Online Randomized Controlled Trials of Restaurant Sodium Warning Labels

Online RCT of Icon Added-Sugar Warning Labels for Restaurant Menus

INTRODUCTION

To reduce added-sugar consumption, jurisdictions are considering requiring restaurant menu labels to identify high-added-sugar items. This study examined the impacts of added-sugar warning labels on hypothetical choices, knowledge of items' added-sugar content, and perceptions of high-added-sugar items.

STUDY DESIGN

The design was an online RCT.

SETTING/PARTICIPANTS

National sample of adults (N=15,496) was recruited to approximate the U.S. distribution of sex, age, race, ethnicity, and education.

INTERVENTION

Participants viewed fast-food and full-service restaurant menus displaying no warning labels (control) or icon-only added-sugar warning labels next to high-added-sugar items (containing >50% of the daily recommended limit).

MAIN OUTCOME MEASURES

The main outcome measures were hypothetical ordering of ≥1 high-added-sugar item, grams of added sugar ordered, and knowledge of items' added-sugar content assessed in 2021 and analyzed in 2021-2022.

RESULTS

Warning labels reduced the relative probability of ordering ≥1 high-added-sugar item by 2.2% (probability ratio=0.978, 95% CI=0.964, 0.992; p=0.002); improved knowledge of added-sugar content (p<0.001); and led to a nonstatistically significant reduction of 1.5 grams of added sugar ordered, averaged across menus (p=0.07). The label modestly reduced the appeal of high-added-sugar items, increased perceptions that consuming such items often will increase Type 2 diabetes risk, increased perceived control over eating decisions, and increased injunctive norms about limiting consumption of high-added-sugar items (ps<0.001). However, in the warning condition, only 47% noticed nutrition labels, and 21% recalled seeing added-sugar labels. When restricting the warning condition to those who noticed the label, the result for grams of added sugar ordered was significant, with the warning condition ordering 4.9 fewer grams than the controls (95% CI= -7.3, -2.5; p<0.001).

CONCLUSIONS

Added-sugar warning labels reduced the probability of ordering a high-added-sugar menu item and increased participants' knowledge of whether items contained >50% of the daily value for added sugar. The modest magnitudes of effects may be due to low label noticeability. Menu warning labels should be designed for noticeability.

REGISTRATION

This study was registered at AsPredicted.org #65655.

Impact of Health, Environmental, and Animal Welfare Messages Discouraging Red Meat Consumption: An Online Randomized Experiment

BACKGROUND

Reducing red meat consumption is a key strategy for curbing diet-related chronic diseases and mitigating environmental harms from livestock farming. Messaging interventions aiming to reduce red meat consumption have focused on communicating the animal welfare, health, or environmental harms of red meat. Despite the popularity of these 3 approaches, it remains unknown which is most effective, as limited studies have compared them side by side.

OBJECTIVE

Our aim was to evaluate responses to red-meat-reduction messages describing animal welfare, health, or environmental harms.

DESIGN

This was an online randomized experiment.

PARTICIPANTS

In August 2021, a convenience sample of US adults was recruited via an online panel to complete a survey (n = 2,773 nonvegetarians and vegans were included in primary analyses).

INTERVENTION

Participants were randomly assigned to view 1 of the 4 following messages: control (neutral, non-red meat message), animal welfare, health, or environmental red-meat-reduction messages.

MAIN OUTCOME MEASURES

After viewing their assigned message, participants ordered hypothetical meals from 2 restaurants (1 full service and 1 quick service) and rated message reactions, perceptions, and intentions.

STATISTICAL ANALYSES PERFORMED

Logistic and linear regressions were performed.

RESULTS

Compared with the control message, exposure to the health and environmental red-meat-reduction messages reduced red meat selection from the full-service restaurant by 6.0 and 8.8 percentage points, respectively (P = .02 and P < .001, respectively), while the animal welfare message did not (reduction of 3.3 percentage points, P = .20). None of the red-meat-reduction messages affected red meat selection from the quick-service restaurant. All 3 red-meat-reduction messages elicited beneficial effects on key predictors of behavior change, including emotions and thinking about harms.

CONCLUSIONS

Red-meat-reduction messages, especially those describing health or environmental harms, hold promise for reducing red meat selection in some types of restaurants. Additional interventions may be needed to discourage red meat selection across a wider variety of restaurants, for example, by making salient which menu items contain red meat.

Consumer Reactions to Positive and Negative Front-of-Package Food Labels

INTRODUCTION

The National Academy of Medicine recommends that the U.S. adopt an interpretative front-of-package food labeling system, but uncertainty remains about how this system should be designed. This study examined reactions to front-of-package food labeling systems that use positive labels to identify healthier foods, negative labels to identify unhealthier foods, or both.

METHODS

In August 2021, U.S. adults (N=3,051) completed an online randomized experiment. Participants were randomly assigned to 1 of 4 labeling conditions: control (calorie), positive, negative, or both positive and negative labels. Labels were adapted from designs for a 'healthy' label drafted by the Food and Drug Administration and displayed on the front of product packaging. Participants selected products to purchase, identified healthier products, and reported reactions to the labels. Analyses, conducted in 2022, examined the healthfulness of participants' selections using the Ofcom Nutrient Profiling Model score (0-100, higher scores indicate being healthier).

RESULTS

Participants exposed to only positive labels, only negative labels, or both positive and negative labels had healthier selections than participants in the control arm (differences vs control=1.13 [2%], 2.34 [4%] vs 3.19 [5%], respectively; all p<0.01). The both-positive-and-negative-labels arm outperformed the only-negative-labels (p=0.03) and only-positive-labels (p<0.001) arms. The only-negative-labels arm outperformed the only-positive-labels arm (p=0.005). All the 3 interpretative labeling systems also led to improvements in the identification of healthier products and beneficial psychological reactions (e.g., attention, thinking about health effects; all p<0.05).

CONCLUSIONS

Front-of-package food labeling systems that use both positive and negative labels could encourage healthier purchases and improve understanding more than systems using only positive or only negative labels.

Changes in consumer purchasing patterns at New York City chain restaurants following adoption of the sodium warning icon rule, 2015-2017

In 2016, New York City (NYC) began enforcing a sodium warning regulation at chain restaurants, requiring placement of an icon next to any menu item containing ≥2,300 mg sodium. As shifts in consumer purchases are a potential outcome of menu labeling, we investigated whether high-sodium purchases from NYC chains changed following policy implementation. Using receipts for verification, consumer purchases were assessed at 2 full-service (FSR) and 2 quick-service (QSR) chain restaurants in NYC and Yonkers, NY, which did not implement sodium menu labeling, in 2015 and 2017. Primary outcomes included the proportion of respondents purchasing high-sodium item(s) (containing ≥2,300 mg sodium) and mean sodium content of purchases; changes were assessed by difference-in-difference regression models, adjusted for demographic and location co-variates. At both FSR and QSR, there was not a significant change in the proportion of NYC respondents purchasing 1 or more high-sodium items, relative to Yonkers (FSR difference-in-difference: -4.6%, p = 0.364; QSR difference-in-difference: -8.9%, p = 0.196). Among NYC FSR respondents, mean sodium content of purchases significantly declined compared to Yonkers (difference-in-difference: -524 mg, p = 0.012); no changes in mean sodium were observed among QSR participants (difference-in-difference: 258 mg, p = 0.185). Although there was a reduction in mean sodium content of purchases among NYC FSR patrons following sodium warning icon implementation, the mechanism behind the relatively larger NYC decline is unknown.

Effect of Front-of-Package Information, Fruit Imagery, and High-Added Sugar Warning Labels on Parent Beverage Choices for Children: A Randomized Clinical Trial

IMPORTANCE

Fruit drinks are widely consumed by young children, and many parents mistakenly believe that these drinks are healthy, potentially due to front-of-package claims and imagery. Research is needed on the influence of this marketing and how labeling regulations could change behavior.

OBJECTIVE

To assess the effects of a front-of-package 100% vitamin C claim, fruit imagery, percentage juice and teaspoons of added sugar disclosures, and high-added sugar warnings on parents' choices, knowledge, and perceptions of beverages.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted May to July 2021 as a single-exposure (no follow-up) online survey of primary caregivers of children ages 0 to 5 years throughout the US.

INTERVENTIONS

Participants were shown no-, low-, and high-added sugar beverages and asked to choose 1 for their child. Participants were randomized to see high-added sugar beverages with 1 of 7 front-of-package conditions: (1) claim and imagery (control); (2) no claim; (3) no imagery; (4) no claim or imagery; (5) claim, imagery, and percentage juice disclosure; (6) claim, imagery, and warning; or (7) claim, imagery, warning, and teaspoons of added sugar disclosure.

MAIN OUTCOMES AND MEASURES

Primary outcomes were type of beverage chosen (eg, high-added sugar beverage) and resulting calories and added sugar (in grams). Secondary outcomes were fruit drink knowledge (added sugar and percent juice) and perceptions.

RESULTS

There were 5005 participants included in the final analysis (mean [SD] age, 31.5 [8.3] years; 3587 female participants [71.7%]), including 714 participants in group 1, 717 participants in group 2, 710 participants in group 3, 717 participants in group 4, 708 participants in group 5, 729 participants in group 6, and 710 participants in group 7. Compared with participants in the control group, who had a mean (standard error [SE]) of 9.4 (0.5) g of added sugar and 81.9 (1.6) kcal in chosen beverages, only participants who saw warnings with teaspoons of added sugar disclosures had significantly reduced added sugar (-1.3 g; 95% CI, -2.6 to -0.1 g [-14.2%; 95% CI, -26.7% to -1.8%]; P = .04) and calories (-5.3 kcal; 95% CI, -9.8 to -0.9 kcal [-6.5%; 95% CI, -11.8% to -1.3%]; P = .02) in selected beverages. In warning conditions (ie, 6 and 7) compared with the control group (mean [SE] 41.0% [1.8%]), the proportion of participants choosing high-added sugar beverages was significantly reduced, by 5.5 percentage points (95% CI, 0.5 to 10.5 percentage points [13.4%; 95% CI, 1.2% to 25.6%]; P = .03) and 6.4 percentage points (95% CI, 1.4 to 11.4 percentage points [15.6%; 95% CI, 3.3% to 27.8%]; P = .01), respectively. The no claim or imagery condition (4) significantly reduced the proportion of parents choosing high-added sugar beverages (-7.6 percentage points; 95% CI, -12.6 to -2.6 percentage points [-18.4%; 95% CI, -30.6% to -6.3%]; P = .003). Percentage juice disclosures did not affect beverage choice.

CONCLUSIONS AND RELEVANCE

These findings suggest that added sugar warnings and prohibitions of front-of-package claims and imagery may reduce parents' purchases of high-added sugar beverages for their young children but that percentage juice disclosures may not change behavior.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04811690.

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

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

Sodium content changes between 2015 and 2019 in restaurant menu items selected for sodium reduction in Daegu

BACKGROUND/OBJECTIVES

South Korea has been conducting the Sodium Reduction Restaurant Project since 2015 to reduce sodium contents in restaurant menus. The purpose of this study was to analyze changes in the sodium content of menus as determined by the Daegu Sodium Reduction Restaurant Project between 2015 and 2019.

MATERIALS/METHODS

Intervention was aimed at reducing the sodium contents of over 10% of menu items in participating restaurants. On-site inspections and evaluations were conducted using a checklist, and reductions in sodium contents were determined by analyzing the salinities and sodium contents of menus after intervention.

RESULTS

Post-intervention salinities and sodium contents were significantly lower than baseline values in 2016 (P < 0.001), 2017 (P < 0.001), 2018 (P < 0.001), and 2019 (P < 0.001). However, sodium contents and salinities differences before and after intervention were not significant in 2015. Sodium contents of more than 20% of menu items offered by restaurants that participated in the Sodium Reduction Restaurant Project for 2 yrs starting in 2016 declined by 28.9%. On the other hand, the sodium reduction rate achieved by restaurants that participated for 4 yrs from 2015 reached 55.4%. The percentage of restaurants that participated in the project increased annually, though some failed to be designated as Sodium Reduction Restaurants because they did not meet sodium reduction rate requirements.

CONCLUSIONS

Positive correlations were found between duration of participation in the project and sodium reduction and designation rates. Sustainable long-term support at the national level is required to expand the project to other regions.

Changes in Calorie Content of Menu Items at Large Chain Restaurants After Implementation of Calorie Labels

IMPORTANCE

Calorie labeling on menus is required in US chain food establishments with 20 or more locations. This policy may encourage retailers to offer lower-calorie items, which could lead to a public health benefit by reducing customers' calorie intake from prepared foods. However, potential reformulation of restaurant menu items has not been examined since nationwide enforcement of this policy in 2018.

OBJECTIVE

To examine the calorie content of menu items at large chain restaurants before and after implementation of federally mandated menu calorie labels.

DESIGN, SETTING, AND PARTICIPANTS

This pre-post cohort study used restaurant menu data from MenuStat, a database of nutrition information for menu items offered in the largest chain restaurants in the US, collected annually from 2012 to 2019. The study comprised 35 354 menu items sold at 59 large chain restaurants in the US. Statistical analysis was conducted from February 4 to October 8, 2021.

INTERVENTION

Nationwide implementation of menu calorie labeling.

MAIN OUTCOMES AND MEASURES

Changes in menu items' calorie content after restaurant chains implemented calorie labels were estimated, adjusting for prelabeling trends. All menu items, continuously available items, items newly introduced to menus, and items removed from menus were examined separately.

RESULTS

Among the 59 restaurant chains included in the study, after labeling, there were no changes in mean calorie content for all menu items (change = -2.0 calories; 95% CI, -8.5 to 4.4 calories) or continuously available items (change = -2.3 calories; 95% CI, -11.5 to 6.3 calories). Items that were newly introduced after labeling, however, had a lower mean calorie content than items introduced before labeling (change = -112.9 calories; 95% CI, -208.6 to -25.2 calories), although there was heterogeneity by restaurant type. Items removed from menus after labeling had similar calorie content as items removed before labeling (change = 0.5 calories; 95% CI, -79.4 to 84.0 calories).

CONCLUSIONS AND RELEVANCE

In this cohort study of large chain restaurants, implementing calorie labels on menus was associated with the introduction of lower-calorie items but no changes in continuously available or removed items.

The ontology of fast food facts: conceptualization of nutritional fast food data for consumers and semantic web applications

Background

Fast food with its abundance and availability to consumers may have health consequences due to the high calorie intake which is a major contributor to life threatening diseases. Providing nutritional information has some impact on consumer decisions to self regulate and promote healthier diets, and thus, government regulations have mandated the publishing of nutritional content to assist consumers, including for fast food. However, fast food nutritional information is fragmented, and we realize a benefit to collate nutritional data to synthesize knowledge for individuals.

Methods

We developed the ontology of fast food facts as an opportunity to standardize knowledge of fast food and link nutritional data that could be analyzed and aggregated for the information needs of consumers and experts. The ontology is based on metadata from 21 fast food establishment nutritional resources and authored in OWL2 using Protégé.

Results

Three evaluators reviewed the logical structure of the ontology through natural language translation of the axioms. While there is majority agreement (76.1% pairwise agreement) of the veracity of the ontology, we identified 103 out of the 430 statements that were erroneous. We revised the ontology and publicably published the initial release of the ontology. The ontology has 413 classes, 21 object properties, 13 data properties, and 494 logical axioms.

Conclusion

With the initial release of the ontology of fast food facts we discuss some future visions with the continued evolution of this knowledge base, and the challenges we plan to address, like the management and publication of voluminous amount of semantically linked fast food nutritional data.

Developing sugar-sweetened beverage warning labels for young adults

OBJECTIVE

There is a lack of qualitative research developing sugar-sweetened beverage (SSB) warning labels with their intended end users. We sought to identify promising SSB warning elements for improving label effectiveness and for future testing in policy and institutional settings.

DESIGN

Mixed methods design using ten focus groups, a design task and a survey. The design task was used to generate ideas for an icon that would dissuade SSB consumption. The survey and focus group guide assessed participant perceptions of SSB warning label mock-ups of text (loss frame, gain frame and loss frame with attribution), colour and icon options.

SETTING

Three large public universities in California from February to March 2018.

PARTICIPANTS

Young adult SSB consumers (n 86) enrolled in one of three diverse California public universities.

RESULTS

Participants perceived the following elements as most effective for reducing SSB consumption: loss-frame text with attribution to a credible source, yellow and red colour for label background and an image or icon to accompany the text. Preferred images included sugar near or inside of an SSB, intuitive shapes like a triangle with exclamation mark or octagon and a visual indicator of SSB sugar content compared with recommended limits. Support was high for using SSB warning labels in university cafeterias and on bottles/cans.

CONCLUSIONS

Loss-frame text with a credible source, yellow or red label colour and icons could potentially enhance effectiveness of SSB warning labels and warrant further testing.

Do nutritional warnings encourage healthier choices on food ordering websites? An exploratory experimental study in Uruguay

OBJECTIVE

To evaluate if the inclusion of nutritional warnings in food ordering websites can discourage consumers from purchasing foods with excessive content of nutrients associated with non-communicable diseases (NCD).

DESIGN

Participants were randomly assigned to one of the two experimental conditions: control (n 225) or nutritional warnings (n 222). Nutritional warnings corresponded to separate black octagonal signs containing the word 'Excess' followed by the corresponding nutrient: total fat, saturated fat, sugars and sodium. Participants were asked to purchase a lunch for themselves using a simulated food ordering website.

SETTING

Online study in Uruguay.

PARTICIPANTS

Convenience sample of 447 Uruguayan participants, recruited using social media.

RESULTS

In the control condition, 76 % of the participants selected a dish or a beverage with excessive content of at least one nutrient in the simulated food ordering website. When nutritional warnings were included, this percentage significantly decreased to 62 % (P = 0·002). In addition, nutritional warnings caused a significant reduction in the percentage of participants who selected dishes with excessive content of total fat: 50 % v. 62 % (P = 0·012).

CONCLUSIONS

Results from the present work provide preliminary evidence that the inclusion of nutritional warnings in food ordering websites could discourage consumers from selecting dishes and beverages with excessive content of nutrients associated with NCD.

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.

How to protect both health and food system sustainability? A holistic 'global health'-based approach via the 3V rule proposal

OBJECTIVE

To define a generic diet to protect human health and food system sustainability based on three dimensions: animal:plant ratio, degree of food processing and food diversity.

DESIGN/SETTING

The percentages of maximum animal and ultra-processed energy content were evaluated from scientific papers (Web of Science database) and reports from international scientific institutions. Then, a weekly French standard diet, including these percentages and food diversity (≥42 different foods), was designed to calculate adequacy to nutritional needs.

RESULTS

Based on traditional and scientifically based healthy diets, and on foresight scenarios for sustainable diets at horizon 2050, a median daily animal energy content intake of 15 % was found to be protective towards both human health and environment. Based on epidemiological studies associating ultra-processed energy consumption with increased overweight/obesity risk, a precautionary threshold of approximately 15 % ultra-processed energy content was observed. The French diet allows addressing all nutritional needs and other nutritional indicators such as maximum salt and simple sugar consumption, α-linolenic acid:linoleic acid ratio and essential amino acids. This diet was named the '3V rule' for Végétal (plant), Vrai (real) and Varié (varied, if possible organic, local and seasonal). This generic diet can be adapted according to regional traditions and environmental characteristics. Excluding only one dimension of it would threaten both health and food system sustainability.

CONCLUSIONS

Tending towards a 3V-based diet, while respecting local constraints, should allow preserving human health, environment (greenhouse gas emissions, pollution, deforestation, etc.), small farmers, animal welfare and biodiversity, culinary traditions and socioeconomics (including an alleviation of public health cost).

Reactions to graphic and text health warnings for cigarettes, sugar-sweetened beverages, and alcohol: An online randomized experiment of US adults

We aimed to examine reactions to graphic versus text-only warnings for cigarettes, SSBs, and alcohol. A convenience sample of US adults completed an online survey in 2018 (n = 1352 in the analytic sample). We randomly assigned participants to view a: 1) text-only warning without efficacy information (i.e., message intended to increase consumers' confidence in their ability to stop using the product), 2) text-only warning with efficacy information, 3) graphic warning without efficacy information, or 4) graphic warning with efficacy information. Participants viewed their assigned warning on cigarettes, SSBs, and alcohol, in a random order. Across product types, graphic warnings were perceived as more effective than text-only warnings (p < .001) and led to lower believability, greater reactance (i.e., resistance), more thinking about harms, and lower product appeal (all p < .05); policy support did not differ. Compared to SSB and alcohol warnings, cigarette warnings led to higher perceived message effectiveness, believability, fear, thinking about harms, policy support, and greater reductions in product appeal (all p < .05). The efficacy information did not influence any outcomes. Graphic warnings out-performed text-only warnings on key predictors of behavior despite causing more reactance.

Selected Predictors of the Importance Attached to Salt Content Information on the Food Packaging (a Study among Polish Consumers)

This paper aims to identify selected antecedents of the importance attached to salt content information (ISCI) placed on food labels, on the basis of a representative survey of 1051 Polish consumers. The study was conducted with the use of the CAWI (Computer Assisted Web Interviews) method in 2018. Quota sampling was applied with reference to the following five criteria: sex, age, education, place of living (urban and rural areas), and region. In a multiple regression model, ISCI depends on the respondent’s: sex, age, evaluation of the quantity of nutrition claims, importance attached to nutrition claims, willingness to pay a price premium for products with nutrition claims, attention paid to health and nutrition claims, agreeing with the opinion that unreliable nutrition claims are a serious problem, evaluation of healthiness of one’s diet, self-rated knowledge about healthy nutrition, buying organic food, and reading front-of-package (FOP) labels during and after the purchase. The strongest effects on the importance attached to salt content information on the food packaging were displayed by the importance of nutrition claims, attention paid to nutrition and health claims, respondent’s age, FOP label reading at home, and agreeing that the use of unreliable nutrition claims is a serious problem.