals with food allergies exhibited higher agreement in the likelihood of eating at a restaurant displaying labels. Additionally, findings revealed that FOPL-style health logos alone may not significantly deter consumers from purchasing labelled menu items, especially if price is affected. Overall, this study highlights the need for further understanding consumer perceptions to effectively develop and implement FOPL initiatives in the food service sector.

Noticing and Responding to Calorie Labels on Restaurant Menus: Patterns in Sexual-Minority Men

INTRODUCTION

A calorie-labeling policy for restaurant menus was implemented in 2018. Whether and how sexual-minority men use this information has not been evaluated.

METHODS

The Men's Body Project, a 2020 cross-sectional survey study of 504 cisgender sexual-minority men (mean age=35.8±10.4 years, 71.0% White, 5.6% Asian, 14.3% Black, 9.1% another/multiple race identities) assessed respondents' awareness of calorie labels on restaurant menus and subsequent responses. Additional questions were asked about weight-change goals, body image, disordered eating behaviors, and muscle-enhancing supplement use. Analyses in 2022-2023 used multivariate logistic regression to assess the associations between noticing calories and weight- and muscularity-oriented behaviors and, among those who noticed calorie labels, whether participants reported using this information to order more or fewer calories.

RESULTS

Approximately half of the participants reported noticing calorie labels. Those who did were more likely to report engaging in disordered eating behaviors (OR=2.03). Among participants who noticed menu labels, ordering fewer calories was the most frequent response, whereas 25% reported not changing the caloric content of their order. Many participants (21%) reported ordering both more and fewer calories, and this heterogeneous ordering pattern was associated with both disordered eating (OR=4.70) and muscle-enhancing behaviors (OR=9.42) compared with that among participants who did not report behaviors. Reporting weight-control efforts was associated with ordering fewer calories than participants not doing anything to change their weight (OR=2.53).

CONCLUSIONS

Most participants noticed calorie labels on menus, and many reported subsequently ordering fewer calories. Disordered eating and muscle-enhancing behaviors were associated with behavior changes in response to calorie information.

Cost Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S

INTRODUCTION

Calorie labeling of standard menu items has been implemented at large restaurant chains across the U.S. since 2018. The objective of this study was to evaluate the cost effectiveness of calorie labeling at large U.S. fast-food chains.

METHODS

This study evaluated the national implementation of calorie labeling at large fast-food chains from a modified societal perspective and projected its cost effectiveness over a 10-year period (2018-2027) using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model. Using evidence from over 67 million fast-food restaurant transactions between 2015 and 2019, the impact of calorie labeling on calorie consumption and obesity incidence was projected. Benefits were estimated across all racial, ethnic, and income groups. Analyses were performed in 2022.

RESULTS

Calorie labeling is estimated to be cost saving; prevent 550,000 cases of obesity in 2027 alone (95% uncertainty interval=518,000; 586,000), including 41,500 (95% uncertainty interval=33,700; 50,800) cases of childhood obesity; and save $22.60 in healthcare costs for every $1 spent by society in implementation costs. Calorie labeling is also projected to prevent cases of obesity across all racial and ethnic groups (range between 126 and 185 cases per 100,000 people) and all income groups (range between 152 and 186 cases per 100,000 people).

CONCLUSIONS

Calorie labeling at large fast-food chains is estimated to be a cost-saving intervention to improve long-term population health. Calorie labeling is a low-cost intervention that is already implemented across the U.S. in large chain restaurants.

Menu Calorie Label Use and Diet Quality: a Cross-Sectional Study

INTRODUCTION

Menu calorie labeling has been implemented in food service businesses to promote healthy food choices; however, evidence is limited on whether label use is associated with healthier dietary intake. This study examined the association between menu calorie label use and diet quality and whether it varied by weight status.

METHODS

Adults in the National Health and Nutrition Examination Survey 2017-2018 who visited restaurants were included. Menu calorie label use was categorized as did not notice labels, noticed labels, and used labels. Diet quality was measured using the Healthy Eating Index 2015 (maximum score 100) by two 24-hour diet recalls. The association between menu calorie label use and diet quality was examined using multiple linear regression and tested for effect modification by weight status. Data were collected during 2017-2018 and analyzed during 2022-2023.

RESULTS

Of 3,312 participants (representing 195,167,928 U.S. adults), 43% did not notice labels, 30% noticed labels, and 27% used labels. Using labels was associated with 4.0 points (95% CI 2.2, 5.8) higher Healthy Eating Index 2015 scores than not noticing labels. Healthy Eating Index 2015 scores in those using labels were higher for adults with normal BMI (3.4 points; 95% CI=0.2, 6.7), overweight (6.5 points; 95% CI=3.6, 9.5), and obesity (3.0 points; 95% CI=1.0, 5.1) (p-interaction=0.0004) than those who did not notice labels.

CONCLUSIONS

Using menu calorie labels was associated with modestly healthier diet quality than not noticing labels, regardless of weight status. This suggests that providing caloric information may help some adults with food decisions.

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.

Public's calorie literacy and perceived effectiveness of restaurant menu calorie labeling in the United Arab Emirates

Restaurant menu calorie labeling is regarded as a promising, cost-effective, and innovative method that will have an impact on the food environment, raise awareness among consumers, and aid in global efforts to prevent obesity. This study aimed to assess the public's calorie literacy, dining practices, and perceived effectiveness of restaurant menu labeling implementation in the United Arab Emirates (UAE). A descriptive, web-based cross-sectional study was conducted among 1279 adults in the UAE. Socio-demographic characteristics, calorie literacy, and perceived effectiveness of restaurant menu labeling among participants were investigated. Chi-square analysis was used to compare indicators across demographic characteristics. More females than males completed the online survey, (56.1% and 43.9%). Most of the participants aged < 30 years old (54.8%), The majority of participants reported eating away from home at least once per week (89.6%). 66.0% of participants were knowledgeable about calorie definition, but only 37.1% knew about average daily energy requirements. Younger participants, with a normal BMI, and higher education levels reported a significantly higher likelihood of eating at a chain restaurant with caloric information on the menu (p <0.05). The majority of participants (76.0%) preferred to see calorie information and other nutrition information on menus. To conclude, menu labeling is a welcomed policy to be implemented in food outlets. Further investigation is necessary to ascertain the most efficacious method of presenting nutrition information to consumers to facilitate informed purchasing decisions considering the potential benefits of mandating calorie declaration in obesity prevention efforts.

The Effects of Ontario Menu Labelling Regulations on Nutritional Quality of Chain Restaurant Menu Items-Cross-Sectional Examination

Restaurant foods are associated with excessive energy intake and poor nutritional quality. In 2017, the Healthy Menu Choices Act mandated food service establishments with ≥20 outlets in Ontario to display the energy content on menus. To examine the potential impact of menu labelling, nutrition information for 18,760 menu items were collected from 88 regulated and 53 unregulated restaurants. Descriptive statistics were calculated for serving size, energy, saturated fat, sodium and total sugars. Quantile regression was used to determine the differences between regulated and unregulated restaurants. The energy content of menu items from regulated restaurants (median (95% CI): 320 kcal (310, 320)) was significantly lower than those from unregulated restaurants (470 kcal (460, 486), p < 0.001). Saturated fat, sodium and total sugars were significantly lower in regulated restaurants (4 g (4, 4), 480 mg (470, 490) and 7 g (6, 7), respectively) than in unregulated restaurants (6 g (6, 6), 830 mg (797, 862) and 8 g (8, 9), respectively, p < 0.001). This study showed that menu items from regulated restaurants had smaller serving size, lower levels of energy and nutrients of public health concern compared to those from the unregulated restaurants, suggesting potential downstream beneficial effects of menu labelling in lowering caloric content and nutrients of public health concern in foods.

Implementing physical activity calorie equivalent (PACE) food labelling: Views of a nationally representative sample of adults in the United Kingdom

BACKGROUND

Nutritional labels aim to support people to make informed healthy food choices, but many people do not understand the meaning of calories on food labels. Another approach is to provide calorie information with an interpretation of what the calorie content of food means for energy expenditure, known as physical activity calorie equivalent (PACE) labelling. PACE aims to illustrate how many minutes of physical activity are equivalent to the calories contained in food/drinks. This study investigated the views of the public about the possible implementation of PACE labelling.

METHODS

Data was obtained from a nationally representative sample of adults in the United Kingdom and collected by UK Ipsos KnowledgePanel. Panellists are recruited via a random probability unclustered address-based sampling method. 4,000 panellists were randomly invited to participate and asked to compare their views about traffic light and PACE labelling preferences and behaviour parameters.

RESULTS

Data were analysed descriptively and using logistic and multinomial regression analyses. 2,668/4,000 (67%) of those invited participated. More participants preferred traffic light (43%vs33%) than PACE labelling, but more reported PACE was easier to understand (41%vs27%) and more likely to catch their attention (49%vs31%). More participants thought PACE was more likely to help them avoid high calorie food than traffic light labelling (44%vs28%). Physically active (3-4 or 5+ days/week) respondents were more likely to report PACE would catch their attention than traffic light labelling, compared with less active participants (weighted adjusted relative risk ratio = 1.42 (1.00-2.00) and 1.45 (1.03-2.05 respectively)). Perceived overweight was the most predictive factor (weighted adjusted OR = 2.24 (1.19 to 4.20)) in whether PACE was considered useful in helping people decide what to eat/buy.

CONCLUSION

The public identified value to their health in labelling food with PACE information. PACE labelling may be a useful approach to complement current approaches to food labelling.

Impact of front-of-pack nutrition labelling in consumer understanding and use across socio-economic status: A systematic review

An unhealthy diet is a leading contributor to the increasing burden of overweight and obesity. Front-of-pack labelling (FOPL) is being recognized as a policy strategy to promote healthier choices yet there is limited evaluation of FOPL to suggest if it is effective for all population subgroups. This systematic review aimed to assess the impact of FOPL on consumer understanding and usage across socio-economic gradients. Six electronic databases were searched through a systematic search process using key terms for FOPL and socioeconomic status (SES) from 2011 to March 2022 to include studies evaluating the effectiveness of FOPL. A narrative synthesis was conducted and the results were assessed according to the effects of FOPL on consumer awareness, understanding, and usage across SES. The review included 36 articles. In general, people of all SES groups were aware of and more likely to pay attention towards FOPL than the nutrition information panel provided on the back of the package. However, the understanding and usage were relatively poor, particularly in low SES groups. While studies conducted in low SES populations suggest FOPL increased the purchase intention of healthy products, the stratified analysis across SES showed less beneficial effects in low SES individuals. The findings highlight simplified and easy-to-understand FOPLs such as Nutri-score and traffic light labelling are likely to be effective for all populations including low SES groups. Overall, the review suggests FOPLs are more visible than the nutrition information panel and may guide healthier food choices for people of all SES backgrounds. It is unclear whether FOPL influences actual purchasing and food intake as there are insufficient studies comparing the effects among higher and lower SES populations.

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.

Qualitative menu labelling in university restaurants and its influence on food choices: A systematic review and synthesis without meta-analysis

Qualitative menu labelling can be defined as descriptive or non-numerical interpretive labels (e.g. traffic light labelling, healthy food symbols, messages or ingredient lists). Qualitative information seems to have a positive influence on consumers' food choices, particularly in institutional food service establishments, such as in universities. The aim of this systematic review was to assess the influence of different formats of qualitative menu labelling on food choices in university restaurants. This systematic review was guided by the Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) and Synthesis Without Meta-Analysis (SWiM) and conducted vote counting of studies based on the direction of effect. Studies were retrieved from Cochrane Library, Scopus, MEDLINE, LILACS, SciELO and Web of Science databases and reference lists of selected articles. Experimental and quasi-experimental studies were included. Two independent researchers searched and extracted the data and assessed the methodological quality using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. From the initial search (460 records), four papers were selected, plus one paper identified in a previous study and a further six from an update search, totalling 11 included studies, reporting 14 different interventions (n = 499 174). Types of interventions included the use of symbols and the inclusion of traffic light labelling. Outcomes of interest were food choice, expressed as mean, median or percent healthy food choices or purchases. Qualitative menu labels increased healthy food choices and/or purchase behaviour, with 10 of 12 interventions favouring the intervention (83%; 95%CI 55-95%; p = 0.0386). Most of the studies favouring the intervention used healthy food symbols for healthier foods or food components, alone or in association with another intervention and were of moderate and weak quality. These findings may serve as a basis for the implementation of nutrition information policies in university restaurants.

Characteristics of successful government-led interventions to support healthier populations: a starting portfolio of positive outlier examples

Despite progress on the Millennium and Sustainable Development Goals, significant public health challenges remain to address communicable and non-communicable diseases and health inequities. The Healthier Societies for Healthy Populations initiative convened by WHO's Alliance for Health Policy and Systems Research; the Government of Sweden; and the Wellcome Trust aims to address these complex challenges. One starting point is to build understanding of the characteristics of successful government-led interventions to support healthier populations. To this end, this project explored five purposefully sampled, successful public health initiatives: front-of-package warnings on food labels containing high sugar, sodium or saturated fat (Chile); healthy food initiatives (trans fats, calorie labelling, cap on beverage size; New York); the alcohol sales and transport ban during COVID-19 (South Africa); the Vision Zero road safety initiative (Sweden) and establishment of the Thai Health Promotion Foundation. For each initiative a qualitative, semistructured one-on-one interview with a key leader was conducted, supplemented by a rapid literature scan with input from an information specialist. Thematic analysis of the five interviews and 169 relevant studies across the five examples identified facilitators of success including political leadership, public education, multifaceted approaches, stable funding and planning for opposition. Barriers included industry opposition, the complex nature of public health challenges and poor interagency and multisector co-ordination. Further examples building on this global portfolio will deepen understanding of success factors or failures over time in this critical area.

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.

College students' attitude toward menu labeling differs by sex, BMI, weight management status, and athletic type

Objective Determine students' attitude toward menu labeling before and after menu labeling implementation at university dining facility. Participants: College students aged 18 years and older eating at campus dining facility. Methods: Survey on attitude toward menu labeling, weight management status, and athletic classification (NCAA, recreational, or non-athlete) was completed 30 days pre- and post-menu labeling implementation. Results: Females showed stronger positive attitude toward menu labeling. Students trying to lose or gain weight had stronger positive attitudes toward menu labeling than students maintaining weight, as did overweight students compared to normal weight students. NCAA athletes had lower attitude mean scores toward menu labeling than other athletic classifications. Conclusion: Attitude toward menu labeling varies by students' gender, body mass index (BMI), and weight management focus, with NCAA athletes having the least positive attitude. Focus future research on effective ways to inform students on menu labeling in university dining facilities in order to nutritionally engage young adults.

Determinants of Healthy Food Consumption and the Effect of Saudi Food Related Policies on the Adult Saudi Population, a National Descriptive Assessment 2019

Saudi Arabia (SA) is a country with an advanced nutritional transition, so this study aims to measure the prevalence of healthy food consumption and its context, and to study the effect of Saudi Arabia's policies on the pattern of food consumption among inhabitants in SA. Through an online self-administered and validated questionnaire, the cross-sectional study recruited 590 randomly chosen adult Saudis who were stratified to represent the 20 health regions in KSA. Ethical approval was obtained for this work. The relevant tests were used to code and analyze the collected data. Of the 590 participants, 50.2% were males, with a mean ± SD age of 35.6±10.52 year.43.2% of the participants did not meet the Ministry of Health recommendation in any food group, while only 1.53% consumed the recommended amounts of all food groups. 47.8% of the participants did not perform any physical activity. 34.7% of participants prefer healthy food, 18.8% prefer unhealthy food, and 46.5% prefer both. Most Saudis do not comply with the national dietary guidelines’ recommendations, they are physically inactive, and they use social media in a way that affects their food choices.

Evaluation of physical activity calorie equivalent (PACE) labels' impact on energy purchased in cafeterias: A stepped-wedge randomised controlled trial

BACKGROUND

A recent meta-analysis suggested that using physical activity calorie equivalent (PACE) labels results in people selecting and consuming less energy. However, the meta-analysis included only 1 study in a naturalistic setting, conducted in 4 convenience stores. We therefore aimed to estimate the effect of PACE labels on energy purchased in worksite cafeterias in the context of a randomised study design.

METHODS AND FINDINGS

A stepped-wedge randomised controlled trial (RCT) was conducted to investigate the effect of PACE labels (which include kcal content and minutes of walking required to expend the energy content of the labelled food) on energy purchased. The setting was 10 worksite cafeterias in England, which were randomised to the order in which they introduced PACE labels on selected food and drinks following a baseline period. There were approximately 19,000 workers employed at the sites, 72% male, with an average age of 40. The study ran for 12 weeks (06 April 2021 to 28 June 2021) with over 250,000 transactions recorded on electronic tills. The primary outcome was total energy (kcal) purchased from intervention items per day. The secondary outcomes were: energy purchased from non-intervention items per day, total energy purchased per day, and revenue. Regression models showed no evidence of an overall effect on energy purchased from intervention items, -1,934 kcals per site per day (95% CI -5,131 to 1,262), p = 0.236, during the intervention relative to baseline, equivalent to -5 kcals per transaction (95% CI -14 to 4). There was also no evidence for an effect on energy purchased from non-intervention items, -5 kcals per site per day (95% CI -513 to 504), p = 0.986, equivalent to 0 kcals per transaction (95% CI -1 to 1), and no clear evidence for total energy purchased -2,899 kcals per site (95% CI -5,810 to 11), p = 0.051, equivalent to -8 kcals per transaction (95% CI -16 to 0). Study limitations include using energy purchased and not energy consumed as the primary outcome and access only to transaction-level sales, rather than individual-level data.

CONCLUSION

Overall, the evidence was consistent with PACE labels not changing energy purchased in worksite cafeterias. There was considerable variation in effects between cafeterias, suggesting important unmeasured moderators.

TRIAL REGISTRATION

The study was prospectively registered on ISRCTN (date: 30.03.21; ISRCTN31315776).

Influence of Using Food Delivery Applications on Adult Saudi Female Dietary Habits and Preferences during COVID-19 Lockdown Restrictions: Attitude Survey

Food delivery applications (FDAs) shined during COVID-19 global lockdown restrictions. Consequently, lifestyle changes imposed a greater use of these applications over this period. These changes may strongly influence the nutritional health of individuals, particularly adult Saudi females. A cross-sectional study was performed to examine the influence of using FDAs during COVID-19 lockdown restrictions on attitude behaviours, including dietary habits and preferences among Saudi adult females. Participants voluntarily submitted their answers to a questionnaire administered via the Google Survey platform. Results illustrated that most Saudi female users of FDAs were aged between 18-24 years with 64.9%, 91.5% being single and 37% ordering food online within one to two days a month. There was a significant association between the influence of using FDAs during COVID-19 lockdown restrictions and age, education, and average days of ordering food online (p ˂ 0.05). Another important factor is that higher education was associated with more frequent use of the FDAs, there were direct relationships between education level and using FDAs, 58% of the participants were educated as undergraduate or postgraduate. Although lifestyle changes increased the use of FDAs during COVID-19 global lockdown restrictions, these changes may negatively affect individuals' dietary habits and preferences, particularly adult Saudi females. These findings can aid in promoting healthy diet management globally and in Saudi Arabia unless the governments lead to significant beneficial changes toward improving food delivery applications.

The Symmetry Effect: Symmetrical Shapes Increase Consumer’s Health Perception of Food

Focusing on the physical appearance of the food itself, and limiting the focus on shape to the concept of symmetry, this research investigated how food shape influences consumer perceptions of healthiness and naturalness and their subsequent food preferences. By conducting three empirical studies involving self-reported preference and trade-off choices, this research verified that it is a two-staged process of naturalness and healthiness that mediates the main effect of symmetry on foods preference. Furthermore, the incremental perceived unhealthiness of food would mitigate the positive effect of food symmetry. These findings are meaningful for food marketing managers and policymakers when making food-related decisions.

Energy labelling of alcoholic drinks: An important or inconsequential obesity policy?

Alcohol is calorie dense, but unlike food products, alcoholic drinks tend to be exempt from nutritional labelling laws that require energy content information to be displayed on packaging or at point of purchase. This review provides a perspective on the likely efficacy of alcoholic drink energy labelling as a public health policy to reduce obesity and discusses key questions to be addressed by future research. First, the contribution that alcohol makes to population level daily energy intake and obesity is outlined. Next, consumer need for alcohol energy labelling and the potential impacts on both consumer and industry behavior are discussed. Pathways and mechanisms by which energy labelling of alcoholic drinks could reduce obesity are considered, as well as possible unintended consequences of alcoholic drink energy labelling. Would widespread energy labelling of alcoholic drinks reduce obesity? The unclear effect that alcohol has on population level obesity, the modest contribution calories from alcohol make to daily energy intake and limited impact nutritional labelling policies tend to have on behavior, suggest alcohol energy labelling may have limited impact on population obesity prevalence as a standalone policy. However, there are a number of questions that will need to be answered by future research to make definitive conclusions on the potential for alcohol energy labelling policies to reduce obesity.

More value from less food? Effects of epicurean labeling on moderate eating in the United States and in France

Emerging research has shown that sensory-based interventions (e.g., inviting people to mindfully focus on the multisensory aspects of eating) can be a viable alternative to nutrition-based interventions (e.g., nutrition labeling) to encourage moderate eating. We contribute to this literature in two ways. First, we propose a novel and simple sensory-based intervention to increase the appeal of moderate food portions in commercial settings, epicurean labeling, which consists in emphasizing the aesthetic, multisensory properties of the food when describing it on menus or packages. Second, we show theory-relevant cross-cultural differences in the effectiveness of this intervention between the United States and France, two food cultures at the opposite ends of the hedonic-utilitarian food attitude spectrum. We report the results of a multi-day field experiment at a French cafeteria showing that epicurean labeling, unlike nutrition labeling, reduces intake while increasing the perceived monetary value of the meal thanks to higher savoring. We then show in a matched cross-national online experiment that epicurean labeling is more effective in France than in the United States. We provide additional evidence of this cross-cultural variation in a study of 9154 food products sold in supermarkets in both countries. We find that epicurean labeling is more prevalent, but also more likely to be associated with smaller portions in France than in the United States. While sensory-based interventions are a promising alternative to nutrition-based interventions, it is necessary to develop business-friendly interventions that can be implemented in everyday life, as well as to consider cultural factors that can modulate their effectiveness.

Consumers' Knowledge, Attitudes, and Practices Toward Calorie Labeling in Riyadh City, Saudi Arabia: A Cross-Sectional Assessment

Background

Menu calorie labeling is a useful means to encourage consumers to be informed about healthy eating and food choices. It is projected as an innovative method that will change the food environment and increases consumers' awareness of calories.

Objective

This study aims to determine the consumer's knowledge, attitudes, and practices toward menu calorie labeling in Saudi Arabia.

Methods

This is a descriptive cross-sectional study involving 435 consumers in Saudi Arabia. The participants filled out an online electronic survey questionnaire that assesses the demographic factors, knowledge, attitudes, practices, and barriers toward menu calorie labeling. Logistic regression was performed to determine the predictor of attitudes of consumers toward menu calorie labeling.

Results

Of those 435 consumers, 50.1% were men, 33% were in the age group of 30–39, and 49.4% had a bachelor's degree. The majority of the participants reported that they can understand the calorie labels that were presented on the menus of the restaurants (N = 365, 83.9%). A high percentage of participants reported that calorie labeling encourages them to choose foods with a smaller number of calories (N = 387, 89%) and supported the posting of calorie content next to the price of the food items on the menus (N = 405, 93.1%). Barriers to using calorie labels were time-consuming and low-calorie food items are usually costly. Gender and educational attainment were found significantly associated with consumers' knowledge while marital status and BMI level were found significantly associated with attitudes and practices to using calorie labels (p < 0.05).

Conclusion

Overall, the participants had adequate knowledge and positive attitudes about menu calorie labeling in Saudi Arabia. Menu calorie labeling may be a useful policy tool for promoting healthy eating habits and appropriate caloric consumption.

Consumption Frequency and Purchase Locations of Foods Prepared Outside the Home in Australia: 2018 International Food Policy Study

BACKGROUND

Foods prepared outside the home (e.g., fast-food chains, restaurants) represent increasing proportions of diets worldwide, and have been associated with higher energy intakes and BMIs. To improve the healthiness of population diets, it is important to understand patterns of consumption of these foods, and whether related policy measures are effective.

OBJECTIVES

This study aimed to identify the frequency and sources of consumption of foods prepared outside the home in Australia, and to understand the impact of nutrition information in restaurants on related food choices.

METHODS

Data were from a web-based survey (the International Food Policy Study) completed in 2018 by Australian adults aged ≥18 years (n = 4103). The number of meals prepared outside the home, their purchase locations, and the extent to which nutrition information was noticed and influenced purchasing decisions were each analyzed by sociodemographic characteristics and BMI, with linear models also adjusted for sex, age group, education, ethnicity, and BMI.

RESULTS

An average of 2.73 (95% CI, 2.61-2.86) meals per week were prepared outside the home, with higher frequencies among men, younger ages, and more highly educated participants. A wide variety of sources for these foods was observed, with fast-food outlets being most common. Around one-quarter of all foods prepared outside the home were delivered. A small percentage (14.9%; 95% CI, 13.3%-16.7%) of participants reported noticing nutrition information, but among those who did, around half reported that it influenced their behavior.

CONCLUSIONS

Foods prepared outside the home are commonly purchased in Australia, particularly by young adults, from a variety of outlet types. While current menu energy labeling regulations may provide some population health benefit, a broader policy focus on foods prepared outside the home is needed as part of efforts to improve population diets.

Menu Labeling Utilization and Socioeconomic Status in West Virginia and Mississippi

OBJECTIVE

Determine the association between socioeconomic status and self-reported noticing and using calorie menu labels in 2 states with high poverty and obesity.

DESIGN

Cross-sectional study of responses to the 2016 Behavioral Risk Factor Surveillance System Menu Labeling Module.

PARTICIPANTS

Representative sample of noninstitutionalized adults aged ≥ 18 years in West Virginia and Mississippi (n = 9,469).

MAIN OUTCOME MEASURES

The outcomes were reported noticing and using menu labels to make decisions at fast-food restaurants. Independent variables were highest attained education and federal poverty level (% FPL).

ANALYSIS

Generalized linear models estimated prevalence ratios for noticing and using menu labels. Models mutually adjusted for education, % FPL, age, sex, race/ethnicity, and body mass index.

RESULTS

Eighty-six percent of respondents reported noticing, and 56% reported using menu labels. Compared with individuals with less than high school education, college graduates were 11% more likely to report noticing (95% confidence interval, 1.06-1.18; P < 0.001) and 18% more likely to report using (95% confidence interval, 1.06-1.30; P < 0.01) menu labels. Patterns were similar for % FPL.

CONCLUSIONS AND IMPLICATIONS

These data support further investigation of menu labels among subgroups and a larger geographic scope. Limitations of the menu labeling module question and the cross-sectional nature of the existing literature warrant additional research.

Impact of the Front-of-Pack Label Nutri-Score on the Nutritional Quality of Food Choices in a Quasi-Experimental Trial in Catering

The front-of-pack labelling Nutri-Score has recently been implemented as a policy measure to improve the healthiness of food choices. The aim of this study was to investigate the impact of the Nutri-Score label in catering. A quasi-experimental trial was conducted in France between 16 December 2019 and 13 March 2020 in two staff restaurants (one intervention and one control site) from the same company. After a control period of seven weeks, the Nutri-Score label was affixed on all proposed products in the intervention site. Overall effects of the intervention were investigated using a difference in difference approach with generalised linear models. Over the 13 weeks of the study, 2063 participants who frequented the restaurant cafeteria at least once were included (1268 and 795 in the intervention and control site, respectively), representing 36,114 meals. Overall, the intervention led to a significant improvement in the nutritional quality of meals (p = 0.008) and a significant reduction in the intake of calories, sugars and saturated fat (p < 0.0001). Mixed effects models showed a qualitative improvement of food choices initially, and an adaptation of the quantities consumed over time, suggesting for the first time longer-term effects of the label on dietary behaviour.

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.

What Is on the Menu?-A Quantitative Analysis on Label Format among (Potential) Restaurant Guests and Restaurant Owners

About 20% of energy intake in the Netherlands is consumed out-of-home. Eating out-of-home is associated with higher energy intake and poorer nutrition. Menu labeling can be considered a promising instrument to improve dietary choices in the out-of-home sector. Effectiveness depends on the presentation format of the label and its attractiveness and usability to restaurant guests and restaurant owners. This exploratory study investigated which menu labeling format would be mostly appreciated by (a) (potential) restaurant guests (n386) and (b) the uninvestigated group of restaurant owners (n41) if menu labeling would be implemented in Dutch full-service restaurants. A cross-sectional survey design was used to investigate three distinct menu labeling formats: a simple health logo; (star) ranking and calorie information. Questionnaires were used as study tool. Ranking has been shown to be the most appreciated menu labeling format by both (potential) restaurant guests and owners. Statistical analysis showed that label preference of potential restaurant guests was significantly associated with age, possibly associated with level of education, and not associated with health consciousness. In summary, we found that ranking is the most appreciated menu label format according to both (potential) restaurant guests and restaurant owners, suggesting it to be a promising way to improve healthy eating out-of-home.

Visual Size Matters: The Effect of Product Depiction Size on Calorie Estimates

Consumers' calorie estimates are often biased and inaccurate. Even the presence of relevant nutritional information may not suffice to prevent consumer biases in calorie estimation. The current work demonstrates across two studies that visual cues given by larger product depictions lead to increased calorie estimates. Further, it demonstrates that these effects occur even when consumers are given, and notice, information about product quantity. The findings thus shed light on a novel biasing effect on consumer calorie evaluation, and, more generally, the findings provide evidence for the importance of visual inputs over textual ones in consumers' nutritional assessment of food products. In this, the current research provides insights relevant to helping nutritional literacy via awareness of biasing influences on caloric assessment. In the same manner, the research also provides insights that may assist the regulator protecting consumers by highlighting factors biasing nutritional assessment.

Projecting the Influence of Sugar-Sweetened Beverage Warning Labels and Restaurant Menu Labeling Regulations on Energy Intake, Weight Status, and Health Care Expenditures in US Adults: A Microsimulation

BACKGROUND

Accurate, readily accessible, and easy-to-understand nutrition labeling is a promising policy strategy to address poor diet quality and prevent obesity.

OBJECTIVE

This study projected the influence of nationwide implementation of sugar-sweetened beverage (SSB) warning labels and restaurant menu labeling regulations.

DESIGN

A stochastic microsimulation model was built to estimate the influences of SSB warning labels and menu labeling regulations on daily energy intake, body weight, body mass index, and health care expenditures among US adults.

PARTICIPANTS/SETTING

The model used individual-level data from the National Health and Nutrition Examination Survey, Medical Expenditure Panel Survey, and other validated sources.

STATISTICAL ANALYSES PERFORMED

The model was simulated using the bootstrapped samples, and the means and associated 95% CIs of the policy effects were estimated.

RESULTS

SSB warning labels and restaurant menu labeling regulations were estimated to reduce daily energy intake by 19.13 kcal (95% CI 18.83 to 19.43 kcal) and 33.09 kcal (95% CI 32.39 to 33.80 kcal), body weight by 0.92 kg (95% CI 0.90 to 0.93 kg) and 1.57 kg (95% CI 1.54 to 1.60 kg), body mass index by 0.32 (95% CI 0.31 to 0.33) and 0.55 (95% CI =0.54 to 0.56), and per-capita health care expenditures by $26.97 (95% CI $26.56 to $27.38) and $45.47 (95% CI $44.54 to $46.40) over 10 years, respectively. The reduced per-capita health care expenditures translated into an annual total medical cost saving of $0.69 billion for SSB warning labels and $1.16 billion for menu labeling regulations. No discernable policy effect on all-cause mortality was identified. The policy effects could be heterogeneous across population subgroups, with larger effects in men, non-Hispanic Black adults, and younger adults.

CONCLUSIONS

SSB warning labels and menu labeling regulations could be effective policy leverage to prevent weight gains and reduce medical expenses attributable to adiposity.

Reverse thinking: taking a healthy diet perspective towards food systems transformations

Food systems that deliver healthy diets without exceeding the planet’s resources are essential to achieve the worlds’ ambitious development goals. Healthy diets need to be safe, accessible, and affordable for all, including for disadvantaged and nutritionally vulnerable groups such as of smallholder producers, traders, and consumers in low- and middle-income countries. Globally, food systems are experiencing rapid and drastic changes and are failing to fulfil these multiple duties simultaneously. The international community therefore calls for rigorous food systems transformations and policy solutions to support the achievement of healthy diets for all. Most strategies, however, are essentially supply- and market-oriented. Incorporation of a healthy diet perspective in food system transformation is essential to enable food systems to deliver not only on supplying nutritious foods but also on ensuring that consumers have access can afford and desire healthy, sustainable, and culturally acceptable diets. This paper argues that this should be guided by information on diets, dietary trends, consumer motives, and food environment characteristics. Transformational approaches and policies should also take into account the stage of food system development requiring different strategies to ensure healthier diets for consumers. We review current knowledge on drivers of consumer choices at the individual and food environment level with special emphasis on low- and middle income countries, discuss the converging and conflicting objectives that exist among multiple food-system actors, and argue that failure to strengthen synergies and resolve trade-offs may lead to missed opportunities and benefits, or negative unintended consequences in food system outcomes. The paper proposes a menu of promising consumer- and food-environment- oriented policy options to include in the food systems transformation agenda in order to shift LMIC consumer demand towards healthier diets in low- and middle income countries.

Toward a Healthy and Environmentally Sustainable Campus Food Environment: A Scoping Review of Postsecondary Food Interventions

Interventions are urgently needed to transform the food system and shift population eating patterns toward those consistent with human health and environmental sustainability. Postsecondary campuses offer a naturalistic setting to trial interventions to improve the health of students and provide insight into interventions that could be scaled up in other settings. However, the current state of the evidence on interventions to support healthy and environmentally sustainable eating within postsecondary settings is not well understood. A scoping review of food- and nutrition-related interventions implemented and evaluated on postsecondary campuses was conducted to determine the extent to which they integrate considerations related to human health and/or environmental sustainability, as well as to synthesize the nature and effectiveness of interventions and to identify knowledge gaps in the literature. MEDLINE (via PubMed), CINAHL, Scopus, and ERIC were searched to identify articles describing naturalistic campus food interventions published in English from January 2015 to December 2019. Data were extracted from 38 peer-reviewed articles, representing 37 unique interventions, and synthesized according to policy domains within the World Cancer Research Foundation's NOURISHING framework. Most interventions were focused on supporting human health, whereas considerations related to environmental sustainability were minimal. Interventions to support human health primarily sought to increase nutrition knowledge or to make complementary shifts in food environments, such as through nutrition labeling at point of purchase. Interventions to support environmental sustainability often focused on reducing food waste and few emphasized consumption patterns with lower environmental impacts. The implementation of integrated approaches considering the complexity and interconnectivity of human and planetary health is needed. Such approaches must go beyond the individual to alter the structural determinants that shape our food system and eating patterns.

Effectiveness of a Multistrategy Behavioral Intervention to Increase the Nutritional Quality of Primary School Students' Web-Based Canteen Lunch Orders (Click & Crunch): Cluster Randomized Controlled Trial

Background

School food outlets represent a key setting for public health nutrition intervention. The recent proliferation of web-based food ordering systems provides a unique opportunity to support healthy purchasing from schools. Embedding evidence-based choice architecture strategies within these routinely used systems provides the opportunity to impact the purchasing decisions of many users simultaneously and warrants investigation.

Objective

This study aims to assess the effectiveness of a multistrategy behavioral intervention implemented via a web-based school canteen lunch ordering system in reducing the energy, saturated fat, sugar, and sodium content of primary students’ web-based lunch orders.

Methods

The study used a parallel-group, cohort, cluster randomized controlled trial design with 2207 students from 17 Australian primary schools. Schools with a web-based canteen lunch ordering system were randomly assigned to receive either a multistrategy behavioral intervention that included choice architecture strategies embedded in the web-based system (n=9 schools) or the standard web-based ordering system only (n=8 control schools). Automatically collected student purchasing data at baseline (term 2, 2018) and 12 months later (term 2, 2019) were used to assess trial outcomes. Primary trial outcomes included the mean energy (kJ), saturated fat (g), sugar (g), and sodium (mg) content of student lunch orders. Secondary outcomes included the proportion of all web-based lunch order items classified as everyday, occasional, and caution (based on the New South Wales Healthy School Canteen Strategy) and canteen revenue.

Results

From baseline to follow-up, the intervention lunch orders had significantly lower energy content (−69.4 kJ, 95% CI −119.6 to −19.1; P=.01) and saturated fat content (−0.6 g, 95% CI −0.9 to −0.4; P<.001) than the control lunch orders, but they did not have significantly lower sugar or sodium content. There was also a small significant between-group difference in the percentage of energy from saturated fat (−0.9%, 95% CI −1.4% to −0.5%; P<.001) but not in the percentage of energy from sugar (+1.1%, 95% CI 0.2% to 1.9%; P=.02). Relative to control schools, intervention schools had significantly greater odds of having everyday items purchased (odds ratio [OR] 1.7, 95% CI 1.5-2.0; P<.001), corresponding to a 9.8% increase in everyday items, and lower odds of having occasional items purchased (OR 0.7, 95% CI 0.6-0.8; P<.001), corresponding to a 7.7% decrease in occasional items); however, there was no change in the odds of having caution (least healthy) items purchased (OR 0.8, 95% CI 0.7-1.0; P=.05). Furthermore, there was no change in schools’ revenue between groups.

Conclusions

Given the evidence of small statistically significant improvements in the energy and saturated fat content, acceptability, and wide reach, this intervention has the potential to influence dietary choices at a population level, and further research is warranted to determine its impact when implemented at scale.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000855224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2019-030538

Calorie Labeling and Product Reformulation: A Longitudinal Analysis of Supermarket-Prepared Foods

INTRODUCTION

The 2010 Affordable Care Act required chain retail food establishments, including supermarkets, to post calorie information for prepared (i.e., ready to eat) foods. Implementation of calorie labeling could spur companies to reduce the calorie content of prepared foods, but few studies have explored this. This study evaluates the changes in the calorie content of prepared foods at 2 large U.S. supermarket chains after they implemented calorie labels in April 2017.

METHODS

The chains (≈1,200 stores) provided data on the calorie content and labeling status of all items sold between July 2015 and January 2019. In 2021, analyses used a difference-in-differences approach to examine the changes in the calorie content of prepared bakery, entree, and deli items introduced before calorie labeling to those introduced after the labeling compared with changes in similar foods not subject to the new labeling requirement. Primary analyses examined continuously available items; exploratory analyses examined items newly introduced to the marketplace.

RESULTS

Relative to changes in comparison foods not subject to the labeling requirement, continuously available prepared bakery items decreased by 7.7 calories per item after calorie labels were implemented (95% CI= -12.9, -2.5, p=0.004, ≈0.5% reduction). In exploratory analyses, prepared bakery items introduced after calorie labeling contained 440 fewer calories per item than those introduced before calorie labeling (95% CI= -773.9, -106.1, p=0.01, ≈27% reduction), driven by reductions in product size. No changes were observed in the calorie content of continuously available or newly introduced prepared entrees or deli items.

CONCLUSIONS

Implementing calorie labels could encourage product reformulation among some types of prepared supermarket foods. These supply-side changes could lead to reductions in caloric intake.

Alcohol, calories, and obesity: A rapid systematic review and meta-analysis of consumer knowledge, support, and behavioral effects of energy labeling on alcoholic drinks

Mandatory energy (calorie) labeling of alcoholic drinks is a public health measure that could be used to address both alcohol consumption and obesity. We systematically reviewed studies examining consumer knowledge of the energy content of alcoholic drinks, public support for energy labeling, and the effect of energy labeling of alcoholic drinks on consumption behavior. Eighteen studies were included. Among studies examining consumer knowledge of the energy content of alcoholic drinks (N = 8) and support for energy labeling (N = 9), there was moderate evidence that people are unaware of the energy content of alcoholic drinks (pooled estimate: 74% [95% CI: 64%-82%] of participants inaccurate) and support energy labeling (pooled estimate: 64% [95% CI: 53%-73%] of participants support policy). Six studies examined the effect of energy labeling on consumption behavior. In these studies, there was no evidence of a beneficial effect of labeling on alcohol drinking-related outcome measures. However, the majority of studies were of low methodological quality and used proxy outcome measures, and none of the studies were conducted in real-world settings, resulting in a very low level of evidence and high degree of uncertainty. Further research is required to determine whether energy labeling of alcoholic drinks is likely to be an effective public health policy.

Increasing availability of lower energy meals vs. energy labelling in virtual full-service restaurants: two randomized controlled trials in participants of higher and lower socioeconomic position

Background

There are a range of interventions designed to promote healthier food choices in full-service restaurants. However, it is unclear how these interventions affect dietary choices in people of lower and higher socioeconomic position (SEP).

Methods

A total of 2091 US participants recruited online completed Study 1 (n = 1001) and Study 2 (n = 1090). Recruitment was stratified by participant highest education level, resulting in higher SEP and lower SEP groups. In a between-subjects design, participants made hypothetical food choices (main dish, plus optional sides and desserts) from six restaurants menus in the absence vs. presence of menu energy labelling and from menus with baseline (10%) vs. increased availability (50%) of lower energy main dishes. Data were collected and analysed in 2019. Two studies were conducted in order to examine replicability and generalisability of findings across different restaurant menu types.

Results

Across both studies, increasing the availability of lower energy main menu options decreased the average energy content of the ordered main dish (− 129 kcal, 95% CI [− 139; − 119]) and total energy ordered (− 117 kcal, 95% CI [− 138; − 95]) in both higher and lower SEP participants. Energy labelling significantly reduced the energy content of ordered main dishes in higher SEP participants (− 41 kcal, 95% CI [− 54; − 29]), but not lower SEP participants (− 5 kcal, 95% CI [− 22; 11]). However, energy labelling reduced total energy ordered (− 83 kcal, 95% CI [− 105; − 60]) irrespective of SEP.

Conclusions

In two virtual experiments, increasing the availability of lower energy restaurant main menu options impacted on main menu dish choice and decreased total energy ordered irrespective of SEP. Energy labelling had a less pronounced effect on total energy ordered and had a larger impact on the energy content of main menu dish choice in higher as opposed to lower SEP participants.

Trial registration

Clinicaltrials.gov NCT04336540 retrospectively registered (7 April, 2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11007-0.

Out of the lab and into the wild: The influence of portion size on food intake in laboratory vs. real-world settings

External influences on eating behaviour, such as portion size, have been reliably shown to influence food intake in the laboratory. However, little research has examined whether laboratory settings under or overestimate the effect that external influences have on food intake compared to when studied in the real-world. In Study 1, 60 participants (mean age = 32 years) were randomized to consume a large (200 g) or small (100 g) portion of popcorn under controlled laboratory conditions and during a separate session in their home. Results showed that the effect of portion size on food intake was larger at home (d = 0.97) than in the laboratory (d = 0.56). Furthermore, participants reported feeling more relaxed eating at home compared to the laboratory. In Study 2, we examined whether comparable results were observed in a semi-naturalistic laboratory designed to resemble a home setting. 59 participants (mean age = 28 years) completed the same procedure as Study 1 in a standard and a semi-naturalistic laboratory setting. Although participants reported having higher levels of private self-awareness in the standard laboratory, the effect that portion size had on food intake did not differ between the standard laboratory (d = 0.50) and the semi-naturalistic laboratory (d = 0.49). The impact that external influences on eating, such as portion size, have on food intake in the real-world may be underestimated when studied under laboratory conditions.

Facilitating Healthier Eating at Restaurants: A Multidisciplinary Scoping Review Comparing Strategies, Barriers, Motivators, and Outcomes by Restaurant Type and Initiator

Restaurants are understudied yet increasingly important food environment institutions for tackling diet-related diseases. This scoping review analyzes research and gray literature (n = 171 records) to assess which healthy eating promotion strategies have been implemented in restaurants and the associated motivations, barriers, and outcomes, compared by restaurant type (corporate/chain vs. independently owned restaurants) and initiator (restaurant-initiated vs. investigator-initiated). We found that the most commonly reported strategy was the increase of generally healthy offerings and the promotion of such offerings. Changes in food availability were more common among corporate restaurants and initiated by restaurants, while environmental facilitators were more commonly initiated by investigators and associated with independently owned restaurants. Aside from those associated with revenue, motivations and barriers for healthy eating promoting strategies varied by restaurant type. While corporate restaurants were also motivated by public health criticism, independently owned restaurants were motivated by interests to improve community health. Revenue concerns were followed by food sourcing issues in corporate restaurants and lack of interest among independently owned restaurants. Among reporting sources, most outcomes were revenue positive. This study shows the need for practice-based evidence and accounting for restaurant business models to tailor interventions and policies for sustained positive changes in these establishments.

Gender differences within the barriers to smoking cessation and the preferences for interventions in primary care a qualitative study using focus groups in The Hague, The Netherlands

OBJECTIVES

This research aimed to provide a deeper insight into the gender-specific barriers to smoking cessation and gender-specific preferences for interventions in primary care, in order to contribute to better aligned cessation care for women.

DESIGN

Qualitative study using focus groups.

SETTING

Regularly smoking female and male adults were recruited from four different general practices in The Hague (The Netherlands).

PARTICIPANTS

A total of 11 women and nine men participated. Participants included were regular smokers with a minimum age of 18 and sufficient command of the Dutch language, who were willing to talk about smoking cessation. Inclusion ended when saturation was reached for both women and men. Participants were selected by means of purposeful sampling, whereby looking at age, educational level and experience with quitting.

RESULTS

The main barriers to smoking cessation in women were psychological factors, such as emotion and stress, compared with environmental factors in men. Women indicated they were in need of support and positivity, and both women and men expressed the desire for assistance without judgement. Contrary to men, women were not drawn to restrictions and (dis)incentives.

CONCLUSION

When counselling smokers, in women the focus should be on perceived internal problems, as opposed to more external obstacles in men. Contrary to men, female smokers seem to prefer non-coercive interventions, such as a group intervention offering support and positivity. Future research should focus on these gender differences, and how they could improve treatment in primary care.

Prevalence and nutrient composition of menu offerings targeted to customers with dietary restrictions at US fast casual and full-service restaurants

OBJECTIVE

To examine the prevalence and nutrient composition of menu offerings targeted to customers with dietary restrictions at US fast casual and full-service chain restaurants.

DESIGN

We used 2018 data from MenuStat, a database of nutrient information for menu items at large US chain restaurants. Five alternative diets were examined: gluten-free, low-calorie, low-carbohydrate, low-fat and vegetarian. Diet offerings were identified by searching MenuStat item descriptions and reviewing online menus. For each diet, we reported counts and proportions. We used bootstrapped multilevel models to examine differences in predicted mean kilojoules, saturated fat, Na and sugars between diet and non-diet menu items.

SETTING

Forty-five US fast casual and full-service chain restaurants in 2018 (including 6419 items in initial analytic sample across small plates, salads and main dishes).

PARTICIPANTS

None.

RESULTS

The most prevalent diets were gluten-free (n 631, 9·8 % of menu items), low-calorie (n 306, 4·8 %) and vegetarian (n 230, 3·6 %). Compared with non-diet counterparts, low-calorie main dishes had significantly lower levels of all nutrients examined and vegetarian main dishes had significantly lower levels of all nutrients except saturated fat. Gluten-free small plates had significantly fewer kilojoules, grams of saturated fat and milligrams of Na compared with non-diet small plates.

CONCLUSIONS

A small proportion of fast casual and full-service restaurant menus are targeted towards customers with dietary restrictions. Compared with non-diet items, those classified as gluten-free, low-calorie or vegetarian generally have healthier nutrient profiles, but overall nutrient values are still too high for most menu items, regardless of dietary label.

Systematic Review on International Salt Reduction Policy in Restaurants

As the catering sector has increasingly contributed to population-level salt intake, many countries have begun developing salt-reduction strategies for restaurants. This paper aims to provide an overview of global salt reduction policies in restaurants. Scientific papers and website materials were systematically searched from Web of Science, Science Direct, and PubMed, as well as official websites of government departments and organizations. A total of 78 full-text papers and grey literature works were included. From 58 countries and regions, 62 independent policies were identified, 27 of which were mandatory (3 with fines). The most common strategy was menu labeling, which was a component of 40 policies. Target setting (n = 23) and reformulation (n = 13) of dishes were also widely implemented. Other salt-reduction strategies included education campaign, chef training, toolkits delivery, table salt removal, media campaign, and government assistance such as free nutrition analysis and toolkits distribution. Most policies focused on chain restaurants. Evaluations of these policies were limited and showed inconsistent results, and more time is needed to demonstrate the clear long-term effects. Attention has been paid to salt reduction in restaurants around the world but is still at its early stage. The feasibility and effectiveness of the strategies need to be further explored.

Informed indulgence: the effects of nutrition information provision and dietary restraint on consecutive food consumption decisions

OBJECTIVE

Nutrition and menu labelling have been increasingly implemented worldwide. This research examines the effect of nutrition information provision on the immediate and subsequent consumption decisions of restrained and unrestrained eaters.

DESIGN

We conducted three scenario-based experiments. In Study 1 (N = 478) and Study 2 (N = 199), we manipulated the availability of nutrition information and measured dietary restraint. Study 3 (N = 275) extended Study 2 by adding a condition where we provided reference information about recommended daily calories.

MAIN OUTCOME MEASURES

We measured choices between relatively low-calorie and high-calorie alternatives (Studies 1-3) and measured a subsequent decision to consume indulgent food (Studies 2 and 3).

RESULTS

Nutrition information did not generally affect choices between low-calorie and high-calorie options, irrespective of dietary restraint. However, restrained eaters who chose a high-calorie option in the presence of nutrition information indicated they would reduce subsequent intake.

CONCLUSION

Nutrition information does not necessarily reduce the choice of relatively high-calorie food, but it can help restrained eaters reduce subsequent intake after a high-calorie choice. These results suggest that despite not having an immediate effect on choices, nutrition and menu labelling may benefit restrained eaters at a later time.

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.

Cross-Sectional Analysis of Calories and Nutrients of Concern in Canadian Chain Restaurant Menu Items in 2016

INTRODUCTION

The nutritional quality of restaurant foods in Canada is not monitored by government and limited research has evaluated the nutrient content of these foods. Given the increasing proportion of foods consumed outside the home, this study aims to assess levels of nutrients of public health concern in Canadian fast-food and sit-down restaurant menu items.

METHODS

Levels of calories, saturated fat, sodium, and sugar of 10,285 menu items from 90 national chain restaurants in Canada were assessed. Data were collected in 2016, extracted and analyzed between 2018 and 2020, and presented overall and by category. Levels in fast-food and sit-down restaurant establishments were compared.

RESULTS

Overall mean levels of saturated fat, sodium, and sugar were high. Entrées contained on average 52% of the total daily value for sodium (1,256 mg/serving) and 45% of the daily value for saturated fat (8.9 g/serving). Beverages and desserts had high levels of total sugar (mean=44 g and 32 g/serving, respectively) but tended to be low in sodium. Sit-down restaurant items had significantly (p≤0.0001) higher levels of calories, saturated fat, and sodium overall, although fast-food restaurant items had higher average sugar levels because of the higher number of beverage and dessert items.

CONCLUSIONS

Levels of nutrients of concern in Canadian menu items are excessive among most food categories. As the frequency of eating out in restaurants rises, government policies to promote reformulation and increase transparency of the nutritional content of these items are required to reduce their negative impact on public health.

Nudge interventions to reduce fish sauce consumption in Thailand

High sodium consumption is one of the four major risk factors contributing to non-communicable diseases around the world. Thailand has one of the highest rates of sodium consumption, with fish sauce being one of the main sources. The aim of this study was to examine whether changes in the micro-environment factors can affect fish sauce consumption behavior in a university setting in Thailand. We implemented four interventions (with one control) in five canteens across a Thai university. The study design was a Latin square, where the five canteens were randomized over five weeks to implement four interventions plus a control. Our interventions included behavior-oriented, cognitive-oriented, and affective-oriented nudges aimed to reduce the amount of fish sauce people add to their noodles during lunchtime at the university canteens. Results indicate that a simple change in how fish sauce was served can reduce fish sauce consumption. Serving fish sauce in a bowl with a spoon reduced the amount of fish sauce used per noodle bowl by 0.25 grams, compared to the normal condition where fish sauce is served in a bottle. Using a specially-designed spoon with a hole induced a larger reduction of 0.58 grams of fish sauce used per bowl. The other two interventions, cognitive- and affective- oriented nudges, also showed reductions of fish sauce usage, but the differences were not statistically significant. The findings can be used for policy implementation to advocate the use of a smaller sized spoon and a bowl to serve fish sauce instead of a bottle to reduce sodium consumption among Thai people.

Lost in the ACA: Bit Parts in a Landmark Law

The Affordable Care Act (ACA) is a mosaic across a spectrum of health policy domains. The law contains hundreds of smaller and mostly unnoticed reforms aimed at nearly every segment of American health policy. Ten years later, these provisions include successes, failures, and mixed bags, which should be considered in any full assessment of the ACA. This article examines 11 from each of these 3 categories, drawn from 9 of the ACA's 10 titles. These mininarratives deepen recognition that the ACA is our best example of comprehensive health reform and defies simplistic judgments.