Effects of Menu Labeling Policies on Transnational Restaurant Chains to Promote a Healthy Diet: A Scoping Review to Inform Policy and Research

The Quality of Menu Offerings in Independently Owned Restaurants in Baltimore, Maryland: Results from Mixed-Methods Formative Research for the FRESH Trial

(1) Background: Independently owned restaurants (IORs) are prevalent in under-resourced racial and ethnic minority communities in the US and present a unique setting for public health nutrition interventions. (2) Methods: We conducted 14 in-depth interviews with IOR owners in Baltimore about their perceptions of healthy food, and customers' acceptance of healthier menus and cooking methods and concurrent observations of the availability of healthy options on their menus. Qualitative data were coded and analyzed using ATLAS.ti. Observations were analyzed with statistical analysis performed in R. (3) Results: Owners perceived non-fried options, lean proteins, and plant-based meals as healthy. While open to using healthier cooking fats, they had mixed feelings about reducing salt, adopting non-frying methods for cooking, and adding vegetables and whole grains to the menu, and were reluctant to reduce sugar in recipes and beverages. Only 17.5% of 1019 foods and 27.6% of 174 beverages in these IORs were healthy, with no significant differences in the healthfulness of restaurant offerings within low-healthy-food-access/low-income neighborhoods and those outside. (4) Conclusion: Healthy options are generally scarce in Baltimore's IORs. Insights from owners inform future interventions to tailor healthy menu offerings that are well-received by customers and feasible for implementation.

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.

Restaurants' compliance with calorie labeling policies in food delivery applications

Background

To encourage consumers to make healthier choices, the Saudi Food and Drug Authority (SFDA) released the Saudi Arabia Nutrition Labeling Policy, which requires restaurants to present caloric information clearly on their menus. Food delivery applications are also mandated to present caloric information on their platforms. The aim of this study is to explore how restaurants on food delivery applications comply with the calorie labeling policy.

Methods

Data were extracted from a widely used food delivery application in Saudi Arabia to include a sample of 120 "healthy food" restaurants. The restaurants were checked for compliance on both the application and the website. Descriptive and logistic regression analyses were performed to examine the distribution and association of relevant factors.

Results

A substantial proportion (43.3%) of healthy foods on delivery applications (n = 120) do not comply with the SFDA calorie labeling policies. Among these restaurants, 56.5% presented the calorie labeling on their menu item. Of those who provided calorie information on their websites (n = 62), 54.8% provided appropriate calorie labeling based on the SFDA policy. There was an association between compliance and the number of restaurant categories but no associations for website calorie labeling, rating, and appropriateness.

Conclusion

This study provides important findings for policymakers that will enable them to reinforce food calorie policies on food delivery platforms, restaurant websites, social media, and marketing campaigns. Not all restaurants comply with the SFDA calorie labeling policies. Suggestions to present the calorie-related words in Arabic and offer more information to help the consumer make the appropriate food selection decision. Further studies are needed to explore the reasons for and barriers to posting nutritional information on menu items.

Availability of calorie information on online food delivery service platforms among major chain restaurants in Canadian provinces with different calorie labelling policies

OBJECTIVE

This study aimed to characterize the availability of calorie labelling on major online food delivery (OFD) platforms for the largest restaurant brands in Canada to examine differences in provinces with and those without mandatory calorie labelling regulations.

METHODS

Data were collected for the 13 largest restaurant brands with locations in Ontario (with mandatory menu labelling) and Alberta and Quebec (with no mandatory menu labelling) from the web applications of the three largest OFD platforms in Canada. Data were sampled from three selected restaurant locations within each province (n = 117 locations across all provinces) on each platform. Univariate logistic regression models were used to test differences in the presence and amount of calorie labelling and other nutritional information across provinces and platforms.

RESULTS

The analytical sample included 48,857 food and beverage items (n = 16,011 in Alberta, n = 16,683 in Ontario, and n = 16,163 in Quebec). Items were more likely to have menu labelling in Ontario (68.7%) than in Alberta (44.4%, OR = 2.75, 95% CI 2.63-2.88) or Quebec (39.1%, OR = 3.42, 95% CI 3.27-3.58). In Ontario, 53.8% of restaurant brands had calorie labelling for  > 90% of items, compared to 23.0% in Quebec and 15.4% in Alberta. The presence of calorie labelling also differed across platforms.

CONCLUSION

Nutrition information from OFD services differed across provinces with and those without mandatory calorie labelling. Chain restaurants on OFD service platforms were more likely to provide calorie information in Ontario, where calorie labelling is mandatory, compared to elsewhere where no such policy exists. In all provinces, calorie labelling was inconsistently implemented across OFD service platforms.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposure

Menu labeling policies in 6 US jurisdictions.

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Sugar labeling information and online marketing strategies for hand-shaken tea drinks in northern Taiwan

Background

Sugar-sweetened beverages (SSBs) are the main cause of excessive sugar intake and increased health risks. Food companies usually use social media to market SSBs in order to increase consumers' purchase intentions. To reduce excessive added sugar consumption from hand-shaken tea drinks, Taiwan has implemented a mandatory policy requiring clear sugar content labeling. This study aimed to investigate the sugar label information and online marketing strategies for hand-shaken tea drinks in northern Taiwan.

Methods

In this cross-sectional study, content analysis was employed to investigate the sugar labeling information and the current situation of online marketing in hand-shaken tea drink brands based in northern Taiwan. Seventy-two hand-shaken tea drink brands' stores were visited to record their sugar labeling presentation methods, with brands lacking labeling, presenting incomplete labeling, or not offering customized sugar levels being excluded, resulting in 60 brands being chosen for the subsequent data collection process. The sugar and energy contents in 1,581 hand-shaken tea drinks were recorded and calculated. Subsequently, the sugar contents were assessed in accordance with World Health Organization (WHO) sugar recommendations (25 g/day), warning label criteria, and Taiwan's regulations for low-sugar packaged beverages. Seven brands that had high online impressions were further selected and their marketing strategies in 560 Facebook posts were analyzed.

Results

The presentation methods of labeling varied among the 60 brands, and only 42 brands had obvious and easily accessible labeling. The most common labeling presentation method was posters (n = 28). After converting the sugar content of half-sugar and low-sugar hand-shaken tea drinks, it was found that 60.2% of half-sugar beverages and 13.0% of low-sugar beverages exceeded 25 g of sugar per cup. Over 90% of brands had Facebook and Instagram accounts. The top marketing strategies for tea drink brands on Facebook were specific beverage information, brand information, and nutrition and health marketing. Most posts promoted sugar-sweetened beverages.

Conclusion

Not all hand-shaken tea drink brands in this study followed Taiwan's labeling regulations. Moreover, high sugar contents in hand-shaken tea drinks labeled as half-sugar and low-sugar could potentially lead people to unconsciously consume excessive amounts of sugar. Future research should explore the impact of online marketing strategies on SSBs consumption behavior and ways to mitigate it among the Taiwanese public.

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.

Exploring restaurant and customer needs, barriers, interests, and food choices induced by the COVID-19 pandemic in Tarragona Province (Catalonia, Spain): A cross-sectional study

Background

COVID-19 has harmed restaurants, but customer preferences remain unknown. This study aims to determine the needs, barriers, interests, and food choice changes in restaurants and customers before and during the COVID-19 pandemic in Tarragona Province (Spain).

Methods

An observational cross-sectional study conducted in spring 2021 collected Mediterranean offerings, food safety, and hygiene information about the pandemic through online surveys and focus group interviews with restaurateurs and customers about the changes in their needs and new barriers.

Results

Fifty-one restaurateurs (44 survey, 7 focus group) and 138 customers (132 survey, 6 focus group) were included. In relation to the economic, emotional, and uncertainty restaurateurs' barriers detected, they implemented measures to tackle it: buy less and more often, reduce restaurant staff and reduce the restaurants offer, among others. Some customers reported changes in their restaurant orders, specifically increasing their takeaway orders. The Mediterranean diet offer (AMed criteria) remained without noticeable changes in any of the criteria. After lockdown, compared to before lockdown, restaurateurs increased their takeaway offerings by 34.1% (p < 0.001) and their use of digital menus by 27.3% (p < 0.001) because of customer demand. The use of local products in the menus remained high. The cleaning and disinfection tasks increased by 21.1% (p = 0.022), and the use of hydroalcoholic solutions increased by 13.7% (p = 0.031).

Conclusion

In restaurants, the first COVID-19 lockdown increased takeaway orders, sanitation, and digital communication. This study provides valuable information for adapting gastronomic offerings during challenging situations.

Potential for Front of Pack Labeling Exposure to Impact US Dietary Choices: A Population-Based Cross-Sectional Study Using NHANES 2017–2018

In recent years, front-of-pack nutrition labeling (FOPL) schemes have proliferated, but the components of the diet subject to FOPL have not been described. This study quantified the proportion and elements of the diet that would be subject to FOPL in the US. The 2017–2018 National Health and Nutrition Examination Survey (n = 7121; age ≥2 year) 24-h dietary recalls were used to identify foods/beverages subject to FOPL. The proportion of dietary energy and additional dietary constituents subject to FOPL was estimated. Overall, 57% of dietary energy would be subject to FOPL. Individuals consuming more away-from-home meals had lower exposure to FOPL. Adults with a healthy-weight and those consuming a more healthful diet had more exposure to FOPL. Protein, sodium, potassium, whole fruit, vegetables, and unprocessed meats were less subject to FOPL as compared to total sugars, added sugars, calcium, fruit juice, milk, yogurt, nuts/seeds and whole grains. Because less than 60% of the diet would be impacted by FOPL, implementation of such a policy may have limited reach for the US diet and demonstrates some inconsistencies with current dietary guidance regarding the under- and over-representation of key food groups and nutrients.

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.

A Hypothetical Tavern Menu for the Evaluation of Calorie Selection through Menu Labelling

The purpose of the present study is to evaluate calories selection according to the type of menu labelling applied on a hypothetical Greek tavern menu. Three questionnaires were designed and each one included a hypothetical menu of Greek tavern food. Menu A did not include any nutritional information, Menu B included calorie posting and Menu C had the “NB” mark next to dishes that were Nutritionally Balanced choices. A total of 437 participants were recruited in the study. The mean calories selection was significantly lower on Menu B (1874 Kcal) and C (1787.7 Kcal) compared to Menu A (2157.3 Kcal). The overweight and obese participants ordered significantly fewer calories on Menu B (−504 Kcal and −404 Kcal) and C (−451.3 Kcal and −393 Kcal) than on the Menu A. Menu labelling should be assessed in real-life settings in Greece. It could be a policy for the prevention and control of obesity in European countries.

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.

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.

The Association between Obesity and Chronic Conditions: Results from a Large Electronic Health Records System in Saudi Arabia

This cross-sectional study aimed to estimate the prevalence of obesity and its association with diabetes and hypertension among beneficiaries in the National Guard Health Affairs system of Saudi Arabia. We included individuals aged 17 years and older, and patients were classified as diabetic or hypertensive if they had any visit during the 4 years where the primary diagnosis was one of those conditions or they were taking diabetes or hypertension medications. The association between obesity (body mass index ≥30) and diabetes and hypertension were evaluated using a multiple logistic regression model, adjusting for age, gender, nationality, and region. A total of 616,092 individuals were included. The majority were Saudi nationals (93.1%). Approximately 68% of the population were either obese (38.9%) or overweight (29.30%). Obesity was more prevalent among Saudi nationals (39.8% vs. 26.7%, p < 0.01) and females (45.3% vs. 31.2%, p < 0.01). Obesity was independently associated with diabetes mellitus (OR = 2.24, p < 0.01) and hypertension (OR = 2.15, p < 0.01). The prevalence of obesity in the study population was alarming and more pronounced among women. Our findings call for efforts to intensify preventive measures to reduce obesity and associated conditions. Using electronic records to examine the impact of interventions to reduce obesity and chronic conditions may help monitor and improve population health.

Post-Secondary Food Service Manager Perspectives on Fruit and Vegetable Nudging Strategies: Qualitative Study

BACKGROUND

Changing the choice architecture in post-secondary food service contexts to "nudge" customers to choose more fruits and vegetables (FV) shows promise in intervention studies to date. If such approaches are to become more widely adopted, they must be feasible and acceptable to food service managers. Among possible early adopters, managers of food services in post-secondary education institutions may have unique insights on implementation of such approaches, as they have dual mandates to support student health and maintain profitability.

OBJECTIVE

The goal of this exploratory study was to examine current knowledge, practice, facilitators, and barriers to uptake of nudge strategies promoting FV in a sample of post-secondary food service managers.

METHODS

A qualitative telephone interview study was undertaken with food service managers across Canada (n = 10 institutions), recruited from a national professional organization. One or more representatives from each institution completed the interview. Interviews were audio-recorded, transcribed, and underwent framework descriptive and interpretative content analysis in NVivo (QSR International). Münscher's Taxonomy of Choice Architecture and the Ottawa Model for Research Use guided development and analysis.

RESULTS

Managers from 9 universities and 1 technical college participated. Local context, governance, and resources varied widely. Eight of 10 institutions used some form of FV nudging as part of their marketing and health promotion, most commonly to reduce the effort associated with choosing FV. Nudging strategies aimed at increasing the range and composition of FV offerings, providing a social reference (opinion leaders) for choosing FV, and changing consequences with loyalty cards were also common. Other nudging strategies were used infrequently. Cost, operational ease of implementation, and students' privacy and choices were critical issues in adoption.

CONCLUSIONS

The results can inform development and testing of locally adapted nudge interventions. It is critical that managers be involved from the outset of any planned academic implementation study.

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.

Appraisal survey of the knowledge, attitudes, and behaviors of Jordanian society toward diet and nutrition during COVID-19 era

INTRODUCTION

This study aimed to evaluate the knowledge, attitudes, and behavior (KAB) of the Jordanian society toward nutrition and diet during the COVID-19 era.

DESIGN AND METHODS

This study is an observational, cross-sectional study using a structured, validated, reproducible, self-administered online Arabic questionnaire. KAB of the study participants was assessed via a web-based, structured, validated, reproducible Arabic questionnaire. The tool for the assessment of the KAB was composed of 33-closed-ended multi-answer questions.

RESULTS

A total of 672 people were surveyed, 70.2% were between 18 and 34, and 69.5% were females. Participants have paid little attention to the healthfulness of their diet in the last year. The majority of participant's attitudes towards using different approaches to manage weight in the next year were: eating smaller portions for weight management, tracking to maximize the amount of time of physical activity, and substituting lower-calorie foods for full-calorie alternatives. Only tenth of participants utilize the time to perform physical activity. The majority made changes to their diet and exercise, and strictly follow commitment in connection with planning for the following year.

CONCLUSIONS

Educators, legislative, food manufacturers, household heads, and policymakers are called upon to improve Jordanians' KAB on nutrition and diet. Furthermore, Jordanian nutrition and diet behavior can be invested to improve the dietary interventions designed by nutrition and dietetics professionals.

Menu Engineering and Dietary Behavior Impact on Young Adults' Kilocalorie Choice

The obesity pandemic is associated with increased consumption of restaurant food. Labeling of menus is an intervention used to provide consumers with kilocalorie (calorie) information in hopes of them making healthier food choices. This study evaluated the relationship between young adults' calorie choices on restaurant menus and menu design, dietary behaviors, and demographic characteristics. A 3 (fast-casual restaurants) × 4 (menu-designs based on menu engineering theories) between-subjects (n = 480, 18-24-year olds) experimental design was used. The relationship between the participants' calorie choices (high versus low) and menu design, stage of change, gender, race, educational level and weight status was evaluated using logistic regression. All independent variables had at least one category that had greater odds (CI 95% ± 5%) of subjects choosing a lower calorie entree, except education level and race/ethnic group. Normal weight and overweight subjects had greater odds of choosing lower calorie entrees than those that were obese. In addition, subjects that had started to control their calorie intake for less than six months or had sustained this change for at least six months, had greater odds of choosing lower calorie entrees compared to others. Including a green symbol and calories on fast casual restaurant menus may influence some young adults to choose lower calorie entrees.

Changes in the calorie and nutrient content of purchased fast food meals after calorie menu labeling: A natural experiment

BACKGROUND

Calorie menu labeling is a policy that requires food establishments to post the calories on menu offerings to encourage healthy food choice. Calorie labeling has been implemented in the United States since May 2018 per the Affordable Care Act, but to the best of our knowledge, no studies have evaluated the relationship between calorie labeling and meal purchases since nationwide implementation of this policy. Our objective was to investigate the relationship between calorie labeling and the calorie and nutrient content of purchased meals after a fast food franchise began labeling in April 2017, prior to the required nationwide implementation, and after nationwide implementation of labeling in May 2018, when all large US chain restaurants were required to label their menus.

METHODS AND FINDINGS

We obtained weekly aggregated sales data from 104 restaurants that are part of a fast food franchise for 3 national chains in 3 US states: Louisiana, Mississippi, and Texas. The franchise provided all sales data from April 2015 until April 2019. The franchise labeled menus in April 2017, 1 year prior to the required nationwide implementation date of May 2018 set by the US Food and Drug Administration. We obtained nutrition information for items sold (calories, fat, carbohydrates, protein, saturated fat, sugar, dietary fiber, and sodium) from Menustat, a publicly available database with nutrition information for items offered at the top revenue-generating US restaurant chains. We used an interrupted time series to find level and trend changes in mean weekly calorie and nutrient content per transaction after franchise and nationwide labeling. The analytic sample represented 331,776,445 items purchased across 67,112,342 transactions. Franchise labeling was associated with a level change of -54 calories/transaction (95% confidence interval [CI]: -67, -42, p < 0.0001) and a subsequent 3.3 calories/transaction increase per 4-week period (95% CI: 2.5, 4.1, p < 0.0001). Nationwide implementation was associated with a level decrease of -82 calories/transaction (95% CI: -88, -76, p < 0.0001) and a subsequent -2.1 calories/transaction decrease per 4-week period (95% CI: -2.9, -1.3, p < 0.0001). At the end of the study, the model-based predicted mean calories/transaction was 4.7% lower (change = -73 calories/transaction, 95% CI: -81, -65), and nutrients/transaction ranged from 1.8% lower (saturated fat) to 7.0% lower (sugar) than what we would expect had labeling not been implemented. The main limitations were potential residual time-varying confounding and lack of individual-level transaction data.

CONCLUSIONS

In this study, we observed that calorie labeling was associated with small decreases in mean calorie and nutrient content of fast food meals 2 years after franchise labeling and nearly 1 year after implementation of labeling nationwide. These changes imply that calorie labeling was associated with small improvements in purchased meal quality in US chain restaurants.

Promoting healthy foods among urban school children in Bangladesh: a qualitative inquiry of the challenges and opportunities

BACKGROUND

In Bangladesh overweight and obesity among urban school children are on the rise. Urban school children tend to consume foods dense in calories and few fruits and vegetables which is associated with overweight and obesity. The current study explored the barriers and opportunities for promoting healthy diets among school children from the perspective of teachers and parents in Dhaka, Bangladesh.

METHODS

We conducted 14 key informant interviews with teachers and principals, six focus group discussions with 31 mothers of school children (5 to 15 year old) and 14 structured observations of the school food environment. Inductive thematic analysis was performed manually.

RESULTS

Schools were important for development of food preferences of children, however, most school cafeterias provided foods based on profit rather than health considerations. A shift in food culture resulted in making eating out acquire many meanings beyond convenience. Mothers, especially those who were employed, struggled to prepare healthy foods due to time pressure. Mothers were generally concerned about chemicals added to raw foods in markets which led to limited fruit and vegetable consumption.

CONCLUSIONS

There were many challenges to promoting healthy foods to school children within and outside the school. It is important to formulate policies and guidance to create a supportive environment for healthy foods in and in the proximity of schools. It is also important to educate consumers about identifying and choosing healthy foods. Laws related to food safety should be adequately implemented to boost the population's confidence in safety of available healthy foods in the food system.

Potential impact of gradual reduction of fat content in manufactured and out-of-home food on obesity in the United Kingdom: a modeling study

BACKGROUND

Manufactured and out-of-home foods contribute to excessive calories and have a critical role in fueling the obesity epidemic. We propose a 20% fat reduction in these foods.

OBJECTIVES

To evaluate the potential impact of the proposed strategy on energy intake, obesity and related health outcomes in the population.

METHODS

We used the National Diet and Nutrition Survey rolling program (NDNS RP) data to calculate fat and energy contributions from 46 manufactured and out-of-home food categories. We considered a gradual fat reduction-focusing on SFA-in these categories to achieve a 20% reduction in 5 years. We estimated the reduction in energy intake in the NDNS RP population and predicted the body weight reduction using a weight loss model. We scaled up the body weight reduction to the UK adult population. We estimated reductions in overweight/obesity and type 2 diabetes cases. We calculated the reductions of LDL, ischemic heart disease (IHD), and stroke deaths that could be prevented from the SFA reduction.

RESULTS

The selected categories contributed to 38.6% of the population's energy intake. By the end of the fifth year, our proposed strategy would reduce the mean energy intake by 67.6 kcal/d/person (95% CI: 66.1-68.8). The energy reduction would reduce the mean body weight by 2.7 kg (95% CI: 2.6-2.8). The obesity prevalence would be reduced by 5.3% and the overweight prevalence by 1.5%, corresponding to 3.5 and 1 million cases of obesity and overweight, respectively, being reduced in the United Kingdom. The body weight reduction could prevent 183,000 (95% CI: 171,000-194,000) cases of type 2 diabetes over 2 decades. Energy from SFA would fall by 2.6%, lowering LDL by 0.13 mmol/L and preventing 87,560 IHD deaths (95% CI: 82,260-112,760) and 9520 stroke deaths (95% CI: 4400-14,660) over 20 years.

CONCLUSIONS

A modest fat reduction (particularly in SFA) in widely consumed foods would prevent obesity, type 2 diabetes, and cardiovascular disease.

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.