Adults Noticing Calorie Counts on Restaurant Menus: Evidence From Nationally Representative Data, 2022

INTRODUCTION

Since May 2018, federal restaurant menu labeling regulations have required large U.S. chain restaurants to disclose calorie counts on menus. This study estimates the share of U.S. adults who notice calorie information on fast-food and sit-down restaurant menus and identifies the consumer characteristics that predict noticing calorie labels.

METHODS

Using a nationally representative sample of 5,185 U.S. adults aged 18 and older from the 2022 Health Information National Trends Survey (HINTS), linear regression models were estimated to predict the likelihood of noticing calorie labels the last time adults ordered food in a fast-food or sit-down restaurant. The 2022 HINTS data were publicly released in April 2023 and these public-use and de-identified data were analyzed in October 2023.

RESULTS

In 2022, about 1 in 2 U.S. adults (49.7%, 95% CI=47.6%, 51.8%) reported noticing calorie labels during their last restaurant visit. The likelihood of noticing calorie information was significantly lower among men, lower income households, unpartnered adults, residents of the Northeast Census Region, and residents of rural areas.

CONCLUSIONS

Approximately half of U.S. adults reported seeing calorie labels when they last ordered food in a fast-food or sit-down restaurant in 2022. Sex, income, marital status, and residential location influenced the likelihood of noticing calorie counts posted on restaurant menus.

The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial

BACKGROUND

Pictorial warnings on tobacco products are promising for motivating behavior change, but few studies have examined pictorial warnings for sugary drinks, especially in naturalistic environments. This study aimed to examine the impact of pictorial warnings on parents' purchases of sugary drinks for their children in a naturalistic store laboratory.

METHODS AND FINDINGS

Parents of children ages 2 to 12 (n = 325, 25% identifying as Black, 20% Hispanic) completed a shopping task in a naturalistic store laboratory in North Carolina. Participants were randomly assigned to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Parents selected 1 beverage and 1 snack for their child, as well as 1 household good; one of these items was selected for them to purchase and take home. The primary outcome was whether parents purchased a sugary drink for their child. Secondary outcomes included reactions to the trial labels, attitudes toward sugary drinks, and intentions to serve their child sugary drinks. Pictorial warnings led to a 17-percentage point reduction in purchases of sugary drinks (95% CI for reduction: 7% to 27%), with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm (p = 0.002). The impact of pictorial warnings on purchases did not differ by any of the 13 participant characteristics examined (e.g., race/ethnicity, income, education, and age of child). Pictorial warnings also led to lower calories (kcal), purchased from sugary drinks (82 kcal in the control arm versus 52 kcal in the pictorial warnings arm, p = 0.003). Moreover, pictorial warnings led to lower intentions to serve sugary drinks to their child, feeling more in control of healthy eating decisions, greater thinking about the harms of sugary drinks, stronger negative emotional reactions, greater anticipated social interactions, lower perceived healthfulness of sugary drinks for their child, and greater injunctive norms to limit sugary drinks for their child (all p < 0.05). There was no evidence of difference between trial arms on noticing of the labels, appeal of sugary drinks, perceived amount of added sugar in sugary drinks, risk perceptions, or perceived tastiness of sugary drinks (all p > 0.05).

CONCLUSIONS

Pictorial warnings reduced parents' purchases of sugary drinks for their children in this naturalistic trial. Warnings on sugary drinks are a promising policy approach to reduce sugary drink purchasing in the US.

TRIAL REGISTRATION

The trial design, measures, power calculation, and analytic plan were registered before data collection at www.clinicaltrials.gov NCT04223687.

Nutritional Quality of Plant-Based Meat Products Available in the UK: A Cross-Sectional Survey

Plant-based meat (PBM) has been gaining popularity due to increasing concerns over health, animal welfare, and environmental issues linked to animal foods. This study aimed to compare the nutrient profile of PBM with equivalent meat products. We conducted a cross-sectional survey of 207 PBM and 226 meat products available from 14 retailers in the UK. We extracted data on energy density, total and saturated fat, protein, fiber, and salt per 100 g from product packaging and calculated the nutrient profile of each product. Compared to meat, PBM had significantly lower energy density, total fat, saturated fat, protein, and significantly higher fiber. Salt content was significantly higher in five out of six PBM categories. Based on the UK’s Nutrient Profiling Model, 14% of PBM and 40% of meat products were classified as “less healthy” (p < 0.001). When considering the UK’s front-of-pack labelling criteria 20% of the PBM and 46% of meat products were considered high in either total fat, saturated fat, or salt (p < 0.001). Nearly three quarters of PBM products did not meet the current UK salt targets. PBM products have a better nutrient profile compared to meat equivalents. However, more progress is needed to reduce salt in these products.

The Effect of Verbal and Iconic Messages in the Promotion of High-Quality Mountain Cheese: A Non-Hypothetical BDM Approach

To ensure the sustainable development of mountain livestock farming, the adequate remuneration of high-quality dairy products is fundamental. In this sense, communication strategies aimed at promoting mountain products and ensure better positioning and higher market prices are fundamental. The present research seeks to expand the literature regarding consumers' willingness to pay for mountain foods by using an online real auction experiment aimed at evaluating the premium price that consumers are willing to pay for summer over winter mountain cheese, depending on the information provided concerning the taste anticipation or animal welfare. The results showed an overall small premium price given to the higher quality summer cheese; this could be, partially, due to a generally low degree of consumer knowledge about mountain dairy farming. With reference to communication strategies, the results provide evidence about the effectiveness of the rational messages founded upon sensorial characteristics and the anticipated taste of cheese. In addition, this study explored that adding a logo had no main effect on the price premium participants were willing to pay. This may be due to the fact that logos and claims, having a lower information content, are more indicated to lead the choice of consumers with a higher level of awareness. In the conclusion section, policy and agribusiness implications of the findings are provided.

Nutrition and Health Claims Spectra of Pre-Packaged Foods on Serbian Supermarket Shelves: A Repeated Cross-Sectional Study

Nutrition and health claims (NHCs) are a powerful tool that influence consumers’ final decision on the choice of food products. The purposes of this repeated cross-sectional study were to (i) assess the prevalence of pre-packaged food products containing nutrition and health claims among different food categories, (ii) to determine the type of NHCs labelled on the examined food products, and (iii) to evaluate the trend in the use of NHCs in comparison to the 2012 survey. The survey was conducted immediately before the full enforcement of the new national legislation on NHCs in 2020. It comprised 3141 pre-packaged food products from 10 product categories. In total, 21.2% of food products contained any claim (19.4% contained any nutrition claim; 8.2% contained any health claim). In comparison to the 2012 survey, we observed a rising trend in the presence of NHCs; the use of nutrition claims on food products increased three times and the use of health claims increased 1.3 times in the 2020 survey. Bearing in mind that NHCs are a powerful tool guiding consumers’ food purchase decisions, NHCs should be supported by precise legislation and strict surveillance by the public health authorities.

Examining the Relationship between Sugar Content, Packaging Features, and Food Claims of Breakfast Cereals

Excessive free-sugar intake has become highly prevalent in numerous countries, and Portugal is not the exception. One product category that contributes to the daily intake of free sugars is breakfast cereals. In the current work, we identified 289 exemplars from two major retailers in Portugal and collected information on their nutritional profile (e.g., sugar, salt, fiber per 100 g), price, packaging features, type of food claims present (e.g., statements about the composition, sensory features, the origin of the product), and ingredients list. Overall, the sugar content of breakfast cereals was high (Mean = 19.9 g), and less than 10% of the products complied with the current national guidelines (i.e., 5 g of sugar per 100 g of product). Sugar (or other sugar sources) was listed in the top three ingredients for over 85% of the products. On average, each product included about four claims (Mean = 3.9), and sugar content was lower when the claims were related to the product composition. Critically, the sugar content was particularly high for children-oriented products (Mean = 26.4 g). Correlation analysis showed that breakfast cereals with higher sugar content also were cheaper and had lower quantities of fiber, proteins, and salt. Our findings suggest the need to implement strategies to reduce sugar in this product category (e.g., incentivize manufacturers to reformulate products). Also, our results may inform strategies aimed at promoting consumers' awareness about the sugar content in breakfast cereals and other processed foods, facilitating healthier decision-making.

The Level of Processing, Nutritional Composition and Prices of Canadian Packaged Foods and Beverages with and without Gluten-Free Claims

Little is known about the healthfulness and cost of gluten-free (GF) foods, relative to non-GF alternatives, in Canada. This study compared the extent of processing, nutritional composition and prices of Canadian products with and without GF claims. Data were sourced from the University of Toronto Food Label Information Program (FLIP) 2013 (n = 15,285) and 2017 (n = 17,337) databases. Logistic regression models examined the association of NOVA processing category with GF claims. Calorie/nutrient contents per 100 g (or mL) were compared between GF and non-GF products. Generalized linear models compared adjusted mean prices per 100 g (or mL) of products with and without GF claims. The prevalence of GF claims increased from 7.1% in 2013 to 15.0% in 2017. GF claims appeared on 17.0% of ultra-processed foods, which were more likely to bear GF claims products than less-processed categories. Median calories and sodium were significantly higher in GF products; no significant differences were observed for saturated fat or sugars. Compared to non-GF products, adjusted mean prices of GF products were higher for 10 food categories, lower for six categories and not significantly different for six categories. Overall, GF claims are becoming increasingly prevalent in Canada; however, they are often less healthful and more expensive than non-GF alternatives, disadvantaging consumers following GF diets.

Nutrition Claims on Fruit Drinks Are Inconsistent Indicators of Nutritional Profile: A Content Analysis of Fruit Drinks Purchased by Households With Young Children

BACKGROUND

Fruit drinks are the most commonly consumed sugar-sweetened beverage among young children. Fruit drinks carry many nutrition-related claims on the front of package (FOP). Nutrition-related claims affect individuals' perceptions of the healthfulness of products and purchase intentions, often creating a "health halo" effect.

OBJECTIVE

The aims of this study were to describe the prevalence of FOP nutrition-related claims on fruit drinks purchased by households with young children and to examine the association between claims and the nutritional profile of fruit drinks.

DESIGN

The sample included 2059 fruit drinks purchased by households with children 0 to 5 years old participating in Nielsen Homescan in 2017. FOP labels were obtained from 2 databases that contain bar code-level information on all printed material on product labels. A codebook was used to code for presence of FOP nutrition-related claims. The coded claims data were linked by bar code with Nutrition Facts label data. Claim type prevalence was calculated, and the association between claim types and median calories and total grams of sugar per 100 mL was analyzed using Wilcoxon rank-sum tests. The percentages of products containing noncaloric sweeteners (NCSs) with and without each claim type were also calculated and compared.

RESULTS

Almost all (97%) fruit drinks sampled had at least 1 nutrition-related FOP claim. Implied natural claims such as "natural flavors" were the most common (55% of products), followed by claims about the presence of juice or nectar (49%). Claims about vitamin C (33%), sugar (29%), and calories (23%) were also common. Fruit drinks with vitamin C, juice or nectar, fruit or fruit flavor, and overt natural claims were higher in calories and sugar and less likely to contain NCSs compared with products without these claims. Fruit drinks with calorie, sugar, NCS, implied natural, and other claims were lower in calories and sugar and more likely to contain NCSs compared with products without these claims.

CONCLUSIONS

Claims are prevalent on fruit drinks purchased by households with young children. This is concerning given prior research demonstrating that claims can mislead consumers. Regulatory actions such as requiring a warning or disclosure on drinks that contain added sugars or NCSs should be considered.

Knowledge about Sugar Sources and Sugar Intake Guidelines in Portuguese Consumers

In this work, we examined knowledge about sugars and guidelines for its consumption and explored the relationship between knowledge and measures related to nutritional information processing as well as sugar consumption. Specifically, we asked participants (n = 1010 Portuguese) to categorize a set of ingredients (e.g., glucose, aspartame) regarding their composition (i.e., intrinsic vs. added/free sugars) and origin (e.g., natural vs. artificial) and if they were aware of the WHO guidelines for sugar intake. Overall, despite using information about sugar frequently and considering attending to such information as very important to stay healthy, most participants were unaware of the WHO guidelines and revealed difficulties in the categorization task. Women, participants with a higher level of education, and those with children in the household reported higher use of sugar content information present in nutritional labels, higher perceived knowledge of nutritional guidelines, and higher hit rates in categorizing sugar sources. Almost one-fourth of the population exceeds the daily limit recommended by the WHO. Therefore, characterizing the knowledge of a Portuguese sample regarding sugar sources and sugar intake guidelines is particularly relevant, and our results emphasize the need to implement effective strategies to reduce sugar intake.

Understanding Vietnamese Urban Consumers' Nutrition Label Use, Health Concerns, and Consumption of Food and Beverages with Added Sugars

Vietnam is experiencing a diet and nutrition transition. Increasing consumption of food and beverages with added sugars is a significant public health concern. Policies and interventions, such as mandatory nutrition labelling, are being considered to improve consumers’ awareness and understanding of diet and health implications of added sugars in food and beverages. The effectiveness of various policy approaches relies on an improved understanding of the interrelationships between urban Vietnamese consumers’ health concerns, nutrition label use, and intake of sugars. We empirically disentangle these relationships for urban Vietnamese households using novel intra-household data covering 4047 adults and 737 adolescents from 1590 households in Hanoi and Ho Chi Minh City. The data are from comprehensive household surveys and 24-hour food diaries. Simultaneous equation regression models are estimated using three-stage least squares (3SLS) to account for possible endogeneity. Nutrition label use is significantly associated with a lower share of calories from foods and beverages with added sugars. These findings suggest that nutrition labelling programs may be an effective policy mechanism to reduce the negative health implications of increasing availability and consumption of food and beverages with added sugars in urban Vietnam.

A Natural Experiment to Evaluate the Nutritional Content of Restaurant Meal Purchases After Calorie Labeling

BACKGROUND

Calorie labeling is mandated in restaurant chains with ≥20 locations nationwide, but the effect of labeling on the nutritional quality of purchased meals in fast-food settings is unclear, especially for adolescents and children.

OBJECTIVE

To estimate the effect of calorie menu labeling on the nutrient content and composition of fast-food meal purchases in McDonald's restaurants vs control restaurants.

DESIGN

From 2010 to 2014, customers were sampled during repeated visits to McDonald's restaurants, which voluntarily labeled menus with calorie information in 2012, and 5 control fast-food restaurant chains that had not labeled their menus over the study period.

PARTICIPANTS/SETTING

Restaurant receipts and questionnaires were collected from 2883 adults, 2131 adolescents, and 433 children in 4 New England cities.

MAIN OUTCOME MEASURES

Saturated fat, sugar, sodium, and fiber content of purchased meals, as well as nutrient densities (ie, nutrient content adjusted for total calories), were calculated after linking purchases to nutrition data from restaurant websites.

STATISTICAL ANALYSES

Difference-in-differences analyses and linear mixed models were used to examine whether calorie labeling in McDonald's was associated with changes in nutrient content and nutrient density of purchased meals separately in adults, adolescents, and children.

RESULTS

After implementation of calorie labeling at McDonald's, adult meals contained on average 4.0% fewer calories from sugar (95% confidence interval: -7.5 to -0.5), but 1.8% more calories from saturated fat (95% confidence interval: 0.7 to 2.9) compared with control chains. The fiber content of children's purchased meals was lower at McDonald's after calorie labeling (change = -1.4 g, 95% confidence interval: -2.5 to -0.3). Calorie labeling was not associated with changes in nutrient quality of adolescent meals.

CONCLUSIONS

Calorie labeling at McDonald's was associated with a possibly small positive change in the nutritional quality of meals in adults but not in adolescents or children. Efforts are needed to improve the nutritional quality of restaurant meals.

A comparison of the nutritional quality of products offered by the top packaged food and beverage companies in Canada

BACKGROUND

Canada's food supply is abundant in less healthy products, increasing Canadians' risk of obesity and non-communicable diseases. Food companies strongly influence the food supply; however, no studies have examined differences in the healthfulness of products offered by various companies in Canada. This study aimed to compare the nutritional quality of products offered by the top packaged food and beverage companies in Canada.

METHODS

Twenty-two top packaged food and beverage manufacturing companies were selected, representing > 50% of the Canadian market share in 2018. Nutritional information for products (n = 8277) was sourced from the University of Toronto Food Label Information Program 2017 database. Descriptive analyses examined the nutritional quality of products based on: 1) the Health Star Rating (HSR) system; 2) calories, sodium, saturated fat and total sugars per 100 g (or mL) and per reference amounts (RAs) defined by Health Canada; and 3) "high in" thresholds for sodium, saturated fat and total sugars proposed by Health Canada for pending front-of-package labelling regulations. Kruskal-Wallis tests compared HSRs of products between companies.

RESULTS

Mean HSRs of companies' total product offerings ranged from 1.9 to 3.6 (out of 5.0). Differences in HSRs of products between companies were significant overall and for 19 of 22 food categories (P < 0.05), particularly for fats/oils and beverages. Calories, sodium, saturated fat and total sugars contents varied widely between companies for several food categories, and depending on whether they were examined per 100 g (or mL) or RA. Additionally, 66.4% of all products exceeded ≥1 of Health Canada's "high in" thresholds for sodium (31.7%), saturated fat (28.3%) and/or sugars (28.4%). The proportion of products offered by a company that exceeded at least one of these thresholds ranged from 38.5 to 97.5%.

CONCLUSIONS

The nutritional quality of products offered by leading packaged food and beverage manufacturers in Canada differs significantly overall and by food category, with many products considered less healthy according to multiple nutrient profiling methods. Variation within food categories illustrates the need and potential for companies to improve the healthfulness of their products. Identifying companies that offer less healthy products compared with others in Canada may help prompt reformulation.

Calorie and nutrient trends in large U.S. chain restaurants, 2012-2018

INTRODUCTION

Large chain restaurants reduced calories in their newly-introduced menu items from 2012 to 2015. The objective of this study was to provide updated calorie trends through 2018 and examine trends in the macronutrient composition of menu items across this time period.

METHODS AND FINDINGS

Data were obtained from the MenuStat project and include 66 of the 100 largest revenue generating U.S. chain restaurants (N = 28,238 items) that had data available in all years from 2012 to 2018. Generalized linear models were used to examine per-item calorie and nutrient changes (saturated fat, trans fat, unsaturated fat, sugar, non-sugar carbohydrates, protein, sodium) among (1) items on the menu in all years (common items) and (2) newly introduced items (2013-2018). Overall, there were no significant changes in calories or nutrients among common items from 2012 to 2018. Among all newly introduced items, calories (-120 kcals, -25%, p = 0.01; p-for-trend = 0.02), saturated fat (-3.4g, -41%, p<0.01, p-for-trend = 0.06), unsaturated fat (-4.5g, -37%, p = 0.02; p-for-trend = 0.04), non-sugar carbohydrates (-10.3g, -40%, p = 0.02, p-for-trend = 0.69), and protein (-4.3g, -25%, p = 0.04, p-for-trend = 0.02) declined.

CONCLUSION

Newly introduced menu items in large chain restaurants have continued to decline in calories through 2018, which may help to reduce calorie intake. Other changes in macronutrient content were sporadic and not clearly toward improved dietary quality.

Consumer Preferences for Traceable Food with Different Functions of Safety Information Attributes: Evidence from a Menu-Based Choice Experiment in China

It is of great value to study consumer demand for safe foods in promoting the development of a safe food market system and the reduction of food safety risks, as well as foodborne diseases in China. This paper takes traceable pork as an example and constructs food safety information attributes with ex ante quality verification and ex post traceability. Interactions between safety information attributes and the consumer's response to cost-driven price changes were investigated for 345 consumers in Wuxi City, Jiangsu Province, China, using a menu-based choice (MBC) experiment and multivariate probit (MVP) model as analysis tools. The results suggest that food safety information attributes are important to consumers, as the consumers preferred pork quality inspection attributes to pre-incident quality assurance functions. Therefore, it is beneficial to include pork quality inspection attributes in the traceable pork attribute systems during the initial construction of traceable pork markets in China. Attribute price was an important factor that affected consumers' choice of information attributes. When customization cannot be achieved, a profile composed of elastic pork quality inspection attribute and supply chain-internal traceability attribute would be the most preferred traceable pork product in the market based on the need of building a fully functional traceable food system and reducing food safety risks. In addition, there was a strong substitution relationship between different information attributes, and there was heterogeneity in consumers' choice of information attributes. Therefore, the government should support manufacturers in producing multi-level safe food to meet diverse consumer demand.

Importance of Health Claims in the Adoption of New Breakfast Cereal Products in the UK

Regular breakfast consumption has the potential to prevent the prevalence of NCDs and to improve the nutritional profile of diets. Given consumers' interest in improving their diets, food suppliers are interested in introducing new cereal products making different health claims to capture consumers' attention. The purpose of this study is threefold: first, it aims to understand whether UK food suppliers are working to increase the availability of breakfast cereals with healthy and nutritious attributes; second, it explores which companies are leading the launch of these products; and third, it assesses to what extent health and nutrition claims made by breakfast cereals have an impact on their market success. The study employs an assembled database combining data from Mintel Global New Products Database (GNPD) and Kantar Worldpanel Dataset (KWDS) for the UK. A hazard-based duration model was used to analyse the success of the new products launched in the UK market in 2011 following them up to 2015. Our results reveal that UK suppliers broadened the number of breakfast cereals on offer in the period 2000 to 2018, with a particular focus on multigrain cereals, porridge and granola. Health and nutrition claims were added to 27% of these products. Although consumers welcome healthy alternatives such as muesli, the impact of positional claims on the success of newly developed breakfast cereals is claim-specific. No clear pattern regarding the impact of health and nutrition claims is identified. However, other elements such as celiac-friendly ingredients and UK origin do have a positive impact on the success of breakfast cereals.

Conflicting Messages on Food and Beverage Packages: Front-of-Package Nutritional Labeling, Health and Nutrition Claims in Brazil

We assessed the prevalence of front-of-package (FoP) claims in the Brazilian packaged food supply and examined whether foods with claims were more likely to be high in critical nutrients. Using data from a random 30% subsample of 11,434 foods and beverages collected in the five largest food retailers in Brazil in 2017 (n = 3491), we classified claims into nutrition, health, and environment. We examined whether foods with claims were more likely to be high in critical nutrients using 95% confidence intervals. Claims were found in 41.2% of the products. Nutrition claims were the most prevalent (28.5%), followed by health (22.1%), and environment-related claims (5.2%). More than 85% of the breakfast cereals, granola bars, and nectars contained claims, which were found in 51% of the dairy beverages. Foods with nutrition claims were more likely to be high in critical nutrients (65.3%; 95% CI 62.3, 68.2% vs. 54.1% 95% CI 52.1, 56.0). Products with health (52.9%; 95% CI 49.3, 56.4% vs. 58.5%; 95% CI 56.6, 60.3) and environment-related claims (33.5%; 95% CI 27.0, 40.8% vs. 58.6%; 95% CI 56.9, 60.2%) were less likely to be high in critical nutrients. FoP claims are prevalent in Brazil, and nutrition claims are more likely to have a poorer nutritional profile. Policymakers should consider restricting the presence of claims on unhealthy products.

Does point-of-sale nutrition information improve the nutritional quality of food choices?

Point-of-sale nutrition information has been adopted by numerous grocery stores to respond to the demand for easy-to-understand nutrition labeling by consumers. Although there is conflicting evidence regarding the effectiveness of providing nutrition information, previous research indicates simplified shelf nutrition labels may lead to healthier choices. However, these studies have not examined how different consumer segments respond to these labels, nor the differential impacts across foods. Using household purchase data from a store that voluntarily adopted the (now defunct) NuVal shelf nutrition labels (a 1-100 numeric score derived from a nutrition-profiling algorithm), we assess NuVal impacts across different consumers and foods. NuVal scores potentially influence not only purchase quantity but also likelihood of buying. Thus, the effect of NuVal was measured by estimating a two-part model and predicting consumers' unconditional purchase responses. We found evidence of heterogeneous impacts of NuVal across consumers and foods. High-income households and households with children shifted their yogurt and frozen dinner purchases to more healthful items. In contrast, households with children and households headed by heads with college education slightly shifted their canned soup purchases to less healthful options. Our findings suggest that specific foods and consumer segments are influenced by simplified shelf nutrition information and further research is necessary to better understand its effect on consumer dietary quality.

Free Sugar Content in Pre-Packaged Products: Does Voluntary Product Reformulation Work in Practice?

Ultra-processed, pre-packaged foods are becoming a growing part of our diet, while displacing whole and minimally processed foods. This results in an increased intake of free sugar, salt, and saturated fats, that have a profoundly negative effect on health. We aimed to assess the trend in free sugar content in pre-packaged foods in Slovenia and evaluate the efficacy of industry self-regulations designed to combat the excess consumption of free sugar. A nation-wide data collection of the Slovenian food supply was performed in 2015 and repeated in 2017. In 2017, 54.5% of all products (n = 21,115) contained free sugars (median: 0.26 g free sugar/100 g). Soft drinks became the main free sugar source among pre-packaged goods (28% of all free sugar sold on the market) in place of chocolates and sweets, of which relative share decreased by 4.4%. In the categories with the highest free sugar share, market-leading brands were often sweeter than the average free sugar value of the category. This indicates that changes in on-shelf availability towards a greater number of healthier, less sweet products are not necessarily reflected in healthier consumers’ choices. Relying solely on voluntary industrial commitments to reduce free sugar consumption will likely not be sufficient to considerably improve public health. While some further improvements might be expected over the longer term, voluntarily commitments are more successful in increasing the availability of healthier alternatives, rather than improving the nutritional composition of the market-leading products. Additional activities are, therefore, needed to stimulate reformulation of the existing market-leading foods and drinks, and to stimulate the consumption of healthier alternatives.

Differences in energy and nutritional content of menu items served by popular UK chain restaurants with versus without voluntary menu labelling: A cross-sectional study

BACKGROUND

Poor diet is a leading driver of obesity and morbidity. One possible contributor is increased consumption of foods from out of home establishments, which tend to be high in energy density and portion size. A number of out of home establishments voluntarily provide consumers with nutritional information through menu labelling. The aim of this study was to determine whether there are differences in the energy and nutritional content of menu items served by popular UK restaurants with versus without voluntary menu labelling.

METHODS AND FINDINGS

We identified the 100 most popular UK restaurant chains by sales and searched their websites for energy and nutritional information on items served in March-April 2018. We established whether or not restaurants provided voluntary menu labelling by telephoning head offices, visiting outlets and sourcing up-to-date copies of menus. We used linear regression to compare the energy content of menu items served by restaurants with versus without menu labelling, adjusting for clustering at the restaurant level. Of 100 restaurants, 42 provided some form of energy and nutritional information online. Of these, 13 (31%) voluntarily provided menu labelling. A total of 10,782 menu items were identified, of which total energy and nutritional information was available for 9605 (89%). Items from restaurants with menu labelling had 45% less fat (beta coefficient 0.55; 95% CI 0.32 to 0.96) and 60% less salt (beta coefficient 0.40; 95% CI 0.18 to 0.92). The data were cross-sectional, so the direction of causation could not be determined.

CONCLUSION

Menu labelling is associated with serving items with less fat and salt in popular UK chain restaurants. Mandatory menu labelling may encourage reformulation of items served by restaurants. This could lead to public health benefits.

Nutrition Facts Panels: Who Uses Them, What Do They Use, and How Does Use Relate to Dietary Intake?

BACKGROUND

Nutrition labels are a low-cost tool with the potential to encourage healthy eating habits.

OBJECTIVE

To investigate correlates of frequent Nutrition Facts label use, describe the types of label information most often used, and measure how label use relates to dietary intake in young adults.

DESIGN

Cross-sectional population-based study of young adults participating in Project Eating and Activity in Teens and Young Adults-IV.

PARTICIPANTS/SETTING

Surveys and food frequency questionnaires were completed during 2015-2016 by young adults (N=1,817; weighted sample=49% women) aged 25 to 36 years.

MAIN OUTCOME MEASURES

Nutrition Facts label use, frequency of using specific information on labels, and dietary intake.

STATISTICAL ANALYSES PERFORMED

Relative risks and adjusted means were used to examine how demographic, behavior, and weight-related factors were associated with Nutrition Facts panel use, and how label use related to dietary outcomes. Associations with P values <0.05 were considered statistically significant.

RESULTS

Approximately one-third (31.4%) of participants used Nutrition Facts labels "frequently." Use was significantly higher for women; for participants with high education and income; among those who prepared food regularly; among those who were physically active; among those with a weight status classified as overweight; and among those who were trying to lose, gain, or maintain weight. Label components used most often included sugars (74.1%), total calories (72.9%), serving size (67.9%), and the ingredient list (65.8%). Nutrition Facts label users consumed significantly more fruits, vegetables, and whole grains and fewer sugar-sweetened beverages, compared with nonusers. Nutrition Facts label users ate significantly more frequently at sit-down restaurants but less frequently at fast-food restaurants compared with nonusers.

CONCLUSIONS

Although Nutrition Facts label use was associated with markers of better dietary quality in a population-based sample of young adults, only one-third of participants used labels frequently. Methods to improve label use should be studied, particularly through leveraging weight- or health-related goals (eg, interest in making healthier food choices), and meeting consumer preferences concerning label content.

Food Label Literacy and Use among US Adults Diagnosed with Cancer: Results from a National Representative Study

For those diagnosed with cancer, lifestyle factors including diet can be more important than ever. However, lack of nutrition-related knowledge can pose a significant barrier to healthy eating. Food labels guide consumers in selecting appropriate portion sizes-that is, caloric content-and ensuring adequate intake of nutrients. Data from the 2013-2014 HINTS were used to examine (a) differences in food label use and food label literacy between respondents ever had a cancer diagnosis and those never had a diagnosis; (b) sociodemographic correlates and health-related correlates of food label use and literacy, in a context of cancer diagnosis; and (c) potential association between food label use/literacy and each of two dietary choices, eating vegetables and fruits and limiting intake of sugary drinks, again, in a context of cancer diagnosis. Data was analyzed via SPSS version 24.0, and cross tabulations using Pearson's Chi-square test and logistic regressions. Income, gender and non-participation in support groups were associated with food label literacy (p<.05). Confidence to take care of self was associated with food label use (p<.05). Relationships were observed between using food labels and curtailing soda intake (b = -.368, p<.05), eating relatively more fruits (b = .558, p<.05), and eating relatively more vegetables (b = .558, p<.05). The overall models predicting consumption of soda [x2 (2) = 13.70, p = .001, Nagelkerke R-square = .059], of fruits [x2 (2) = 33.87, p < .001, Nagelkerke R-square = .136], and of vegetables [x2 (2) = 36.08, p < .001, Nagelkerke R-square = .144] was statistically significant. Implications for research and practice can be found in results linking food label use to better quality diets. They include the usefulness of nutrition education interventions targeting lower-income men with cancer diagnoses; one lesson should be the use of food labels.

Nutrition Label Use Is Related to Chronic Conditions among Mexicans: Data from the Mexican National Health and Nutrition Survey 2016

BACKGROUND

Non-communicable diseases, such as obesity, diabetes, and hypertension, can be prevented and treated through a balanced nutrient-rich diet. Nutrition labels have been recognized as crucial to preventing obesity and non-communicable diseases through a healthier diet.

OBJECTIVE

Our aim was to examine the association between nutrition label use and chronic conditions (overweight, obesity, previously diagnosed diabetes, and hypertension) among an adult Mexican population.

DESIGN

This was a cross-sectional study that used data from the Mexican National Health and Nutrition Survey of 2016 (ENSANUT MC 2016).

PARTICIPANTS/SETTING

The participants were 5,013 adults aged 20 to 70 years old. Older adults (>70 years), illiterate participants, pregnant women, and participants with implausible blood pressure data were excluded from the sample. The survey was conducted from May to August 2016 in the participants' households.

MAIN OUTCOME MEASURES

We measured chronic conditions (overweight, obesity, previously diagnosed diabetes, and hypertension).

STATISTICAL ANALYSES PERFORMED

Pearson χ² test was used to examine the associations among the use of nutrition labels and sociodemographic characteristics and chronic conditions. Multiple logistic regression was used to determine the association between nutrition label use and chronic conditions adjusting for the effect of confounding variables like sex, age, body mass index, education level, marital status, ethnicity, residence area, region, and socioeconomic status.

RESULTS

From the total sample, 40.9% (95% CI 38.4% to 43.8%) reported using nutrition labeling. Respondents with overweight or obesity were less likely to use nutrition labels (odds ratio 0.74; P<0.05). Participants who self-reported diabetes had significantly lower odds of nutrition label use than participants who did not report to have diabetes (odds ratio 0.66; P<0.05). Participants having 3 chronic conditions had lower odds of nutrition label use (odds ratio 0.34; P<0.01) relative to having zero chronic conditions.

CONCLUSIONS

This study suggests an association between nutrition label use and chronic conditions (obesity and diabetes). These findings demonstrate that people with obesity, diabetes, and a combination of chronic conditions were less likely to use nutrition labels than people without these conditions.

Calorie and Nutrient Profile of Combination Meals at U.S. Fast Food and Fast Casual Restaurants

INTRODUCTION

The nutrient profile of combination meals in large chain restaurants is not well understood.

METHODS

Combination meals from 34 U.S. fast food and fast casual restaurants (lunch/dinner, n=1,113; breakfast, n=366) were identified from online menus in 2017-2018 and corresponding nutrition information for each menu item was obtained from a restaurant nutrition database (MenuStat). Three options for each combination meal were analyzed: (1) default (as advertised on menu), (2) minimum (low-calorie option), and (3) maximum (high-calorie option). In 2018, meal nutrient composition was compared with the Healthier Restaurant Meal Guidelines, and linear models examined to what extent each meal component (entrée, side, beverage) drove differences in nutrients across meal options.

RESULTS

There was substantial variation across the default, minimum, and maximum options of lunch/dinner combination meals for calories (default,: 1,193 kilocalories;, minimum,: 767 kilocalories;, maximum,: 1,685 kilocalories), saturated fat (14 g, 11 g, 19 g), sodium (2,110 mg, 1,783 mg, 2,823 mg), and sugar (68 g, 10 g, 117 g). Most default meals exceeded the Healthier Restaurant Meal Guidelines for calories (97%) and sodium (99%); fewer exceeded the standards for saturated fat (50%) and total sugar (6%). Comparing the maximum and default lunch/dinner combination meals, beverages were the largest driver of differences in calories (178 kilocalories, 36% of difference) and sugar (46 g, 93% of difference), and entrées were the largest driver of differences in saturated fat (3 g, 59% of difference) and sodium (371 g, 52% of difference). Results were similar for breakfast meals.

CONCLUSIONS

Combination meals offered by large U.S. chain restaurants are high in calories, sodium, saturated fat, and sugar, with most default meals exceeding recommended limits for calories and sodium.

Health claims and information sources in relation to bean consumption in older adults

Bean consumption can reduce chronic disease risk and improve diet quality; however, bean consumption among North Americans is low. Since health claims and other information sources could increase bean consumption, their exploration is warranted, particularly among older adults, a population well positioned to benefit. The purpose of this study was to explore bean consumption among older adults (≥65 years old) in relation to health claims and other information sources. A mixed-methods explanatory sequential study design utilizing a between strategy data collection approach was used. Community-dwelling older adults (n = 250; 76.0% female) completed a validated researcher-administered questionnaire to explore bean consumption, awareness and reading of health claims, the likelihood of health claims influencing bean consumption, and current and preferred sources of nutrition and/or health information regarding beans. The questionnaire was followed up with 10 semi-structured focus groups (n = 46; 76.1% female). Awareness of nutrient content, nutrient function, therapeutic and disease risk reduction claims was reported by 94.4%, 64.0%, 79.6% and 77.2% of participants, respectively. Among those aware, these health claims were read by 91.5%, 85.6%, 87.9% and 88.6% of participants, respectively. The prevalence of bean consumption was 51.2% and participants (46.8%) most frequently indicated that all health claims would equally increase their likelihood of bean consumption. Participants (72.0%) reported that they would like more information about the nutrition and/or health properties of beans, with their most common preferred sources including food labels (54.8%), brochures (51.2%) and the internet (47.2%). This research advances the literature on how health claims relate to eating behaviour and can inform regulatory and food industry scientists about consumer perception to bean health claims, and healthcare professionals about preferred information sources for their clients.

Effects of health star labelling on the healthiness of adults' fast food meal selections: An experimental study

The addition of Health Star Rating (HSR) labelling to menus at fast food outlets is feasible, however how this would impact consumer menu selection remains unclear. The aim of this study was to test whether the addition of HSR labelling to kilojoule (kJ) labelling on menus at fast food outlets would prompt consumers to select healthier meals. Using a between-subjects experimental design, 1007 adults aged 18-49 were allocated to one of four menu labelling conditions: (i) no labelling; (ii) kilojoule labelling; (iii) HSR labelling; and (iv) kilojoule + HSR labelling. Respondents were presented with their assigned menu online and instructed to select an evening meal as they would at a fast food restaurant. The main analyses tested differences by menu labelling condition in the total mean kilojoule content and Nutrient Profiling Score (NPS) of respondents' evening meal selections using one-way ANOVA. The mean kilojoule content of meals did not differ significantly by menu labelling condition. However, respondents in the kilojoule + HSR labelling condition selected healthier meals (lower mean NPS) than those who viewed menu boards with kilojoule labelling only (M = 2.88 cf. M = 3.78, p = 0.046). In addition, in a post hoc per-protocol analysis of respondents who reported using menu labelling to assist their meal selection, respondents shown kilojoule + HSR menu labelling selected meals with a significantly lower kilojoule content compared to those shown HSR labelling only (4751 kJ cf. 5745 kJ, p = 0.038). Findings provide evidence that adding HSRs to kilojoule labelling on menu boards at fast food outlets has the potential to assist adults to make healthier evening meal selections.

Assessment of Packaged Foods and Beverages Carrying Nutrition Marketing against Canada's Food Guide Recommendations

Canadians' food purchases consist largely of packaged processed and ultra-processed products, which typically fall outside the "core" foods recommended by Canada's Food Guide (CFG). Almost half of packaged products in Canada carry nutrition marketing (i.e., nutrient content and health claims). This study assessed whether packaged foods carrying nutrition marketing align with recommendations outlined in the 2007 CFG. Label data (n = 9376) were extracted from the 2013 Food Label Information Program (FLIP). Label components (including nutrition marketing) were classified using the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) labelling taxonomy. The Health Canada Surveillance Tool (HCST) was used to assess the alignment of products to CFG. Each food or beverage was classified into one of five groups (i.e., Tier 1, Tier 2, Tier 3, Tier 4, "Others"). Products in Tier 1, 2 or water were considered "in line with CFG". Most products in the analyzed sample were classified as Tier 2 (35%) and Tier 3 (27%). Although foods with nutrition marketing were significantly more likely to align to CFG recommendations (p < 0.001), many products not "in line with CFG" still carried nutrition marketing. This study provides important baseline data that could be used upon the implementation of the new CFG.

A Meta-Analysis of Food Labeling Effects on Consumer Diet Behaviors and Industry Practices

CONTEXT

The influence of food and beverage labeling (food labeling) on consumer behaviors, industry responses, and health outcomes is not well established.

EVIDENCE ACQUISITION

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Ten databases were searched in 2014 for studies published after 1990 evaluating food labeling and consumer purchases/orders, intakes, metabolic risk factors, and industry responses. Data extractions were performed independently and in duplicate. Studies were pooled using inverse-variance random effects meta-analysis. Heterogeneity was explored with I2, stratified analyses, and meta-regression; and publication bias was assessed with funnel plots, Begg's tests, and Egger's tests. Analyses were completed in 2017.

EVIDENCE SYNTHESIS

From 6,232 articles, a total of 60 studies were identified, including 2 million observations across 111 intervention arms in 11 countries. Food labeling decreased consumer intakes of energy by 6.6% (95% CI= -8.8%, -4.4%, n=31), total fat by 10.6% (95% CI= -17.7%, -3.5%, n=13), and other unhealthy dietary options by 13.0% (95% CI= -25.7%, -0.2%, n=16), while increasing vegetable consumption by 13.5% (95% CI=2.4%, 24.6%, n=5). Evaluating industry responses, labeling decreased product contents of sodium by 8.9% (95% CI= -17.3%, -0.6%, n=4) and artificial trans fat by 64.3% (95% CI= -91.1%, -37.5%, n=3). No significant heterogeneity was identified by label placement or type, duration, labeled product, region, population, voluntary or legislative approaches, combined intervention components, study design, or quality. Evidence for publication bias was not identified.

CONCLUSIONS

From reviewing 60 intervention studies, food labeling reduces consumer dietary intake of selected nutrients and influences industry practices to reduce product contents of sodium and artificial trans fat.

Analysis of the National Adult Nutrition Survey (Ireland) and the Food4Me Nutrition Survey Databases to Explore the Development of Food Labelling Portion Sizes for the European Union

The present study set out to explore the option of developing food portion size for nutritional labelling purposes using two European Union (EU) dietary surveys. The surveys were selected as they differed in (a) methodologies (food diary versus food frequency questionnaire), (b) populations (Irish National Adult Nutrition Survey (NANS) versus a seven-country survey based on the pan EU study Food4Me), (c) food quantification (multiple options versus solely photographic album) and (d) duration (4 consecutive days versus recent month). Using data from these studies, portion size was determined for 15 test foods, where portion size was defined as the median intake of a target food when consumed. The median values of the portion sizes derived from both the NANS and Food4Me surveys were correlated (r = 0.823; p < 0.00) and the mean of the two survey data sets were compared to US values from the Recognized as Customarily Consumed (RACC) database. There was very strong agreement across all food categories between the averaged EU and the US portion size (r = 0.947; p < 0.00). It is concluded that notwithstanding the variety of approaches used for dietary survey data in the EU, the present data supports using a standardized approach to food portion size quantification for food labelling in the EU.

(Over)eating out at major UK restaurant chains: observational study of energy content of main meals

OBJECTIVES

To examine the energy content of main meals served in major UK restaurant chains and compare the energy content of meals in fast food and "full service" restaurant chains.

DESIGN

Observational study.

SETTING

Menu and nutritional information provided by major UK restaurant chains.

MAIN OUTCOME MEASURES

Mean energy content of meals, proportion of meals meeting public health recommendations for energy consumption (≤600 kcal), and proportion of meals with excessive energy content (≥1000 kcal).

RESULTS

Main meals from 27 restaurant chains (21 full service; 6 fast food) were sampled. The mean energy content of all eligible restaurant meals (13 396 in total) was 977 (95% confidence interval 973 to 983) kcal. The percentage of all meals that met public health recommendations for energy content was low (9%; n=1226) and smaller than the percentage of meals with an excessive energy content (47%; 6251). Compared with fast food restaurants, full service restaurants offered significantly more excessively calorific main meals, fewer main meals meeting public health recommendations, and on average 268 (103 to 433) kcal more in main meals.

CONCLUSIONS

The energy content of a large number of main meals in major UK restaurant chains is excessive, and only a minority meet public health recommendations. Although the poor nutritional quality of fast food meals has been well documented, the energy content of full service restaurant meals in the UK tends to be higher and is a cause for concern.

REGISTRATION

Study protocol and analysis strategy pre-registered on Open Science Framework (https://osf.io/w5h8q/).

Comparison of Label and Laboratory Sodium Values in Popular Sodium-Contributing Foods in the United States

BACKGROUND

Nutrition labels are important tools for consumers and for supporting public health strategies. Recent, published comparison of label and laboratory sodium values for US foods, and differences by brand type (national or private-label) or source (store or restaurant [fast-food and sit-down]) is unavailable.

OBJECTIVE

The objective was to compare label and laboratory values for sodium and related nutrients (ie, total sugars, total fat, and saturated fat) in popular, sodium-contributing foods, and examine whether there are differences by brand type, and source.

DESIGN

During 2010 to 2014, the Nutrient Data Laboratory of the US Department of Agriculture collected 3,432 samples nationwide of 125 foods, combined one or more samples of the same food (henceforth referred to as composites), and chemically analyzed them. For this comparative post hoc analysis, the Nutrient Data Laboratory linked laboratory values for 1,390 composites (consisting of one or more samples of the same food) of 114 foods to corresponding label or website (restaurant) nutrient values.

MAIN OUTCOME MEASURES

Label and laboratory values and their ratio for each composite, for each of the four nutrients (sodium, total fat, total sugars, and saturated fat).

STATISTICAL ANALYSES PERFORMED

Nutrient Data Laboratory analysis determined the ratio of laboratory to label value for each composite, and categorized them into six groups: ≥141%, 121% to 140%, 101% to 120%, 81% to 100%, 61% to 80%, and ≤60%. For sodium, the Nutrient Data Laboratory analysis determined the distribution of the ratios by food, food category, brand type, and source.

RESULTS

For sodium, 5% of the composites had ratios of laboratory to label values >120% and 14% had ratios ≤80%. Twenty-two percent of private-label brand composites had ratios ≤80%, compared with 12% of national brands. Only 3% of store composites had ratios >120% compared with 11% of restaurant composites. Ratios ≤80% were more prevalent among sit-down restaurants (37%) compared with fast-food restaurants (9%).

CONCLUSIONS

This study shows that a majority of label and laboratory values sampled agree and underdeclaration of label values is limited. However, there is some disagreement. Periodic monitoring of the nutrient content of foods through laboratory analyses establishes validity of the food labels and helps identify foods and food categories where the label and laboratory values do not compare well, and hence may need laboratory analyses to support accuracy of food composition data.

Calories in Context: Conceptual Metaphors and Consumers' Perception and Use of Calorie Information

The U.S. Food and Drug Administration (FDA) recently made changes to the nutrition facts label so that calories will be emphasized over all other nutrient information (U.S. Food and Drug Administration (FDA), 2016a, August 3). In light of calories' increased visibility, strategic health communicators need to understand both how individuals perceive calorie information and how calories influence consumption decisions. Therefore, a qualitative study was conducted to analyze the metaphors that structure consumers' thoughts about calorie information and food choices. In-depth interviews were conducted with 34 women from diverse racial/ethnic and socioeconomic backgrounds. Through the interviews and subsequent thematic analysis, metaphors were gathered that explained perceptions of different kinds of calories and how calories function in the diet. Five conceptual metaphors were uncovered. The metaphors individuals used varied based on their eating paradigms, and the metaphors were related to different approaches to consumption decisions. The implications of using these different calorie metaphors for translational communication interventions are further discussed.

Influence of front-of-package nutrition labels on beverage healthiness perceptions: Results from a randomized experiment

The current study explored the influence of three summary indicator front-of-pack (FOP) nutrition labels on consumer perceptions of the healthiness of different beverage products. In 2016, a total of 675 respondents in southwestern Ontario aged 16 and over viewed images of soda, unflavoured milk and chocolate milk displaying one of four FOP label conditions (no FOP label, numeric rating, health star rating (HSR), or simplified traffic light (STL)), and rated the products' healthiness. Participants also indicated their preference for summary indicator versus nutrient-specific FOP labels. Logistic regression models comparing correct responses across label conditions found no differences across label conditions for unflavoured milk or soda. Consumers in the HSR and STL conditions were more likely to correctly perceive a chocolate milk beverage as 'moderately healthy' (p = 0.004, p = 0.016). No differences in responses were identified across sociodemographic groups. Most respondents (93%) indicated that they would like to see a health rating or nutrient-specific information on the front of food products. Results of this study suggest that the influence of FOP labels may vary based on the nutritional quality of food products, and may have the greatest influence on consumer perceptions of 'nutritionally ambiguous' foods. Consumers indicated almost unanimous support for implementing FOP nutrition labelling systems.

Impact of tax and subsidy framed messages on high- and lower-sugar beverages sold in vending machines: a randomized crossover trial

OBJECTIVE

Framing of fiscal incentives has been suggested to be important in influencing purchase decisions. We aimed to examine the effect of framing a modest price difference between high- and lower-sugar beverages as a tax or a subsidy respectively, using messages placed on vending machines to influence beverage purchases.

DESIGN/SETTING

This is an 11-week randomized crossover trial conducted between August and November 2015, with a two-week run-in period before intervention, targeted at students, staff and faculty of a university campus in Singapore. Twenty-one beverage vending machines were used to implement the intervention involving 'tax message', 'subsidy message' and 'no message (control)'. The former two messages suggest 'a tax for high sugar beverages' or 'a subsidy for lower sugar beverages' respectively. Prices of the beverages offered were fixed at baseline and remained the same in all three experimental conditions: lower-sugar beverage options were priced ~ 10% lower than the corresponding high-sugar option. The machines were randomized to one of the 6 sequences of intervention. Each message intervention period was 3 weeks. The effect of messages was assessed by comparing average weekly units of beverages sold between interventions using mixed effects model.

RESULTS

The average weekly units of high and lower-sugar beverages sold per vending machine were 115 and 98 respectively in the control condition. The percentage of high-sugar beverages sold was 54% in the control, 53% in the tax, and 54% in the subsidy message condition. There was no difference in the weekly units of high-sugar beverages sold for the tax message (- 2, 95% CI -8 to 5, p = 0.61) or the subsidy message (0, 95% CI -10 to 10, p = 0.96) conditions as compared with the control condition. Similarly, there was no difference in the weekly units of lower-sugar beverages sold for the tax message (4, 95% CI -4 to 13, p = 0.32) or the subsidy message (7, 95% CI -4 to 18, p = 0.18) conditions as compared with the control condition.

CONCLUSIONS

The use of tax and subsidy messages to highlight modest price differences did not substantially reduce high-sugar beverage sales in vending machines on an Asian university campus.

Traffic Light System Can Increase Healthfulness Perception: Implications for Policy Making

OBJECTIVE

To evaluate how information about low nutrient content included in the traffic light labeling system influences consumers' perception of the healthfulness of products with high content of 1 key nutrient, and to compare the traffic light system with warnings in terms of the perception of healthfulness.

DESIGN

Images of front-of-pack (FOP) nutrition labels (the traffic light labeling system with different numbers of nutrients with low content, and warnings) were evaluated in study 1, whereas product labels featuring the different FOP nutrition labels were evaluated in study 2.

SETTING

Online studies conducted in Montevideo, Uruguay.

PARTICIPANTS

A total of 1,228 Uruguayan Facebook users.

MAIN OUTCOME MEASURES

Perception of healthfulness.

ANALYSIS

The researchers used ANOVA to evaluate the influence of FOP nutrition labels on perceived healthfulness.

RESULTS

The inclusion of information about low nutrient content in the traffic light system statistically significantly increased the perception of the healthfulness of products with high nutrient content. Nutritional warnings showed healthfulness ratings similar to those of the simplified version of the traffic light system.

CONCLUSIONS AND IMPLICATIONS

Information about low nutrient content in the traffic light system might be used to infer health, and thus could raise the perception of healthfulness and decrease the traffic light system's efficacy in discouraging the consumption of unhealthful products. A simplified version of the traffic light highlighting only high-nutrient content or nutritional warnings seems to overcome this problem.

Nutrition Facts Use in Relation to Eating Behaviors and Healthy and Unhealthy Weight Control Behaviors

OBJECTIVE

Investigate the relationship between use of Nutrition Facts labels on packaged foods and weight-related behaviors.

DESIGN

Cross-sectional survey in 2015-2016.

PARTICIPANTS

Young adult respondents (n = 1,817; 57% women; average age 31.0 ± 1.6 years) to the Project Eating and Activity in Teens and Young Adults-IV survey, the fourth wave of a longitudinal cohort study.

VARIABLES MEASURED

Use of Nutrition Facts labels on packaged foods; healthy, unhealthy, and extreme weight control behaviors; intuitive eating; binge eating.

ANALYSIS

Linear and logistic regression models were adjusted for age, ethnicity/race, education, income, and weight status.

RESULTS

In women, greater Nutrition Facts use was associated with a 23% and 10% greater likelihood of engaging in healthy and unhealthy weight control behaviors, respectively, and a 17% greater chance of engaging in binge eating. In men, greater label use was associated with a 27% and 17% greater likelihood of engaging in healthy and unhealthy weight control behaviors, respectively, and a lower level of intuitive eating.

CONCLUSIONS AND IMPLICATIONS

Professionals advising patients and clients on weight management may consider possible gender differences in response to weight loss and management guidance. Since label use was related to engagement in some unhealthy behaviors in addition to healthy behaviors, it is important to consider how individuals may use labels, particularly those at risk for, or engaging in, disordered eating behaviors. Future research investigating potential relationships between Nutrition Facts use, intuitive eating, and binge eating is needed.

Are food and drink retailers within NHS venues adhering to NICE Quality standard 94 guidance on childhood obesity? A cross-sectional study of two large secondary care NHS hospitals in England

OBJECTIVE

To assess whether the food and drink retail outlets in two major National Health Service (NHS) district general hospitals in England adhere to quality statements 1-3 of the UK National Institute for Health and Care Excellence (NICE) quality standard 94.

DESIGN

Cross-sectional, descriptive study to assess the food and drink options available in vending machines, restaurants, cafes and shops in two secondary care hospitals.

MAIN OUTCOME MEASURES

Adherence to quality statement 1 whereby the food and drink items available in the vending machines were classified as either healthy or less healthy using the Nutrient Profiling Model (NPM). Compliance with quality statements 2 and 3 was assessed through the measurement of how clearly the shops, cafes and restaurants displayed nutrition information on menus, and the availability and prominent display of healthy food and drink options in retail outlets, respectively.

RESULTS

Adherence to quality statement 1 was poor. Of the 18 vending machines assessed, only 7 (39%) served both a healthy food and a healthy drink option. Neither hospital was compliant with quality statement 2 wherein nutritional information was not available on menus of food providers in either hospital. There was inconsistent compliance with quality standard 3 whereby healthy food and drink options were prominently displayed in the two main hospital restaurants, but all shops and cafes prioritised the display of unhealthy items.

CONCLUSIONS

Neither hospital was consistently compliant with quality statements 1-3 of the NICE quality standard 94. Improving the availability of healthy foods and drinks while reducing the display and accessibility to less healthy options in NHS venues may improve family awareness of healthy alternatives. Making it easier for parents to direct their children to healthier choices is an ostensibly central component of our healthcare system.

A Cross-Sectional Study of the Relationship between Nutrition Label Use and Food Selection, Servings, and Consumption in a University Dining Setting

BACKGROUND

Nutrition labels at the point of purchase are recommended to improve food choice, yet food choice does not always translate into food consumption. It is important to understand the relationship between label use, food selection, servings, and consumption. Previous research, which has relied on self-reported intake or inferred label use or intake based on sales data, has not adequately answered this question.

OBJECTIVE

To combine survey and meal photographic data to compare food selection, servings, and consumption between label users and nonusers.

DESIGN

Diners were surveyed in two cross-sectional waves during the fall 2014 semester. Food selections were recorded, and pre- and postmeal photographs were taken of diners' plate. Photographs were coded to identify the selection, servings, and consumption of MyPlate food categories.

PARTICIPANTS/SETTING

Convenience sample of 1,069 diners (39% women, 53% freshman) in two university dining halls. Students had to be older than age 18 years and just beginning their meal to participate.

MAIN OUTCOME MEASURES

Selection, servings, and consumption of MyPlate food categories for label users and nonusers.

STATISTICAL ANALYSES PERFORMED

Differences in food selection were tested via χ² tests, and differences in adjusted least squares means for servings and consumption were tested via t tests.

RESULTS

A greater proportion of nutrition label users selected fruits, vegetables, and beans and fewer selected potatoes compared with nonusers. In addition, fewer label users selected fried foods and foods with added sugars (all P values <0.05). Label users served themselves and consumed more vegetables and fewer potatoes and refined grains compared with nonusers (all P values <0.05).

CONCLUSIONS

Our results suggest label users behave differently compared with nonusers. Based on the meals observed, these differences appear more qualitative in nature (selecting different foods) than quantitative (selecting more or less food).

Attention to Physical Activity-Equivalent Calorie Information on Nutrition Facts Labels: An Eye-Tracking Investigation

OBJECTIVE

Investigate attention to Nutrition Facts Labels (NFLs) with numeric only vs both numeric and activity-equivalent calorie information, and attitudes toward activity-equivalent calories.

DESIGN

An eye-tracking camera monitored participants' viewing of NFLs for 64 packaged foods with either standard NFLs or modified NFLs. Participants self-reported demographic information and diet-related attitudes and behaviors.

SETTING

Participants came to the Behavioral Medicine Lab at Colorado State University in spring, 2015.

PARTICIPANTS

The researchers randomized 234 participants to view NFLs with numeric calorie information only (n = 108) or numeric and activity-equivalent calorie information (n = 126).

MAIN OUTCOME MEASURE(S)

Attention to and attitudes about activity-equivalent calorie information.

ANALYSIS

Differences by experimental condition and weight loss intention (overall and within experimental condition) were assessed using t tests and Pearson's chi-square tests of independence.

RESULTS

Overall, participants viewed numeric calorie information on 20% of NFLs for 249 ms. Participants in the modified NFL condition viewed activity-equivalent information on 17% of NFLs for 231 ms. Most participants indicated that activity-equivalent calorie information would help them decide whether to eat a food (69%) and that they preferred both numeric and activity-equivalent calorie information on NFLs (70%).

CONCLUSIONS AND IMPLICATIONS

Participants used activity-equivalent calorie information on NFLs and found this information helpful for making food decisions.

The incidence of calorie labeling on fast food choices: A comparison between stated preferences and actual choices

In order to test the effect of calorie information on fast food choices, we conducted a questionnaire employing two types of stated preferences methods (the best-worst-scaling and intentional questions) and a follow-up randomized field experiment in a sample of 119 participants. This combined approach allowed us to test the internal validity of preferences for fast food meals across elicitation scenarios. The results showed that calorie information reduces the probability of selecting high calorie meals only in the questionnaire, while it did not have any significant impact on actual purchasing behavior in the field experiment. Thus, the findings show that there is a clear difference between the role of calorie information on immediate stated preference choices, and the relatively low level of responsiveness in real choices in a restaurant. We believe that the current results are quite suggestive, indicating the limits of predicting actual fast food behavior, and may open the way to using data sources that combine stated methods with field experiments.

Parental Nutrition Knowledge Rather Than Nutrition Label Use Is Associated With Adiposity in Children

OBJECTIVE

Determine how parental nutrition label use, label literacy, and nutrition knowledge may be associated with cardiovascular health in parents and their children.

DESIGN AND SETTING

Cross-sectional analyses of 2006 data from the Healthy Heart Project in Montreal, Canada.

PARTICIPANTS

Among community recruited families, parents were predominantly mothers (n = 127 [80%]; mean age, 45.0 years) and half of their children were female (44%; mean age, 12.5 years).

MAIN OUTCOME MEASURES

Blood pressure, lipids, and weight. Nutrition label use, label literacy, and nutrition knowledge among parents were collected using existing scales.

ANALYSES

Multivariable linear regression models.

RESULTS

Among parents, nutrition label use was associated with lower total cholesterol (B[SE] = -.53 [.20]; P = .009), lower low-density lipoprotein (B[SE] = -.57 [.21]; P = .007), and lower total cholesterol/high-density lipoprotein cholesterol ratio (B[SE] = -.82 [.30]; P = .008) but was not associated with adiposity. Among children, greater parental nutrition knowledge was associated with lower body mass index percentiles (B[SE] = -3.6 [1.49]; P = .02), lower waist circumference (B[SE] = -1.27 [.55]; P = .02), and lower percent body fat (B[SE] = -1.28 [.47]; P = .008). Parental nutrition label use or nutrition knowledge was not associated with children's lipids.

CONCLUSIONS AND IMPLICATIONS

Parents with greater nutrition label use had more favorable lipids, but children's lipids were unaffected. Children of parents with greater nutrition knowledge had lower adiposity. Further research on the correlates of label use and health is needed.

Effects of Food Label Use on Diet Quality and Glycemic Control Among Latinos With Type 2 Diabetes in a Community Health Worker-Supported Intervention

OBJECTIVES

To determine the impact of an intervention led by community health workers (CHWs) on food label use and to assess whether food label use and diet quality mediate the intervention's impact on glycemic control.

METHODS

From 2006 to 2010, 203 Latinos (intervention group, n = 100; control group, n = 103) in Hartford County, Connecticut, with type 2 diabetes were randomized to an intervention that included 17 CHW-led home-based sessions over a 12-month period in addition to the standard of care available in both study arms. Data on food label use, diet quality, covariates, and glycated hemoglobin (HbA1c) were collected at baseline and at 3, 6, 12, and 18 months. Data were analyzed via mixed effects and multilevel structural equation modeling.

RESULTS

Food label use in the intervention (vs control) group was significantly higher at 3, 12, and 18 months (odds ratio = 2.99; 95% confidence interval = 1.69, 5.29). Food label use and diet quality were positive mediators of improved HbA1c levels.

CONCLUSIONS

Culturally tailored interventions led by CHWs could increase food label use. Also, CHW-delivered food label education may lead to better diet quality and improve glycemic control among Latinos with type 2 diabetes.

Snacks With Nutrition Labels: Tastiness Perception, Healthiness Perception, and Willingness to Pay by Norwegian Adolescents

OBJECTIVE

Consumers tend to have the perception that healthy equals less tasty. This study aimed to identify whether information provided by the Keyhole symbol, a widely used front-of-package symbol in Nordic countries to indicate nutritional content, and percent daily values (%DVs) affect Norwegian adolescents' perception of the healthiness of snacks and their intention to buy them.

DESIGN

Two tasks were used to evaluate adolescents' perception of snacks with the Keyhole symbol: with %DVs or with no nutrition label. A third task was used to test their abilities to use %DVs (pairwise selections). A survey obtained personal attributes.

PARTICIPANTS

A total of 566 Norwegian adolescents.

MAIN OUTCOME MEASURES

Taste perception, health perception, and ability to use %DVs.

ANALYSIS

Linear mixed models and logistic models that tested effects of labels and personal attributes on main outcome measures.

RESULTS

The Keyhole symbol increased health perception without influencing taste perception of snacks. Norwegian adolescents had limited abilities to use information from the %DVs correctly to identify healthier foods.

CONCLUSIONS AND IMPLICATIONS

Norwegian adolescents had a positive perception of the Keyhole symbols. Keyhole symbols as a simple, heuristic front-of-package label have potential as an information strategy that may influence self-efficacy in promoting healthy snack choices among adolescents.

College Students Must Overcome Barriers to Use Calorie Labels in Fast-Food Restaurants

OBJECTIVE

To explore predictors of intention of college students to use calorie labels on fast-food menus and differences in calories ordered after viewing calorie information.

DESIGN

Quasi-experimental design. Participants selected a meal from a menu without calorie labels, selected a meal from the same menu with calorie labels, and completed a survey that assessed demographics, dietary habits, Theory of Planned Behavior constructs, and potential barriers to use of calorie labeling.

SETTING

A southern university.

PARTICIPANTS

Undergraduate university students (n = 97).

MAIN OUTCOME MEASURES

Predictors of intention to use calorie labels and whether calories selected from the nonlabeled menu differed from the labeled menu.

ANALYSIS

Confirmatory factor analysis, exploratory factor analysis, multiple regression, and paired t tests.

RESULTS

Participants ordered significantly fewer calories (P = .02) when selecting from the labeled menu vs the menu without labels. Attitudes (P = .006), subjective norms (P < .001), and perceived behavioral control (P = .01) predicted intention to use calorie information but did not predict a difference in the calories ordered. Hunger (P = .03) and cost (P = .04) were barriers to using the calorie information.

CONCLUSIONS AND IMPLICATIONS

If students can overcome barriers, calorie labeling could provide information that college students need to select lower-calorie items at fast-food restaurants.

Calorie Changes in Large Chain Restaurants: Declines in New Menu Items but Room for Improvement

INTRODUCTION

Large chain restaurants reduced the number of calories in newly introduced menu items in 2013 by about 60 calories (or 12%) relative to 2012. This paper describes trends in calories available in large U.S. chain restaurants to understand whether previously documented patterns persist.

METHODS

Data (a census of items for included restaurants) were obtained from the MenuStat project. This analysis included 66 of the 100 largest U.S. restaurants that are available in all three of the data years (2012-2014; N=23,066 items). Generalized linear models were used to examine: (1) per-item calorie changes from 2012 to 2014 among items on the menu in all years; and (2) mean calories in new items in 2013 and 2014 compared with items on the menu in 2012 only. Data were analyzed in 2014.

RESULTS

Overall, calories in newly introduced menu items declined by 71 (or 15%) from 2012 to 2013 (p=0.001) and by 69 (or 14%) from 2012 to 2014 (p=0.03). These declines were concentrated mainly in new main course items (85 fewer calories in 2013 and 55 fewer calories in 2014; p=0.01). Although average calories in newly introduced menu items are declining, they are higher than items common to the menu in all 3 years. No differences in mean calories among items on menus in 2012, 2013, or 2014 were found.

CONCLUSIONS

The previously observed declines in newly introduced menu items among large restaurant chains have been maintained, which suggests the beginning of a trend toward reducing calories.

Differences in consumer use of food labels by weight loss strategies and demographic characteristics

BACKGROUND

Little is known about national patterns in the use of fast food and packaged food labels among adults by weight loss strategies and demographic characteristics.

METHODS

We analyzed the Consumer Behavior Module in the National Health and Nutrition Examination Survey 2007-2010 among adults (N = 9,690). For each of the outcome variables - use of packed food and fast food menu labels - multiple logistic regressions were used to adjust for potential differences in population characteristics by weight loss activities and demographic characteristics.

RESULTS

Overall, 69 percent of adults reported they would use fast food information and 76 percent reported using the nutrition facts panel on packaged foods. Adults trying to lose weight had a greater likelihood of reporting use of nutrition information to choose fast foods (OR = 1.72; 95 % CI: 1.29, 2.29) and using the nutrition facts panel on food labels (OR = 1.92; 95 % CI: 1.60, 2.30). Black and Hispanic adults were more likely to report using ingredients lists on packaged foods compared to Whites (White -63 %, Black/Hispanic -68 %, p < 0.05).

CONCLUSION

Regardless of weight loss activities or demographic characteristics, a majority of adults report they would use fast food nutrition information.

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Celiac disease is an autoimmune enteropathy. The only known treatment consists of a permanent adherence to a strict gluten-free diet, which represents an important challenge for patients. Objective. To describe the gluten-free processed food offer in food locals from 3 neighborhoods representative of high, middle and low economic status in Buenos Aires, Argentina.

METHODS

Cross-sectional study. Specially trained monitors performed a standardized direct assessment of food locals. Whenever direct observation was not possible, we interviewed the personnel as an indirect assessment. We classified dish offer in different categories, and evaluated the processes of food elaboration, storage and distribution.

RESULTS

We included 112 food locals. Results for neighborhoods representative of high, middle and low economic status were, respectively: no gluten free dish available in 27.5% (45/62), 27.0% (27/37) and 30.8% (9/13), (p = 0.96); adequate elaboration in 17.7%, 13.5% and 7.7%, (p = 0.61); appropriate food storage in 12.9% (8), 13.5% (5) and 7.7% (1); (p = 0.85); adequate distribution in 8.1%, 8.1% and 0% (0), (p = 0.56). Conclusion. In 1 out of 4 food locals there was not even one gluten free dish. In addition, there was a lack of compliance with safety measures to avoid gluten cross-contamination.

Influence of Interpretation Aids on Attentional Capture, Visual Processing, and Understanding of Front-of-Package Nutrition Labels

OBJECTIVE

To study the influence of 2 interpretational aids of front-of-package (FOP) nutrition labels (color code and text descriptors) on attentional capture and consumers' understanding of nutritional information.

DESIGN

A full factorial design was used to assess the influence of color code and text descriptors using visual search and eye tracking.

PARTICIPANTS

Ten trained assessors participated in the visual search study and 54 consumers completed the eye-tracking study.

MAIN OUTCOME MEASURES

In the visual search study, assessors were asked to indicate whether there was a label high in fat within sets of mayonnaise labels with different FOP labels. In the eye-tracking study, assessors answered a set of questions about the nutritional content of labels.

ANALYSIS

The researchers used logistic regression to evaluate the influence of interpretational aids of FOP nutrition labels on the percentage of correct answers. Analyses of variance were used to evaluate the influence of the studied variables on attentional measures and participants' response times.

RESULTS

Response times were significantly higher for monochromatic FOP labels compared with color-coded ones (3,225 vs 964 ms; P < .001), which suggests that color codes increase attentional capture. The highest number and duration of fixations and visits were recorded on labels that did not include color codes or text descriptors (P < .05). The lowest percentage of incorrect answers was observed when the nutrient level was indicated using color code and text descriptors (P < .05).

CONCLUSIONS AND IMPLICATIONS

The combination of color codes and text descriptors seems to be the most effective alternative to increase attentional capture and understanding of nutritional information.

A Statistical Analysis of a Traffic-Light Food Rating System to Promote Healthy Nutrition and Body Weight

BACKGROUND

Restaurant eating while optimizing nutrition and maintaining a healthy weight is challenging. Even when nutritional information is available, consumers often consider only calories. A quick and easy method to rate both caloric density and nutrition is an unmet need. A food rating system created to address that need is assessed in this study.

METHODS

The food rating system categorizes food items into 3 color-coded categories: most healthy (green), medium healthy (yellow), or least healthy (red) based on calorie density and general nutritional quality from national guidelines. Nutritional information was downloaded from 20 popular fast-food chains. Nutritional assessments and the 3 color coded categories were compared using the Wilcoxon and Median tests to demonstrate the significance of nutrition differences.

RESULTS

Green foods were significantly lower than yellow foods, which in turn were significantly lower than red foods, for calories and calories from fat, in addition to content of total fat, saturated fat and carbohydrates per 100 g serving weight (all P < .02). The green foods had significantly lower cholesterol than the yellow (P = .0006) and red (P < .0001) foods. Yellow foods had less sugar than red foods (P < .0001). Yellow foods were significantly higher in dietary fiber than red foods (P = .001).

CONCLUSION

The food rating color-coded system identifies food items with superior nutrition, and lower caloric density. The smartphone app, incorporating the system, has the potential to improve nutrition; reduce the risk of developing diabetes, hypertension, heart disease, and stroke; and improve public health.

Reported use and perceived understanding of sodium information on US nutrition labels

INTRODUCTION

Comparing nutrition labels and choosing lower sodium foods are tactics to help reduce excessive sodium intake, a major risk factor for hypertension. Our objective was to assess US adult consumers' reported use and perceived understanding of sodium information on nutrition labels by sociodemographic and health status.

METHODS

We analyzed responses to questions from 3,729 adults aged 18 years or older participating in 2 national cross-sectional mail panel surveys in 2010.

RESULTS

We found that 19.3% (95% confidence interval [CI], 17.2%-21.6%) of respondents agreed they were confused about how to figure out how much sodium is in the foods they eat; 57.9% (95% CI, 55.4%-60.5%) reported that they or the person who shops for their food buy items labeled low salt or low sodium; and 46.8% (95% CI, 44.3%-49.4%) reported they check nutrition labels for sodium content as a tactic to limit salt. Consumers with a high school education or less were more likely than college graduates to report they were confused about sodium content on labels (adjusted odds ratio [AOR], 1.9; 95% CI, 1.4-2.8) and less likely to check labels for sodium as a tactic to limit salt intake (AOR, 0.7; 95% CI, 0.6-0.98).

CONCLUSION

Most survey respondents in our study reported buying low sodium food items. However, a higher proportion of respondents with low education than respondents with high education reported confusion with and less use of sodium content information, suggesting enhanced efforts may be needed to assist this group. Opportunity exists for health care professionals to educate patients about using and understanding nutrition labels and consuming a diet consistent with the Dietary Approaches to Stop Hypertension (DASH) eating plan.