Customer Responses to Mandatory Menu Labeling at Full-Service Restaurants

ArticleinAmerican journal of preventive medicine 45(6):710-9 · December 2013with 207 Reads 
How we measure 'reads'
A 'read' is counted each time someone views a publication summary (such as the title, abstract, and list of authors), clicks on a figure, or views or downloads the full-text. Learn more
Cite this publication
Abstract
In 2010, Philadelphia enacted a menu-labeling law requiring full-service restaurant chains to list values for calories, sodium, fat, and carbohydrates for each item on all printed menus. The goal of the study was to determine whether purchase decisions at full-service restaurants varied depending on the presence of labeling. In August 2011, this cross-sectional study collected 648 customer surveys and transaction receipts at seven restaurant outlets of one large full-service restaurant chain. Two outlets had menu labeling (case sites); five outlets did not (control sites). Outcomes included differences in calories and nutrients purchased and customers' reported use of nutrition information when ordering. Data were analyzed in 2012. Mean age was 37 years; 60% were female; 50% were black/African-American and reported incomes ≥$60,000. Customers purchased food with approximately 1600 kcal (food plus beverage, 1800 kcal); 3200 mg sodium; and 35 g saturated fat. After adjustment for confounders, customers at labeled restaurants purchased food with 151 fewer kilocalories (95% CI=-270, -33); 224 mg less sodium (95% CI=-457, +8); and 3.7 g less saturated fat (95% CI=-7.4, -0.1) compared to customers at unlabeled restaurants (or 155 less kilocalories from food plus beverage, 95% CI=-284, -27). Those reporting that nutrition information affected their order purchased 400 fewer food calories, 370 mg less sodium, and 10 g less saturated fat. Mandatory menu labeling was associated with better food choices among a segment of the public dining at full-service restaurants. Consumer education on the availability and use of nutrition information may extend the impact of menu labeling.

Do you want to read the rest of this article?

Request Full-text Paper PDF
Advertisement
  • ... In a few fast-food restaurant intercept studies in the USA, only 50 % of customers saw calorie labels after they were posted on fast-food menu boards and only about 10 % of customers self-reported using the calorie information to decide what to buy (6,7) . Recent studies of labelling use among customers at full-service restaurants suggest that a larger proportion of diners used the labels: approximately 75 % of customers saw nutrition labels on printed menus and about one-third reported using the labels; however, most diners are not utilizing labels despite very high calories, fat and sodium in the menu items (8,9) . Little is known about why and under what conditions customers notice and use nutritional information at full-service restaurants and whether consumers' ability to comprehend the numbers varies by menu display. ...
    ... Sample size and participant recruitment A convenience sample of focus group participants was recruited in August 2011, during the same date/time as participant recruitment for a companion study, the Drexel Restaurant Study, a consecutive sample of 385 customers who exited two Philadelphia outlets of a national fullservice chain restaurant during evening hours (8) . All adult customers exiting the restaurants were invited to participate in the focus groups if they ordered food at the restaurant and anticipated being available to attend one focus group session in Philadelphia in September 2011 during lunchtime or evening, weekdays or weekends. ...
    ... Nevertheless, most participants acknowledged they were not likely to use the information. Recent studies of labelling use among customers at full-service restaurants confirm that labels are being used by only about one-third of restaurant patrons when deciding what to order (8,9) despite very high calories, fat and sodium levels in menu items (13,18) . ...
    Article
    Full-text available
    Objective: Numerous localities have mandated that chain restaurants post nutrition information at the point of purchase. However, some studies suggest that consumers are not highly responsive to menu labelling. The present qualitative study explored influences on full-service restaurant customers’ noticing and using menu labelling. Design: Five focus groups were conducted with thirty-six consumers. A semi-structured script elicited barriers and facilitators to using nutrition information by showing excerpts of real menus from full-service chain restaurants. Setting: Participants were recruited from a full-service restaurant chain in Philadelphia, Pennsylvania, USA, in September 2011. Subjects: Focus group participants were mostly female, African American, with incomes <$US 60 000, mean age 36 years and education 14·5 years. At recruitment, 33 % (n 12) reported changing their order after seeing nutrition information on the menu. Results: Three themes characterized influences on label use in restaurants: nutrition knowledge, menu design and display, and normative attitudes and behaviours. Barriers to using labels were low prior knowledge of nutrition; displaying nutrition information using codes; low expectations of the nutritional quality of restaurant food; and restaurant discounts, promotions and social influences that overwhelmed interest in nutrition and reinforced disinterest in nutrition. Facilitators were higher prior knowledge of recommended daily intake; spending time reading the menu; having strong prior interest in nutrition/healthy eating; and being with people who reinforced dietary priorities. Conclusions: Menu labelling use may increase if consumers learn a few key recommended dietary reference values, understand basic energy intake/expenditure scenarios and if chain restaurants present nutrition information in a user-friendly way and promote healthier items.
  • ... Eighteen of forty-eight studies evaluated calorie information in realworld restaurant settings (Table 1). There was one RCT (22), one quasi-real-world RCT (23), seven natural experiments evaluating menu labeling before and after implementation and compared to control locations (24)(25)(26)(27)(28)(29)(30), seven studies evaluating labeling before and after implementation without a control comparison (31)(32)(33)(34)(35)(36)(37), and two using cross-sectional designs to compare labeled versus unlabeled locations (38,39). Three of these studies included children and/or adolescents (27,30,33). ...
    ... Cross-sectional comparing labeled vs. unlabeled sites. Auchincloss et al. (38) collected dinnertime receipts from 648 customers at two locations of a full-service restaurant chain in Philadelphia (labeled) and five outside of Philadelphia (unlabeled). Customers at labeled restaurants ordered statistically significantly fewer calories (151-calorie reduction) than those at unlabeled restaurants; results held when different propensity scoring methods were used to improve causal inference (40). ...
    ... Although two other well-designed natural experiments reported null effects of calorie labeling at fast-food restaurants, both studies were only powered to detect large effects of calorie labeling (26,29). Further, there was only one real-world, full-service chain restaurant analysis with an adequate sample size, which found that calorie labeling was associated with a 150-calorie reduction, but this study was limited by a cross-sectional design (38). Although other reviews have concluded that menu labeling has little impact on fastfood purchases (13)(14)(15)(16), there is an extraordinary dearth of welldesigned and adequately powered studies to truly test this hypothesis in both fast-food and full-service chain settings. ...
    Article
    Objective: Evidence on the effects of restaurant calorie labeling on consumer and restaurant behavior is mixed. This paper examined: (1) consumer responses to calorie information alone or compared to modified calorie information and (2) changes in restaurant offerings following or in advance of menu labeling implementation. Methods: Searches were conducted in PubMed, Web of Science, Policy File, and PAIS International to identify restaurant calorie labeling studies through October 1, 2016, that measured calories ordered, consumed, or available for purchase on restaurant menus. The reference lists of calorie labeling articles were also searched. Results: Fifty-three studies were included: 18 in real-world restaurants, 9 in cafeterias, and 21 in laboratory or simulation settings. Five examined restaurant offerings. Conclusions: Because of a lack of well-powered studies with strong designs, the degree to which menu labeling encourages lower-calorie purchases and whether that translates to a healthier population are unclear. Although there is limited evidence that menu labeling affects calories purchased at fast-food restaurants, some evidence demonstrates that it lowers calories purchased at certain types of restaurants and in cafeteria settings. The limited data on modified calorie labels find that such labels can encourage lower-calorie purchases but may not differ in effects relative to calorie labels alone.
  • ... One investigator (SLM) screened 1,175 abstracts and two investigators (SLM, AHA) reviewed 115 full-text papers for inclusion, which included 15 papers that were not identified in the PubMed search, but were identified based on expert knowledge (28,(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43). Figure 1 outlines the review process. ...
    ... Most of the studies (n = 8) focused on responses to nutrition labelling and used food purchase receipts to assess the potential impact on calories and dietary quality (30,33,34,42,(55)(56)(57)(58). Six of these studies assessed impacts soon after implementation (range 1-9 months, average 3 months) and overall had no impact on food purchasing or on improving nutritional outcomes. ...
    ... Six of these studies assessed impacts soon after implementation (range 1-9 months, average 3 months) and overall had no impact on food purchasing or on improving nutritional outcomes. Two studies assessed impacts at least 1 year post-implementation and found expected results (30,57). For example, a study of a sit-down chain restaurant (using a one-time crosssectional with comparison group design) found that customers at restaurants with menu labelling purchased food with 151 kcal fewer (95% confidence interval [CI]: 33, 270) compared with customers at restaurants without labelling, as well as decreased saturated fat and sodium (30). ...
    Article
    Policies and changes to the built environment are promising targets for obesity prevention efforts and can be evaluated as 'natural'- or 'quasi'-experiments. This systematic review examined the use of natural- or quasi-experiments to evaluate the efficacy of policy and built environment changes on obesity-related outcomes (body mass index, diet or physical activity). PubMed (Medline) was searched for studies published 2005-2013; 1,175 abstracts and 115 papers were reviewed. Of the 37 studies included, 18 studies evaluated impacts on nutrition/diet, 17 on physical activity and 3 on body mass index. Nutrition-related studies found greater effects because of bans/restrictions on unhealthy foods, mandates offering healthier foods, and altering purchase/payment rules on foods purchased using low-income food vouchers compared with other interventions (menu labelling, new supermarkets). Physical activity-related studies generally found stronger impacts when the intervention involved improvements to active transportation infrastructure, longer follow-up time or measured process outcomes (e.g. cycling rather than total physical activity), compared with other studies. Only three studies directly assessed body mass index or weight, and only one (installing light-rail system) observed a significant effect. Studies varied widely in the strength of their design and studies with weaker designs were more likely to report associations in the positive direction. © 2015 World Obesity.
  • ... The term menu labeling has been used with different meanings. Some authors employ it as a synonym for calorie information, 3,4 while others use it to designate nutritional information such as calories and nutrients 5,6 or as a reference to the traffic-light system 7,8 or other food information. 9,10 In this study, the term menu labeling was broadly applied to designate all calorie information, nutritional information (eg, nutrient counts), contextual information (eg, daily calorie recommendations), food information (eg, ingredients, alerts such as "contains gluten," and symbols or phrases to identify healthy food, such as keyhole or heart symbols), and traffic-light labeling. ...
    ... 22,43 Observational studies at sit-down restaurants showed partial effects of menu labeling, including one AB study 41 and one crosssectional study. 6 Only one study in sit-down restaurants showed overall positive effects, which was also the only included study conducted in a fine dining restaurant. Calorie labeling was associated with a reduction in the calorie content of ordered meals (À221 kcal) and an increase in the ordering of the lower-calorie menu option (1630 calories), which was selected 5 times more frequently during the labeling phase (36.7%) than during the prelabeling phase (7.8%). ...
    ... Auchincloss et al. 6 found significant reductions in calories (À151 kcal), saturated fats (À3.7 g), and carbohydrates (À14.7 g) in selected foods (P < 0.05 for all), but not in sodium (À224 mg, P > 0.05, not significant) or trans fats (adjusted data not shown). ...
    Article
    Full-text available
    Context: Evidence that menu labeling influences food choices in real-life settings is lacking. Reviews usually focus on calorie counts without addressing broader issues related to healthy eating. Objective: This systematic review assessed the influence of diverse menu-labeling formats on food choices in real-life settings. Data sources: Several databases were searched: Cochrane Library, Scopus, MEDLINE, Web of Science, Food Science and Technology Abstracts, Biological Abstracts, CAB Abstracts, EconLit, SciELO, and LILACS. Study selection: Articles reporting experiments, quasi-experiments, and observational studies using control or preintervention groups were selected blindly by two reviewers. Data extraction: Data was extracted using a standard form. Analyses differentiated between foodservice types. The quality of the 38 included studies was assessed blindly by two reviewers. Data analysis: The results were mixed, but a partial influence of menu labeling on food choices was more frequent than an overall influence or no influence. Menu labeling was more effective in cafeterias than in restaurants. Qualitative information, such as healthy-food symbols and traffic-light labeling, was most effective in promoting healthy eating. In general, the studies were of moderate quality and did not use control groups. Conclusions: Calorie labeling in menus is not effective to promote healthier food choices. Further research in real-life settings with control groups should test diverse qualitative information in menu labeling.
  • ... Calorie posting on menus at chain restaurants has been the most comprehensively examined intervention of the approaches identified in this study. Our review identified 19 individual studies with predominantly pre-post designs or repeat cross-sectional surveys with a control group, with sample sizes ranging from a few hundred participants [16,23,29,32] to over 100 million transactions [17]. In the following, we synthesize the study results by the type of outcome examined, starting with the outcomes most distal from the intervention in accordance with the program logic outlined in Fig 1 in the methods section (Fig 1). ...
    ... The first used two outlets of a non-identified fast food chain in Philadelphia and control locations in neighboring states, resulting in a total sample of 648 verified purchases. This study reported a 9% drop, equivalent to 151 food calories less purchased on average compared to non-regulated jurisdictions [16]. The second study was limited to the Starbucks chain in New York City, with Boston and Baltimore as control locations [17]. ...
    ... However, the caloric value of average purchases at Starbucks were much lower than at other regulated chains both pre-and post-implementation. For instance, in the other single chain study, customers at regulated outlets purchased an average of 1,556 calories [16] and the average entrée in King County contained 777 calories at 18 months post-labelling before adding any side orders [18]. This suggests that the Starbucks study may not be representative of the regulation's impact in the broader fast food sector. ...
    Article
    Full-text available
    Background This systematic review (PROSPERO: CRD42015025276) employs a realist approach to investigate the effect of “real-world” policies targeting different aspects of the food environment that shape individual and collective nutrition. Objectives We were interested in assessing intermediate outcomes along the assumed causal pathway to “policy success”, in addition to the final outcome of changed consumption patterns. Data sources We performed a search of 16 databases through October 2015, with no initial restriction by language. Study eligibility criteria We included all publications that reported the effect of statutory provisions aimed at reducing the consumption of energy-dense foods and beverages in the general population. We allowed all methodological approaches that contained some measure of comparison, including studies of implementation progress. Study appraisal and synthesis methods We reviewed included studies using the appraisal tools for pre-post and observational studies developed by the National Heart, Lung, and Blood Institute. Given the considerable heterogeneity in interventions assessed, study designs employed, and outcome measures reported, we opted for a narrative synthesis of results. Results and implications Results drawn from 36 peer-reviewed articles and grey literature reports demonstrated that isolated regulatory interventions can improve intermediate outcomes, but fail to affect consumption at clinically significant levels. The included literature covered six different types of interventions, with 19 studies reporting on calorie posting on chain restaurant menus. The large majority of the identified interventions were conducted in the US. Early results from recent taxation measures were published after the review cut-off date but these suggested more favorable effects on consumption levels. Nevertheless, the evidence assessed in this review suggests that current policies are generally falling short of anticipated health impacts.
  • ... Fifty-six full-text publications were included in the full-text review and 42 were excluded [36,. Five studies [51,[97][98][99][100] classified as "A" and nine [50,[101][102][103][104][105][106][107][108] studies classified as "B" containing consumed and/or ordered calories as an outcome were included in the meta-analysis, collectively representing 0.07% of the total titles (without duplicates) identified ( Figure 1). The sum of participants in all fourteen selected studies ("A" and "B") was 552,029. ...
    ... Before-intervention means and standard deviations from studies with BA and ITS designs were included with the control means and standard deviations from the other study designs. Nine articles reported menu label implementation in away-from-home settings [50,97,98,[101][102][103][104]106,107] and five involved laboratory settings [51,99,100,105,108] (Table 2). * After applicable exclusions, as follows: a Groups "calories plus price" and "price interventions" were excluded from this analysis; b Adults ≥18 were included in this meta-analysis so participants stratified to the ≥14 and <40 year group in Krieger et al. were excluded along with those from coffee chains; characteristics shown reflect those of the entire sample; c The group receiving calorie plus exercise equivalents in lunch Section 2 was excluded from this analysis; d Only data from parents were included in this analysis; e Only data from participants in experimental condition 1 were included in this analysis. ...
    ... *** Additional nutrient menu labeling was provided as follows: f sodium, saturated fat, trans fat, carbohydrates; g fat, cholesterol, sodium, dietary fiber; h fat, sodium, carbohydrates. **** Other nutrients were evaluated in the studies of Auchincloss et al. [101] (trans fat); Elbel et al. [97] (sugar); Pulos and Leng (carbohydrates) [106]; Harnack et al. [51] (calcium, vitamin C, dietary fiber, and protein) and Nelson et al. [104] (dietary fiber) but were not included in this meta-analysis because there were too few studies evaluating these outcomes. ...
    Article
    Full-text available
    A systematic review and meta-analysis determined the effect of restaurant menu labeling on calories and nutrients chosen in laboratory and away-from-home settings in U.S. adults. Cochrane-based criteria adherent, peer-reviewed study designs conducted and published in the English language from 1950 to 2014 were collected in 2015, analyzed in 2016, and used to evaluate the effect of nutrition labeling on calories and nutrients ordered or consumed. Before and after menu labeling outcomes were used to determine weighted mean differences in calories, saturated fat, total fat, carbohydrate, and sodium ordered/consumed which were pooled across studies using random effects modeling. Stratified analysis for laboratory and away-from-home settings were also completed. Menu labeling resulted in no significant change in reported calories ordered/consumed in studies with full criteria adherence, nor the 14 studies analyzed with ≤1 unmet criteria, nor for change in total ordered carbohydrate, fat, and saturated fat (three studies) or ordered or consumed sodium (four studies). A significant reduction of 115.2 calories ordered/consumed in laboratory settings was determined when analyses were stratified by study setting. Menu labeling away-from-home did not result in change in quantity or quality, specifically for carbohydrates, total fat, saturated fat, or sodium, of calories consumed among U.S. adults.
  • ... Furthermore, the disclosure of energy values at the point of purchase has overwhelming public support in several countries, including those where ML has been implemented (3,(16)(17)(18)(19) . Consumers otherwise rarely notice or access energy declarations provided by food-service establishments in any other format, including tray liners, food packaging or company websites (17,20) , despite energy being sought-after nutrition information (21)(22)(23)(24) . ...
    ... Three studies considered the effects of ML on energy ordered and subsequently consumed (21,43,44) . Six studies reported on energy ordered (22,38,39,(45)(46)(47) , while six assessed the effects on energy selected (4,16,40,(48)(49)(50) . Seven studies were conducted in real-world settings (21,22,38,39,(45)(46)(47) and eight studies were conducted in experimental settings (4,16,40,43,44,(48)(49)(50) . ...
    ... Six studies reported on energy ordered (22,38,39,(45)(46)(47) , while six assessed the effects on energy selected (4,16,40,(48)(49)(50) . Seven studies were conducted in real-world settings (21,22,38,39,(45)(46)(47) and eight studies were conducted in experimental settings (4,16,40,43,44,(48)(49)(50) . Eight studies reported on the proportion of participants noticing ML (16,21,22,(43)(44)(45)(46)48) . ...
    Article
    Full-text available
    Despite recognizing the potential of retail settings for interventions aimed at bringing the rate of obesity down, there have been few attempts to implement experimental studies aiming to increase consumption of healthy foods and decrease consumption of unhealthy foods in the retail setting. An experimental controlled trial has been conducted using 10 supermarkets in Denmark. The study looked specifically into the possible effect of shelf space management intervention at supermarkets. The study found a significant intervention effect for individual products targeted by the project. But overall, care is needed to interpret results on aggregate level since statistical findings do not support category wide effect of shelf space intervention.
  • ... Furthermore, the disclosure of energy values at the point of purchase has overwhelming public support in several countries, including those where ML has been implemented (3,(16)(17)(18)(19) . Consumers otherwise rarely notice or access energy declarations provided by food-service establishments in any other format, including tray liners, food packaging or company websites (17,20) , despite energy being sought-after nutrition information (21)(22)(23)(24) . ...
    ... Three studies considered the effects of ML on energy ordered and subsequently consumed (21,43,44) . Six studies reported on energy ordered (22,38,39,(45)(46)(47) , while six assessed the effects on energy selected (4,16,40,(48)(49)(50) . Seven studies were conducted in real-world settings (21,22,38,39,(45)(46)(47) and eight studies were conducted in experimental settings (4,16,40,43,44,(48)(49)(50) . ...
    ... Six studies reported on energy ordered (22,38,39,(45)(46)(47) , while six assessed the effects on energy selected (4,16,40,(48)(49)(50) . Seven studies were conducted in real-world settings (21,22,38,39,(45)(46)(47) and eight studies were conducted in experimental settings (4,16,40,43,44,(48)(49)(50) . Eight studies reported on the proportion of participants noticing ML (16,21,22,(43)(44)(45)(46)48) . ...
    Article
    Full-text available
    Objective: Menu labelling is a practical tool to inform consumers of the energy content of menu items and help consumers make informed decisions in the eating-out environment, and the volume of studies published recently regarding its effects is expanding, both quantitatively and geographically. The aim of the present review and meta-analysis is to consider the most recent evidence which assesses the effect of menu labelling regarding changes in energy consumed, ordered or selected in both real-world and experimental settings. Design: The review included fifteen peer-reviewed, full-text articles published between 2012 and 2014. Pertinent methodological information was extracted from each of the included studies and a quality assessment scheme was applied to classify the studies, after which systematic across-study comparisons were conducted. A meta-analysis was conducted including twelve of the fifteen studies, and stratified according to type of research setting and outcome: energy consumed, ordered or selected. Results: The rating yielded studies categorized by study quality: good (n 3), fair (n 9) and weak (n 3). Overall nine studies showed statistically significant reductions in energy consumed, ordered or selected. Three articles reported no effect of menu labelling. The meta-analysis showed statistically significant effects of menu labelling: overall energy consumed was reduced by a mean of 419·5 kJ (100·2 kcal) and energy ordered in real-world settings decreased by a mean of 325·7 kJ (77·8 kcal). Conclusions: The review supports that menu labelling can effectively reduce energy ordered and consumed in the away-from-home food environment.
  • ... However, quasi-experimental studies evaluating the effectiveness of these policies have reported mixed results. [4][5][6][7][8][9] One of the few studies to find a labeling impact was Auchincloss et al (2013) which studied the impact of the city of Philadelphia's menu-labeling ordinance. [10] The study found that customers at full-service restaurants with labeling purchased fewer calories, sodium, and saturated fat compared to customers at restaurants without labeling. ...
    ... However, quasi-experimental studies evaluating the effectiveness of these policies have reported mixed results. [4][5][6][7][8][9] One of the few studies to find a labeling impact was Auchincloss et al (2013) which studied the impact of the city of Philadelphia's menu-labeling ordinance. [10] The study found that customers at full-service restaurants with labeling purchased fewer calories, sodium, and saturated fat compared to customers at restaurants without labeling. ...
    ... [10] The study found that customers at full-service restaurants with labeling purchased fewer calories, sodium, and saturated fat compared to customers at restaurants without labeling. [5] However, the cross-sectional study design was suboptimal and there was imperfect covariate balance between customers who dined at labeled versus unlabeled restaurants. Imbalance can lead to selection bias, in which those who have the opportunity to be exposed to the policy differ from those who do not on certain measured or unmeasured characteristics related to the outcome of interest. ...
    Article
    Full-text available
    Background Quasi-experimental studies of menu labeling have found mixed results for improving diet. Differences between experimental groups can hinder interpretation. Propensity scores are an increasingly common method to improve covariate balance, but multiple methods exist and the improvements associated with each method have rarely been compared. In this re-analysis of the impact of menu labeling, we compare multiple propensity score methods to determine which methods optimize balance between experimental groups. Methods Study participants included adult customers who visited full-service restaurants with menu labeling (treatment) and without (control). We compared the balance between treatment groups obtained by four propensity score methods: 1) 1:1 nearest neighbor matching (NN), 2) augmented 1:1 NN (using caliper of 0.2 and an exact match on an imbalanced covariate), 3) full matching, and 4) inverse probability weighting (IPW). We then evaluated the treatment effect on differences in nutrients purchased across the different methods. Results 1:1 NN resulted in worse balance than the original unmatched sample (average standardized absolute mean distance [ASAM]: 0.185 compared to 0.171). Augmented 1:1 NN improved balance (ASAM: 0.038) but resulted in a large reduction in sample size. Full matching and IPW improved balance over the unmatched sample without a reduction in sample size (ASAM: 0.049 and 0.031, respectively). Menu labeling was associated with decreased calories, fat, sodium and carbohydrates in the unmatched analysis. Results were qualitatively similar in the propensity score matched/weighted models. Conclusions While propensity scores offer an increasingly popular tool to improve causal inference, choosing the correct method can be challenging. Our results emphasize the benefit of examining multiple methods to ensure results are consistent, and considering approaches beyond the most popular method of 1:1 NN matching.
  • ... Of the 16 studies included in this review, 13 focused on adults' purchases [31][32][33][34][35][36][37][38][39][40][41][42][43], while three focused on children's or parents' and children's purchases [44][45][46]. Twelve [31-33, 37-41, 43-46] of the 16 real-world restaurant studies included comparison groups by either examining similar locations where menu labeling laws were not in effect or using a randomized-controlled design. ...
    ... Positive Effects of Menu Labeling-Three studies detected positive effects of menu labeling [31][32][33]. One study compared energy content of food purchased from two fullservice chain restaurant locations displaying labels relative to five locations that did not [31]. ...
    ... Positive Effects of Menu Labeling-Three studies detected positive effects of menu labeling [31][32][33]. One study compared energy content of food purchased from two fullservice chain restaurant locations displaying labels relative to five locations that did not [31]. Receipts and surveys were collected from 648 restaurant patrons after their evening meal and revealed that, on average, those eating at the labeled restaurants ordered 151 fewer calories (p = .018) ...
    Article
    In response to high rates of obesity in the USA, several American cities, counties, and states have passed laws requiring restaurant chains to post labels identifying the energy content of items on menus, and nationwide implementation of menu labeling is expected in late 2016. In this review, we identify and summarize the results of 16 studies that have assessed the impact of real-world numeric calorie posting. We also discuss several controversies surrounding the US Food and Drug Administration's implementation of federally mandated menu labeling. Overall, the evidence regarding menu labeling is mixed, showing that labels may reduce the energy content of food purchased in some contexts, but have little effect in other contexts. However, more data on a range of ong-term consumption habits and restaurant responses is needed to fully understand the impact menu labeling laws will have on the US population's diet.
  • ... However, many fastfood consumers may just not find this information helpful; about half of participants responded that calories were "not at all" important in their meal selection. Other types of health communication, such as traffic light labels, may better communicate the importance of energy balance for health [41], and labels might be more effective in other settings like full-service chain restaurants [42,43] or cafeterias [10,11,44,45]. ...
    ... The recent nationwide implementation of the calorie labeling law offers future opportunities to investigate these effects in larger studies, particularly in full-service restaurants, where the effect of calorie labeling on diet quality may be stronger [42]. Because of the now widespread implementation of labeling, chains might offer lower calorie options, decreasing calorie content by default [47], which should also be examined further. ...
    Article
    Full-text available
    Background: The long-term effect of calorie labeling on fast-food purchases is unclear. McDonald's voluntarily labeled its menus with calories in 2012, providing an opportunity to evaluate this initiative on purchases. Methods: From 2010 to 2014, we collected receipts from and administered questionnaires to 2971 adults, 2164 adolescents, and 447 parents/guardians of school-age children during repeated visits to 82 restaurants, including McDonald's and five control chains that did not label menus over the study period in four New England cities. In 2018, we analyzed the data by using difference-in-differences analyses to estimate associations of calorie labeling with calories purchased (actual and estimated) and predicted probability of noticing calorie information on menus. Results: Calorie labeling at McDonald's was not associated with changes in calories purchased in adults (change = - 19 cal pre- vs. post-labeling at McDonald's compared to control chains, 95% CI: - 112, 75), adolescents (change = - 49 cal, 95% CI: - 136, 38), or children (change = 13 cal, 95% CI: - 108, 135). Calorie labeling generally increased the predicted probability of noticing calorie information, but did not improve estimation of calories purchased. Conclusions: Calorie labeling at McDonald's was not associated with changes in calories purchased in adults, adolescents, or children. Although participants were more likely to notice calories on menus post-labeling, there was no improvement in ability to accurately estimate calories purchased.
  • ... In NYC, sodium (Johnson et al., 2010) and sugary drinks (Taskler et al., 2016) purchased at fast-food chain restaurants have also been reported on, to a lesser extent. Elsewhere, two studies assessed calories and sodium, among other nutrients, in purchases at chain (Auchincloss et al., 2013) and non-chain (Pulos and Leng, 2010) FSR. Our study adds to the current body of research by collectively assessing sodium, calories and sugary drinks in both QSR and FSR. ...
    ... Data collection occurred between October-December 2015. Teams of 2 to 4 interviewers visited QSR locations between 12 and 3 pm on weekdays, and FSR locations between 5 and 9 pm on weekdays and weekends; these times of data collection are similar to other customerintercept studies in each environment (Dumanovsky et al., 2009;Auchincloss et al., 2013). Interviewers received training from senior study team members, and supervision included random quality assurance monitoring. ...
    Article
    Full-text available
    To understand how consumer purchases in chain restaurants relate to nutrients of public health concern, sodium, calories and sugary drinks purchased for personal consumption were assessed through a customer intercept receipt study at a sample of New York City quick- and full-service chain restaurants (QSR and FSR) in 2015. The percentages of respondents purchasing ≥2,300 mg sodium, ≥2,000 calories, and a sugary drink, respectively, were 14%, 3% and 32% at QSR, and 56%, 23%, and 22% at FSR. Sodium content of purchases averaged 1,260 mg at QSR and 2,897 mg at FSR and calories averaged 770 at QSR and 1,456 at FSR. 71% of QSR sugary drink purchases contained at least 200 calories. Purchasing patterns that are exceptionally high in sodium and calories, and that include sugary drinks, are common in chain restaurants. Because restaurant-sourced foods are a cornerstone of the American diet, fostering conditions that support healthful purchases is essential to reduce preventable disease and advance health.
  • ... One of the reasons for this phenomenon should be considered as the result of the low scale of education concerning nutrition within the scope of nutritional information in Poland [28]. The research completed so far shows that the level of knowledge regarding nutrition has a considerable influence on perception, evaluation and use of nutritional information [2,23]. Another reason for the poor understanding of information about nutrition may be that too much information is given, which also limits the possibility of using it [1,30,32]. ...
    ... Lower grades of compliance were noted for the statements about innovativeness, and the healthier food on offer by the eating out establishments, which provided nutritional information (3.78 and 3.63) ( Table 2). A reason for this may be that nutritional information is most often provided by network enterprises (overseas food chains for example), which offer fast food and are accused of a low nutritive value of their products [2]. ...
    Article
    Full-text available
    Background. Providing nutritional information in catering establishments in Poland, it is not mandatory, at the same time this type of information may affect the attitudes and behavior of consumers. Objective. The purpose of this research was to define the influence of nutritional information upon customer attitude and behaviour in eating out establishments. Material and methods: An online consumer survey was conducted in 2016. The quantitative research was undertaken in the form of a questionnaire among a group of 403 people selected in terms of age (18-35 years old), residence (big cities) and frequency of eating out or away from the home. Results. The results of this research show that the respondents’ perception of information was positive and influenced both their perception of the eating out establishment, as well as their purchasing decisions. Only gender was statistically important for the differentiation of the consumers’ behaviour within the scope analyzed. Conclusions. The results obtained lead to the conclusion that providing nutritional information may increase the competitiveness of eating out establishments. It may also lead to a more rational marketplace, where choices in terms of health may impact social health, taking into consideration the growing popularity of eating out or away from home.
  • ... Indeed, several studies have provided evidence that this information leads to an increase in kilocalorie estimation abilities and a decrease in kilocalorie consumption. [11][12][13] However, the findings of these studies have been inconsistent, and further research on the efficacy of restaurant nutrition information is necessary. 14,15 Furthermore, many restaurants do not meet the 20 store minimum, and subsequently are not likely to provide kilocalorie information for their menu items unless required to by their local jurisdiction. ...
    Article
    Full-text available
    Background: Current methods of self-monitoring kilocalorie intake outside of laboratory/clinical settings suffer from a systematic underreporting bias. Recent efforts to make kilocalorie information available have improved these methods somewhat, but it may be possible to derive an objective and more accurate measure of kilocalorie intake from bite count. Objective: This study sought to develop and examine the accuracy of an individualized bite-based measure of kilocalorie intake and to compare that measure to participant estimates of kilocalorie intake. It was hypothesized that kilocalorie information would improve human estimates of kilocalorie intake over those with no information, but a bite-based estimate of kilocalorie intake would still outperform human estimates. Participants/settings: Two-hundred eighty participants were allowed to eat ad libitum in a cafeteria setting. Their bite count and kilocalorie intake were measured. After completion of the meal, participants estimated how many kilocalories they consumed, some with the aid of a menu containing kilocalorie information and some without. Using a train and test method for predictive model development, participants were randomly divided into one of two groups: one for model development (training group) and one for model validation (test group). Statistical analysis: Multiple regression was used to determine whether height, weight, age, sex, and waist-to-hip ratio could predict an individual's mean kilocalories per bite for the training sample. The model was then validated with the test group, and the model-predicted kilocalorie intake was compared with human-estimated kilocalorie intake. Results: Only age and sex significantly predicted mean kilocalories per bite, but all variables were retained for the test group. The bite-based measure of kilocalorie intake outperformed human estimates with and without kilocalorie information. Conclusions: Bite count might serve as an easily measured, objective proxy for kilocalorie intake. A tool that can monitor bite count may be a powerful assistant to self-monitoring.
  • ... These results provide modest support to the evidence base suggesting that menu labeling may positively impact consumer behavior by encouraging lower calorie [13,14] or healthier food purchases [15]. Although the literature related to menu labeling and consumer purchases is mixed with several systematic reviews of the impact of menu labeling on calorie purchases finding inconsistent or null results [16][17][18][19]. ...
    Article
    Full-text available
    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.
  • ... Restaurants and supermarkets (The Robert Wood Johnson Foundation & The Food Trust, 2011) have been proposed as suitable settings in which to influence dietary practices because of the frequency with which customers make food-related choices that affect individual-and household-level eating practices (Story, Kaphingst, Robinson-O'Brien, & Glanz, 2008). Research suggests that programs using a combination of point-of-purchase (POP) information, pricing, increased availability of healthful foods, and promotion and advertising strategies can influence customer choices toward healthier options (Auchincloss et al., 2013;Escaron, Meinen, Nitzke, & Martinez-Donate, 2013;Gittelsohn, Lee-Kwan, & Batorsky, 2013;Gittelsohn, Rowan, & Gadhoke, 2012;Glanz & Hoelscher, 2004;Seymour, Yaroch, Serdula, Blanck, & Khan, 2004;Vadiveloo, Dixon, & Elbel, 2011). POP information is the use of labels and/or signage that highlight healthy food choices. ...
    Article
    Full-text available
    Purpose: Restaurants and food stores are suitable settings for healthy eating interventions. A community-academic partnership developed and implemented "Waupaca Eating Smart" (WES), a healthy eating program in restaurants and supermarkets of a rural, Midwest community. Previous interventions targeted either restaurants or small food stores nearly all in urban areas. Intervention design and implementation is rarely documented, making replication difficult for interested researchers and communities. In this article, we report the activities we undertook to develop and implement WES. Methods: Working with a local nutrition and activity coalition, we used evidence-based strategies guided by the social ecological model and social marketing principles to inform the content of WES. Formative assessment included a review of the literature, statewide key informant interviews and focus groups with restaurant and food store operators and patrons, a local community survey, and interviews with prospective WES businesses. WES was implemented in seven restaurants and two supermarkets and evaluated for feasibility and acceptance using surveys and direct observation of WES implementation. Findings: Prior to this intervention, only one of seven restaurants had three or more meals that met WES nutrition criteria. By the end of the program, 38 meals were labeled and promoted to restaurant customers, and the team had staffed four side salad taste tests for supermarket customers. Four and 10 months after intervention launch, the majority of the program's strategies were observed in participating outlets, suggesting that these program's strategies are feasible and can be sustained. Operators reported strong satisfaction overall. Conclusions: A combined restaurant- and supermarket-based healthy eating intervention is feasible and positively valued in rural communities. Further research is needed to better understand how to foster sustainability of these interventions and their impact on customer food choices.
  • ... Some, but not all, research suggests having sodium content available on menus would encourage making healthier choices at restaurants. 24,25 Changes may occur in the proportion of respondents requesting lower-sodium meals when eating out after implementation of the 2010 Affordable Care Act provision to require chain restaurants with 20 or more U.S. locations to have sodium and nutrient information available in writing if requested. 26 Along with health professional advice at the individual level and public health messaging and policy changes at the national level, policy, system, and environmental changes can be implemented at the community level to address sodium reduction. ...
    Article
    Purpose: To describe the prevalence and determinants of sodium-related knowledge, attitudes, and behaviors among U.S. adults Design. A cross-sectional survey was used. Setting: The study was set in the United States in 2012. Subjects: Participants were 6122 U.S. adults. Measures: Sodium-related knowledge, attitudes, and behaviors were measured. Analysis: Chi-squared tests were used to determine differences in sodium-related knowledge, attitude, and behaviors by respondent characteristics; multiple logistic regression was used to examine associations between selected respondent characteristics and health professional advice, reported action, or knowledge, attitudes, and behaviors (adjusted for all other respondent characteristics). Results: About three-fourths of respondents answered eating too much sodium is "somewhat" or "very" harmful to their health. Twenty-six percent reported receiving health professional advice, and 45% reported taking action to reduce their sodium intake. The prevalence of reported action was highest among adults receiving advice, those with hypertension, blacks, and those aged ≥65 years. Sixty-two percent who reported action agreed that most of their sodium comes from processed or restaurant foods. Of those reporting action, the most common tactics to reduce sodium intake were checking nutrition labels, using other spices than salt, and choosing low-sodium foods; requesting lower-sodium options when eating out was the least common tactic. Conclusion: Results suggest almost half of adults overall and the vast majority of those receiving health professional advice are taking some action to watch or reduce sodium intake. Although a substantial proportion report using recommended tactics to lower intake, many are not using the most effective tactics. In order to reach the general population, health communication messages could be simpler and focus on the most effective tactics to reduce sodium intake. Furthermore, health professionals can help reduce sodium intake by discussing the benefits of sodium reduction and tactics to do so, regardless of a hypertension diagnosis.
  • ... 20 Yet, virtually all research to date evaluating local menu labeling efforts has focused on individual changes and the evidence as to the degree to which they influence food choices is mixed. 18,19,[21][22][23][24][25][26][27][28][29][30] The bigger impacts of menu labeling may be seen through its effects on restaurant industry's reformulation of products to have fewer calories. In fact, in anticipation of these regulations, many large restaurants have already implemented what they describe as self-regulatory actions to increase the transparency of nutritional information (e.g., McDonalds began voluntary menu labeling in 2012). ...
    Article
    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. 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. 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. 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. Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
  • ... In response to the increasing prevalence of obesity, the Patient Protection and Affordable Care Act (ACA) as part of the 2010 Health Care Law, was implemented in the USA (Pizam, 2011). The aim of the legislation was to discourage overconsumption and promote healthy eating to reduce obesity (Auchincloss, 2013). However, menu labelling is not currently enforced in the UK and to date research has not examined its effectiveness. ...
    Conference Paper
    Full-text available
    In response to the increasing prevalence of obesity, the Patient Protection and Affordable Care Act (ACA) as part of the 2010 Health Care Law, was implemented in the USA (Pizam, 2011). The aim of the legislation was to discourage overconsumption and promote healthy eating to reduce obesity (Auchincloss, 2013). However, menu labelling is not currently enforced in the UK and to date research has not examined its effectiveness. Thus the aim of the present study was to examine the effectiveness of menu labelling in a UK obese population (BMI >30 kg·m2). Using a repeated measures design, 61 patients (50.52 ± 2.07 years) at Rotherham Institute for Obesity (RIO) completed four questionnaires to assess their food choice (control) and behaviour change when presented with 3 separate menu labelling formats: information about the calorie content; nutrient content; and energy expenditure. There was significant difference between the control and the 3 menu labelling formats (P < .05) and between the three menu labelling formats (P < .05). The calorie condition had the largest percentage decrease in calories of the food ordered from the menu (26.02%) followed by energy expenditure (16.46%) and nutrient content (14.76%). Furthermore, participants reported a desire to enforce menu labelling in the UK (>90%). In conclusion the findings suggest menu labelling laws should be enforced in the UK and would contribute to more informed decisions that may have an impact on obesity prevalence and other health related concerns associated with overconsumption and unhealthy eating.
  • ... In response to the increasing prevalence of obesity, the Patient Protection and Affordable Care Act (ACA) as part of the 2010 Health Care Law, was implemented in the USA (Pizam, 2011). The aim of the legislation was to discourage overconsumption and promote healthy eating to reduce obesity (Auchincloss, 2013). However, menu labelling is not currently enforced in the UK and to date research has not examined its effectiveness. ...
    Article
    In response to the increasing prevalence of obesity, the Patient Protection and Affordable Care Act (ACA) as part of the 2010 Health Care Law, was implemented in the USA (Pizam, 2011). The aim of the legislation was to discourage overconsumption and promote healthy eating to reduce obesity (Auchincloss, 2013). However, menu labelling is not currently enforced in the UK and to date research has not examined its effectiveness. Thus the aim of the present study was to examine the effectiveness of menu labelling in a UK obese population (BMI >30 kg·m2). Using a repeated measures design, 61 patients (50.52 ± 2.07 years) at Rotherham Institute for Obesity (RIO) completed four questionnaires to assess their food choice (control) and behaviour change when presented with 3 separate menu labelling formats: information about the calorie content; nutrient content; and energy expenditure. There was significant difference between the control and the 3 menu labelling formats (P < .05) and between the three menu labelling formats (P < .05). The calorie condition had the largest percentage decrease in calories of the food ordered from the menu (26.02%) followed by energy expenditure (16.46%) and nutrient content (14.76%). Furthermore, participants reported a desire to enforce menu labelling in the UK (>90%). In conclusion the findings suggest menu labelling laws should be enforced in the UK and would contribute to more informed decisions that may have an impact on obesity prevalence and other health related concerns associated with overconsumption and unhealthy eating.
  • ... Other researchers found that customers in full-service restaurants who used calorie labels when choosing their meals ordered 20% fewer calories than those customers who did not use the labels. 24 Further research is required to further explore the effects of posted calorie information in fullservice restaurants. For the college population, research on the impact of menu labeling should extend to other facilities beyond the dining halls. ...
    Article
    Background: Obesity continues to be an epidemic in the United States and is associated with multiple chronic diseases. Greater numbers of people eat in restaurants and select high calorie foods. Labeling laws require calorie information on menus in some restaurants. Purpose: The purpose of this study was to determine the predictors of intention to use calorie labels among college students using constructs of the Theory of Planned Behavior (TPB). Methods: College students selected a meal from a menu without calories and from the same menu with calorie information, and completed a survey that addressed TPB constructs. Regression analysis was used to determine predictors of intention to use labels and calorie changes of meals ordered. Results: Students (n = 100) ordered significantly fewer calories with posted calorie information. Intention was significantly correlated with attitudes, subjective norms, and perceived behavioral control. Discussion: The TPB may help explain factors involved in the intention to use posted calorie information on a restaurant menu. Results support the inclusion of the calorie statements on these menus. Translation to Health Education Practice: Education efforts should include constructs of the TPB. When planning, implementing and evaluating programs, utilizing strategies to influence attitudes, subjective norms and perceived behavioral control is suggested.
  • ... Accordingly, the use of nutrition information allows consumers to control their nutrient intake, which has a positive effect on public health [20]. The implementation of nutritional information has been studied widely in many types of restaurants [21][22][23][24][25][26][27][28]. ...
    Article
    Full-text available
    Background/objectives: With the advances in technologies, self-service kiosks at foodservice operations are becoming a new way of service provision. This study examined the relationships among the menu information quality, nutrition information quality, technology acceptance characteristics, and customer behavioral intention toward the kiosks in fast food restaurants. Subjects/methods: A survey with a self-administered method was distributed online and offline. The sample consisted of customers who had used the kiosks at fast food restaurants in the last six months prior to the survey. The study hypotheses were tested by applying structural equation modeling. Results: Structural equation modeling revealed the positive impacts of menu information quality and nutrition information quality, technology acceptance characteristics, and behavioral intention toward kiosks at fast food restaurants. On the other hand, one hypothesis (Hypothesis 4) on the impact of nutrition information quality on the perceived usefulness was rejected. Conclusion: The study is the first to investigate nutrition and menu information at foodservice kiosks and relate them to technology acceptance. The study is very timely and adequate in the time of the 4th industrial revolution. The critical importance of the presentation of nutrition information and menu information at the kiosks at fast food restaurants was verified. The academic and industrial implications of the study findings were discussed.
  • ... edu (David R. Just). sumption and obesity (Cutler et al. 2003;Just and Payne 2009;Lakdawalla et al. 2005) as well as much of the literature outside of economics (Auchincloss et al. 2013). The simple rational model supposes that individuals make food and exercise decisions in order to maximize their utility or wellbeing subject to constraints on expenditures, time, and the information available to the consumer. ...
    Article
    A growing body of literature now demonstrates the importance of behavioral factors in individual food consumption. However, whether addressing hunger, nutrition, or obesity, food policies are often created to target changes at the aggregate level. These policies ignore such behavioral tools or effects and their potential heterogeneous effects on consumers. In this article, we review the most important results examining food consumption and behavioral economics and provide a thorough discussion of how such tools are now being added to the lexicon of effective policy tools. In addition, we discuss how traditional policy tools that ignore the individual behavioral effects can miss the mark or even backfire. The implication is clear: a thorough understanding of behavioral economics is necessary to create efficient food policy.
  • ... This is supported by observations that customers at FSRs that provided menu labels with nutritional information consumed options with lower fat and calorie contents than those that did not. 36 If FFRs and FSRs are associated with elevated risk of CVD mortality, they might be a reasonable target for public health interventions aimed at reducing CVD and related conditions, including T2D. We, therefore, aimed to evaluate the association between both FFR and FSR densities, obtained from the US Department of Agriculture Economic Research Service, with mortality rates from CVD and stroke and the prevalence of T2D (from the Centers for Disease Control and Prevention [CDC]), controlling for the potential confounding effects of poverty, education, ethnicity, physical inactivity, and smoking (from the US census). ...
    Article
    Full-text available
    Background We explored whether higher densities of fast‐food restaurants (FFRs) and full‐service restaurants are associated with mortality from cardiovascular disease (CVD) and stroke and the prevalence of type 2 diabetes mellitus (T2D) across the mainland United States. Methods and Results In this cross‐sectional study county‐level data for CVD and stroke mortality, and prevalence of T2D, were combined with per capita densities of FFRs and full‐service restaurants and analyzed using regression. Mortality and diabetes mellitus prevalence were corrected for poverty, ethnicity, education, physical inactivity, and smoking. After adjustment, FFR density was positively associated with CVD (β=1.104, R²=2.3%), stroke (β=0.841, R²=1.4%), and T2D (β=0.578, R²=0.6%) and full‐service restaurant density was positively associated with CVD mortality (β=0.19, R²=0.1%) and negatively related to T2D prevalence (β=−0.25, R²=0.3%). In a multiple regression analysis (FFRs and full‐service restaurants together in same model), only the densities of FFRs were significant (and positive). If we assume these relationships are causal, an impact analysis suggested that opening 10 new FFRs in a county would lead to 1 extra death from CVD every 42 years and 1 extra death from stroke every 55 years. Repeated nationally across all counties, that would be an extra 748 CVD deaths and 567 stroke deaths (and 390 new cases of T2D) over the next 10 years. Conclusions These results suggest that an increased density of FFRs is associated with increased risk of death from CVD and stroke and increased T2D prevalence, but the maximal impact (assuming the correlations reflect causality) of each individual FFR is small. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03243253.
  • ... Despite these differences, our study is consistent with previous studies reporting only small decreases in calories per transaction after implementation of calorie labeling in fast food restaurants. Studies suggest that associations of calorie labeling in sit-down settings might be stronger,[36][37][38][39][40] though few studies have been conducted in these types of restaurants.7 ...
    Article
    Full-text available
    Objective To evaluate whether calorie labeling of menus in large restaurant chains was associated with a change in mean calories purchased per transaction. Design Quasi-experimental longitudinal study. Setting Large franchise of a national fast food company with three different restaurant chains located in the southern United States (Louisiana, Texas, and Mississippi) from April 2015 until April 2018. Participants 104 restaurants with calorie information added to in-store and drive-thru menus in April 2017 and with weekly aggregated sales data during the pre-labeling (April 2015 to April 2017) and post-labeling (April 2017 to April 2018) implementation period. Main outcome measures Primary outcome was the overall level and trend changes in mean purchased calories per transaction after implementation of calorie labeling compared with the counterfactual (ie, assumption that the pre-intervention trend would have persisted had the intervention not occurred) using interrupted time series analyses with linear mixed models. Secondary outcomes were by item category (entrees, sides, and sugar sweetened beverages). Subgroup analyses estimated the effect of calorie labeling in stratums defined by the sociodemographic characteristics of restaurant census tracts (defined region for taking census). Results The analytic sample comprised 14 352 restaurant weeks. Over three years and among 104 restaurants, 49 062 440 transactions took place and 242 726 953 items were purchased. After labeling implementation, a level decrease was observed of 60 calories/transaction (95% confidence interval 48 to 72; about 4%), followed by an increasing trend of 0.71 calories/transaction/week (95% confidence interval 0.51 to 0.92) independent of the baseline trend over the year after implementation. These results were generally robust to different analytic assumptions in sensitivity analyses. The level decrease and post-implementation trend change were stronger for sides than for entrees or sugar sweetened beverages. The level decrease was similar between census tracts with higher and lower median income, but the post-implementation trend in calories per transaction was higher in low income (change in calories/transaction/week 0.94, 95% confidence interval 0.67 to 1.21) than in high income census tracts (0.50, 0.19 to 0.81). Conclusions A small decrease in mean calories purchased per transaction was observed after implementation of calorie labeling in a large franchise of fast food restaurants. This reduction diminished over one year of follow-up.
  • ... A smaller number of studies gauged the effect of restaurant menu labeling on consumer behavior at full-service restaurants. Among these studies, Auchincloss et al. (2013) found that consumers at a full-service restaurant ordered 155 fewer calories. Pulos and Leng (2010) found that consumers at six different full-service restaurants chose entrées with 15 fewer calories. ...
    Book
    Full-text available
    This report examines the growing availability of food away from home (FAFH), presenting research on food choices and availability; nutrition and diet quality; and food policies, including menu labeling and food assistance programs. It also examines how FAFH choices relate to diet quality and sociodemographic characteristics.
  • ... Many studies abroad have examined the effectiveness of disclosing nutritional information at restaurants. While some studies presented empirical evidence demonstrating positive effects of nutritional information on consumers' healthier food choices [10][11][12][13], there are other studies reporting no significant difference in calorie intakes [14][15][16][17][18]. Some systematic reviews have also reported mixed findings about the effect of nutritional labeling at restaurants [19][20][21]. ...
    Article
    Full-text available
    BACKGROUND/OBJECTIVES This study examined the effect of nutrition labeling formats on parents' food choices for their children at different restaurant types. SUBJECTS/METHODS An online survey was conducted with 1,980 parents of children aged 3–12 years. Participants were randomly assigned to fast food or family restaurant scenarios, and one of four menu stimuli conditions: no labeling, low-calorie symbol (symbol), numeric value (numeric), and both low-calorie symbol and numeric value (symbol + numeric). Participants selected menu items for their children. Menu choices and total calories were compared by nutrition labeling formats in each type of the restaurant. RESULTS Low-calorie item selections were scored and a two-way analysis of variance (ANOVA) was conducted for an interaction effect between restaurant and labeling type. In the fast food restaurant group, parents presented with low-calorie symbols selected the lowest calorie items more often than those not presented with the format. Parents in the symbol + numeric condition selected significantly fewer calories (653 kcal) than those in the no labeling (677 kcal) or numeric conditions (674 kcal) (P = 0.006). In the family restaurant group, no significant difference were observed among different labeling conditions. A significant interaction between restaurant and labeling type on low-calorie selection score (F = 6.03, P < 0.01) suggests that the effect of nutrition labeling format interplays with restaurant type to jointly affect parents' food choices for their children. CONCLUSIONS The provision of easily interpretable nutritional information format at fast food restaurants may encourage healthier food choices of parents for their children; however, the effects were negligible at family restaurants.
  • ... Studies have shown modest effects of menu calorie labeling on food purchasing behavior (Cawley, 2016;VanEpps, Roberto, Park, Economos, & Bleich, 2016). Some studies have found that menu labeling leads to decreases in the number of calorie purchased (Auchincloss et al., 2013;Bollinger, Leslie, & Sorensen, 2011;Pulos & Leng, 2010;Wisdom, Downs, & Loewenstein, 2010), while others have found null effects on consumer behavior (Cantor, Torres, Abrams, & Elbel, 2015;Downs, Wisdom, Wansink, & Loewenstein, 2013;Dumanovsky et al., 2011;Elbel, Kersh, Brescoll, & Dixon, 2009;Elbel et al., 2013;Ellison, Lusk, & Davis, 2013;Finkelstein, Strombotne, Chan, & Krieger, 2011;Schwartz, Riis, Elbel, & Ariely, 2012). ...
    Article
    Menu calorie labeling aims to empower customers to make healthier food choices, but researchers have questioned whether labels will empower those with greater health literacy, literacy or numeracy more, possibly reinforcing racial/ethnic or socioeconomic disparities in obesity. The goal of this study was to investigate differences in seeing and using restaurant menu calorie labels and whether differences have compounded over time. Using data from three rounds of the National Health and Nutrition Examination Survey covering the period 2007-2014, we investigate race-ethnic and socio-economic differences in menu label usage over time adjusting for sex, age and body weight. While menu label usage increased over time, not all groups increased their use equally. While we find that Blacks and Hispanics use labels more than Whites in sit-down restaurants, more educated individuals, higher income groups and Whites each increased the degree to which they saw and/or used labels in certain settings compared with other groups. This study reinforces concerns that menu-calorie labeling may exacerbate socio-economic and certain racial-ethnic obesity differences. As menu labeling policy moves forward to be implemented federally, more attention may need to be diverted to educational campains accompanying the implementation and improving the labels so the information is easier to use.
  • ... Among all survey respondents (the full sample), those who saw labeled menus selected items with 24 fewer calories (95 percent; CI: 12-35; p-value < 0.001). The approach used for calculating average treatment effect in field studies that either collected receipts (e.g., Auchincloss et al., 2013;Krieger et al., 2013;Elbel, 2011) or used sales data (Bollinger et al., 2011) corresponds to that of the customer comparison. The full sample comparison, however, includes zero values for people who would not frequent this type of food outlet and who, in our experiment, indicated that they would not order anything. ...
  • ... The term menu labelling can be used in different contexts as a synonym for calorie information ( Roberto et al., 2013;Brochu and Dovidio, 2014), for nutritional information (Yoon and George, 2012;Auchincloss et al., 2013), for the coloured traffic light system (Gerlach, 2013;Morley et al., 2013) or for food and nutritional information (Thunstrom and Nordstrom, 2011;Feldman et al., 2013). For the purposes of the present study, menu labelling refers to all calorie information, nutritional information (such as calories and nutrients) and food information (e.g. ...
    Article
    Full-text available
    Purpose: The purpose of this paper is to examine the effects of different menu labelling formats on healthy food choices in a real restaurant setting. Design/methodology/approach: This cross-sectional, randomised and controlled parallel-group trial was conducted in Brazil in 2013. In total, 313 university students were randomly assigned to one of three parallel groups with different menu labelling formats. Of these, data from 233 students were analysed. The others did not attend and were excluded. Intervention Group 1 (n=88) received information in the form of a traffic light plus guideline daily amounts, while Intervention Group 2 (n=74) was presented with ingredients list plus highlighted symbols (IL+S). The control group (n=71) received a menu with no menu labelling. Data were collected on one weekday in a restaurant setting. Trial outcomes were assessed by healthy food choices. Findings: Healthy food choices of students who received the menu showing IL+S were significantly higher when compared to the other groups. This same menu labelling format positively affected healthy food choices in women, not overweight participants and in participants who often ate out more than twice a week. Originality/value: Menu labelling format presenting ingredients list and highlighted symbols was positively associated with healthy food choices among the university students in Brazil. This type of labelling could be adopted in future legislation on menu labelling in Brazil and around the world.
  • ... To date, no field experiment has sought to reduce hedonic enhancement expectations for unhealthy options by using disparaging descriptions or unattractive photos. These interventions are affectively Calorie or nutrition labeling (Dubbert et al. 1984;Chu et al. 2009;Elbel et al. 2009Elbel et al. , 2011Elbel et al. , 2013Pulos and Leng 2010;Roberto et al. 2010;Bollinger et al. 2011;Dumanovsky et al. 2011;Finkelstein et al. 2011;Tandon et al. 2011;Webb et al. 2011;Auchincloss et al. 2013;Brissette et al. 2013;Downs et al. 2013;Ellison et al. 2013;Krieger et al. 2013;Vanderlee and Hammond 2014;Vasiljevic et al. 2018) Evaluative nutritional labeling (k = 43) Green stickers, smileys, "heart healthy" logos (Levin 1996;Hoefkens et al. 2011;Ogawa et al. 2011;Kiesel and Villas-Boas 2013;Levy et al. 2012;Reicks et al. 2012;Thorndike et al. 2012Thorndike et al. , 2014Cawley et al. 2015;Ensaff et al. 2015;Gaigi et al. 2015;Olstad et al. 2015;Mazza et al. 2017) Red stickers next to unhealthier options (Hoefkens et al. 2011;Levy et al. 2012;Thorndike et al. 2012Thorndike et al. , 2014Crockett et al. 2014;Shah et al. 2014;Olstad et al. 2015) Visibility enhancements (k = 25) ...
    Article
    Full-text available
    We examine the effectiveness in field settings of seven healthy eating nudges, classified according to whether they are (1) cognitively oriented, such as “descriptive nutritional labeling,” “evaluative nutritional labeling,” or “visibility enhancements”; (2) affectively oriented, such as “hedonic enhancements or “healthy eating calls”; or (3) behaviorally oriented, such as “convenience enhancements” or “size enhancements.” Our multivariate, three-level meta-analysis of 299 effect sizes, controlling for eating behavior, population, and study characteristics, yields a standardized mean difference (Cohen’s d) of 0.23 (equivalent to −124 kcal/day). Effect sizes increase as the focus of the nudges shifts from cognition (d = 0.12, −64 kcal) to affect (d = 0.24, −129 kcal) to behavior (d = 0.39, −209 kcal). Interventions are more effective at reducing unhealthy eating than increasing healthy eating or reducing total eating. Effect sizes are larger in the United States than in other countries, in restaurants or cafeterias than in grocery stores, and in studies including a control group. Effect sizes are similar for food selection versus consumption and for children versus adults and are independent of study duration. Compared with the typical nudge study (d = 0.12), one implementing the best nudge scenario can expect a sixfold increase in effectiveness (to d = 0.74) with half the result of switching from cognitively oriented to behaviorally oriented nudges.
  • ... For example, several countries require various nutrition information to appear on food package labels, either in detail (as in the US), or in simple displays, or both. More recently, we have seen a move in the US to require calorie counts to be displayed at chain restaurants (Farley et al., 2009;Bollinger et al., 2010;Bleich and Pollack, 2010;Auchincloss et al., 2013). The idea is that by providing this nutrition information, individuals will be enabled to make better decisions and potentially avoid overeating. ...
    Article
    As developed countries have grappled with rising rates of obesity, policymakers’ efforts have been frustrated. Traditional approaches have treated food consumers as if they were making deliberate and calculated food decisions, leading to policies that provide more detailed health information, pricing incentives and direct prohibitions. The results have fallen far short of expectations, and have often generated significant backlash in the process. Alternative approaches recognizing the passive nature of food decisions has recently gained some traction. These approaches, based on behavioral economics, rely on subtle changes in the food choice environment. The hallmark of these “nudges” are relatively large impacts on choice within the altered environment, relatively low costs, and little in the way of consumer resistance. In this paper we review the relevant literature within the developed world, and document the systematic policy applications. One key theme has been the importance of such interventions in food environments affecting the poor and food insecure. This is the case for two distinct reasons: First, it is the food insecure that are at greatest risk for obesity; second, the food insecure are most likely to be susceptible to food choice nudges. For these reasons, nudges may be of import in developing country settings. As obesity is on the rise in many developing countries, lessons learned in developed countries may be directly applicable. Alternatively, similar principles may be of use in ensuring proper nutrition among the food insecure as a means to prevent malnutrition or other acute diet related diseases. We provide some discussion of what these applications may look like, as well as the research needed to make effective use of behavioral choice in this new frontier.
  • Article
    Full-text available
    In this issue of the Food and Drug Policy Forum British health researchers Stuart Flint and Sophie Reale review calorie and health information legislation from the US and elsewhere as potential models for adoption in the UK. As in other countries, rising obesity is a concern in the UK, where consumers are increasingly eating outside the home.
  • Article
    Purpose of Review This review describes policy and regulatory strategies to prevent obesity and summarizes worldwide progress and impediments to scaling up strategies globally. Recent Findings While there is considerable variation in the breadth and depth of uptake of recommended strategies, the adoption of effective obesity prevention policies has been slow and inconsistent. There is broad consensus that strong government, corporate, and consumer actions, including regulatory measures, are needed to advance obesity prevention policies. Governments have lacked sufficient will to take necessary action, the food industry has actively worked to thwart policies to protect its commercial interests, and consumers have not exerted sufficient influence or demand to produce change. Summary Advancing obesity prevention will require the use of effective strategies to shape and influence the information environments and political environments towards messages and actions to support public health. Greater emphasis is needed on reducing the influence of commercial interests, mobilizing civil society, and targeting vulnerable populations through equity-focused frameworks.
  • Article
    To assess the nutritional value of meals at full-service national restaurant chains with outlets in the Philadelphia region in 2011. Chains were eligible if nutritional information for all menu items was on company Web pages or printed menus at Philadelphia outlets. Nutrient profiles were analyzed for 2,615 items from 21 eligible chains (out of 29) and compared with United States Department of Agriculture guidelines. Adult meals (entree, side dish, and one-half appetizer) approximated 1,495 kcal, 28 g saturated fat, 3,512 mg sodium, and 11 g fiber; and rose to 2,020 kcal after including a beverage and one-half dessert. Better calorie and fat profiles were observed for entrees tagged "healthy choice" or aimed at seniors or children; however, sodium far exceeded recommended limits. Foods served at full-service restaurant chains are high in calories, saturated fat, and sodium. Standard definitions are needed for "healthy choice" tags and for entrees targeted to vulnerable age groups.
  • Article
    Current approaches to addressing obesity have fallen short. This is largely due to the many environmental forces that undermine people’s self-regulatory capacity to be personally responsible for their food choices. Novel insights from the social sciences are needed to inform voluntary, health-promoting actions by companies, institutions, and citizens as well as the design of public health policies. Voluntary interventions that rely on nudges should complement traditional public health strategies such as taxation and restriction of child-targeted marketing in schools. In this commentary, we discuss four food policy issues that would benefit from consumer psychology research: (a) the restriction of food marketing to children, (b) provision of nutrition information through food labels, (c) improving school food environments, and (d) placing limits on portion sizes. Identifying effective solutions for obesity will require approaches that integrate psychological, public health, and legal perspectives and methods.
  • Article
    Provisions in the 2010 Affordable Care Act will require chain restaurants with 20 or more US locations to display calorie information on their menus, including drive-through menu boards. The US Food and Drug Administration released preliminary regulations in April 2011, and the long-delayed final regulations are expected soon, perhaps as early as summer 2014. The documented effects of menu labeling on consumer and restaurant industry behavior suggest that menu labeling will likely encourage some consumers to eat more healthfully some of the time, and the policy is likely an important first step toward improving the public’s eating habits.
  • Article
    Background Supply-side reductions to the calories in chain restaurants are a possible benefit of upcoming menu labeling requirements. Purpose To describe trends in calories available in large U.S. restaurants. Methods Data were obtained from the MenuStat project, a census of menu items in 66 of the 100 largest U.S. restaurant chains, for 2012 and 2013 (N=19,417 items). Generalized linear models were used to calculate (1) the mean change in calories from 2012 to 2013, among items on the menu in both years; and (2) the difference in mean calories, comparing newly introduced items to those on the menu in 2012 only (overall and between core versus non-core items). Data were analyzed in 2014. Results Mean calories among items on menus in both 2012 and 2013 did not change. Large restaurant chains in the U.S. have recently had overall declines in calories in newly introduced menu items (–56 calories, 12% decline). These declines were concentrated mainly in new main course items (–67 calories, 10% decline). New beverage (–26 calories, 8% decline) and children’s (–46 calories, 20% decline) items also had fewer mean calories. Among chain restaurants with a specific focus (e.g., burgers), average calories in new menu items not core to the business declined more than calories in core menu items. Conclusions Large chain restaurants significantly reduced the number of calories in newly introduced menu items. Supply-side changes to the calories in chain restaurants may have a significant impact on obesity prevention.
  • Article
    Understanding the psychology of how people make decisions can shed light on important factors contributing to the cause and maintenance of public health problems like obesity. This knowledge can and should inform the design of government and private-sector public health interventions. Several insights from psychology and behavioral economics that help explain why people are particularly vulnerable to the current food environment are discussed. These insights fall into the following categories: the influence of starting points (status quo bias and anchoring effects); communicating health information (simplicity and framing); and unintended consequences of policy interventions (compensation, substitution, and the peanuts effect). The paper discusses opportunities for improving the design of food policies and interventions by altering default options, providing the public with simple and meaningful nutrition information, carefully constructing the framing of public health messages, and designing food policies to minimize unintended consequences, such as compensation and substitution.
  • Article
    Full-text available
    In the United States (US), Medical Examiners and Coroners (ME/Cs) have the legal authority for the management of mass fatality incidents (MFI). Yet, preparedness and operational capabilities in this sector remain largely unknown. The purpose of this study was twofold; first, to identify appropriate measures of preparedness, and second, to assess preparedness levels and factors significantly associated with preparedness. Three separate checklists were developed to measure different aspects of preparedness: MFI Plan Elements, Operational Capabilities, and Pre-existing Resource Networks. Using a cross-sectional study design, data on these and other variables of interest were collected in 2014 from a national convenience sample of ME/C using an internet-based, anonymous survey. Preparedness levels were determined and compared across Federal Regions and in relation to the number of Presidential Disaster Declarations, also by Federal Region. Bivariate logistic and multivariable models estimated the associations between organizational characteristics and relative preparedness. A large proportion (42%) of respondents reported that less than 25 additional fatalities over a 48-hour period would exceed their response capacities. The preparedness constructs measured three related, yet distinct, aspects of preparedness, with scores highly variable and generally suboptimal. Median scores for the three preparedness measures also varied across Federal Regions and as compared to the number of Presidential Declared Disasters, also by Federal Region. Capacity was especially limited for activating missing persons call centers, launching public communications, especially via social media, and identifying temporary interment sites. The provision of staff training was the only factor studied that was significantly (positively) associated (p < .05) with all three preparedness measures. Although ME/Cs ranked local partners, such as Offices of Emergency Management, first responders, and funeral homes, as the most important sources of assistance, a sizeable proportion (72%) expected federal assistance. The three measures of MFI preparedness allowed for a broad and comprehensive assessment of preparedness. In the future, these measures can serve as useful benchmarks or criteria for assessing ME/Cs preparedness. The study findings suggest multiple opportunities for improvement, including the development and implementation of national strategies to ensure uniform standards for MFI management across all jurisdictions.
  • Article
    Full-text available
    Mark Moore works as a restaurant manager and has recently earned a Master’s Degree in Hospitality Management. In recent months he has started to show varying levels of job burnout and has been finding it increasingly difficult to recover as the episodes of burnout are becoming more frequent. Mark feels that he excels in his job; he is also very good at hiding his feelings. However, under the surface, he knows that he needs to make some radical changes. In light of his extensive experience, advanced job skills and his education, Mark feels that job offers should be pouring in yet he has not made it past the first level interviews for any of the positions he has applied for. This case study aims to generate discussions on Mark’s situation as well as other managers in similar situations with a view to develop solutions to help the ‘working wounded’ who are suffering from burnout in the hospitality industry. These solutions may include a personal plan for Mark; some strategies that will help him overcome burnout, and what his immediate supervisors and his organization should do to assist him in this situation.
  • Article
    Many restaurants are increasingly required to display calorie information on their menus. We present a study examining how consumers' food choices are affected by the presence of calorie information on restaurant menus. However, unlike prior research on this topic, we focus on the effect of calorie information on food choices made from a menu that contains both full size portions and half size portions of entrées. This different focus is important because many restaurants increasingly provide more than one portion size option per entrée. Additionally, we examine whether the impact of calorie information differs depending on whether full portions are cheaper per unit than half portions (non-linear pricing) or whether they have a similar per unit price (linear pricing). We find that when linear pricing is used, calorie information leads people to order fewer calories. This decrease occurs as people switch from unhealthy full sized portions to healthy full sized portions, not to unhealthy half sized portions. In contrast, when non-linear pricing is used, calorie information has no impact on calories selected. Considering the impact of calorie information on consumers' choices from menus with more than one entrée portion size option is increasingly important given restaurant and legislative trends, and the present research demonstrates that calorie information and pricing scheme may interact to affect choices from such menus.
  • Article
    Large changes to food retail settings are required to improve population diet. However, limited research has comprehensively considered the business implications of healthy food retail strategies for food retailers. We performed a systematic scoping review to identify types of business outcomes that have been reported in healthy food retail strategy evaluations. Peer‐reviewed and grey literature were searched. We identified qualitative or quantitative real‐world food or beverage retail strategies designed to improve the healthiness of the consumer nutrition environment (eg, changes to the “marketing mix” of product, price, promotion, and/or placement). Eligible studies reported store‐ or chain‐level outcomes for measures of commercial viability, retailer perspectives, customer perspectives, and/or community outcomes. 11 682 titles and abstracts were screened with 107 studies included for review from 15 countries. Overall item sales, revenue, store patronage, and customer level of satisfaction with strategy were the most frequently examined outcomes. There was a large heterogeneity in outcome measures reported and in favourability for retailers of outcomes across studies. We recommend more consistent reporting of business outcomes and increased development and use of validated and reliable measurement tools. This may help generate more robust research evidence to aid retailers and policymakers to select feasible and sustainable healthy food retail strategies to benefit population health within and across countries.
  • Article
    Background: Restaurant foods have been shown to be high in sodium and limited sodium content information provided through menu nutrition information (MNI) is available at the point of purchase. Dining out and use of MNI are behaviors that can be altered by consumers who are trying to decrease their sodium intake. Objective: The aim of this study was to determine the relationship between reported consumer actions to decrease sodium intake and dining out frequency and awareness and use/or intended use of MNI. Design/participants: A secondary analysis was conducted using responses from 5,588 US adults aged 20 years or older who participated in the 2013-2014 cross-sectional National Health and Nutrition Examination Survey household interview. Main outcome measures: The main outcomes were dining out frequency and seeing MNI, using MNI if seen, or would use MNI if provided. Statistical analyses performed: Linear and logistic regression models were used to assess the relationship of consumers reporting and not reporting action to decrease sodium intake and the outcome measures. Results: Reported consumer action to decrease sodium intake compared to no action was associated with an overall decreased dining out frequency of approximately one meal per week (mean±standard error=3.12±0.10 compared to 4.11±0.14; P<0.01). When separated by type of restaurant, the relationship was significant for fast-food or pizza establishments (mean±standard error=1.35±0.05 meals compared to 2.00±0.07 meals; P<0.001), but not other types of foodservice operations. The odds of seeing MNI, using MNI when seen, or would use MNI if provided were higher for consumers reporting actions to decrease their sodium intake compared to those who were not for both fast-food or pizza establishments and restaurants with wait staff (odds ratio ranged from 1.17 [95% CI 1.04 to 1.32] to 2.24 [95% CI 1.82 to 2.76]; P values ranged from <0.05 to <0.001). Conclusions: Compared to consumers reporting no actions to decrease sodium intake, consumers reporting actions indicate they dine out less frequently, specifically at fast-food or pizza restaurants and report they are more likely to use MNI. These results may inform the restaurant industry of the actions of a potentially growing consumer group and provide insights for future public health initiatives targeting population sodium reduction.
  • Article
    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.
  • Chapter
    Advances in agri-food productivity coupled with improvements in food distribution systems globally have increased food production and facilitated food distribution. Despite these gains, food insecurity (having sufficient amounts of food in a reliable manner) and nutrition security (access to all essential nutrients required to maintain health) continue to exist. The discovery of vitamins in the early 1900’s and commercial production to enrich and fortify foods has helped prevent vitamin deficiency diseases. Despite the millions of lives which have been saved by enrichment/fortification, significant proportions of the world population are still underconsuming vitamins A, C, D, E, folate, calcium, iron, magnesium, fiber and potassium. At present, human nutrition policy is being buffeted by discourse over the optimal balance of macronutrients (amount and type of fat, carbohydrate and protein) and the types of foods which should be consumed (natural, organic, enriched/fortified, etc.). As populations shift from rural to urban areas, fewer people will produce food or live in close proximity to farmers who grow crops or raise livestock. In essence, an increasing proportion of a growing population will depend upon a robust, global food system. Food fortification is an efficient, cost-effective means to fill micronutrient gaps; the same can be said for dietary supplementation. As people make dietary choices based on convenience, taste, cost, cultural and personal values, it is important to assess nutritional status objectively. Dietary intake records are not an accurate measure of nutrient exposure. Micronutrient status needs to be assessed by measuring concentrations in biological samples and applying criterion of adequacy, i.e. serum 25(OH)D3 concentration needed to maintain bone health, to guide individual practice and nutrition policy. Using objective biological measures of nutritional status, individuals and communities at greatest risk of nutrient insufficiency (or excess) can be identified and appropriate education and/or regulatory actions can be implemented. By adopting technological innovations in nutritional status assessment, agricultural production, processing, and distribution, consumers can be provided with a variety of products meeting their nutritional needs and personal values.
  • Article
    The goal of this study was to analyze the effect of local and state mandatory restaurant menu labeling laws on alcohol use. Using a difference-in-differences estimation approach and data on adults aged 21 and older (n = 2,157,722) from the 2002–2012 Behavioral Risk Factor Surveillance System, we estimated the effect of menu labeling laws on self-reported consumption of alcoholic beverages in the past month. The regression analysis indicates that on average implementation of menu labeling laws is associated with a 1.2 percentage-point drop in the fraction of survey respondents reporting that they drank an alcoholic beverage in the past month (95% confidence interval = − 0.020, − 0.004), compared with jurisdictions that had not implemented menu labeling laws. Moreover, we find that the estimated policy effects on alcohol use are larger among men than among women and larger among minorities than among non-Hispanic whites. Further provision of calorie information on foods and beverages in food service establishments, such as through federal menu labeling regulations, may have the potential to lead to a meaningful reduction in alcohol use throughout the U.S. and may result in larger reductions in alcohol use among men and minorities.
  • Article
    To follow up on a previous study that examined how the mandated displaying of calorie information on menu boards in fast-food restaurants in New York City influenced consumers' behavior, we analyzed itemized cash register receipts and survey responses from 7,699 consumers at four fast-food chains. Using a difference-in-differences study design, we found that consumers exposed to menu labeling immediately after the mandate took effect in 2008 and at three points in 2013-14 reported seeing and using the information more often than their counterparts at fast-food restaurants without menu labeling. In each successive period of data collection, the percentage of respondents noticing and using the information declined, while remaining above the prelabeling baseline. There were no statistically significant changes over time in levels of calories or other nutrients purchased or in the frequency of visits to fast-food restaurants. Menu labeling at fast-food chain restaurants, which the Affordable Care Act requires to be implemented nationwide in 2016, remains an unproven strategy for improving the nutritional quality of consumer food choices at the population level. Additional policy efforts that go beyond labeling and possibly alter labeling to increase its impact must be considered. © 2015 Project HOPE-The People-to-People Health Foundation, Inc.
  • Article
    Restaurant foods are typically higher in calories than meals consumed at home. A goal of the 2010 Patient Protection and Affordable Care Act is to encourage healthier food choices at restaurants by providing consumers with information about the calorie content of menu items. However, doesn't a well-informed consumer already know that a 12-piece bucket of chicken has more calories than a salad? Following research in marketing science and behavioral economics, we evaluate a representative consumer's ability to discriminate between low-calorie and high-calorie menu items using only some basic “rules of thumb” nutrition knowledge. Results reveal the extent to which menu labeling may increase consumers' knowledge about the calories in restaurant foods.
  • Behavioral Risk Factor Surveillance System survey questionnaire
    • Cdc
    CDC. Behavioral Risk Factor Surveillance System survey questionnaire. Atlanta GA: DHHS, CDC, 2010.
  • Use of the Danish adoption register for the study of obesity and thinness Genetics of neurological and psychi-atric disorders
    • Aj Stunkard
    • T Sorensen
    • Schulsinger
    • Kety
    • Rowland Lp Ss
    • Sidman Rl
    • Matthysse
    • Sw
    Stunkard AJ, Sorensen T, Schulsinger F. Use of the Danish adoption register for the study of obesity and thinness.. In: Kety SS, Rowland LP, Sidman RL, Matthysse SW, eds. Genetics of neurological and psychi-atric disorders. New York: Raven Press, 1983:115–20.
  • An analysis of a sit-down chain restaurant menu and its customers: how " healthy " are menu items and what are customers purchasing
    • S Bellitz
    Bellitz S. An analysis of a sit-down chain restaurant menu and its customers: how " healthy " are menu items and what are customers purchasing? Philadelphia PA: Drexel University, 2012.
  • S. independent restaurants account for 87 percent of industry traffic losses since 2008
    • U Npd Group
    NPD Group. U.S. independent restaurants account for 87 percent of industry traffic losses since 2008. Port Washington NY: NPD Group, 2012.
  • Top 500 chain restaurant report, full-service chain share by menu category (Appendix E) and glossary of terms
    • Technomic
    Technomic. Top 500 chain restaurant report, full-service chain share by menu category (Appendix E) and glossary of terms. Technomic, Inc., 2011.
  • Consumers' use of nutri-tional labels: a review of research studies and issues
    • Lazaridis P Nayga
    • Jr
    Drichoutis AC, Lazaridis P, Nayga RM Jr. Consumers' use of nutri-tional labels: a review of research studies and issues. Acad Market Sci Rev 2006;9:1–22.
  • Article
    A number of studies, including the Danish adoption study, have shown that, in adults, the familial resemblance of obesity, as measured by the body mass index (weight in kg/(height in m)2), is mainly due to genes. The body mass index may reflect both fat and fat-free body mass. In this further analysis of the Danish adoption study, the degree of obesity was assessed by a silhouette score. There was a significant relationship in scores between the adult adoptees and their biological mothers and between the adoptees and their biological full siblings reared by the biological parents. Weaker, nonsignificant associations were found for the biological fathers and for the maternal and paternal half-siblings. There were no relationships in silhouette scoring between adoptees and adoptive parents. The results confirm the results of our previous analysis of body mass index. We conclude that human obesity is under genetic control, whereas the childhood family environment has little, if any, influence on obesity in adults. It is an important task for future research to identify the genes involved.
  • Conference Paper
    Full-text available
    Propensity score analysis is frequently used to reduce the potential bias in estimated effects obtained from observational studies. Appropriate implementation of propensity score adjustments is a multi-step process presenting many alternatives for researchers in terms of estimation and conditioning methods. Further, evaluation of the sample data after conditioning on the propensity score informs researchers about threats to the validity of the adjustments obtained from such an analysis. This paper describes the steps required for a propensity score analysis, and presents SAS code that can be used to implement each step.
  • Article
    To assess the nutritional value of meals at full-service national restaurant chains with outlets in the Philadelphia region in 2011. Chains were eligible if nutritional information for all menu items was on company Web pages or printed menus at Philadelphia outlets. Nutrient profiles were analyzed for 2,615 items from 21 eligible chains (out of 29) and compared with United States Department of Agriculture guidelines. Adult meals (entree, side dish, and one-half appetizer) approximated 1,495 kcal, 28 g saturated fat, 3,512 mg sodium, and 11 g fiber; and rose to 2,020 kcal after including a beverage and one-half dessert. Better calorie and fat profiles were observed for entrees tagged "healthy choice" or aimed at seniors or children; however, sodium far exceeded recommended limits. Foods served at full-service restaurant chains are high in calories, saturated fat, and sodium. Standard definitions are needed for "healthy choice" tags and for entrees targeted to vulnerable age groups.
  • Article
    BACKGROUND: The federal menu labeling law will require chain restaurants to post caloric information on menus, but the impact of labeling is uncertain. PURPOSE: The goal of the current study was to examine the effect of menu labeling on calories purchased, and secondarily, to assess self-reported awareness and use of labels. DESIGN: Single-community pre-post-post cross-sectional study. Data were collected in 2008-2010 and analyzed in 2011-2012. SETTING/PARTICIPANTS: 50 sites from 10 chain restaurants in King County, Washington, selected through stratified, two-stage cluster random sampling. A total of 7325 customers participated. Eligibility criteria were: being an English speaker, aged≥14 years, and having an itemized receipt. The study population was 59% male, 76% white non-Hispanic, and 53% aged<40 years. INTERVENTION: A regulation requiring chain restaurants to post calorie information on menus or menu boards was implemented. MAIN OUTCOME MEASURES: Mean number of calories purchased. RESULTS: No significant changes occurred between baseline and 4-6 months postregulation. Mean calories per purchase decreased from 908.5 to 870.4 at 18 months post-implementation (38 kcal, 95% CI=-76.9, 0.8, p=0.06) in food chains and from 154.3 to 132.1 (22 kcal, 95% CI=-35.8, -8.5, p=0.002) in coffee chains. Calories decreased in taco and coffee chains, but not in burger and sandwich establishments. They decreased more among women than men in coffee chains. Awareness of labels increased from 18.8% to 61.7% in food chains and from 4.4% to 30.0% in coffee chains (both p<0.001). Among customers seeing calorie information, the proportion using it (about one third) did not change substantially over time. After implementation, food chain customers using information purchased on average fewer calories compared to those seeing but not using (difference=143.2 kcal, p<0.001) and those not seeing (difference=135.5 kcal, p<0.001) such information. CONCLUSIONS: Mean calories per purchase decreased 18 months after implementation of menu labeling in some restaurant chains and among women but not men.
  • Article
    Full-text available
    Objective: Numerous localities have mandated that chain restaurants post nutrition information at the point of purchase. However, some studies suggest that consumers are not highly responsive to menu labelling. The present qualitative study explored influences on full-service restaurant customers’ noticing and using menu labelling. Design: Five focus groups were conducted with thirty-six consumers. A semi-structured script elicited barriers and facilitators to using nutrition information by showing excerpts of real menus from full-service chain restaurants. Setting: Participants were recruited from a full-service restaurant chain in Philadelphia, Pennsylvania, USA, in September 2011. Subjects: Focus group participants were mostly female, African American, with incomes <$US 60 000, mean age 36 years and education 14·5 years. At recruitment, 33 % (n 12) reported changing their order after seeing nutrition information on the menu. Results: Three themes characterized influences on label use in restaurants: nutrition knowledge, menu design and display, and normative attitudes and behaviours. Barriers to using labels were low prior knowledge of nutrition; displaying nutrition information using codes; low expectations of the nutritional quality of restaurant food; and restaurant discounts, promotions and social influences that overwhelmed interest in nutrition and reinforced disinterest in nutrition. Facilitators were higher prior knowledge of recommended daily intake; spending time reading the menu; having strong prior interest in nutrition/healthy eating; and being with people who reinforced dietary priorities. Conclusions: Menu labelling use may increase if consumers learn a few key recommended dietary reference values, understand basic energy intake/expenditure scenarios and if chain restaurants present nutrition information in a user-friendly way and promote healthier items.
  • Article
    Full-text available
    Objective: The U.S. Food and Drug Administration and Institute of Medicine are currently investigating front-of-package (FOP) food labelling systems to provide science-based guidance to the food industry. The present paper reviews the literature on FOP labelling and supermarket shelf-labelling systems published or under review by February 2011 to inform current investigations and identify areas of future research. Design: A structured search was undertaken of research studies on consumer use, understanding of, preference for, perception of and behaviours relating to FOP/shelf labelling published between January 2004 and February 2011. Results: Twenty-eight studies from a structured search met inclusion criteria. Reviewed studies examined consumer preferences, understanding and use of different labelling systems as well as label impact on purchasing patterns and industry product reformulation. Conclusions: The findings indicate that the Multiple Traffic Light system has most consistently helped consumers identify healthier products; however, additional research on different labelling systems' abilities to influence consumer behaviour is needed.
  • Article
    Full-text available
    Nutrition labels are one strategy being used to combat the increasing prevalence of overweight and obesity in the United States. The Patient Protection and Affordable Care Act of 2010 mandates that calorie labels be added to menu boards of chain restaurants with 20 or more locations. This systematic review includes seven studies published since the last review on the topic in 2008. Authors searched for peer-reviewed studies using PUBMED and Google Scholar. Included studies used an experimental or quasi-experimental design comparing a calorie-labeled menu with a no-calorie menu and were conducted in laboratories, college cafeterias, and fast food restaurants. Two of the included studies were judged to be of good quality, and five of were judged to be of fair quality. Observational studies conducted in cities after implementation of calorie labeling were imprecise in their measure of the isolated effects of calorie labels. Experimental studies conducted in laboratory settings were difficult to generalize to real world behavior. Only two of the seven studies reported a statistically significant reduction in calories purchased among consumers using calorie-labeled menus. The current evidence suggests that calorie labeling does not have the intended effect of decreasing calorie purchasing or consumption.
  • Article
    Rising prevalence of obesity is a worldwide health concern because excess weight gain within populations forecasts an increased burden from several diseases, most notably cardiovascular diseases, diabetes, and cancers. In this report, we used a simulation model to project the probable health and economic consequences in the next two decades from a continued rise in obesity in two ageing populations--the USA and the UK. These trends project 65 million more obese adults in the USA and 11 million more obese adults in the UK by 2030, consequently accruing an additional 6-8·5 million cases of diabetes, 5·7-7·3 million cases of heart disease and stroke, 492,000-669,000 additional cases of cancer, and 26-55 million quality-adjusted life years forgone for USA and UK combined. The combined medical costs associated with treatment of these preventable diseases are estimated to increase by $48-66 billion/year in the USA and by £1·9-2 billion/year in the UK by 2030. Hence, effective policies to promote healthier weight also have economic benefits.
  • Article
    Full-text available
    The propensity score is the probability of treatment assignment conditional on observed baseline characteristics. The propensity score allows one to design and analyze an observational (nonrandomized) study so that it mimics some of the particular characteristics of a randomized controlled trial. In particular, the propensity score is a balancing score: conditional on the propensity score, the distribution of observed baseline covariates will be similar between treated and untreated subjects. I describe 4 different propensity score methods: matching on the propensity score, stratification on the propensity score, inverse probability of treatment weighting using the propensity score, and covariate adjustment using the propensity score. I describe balance diagnostics for examining whether the propensity score model has been adequately specified. Furthermore, I discuss differences between regression-based methods and propensity score-based methods for the analysis of observational data. I describe different causal average treatment effects and their relationship with propensity score analyses.
  • Article
    Full-text available
    To assess the impact of fast food restaurants adding calorie labelling to menu items on the energy content of individual purchases. Cross sectional surveys in spring 2007 and spring 2009 (one year before and nine months after full implementation of regulation requiring chain restaurants' menus to contain details of the energy content of all menu items). Setting 168 randomly selected locations of the top 11 fast food chains in New York City during lunchtime hours. 7309 adult customers interviewed in 2007 and 8489 in 2009. Energy content of individual purchases, based on customers' register receipts and on calorie information provided for all items in menus. For the full sample, mean calories purchased did not change from before to after regulation (828 v 846 kcal, P = 0.22), though a modest decrease was shown in a regression model adjusted for restaurant chain, poverty level for the store location, sex of customers, type of purchase, and inflation adjusted cost (847 v 827 kcal, P = 0.01). Three major chains, which accounted for 42% of customers surveyed, showed significant reductions in mean energy per purchase (McDonald's 829 v 785 kcal, P = 0.02; Au Bon Pain 555 v 475 kcal, P<0.001; KFC 927 v 868 kcal, P<0.01), while mean energy content increased for one chain (Subway 749 v 882 kcal, P<0.001). In the 2009 survey, 15% (1288/8489) of customers reported using the calorie information, and these customers purchased 106 fewer kilocalories than customers who did not see or use the calorie information (757 v 863 kcal, P<0.001). Although no overall decline in calories purchased was observed for the full sample, several major chains saw significant reductions. After regulation, one in six lunchtime customers used the calorie information provided, and these customers made lower calorie choices.
  • Article
    Recently, localities across the United States have passed laws requiring the mandatory labeling of calories in all chain restaurants, including fast food restaurants. This policy is set to be implemented at the federal level. Early studies have found these policies to be at best minimally effective in altering food choice at a population level. This paper uses receipt and survey data collected from consumers outside fast food restaurants in low-income communities in New York City (NYC) (which implemented labeling) and a comparison community (which did not) to examine two fundamental assumptions necessary (though not sufficient) for calorie labeling to be effective: that consumers know how many calories they should be eating throughout the course of a day and that currently customers improperly estimate the number of calories in their fast food order. Then, we examine whether mandatory menu labeling influences either of these assumptions. We find that approximately one-third of consumers properly estimate that the number of calories an adult should consume daily. Few (8% on average) believe adults should be eating over 2,500 calories daily, and approximately one-third believe adults should eat lesser than 1,500 calories daily. Mandatory labeling in NYC did not change these findings. However, labeling did increase the number of low-income consumers who correctly estimated (within 100 calories) the number of calories in their fast food meal, from 15% before labeling in NYC increasing to 24% after labeling. Overall knowledge remains low even with labeling. Additional public policies likely need to be considered to influence obesity on a large scale.
  • Article
    Full-text available
    To validate a culturally relevant body image instrument among urban African Americans through three distinct studies. In Study 1, 38 medical practitioners performed content validity tests on the instrument. In Study 2, three research staff rated the body image of 283 African-American public housing residents (75% women, mean age = 44 years), with the residents completing body image, BMI, and percentage body fat measures. In Study 3, 35 African Americans (57% men, mean age = 42) completed body image measures and evaluated their cultural relevance. In Study 1, 97% to 100% of practitioners sorted the jumbled figures into the correct ascending order. The correlation between the body image figures and the practitioners' weight classifications of the figures was high (r = 0.91). In Study 2, observers arrived at similar ratings of body size with excellent consistency (alpha = 0.95). Ratings of body image were strongly correlated with participant BMI (r = 0.89 to 0.93 across observers and 0.81 for all participants) and percentage of body fat (r = 0.77 to 0.89 across observers and 0.76 for all participants). In Study 3, body image ratings with the new scale were positively correlated with other validated figural scales. The majority of participants reported that figures in the new body image scale looked most like themselves and other African Americans and were easiest to identify themselves with. The instrument displayed strong psychometric performance and cultural relevance, suggesting that the scale is a promising tool for examining body image and obesity among African Americans.
  • Article
    The U.S. Department of Agriculture developed Dietary Guidelines for Americans, 2010, by taking into consideration evidence-based nutritional science, changes in the food supply and environmental influences. The 2010 guidelines emphasize the importance of maintaining caloric balance to support a healthy weight and selecting nutrient-dense foods and beverages to ensure adequate nutrient intakes. Americans' compliance with previous dietary guidelines has been poor, and the 2010 guidelines acknowledge the need for collaboration among individuals, the community, government and industry to ensure consumers' access to and acceptance of appropriate foods. As part of the greater community, the oral health practitioner will find that familiarity with the 2010 guidelines will enable him or her to assist patients in making better food choices for oral and systemic health.
  • Article
    To review research on consumer use and understanding of nutrition labels, as well as the impact of labelling on dietary habits. A systematic review was conducted by searching electronic databases. Relevant articles were screened by two reviewers and included if they met inclusion criteria, including eight methodological criteria. A total of 120 articles were included in the review, including cross-sectional surveys (n 96), experimental designs (n 17), 'natural experiments' (n 7) and longitudinal population-based surveys (n 2). Articles covered seven jurisdictions: USA (n 88), Europe (n 12), Canada (n 9), Australia and New Zealand (n 4), Norway (n 2), Thailand (n 1) and Trinidad (n 1). Participants were from a wide range of age groups, socio-economic strata and geographical regions. Nutrition labels on pre-packaged foods are among the most prominent sources of nutrition information. Nutrition labels are perceived as a highly credible source of information and many consumers use nutrition labels to guide their selection of food products. Evidence also shows a consistent link between the use of nutrition labels and healthier diets. However, the use of labels varies considerably across subgroups, with lower use among children, adolescents and older adults who are obese. Research also highlights challenges in terms of consumer understanding and appropriate use of labelling information. Nutrition labels on pre-packaged foods are a cost-effective population-level intervention with unparalleled reach. However, to capitalize on their potential, governments will need to explore new formats and different types of information content to ensure that nutrition information is accessible and understandable.
  • Article
    As part of a comprehensive effort to stem the rise in obesity, King County, Washington, enforced a mandatory menu-labeling regulation requiring all restaurant chains with 15 or more locations to disclose calorie information at the point of purchase beginning in January 2009. The purpose of this study is to quantify the impact of the King County regulation on transactions and purchasing behavior at one Mexican fast-food chain with locations within and adjacent to King County. To examine the effect of the King County regulation, a difference-in-difference approach was used to compare total transactions and average calories per transaction between seven King County restaurants and seven control locations focusing on two time periods: one period immediately following the law until the posting of drive-through menu boards (January 2009 to July 2009) and a second period following the drive-through postings (August 2009 through January 2010). Analyses were conducted in 2010. No impact of the regulation on purchasing behavior was found. Trends in transactions and calories per transaction did not vary between control and intervention locations after the law was enacted. In this setting, mandatory menu labeling did not promote healthier food-purchasing behavior.
  • Article
    This paper evaluates a pilot program run by a company called OPOWER, previously known as Positive Energy, to mail home energy reports to residential utility consumers. The reports compare a household’s energy use to that of its neighbors and provide energy conservation tips. Using data from randomized natural field experiment at 80,000 treatment and control households in Minnesota, I estimate that the monthly program reduces energy consumption by 1.9 to 2.0 percent relative to baseline. In a treatment arm receiving reports each quarter, the effects decay in the months between letters and again increase upon receipt of the next letter. This suggests either that the energy conservation information is not useful across seasons or, perhaps more interestingly, that consumers’ motivation or attention is malleable and non-durable. I show that “profiling,” or using a statistical decision rule to target the program at households whose observable characteristics suggest larger treatment effects, could substantially improve cost effectiveness in future programs. The effects of this program provide additional evidence that non-price “nudges” can substantially affect consumer behavior.
  • Article
    Full-text available
    Excessive consumption of dietary sodium is an important public health issue. Little is known about the knowledge, attitudes and behaviours related to sodium consumption among Canadians. To examine knowledge, attitudes and behaviours related to sodium consumption among a sample of Canadians 35 to 50 years of age. A random-digit-dial telephone survey was conducted among adults aged 35 to 50 years of age in two regions in Ontario. Logistic regression was used to examine the likelihood of having taken action in the past 30 days to reduce sodium consumption, and the likelihood that respondents were intending to reduce sodium in the next six months. A total of 3130 interviews were completed. The majority of respondents were aware of excessive sodium consumption as a health issue and reported that they were taking action to reduce their dietary sodium intake. A large proportion of respondents did not correctly identify many foods as being high in sodium and, consequently, may have incorrectly believed they were consuming healthy amounts of sodium. Respondents who believed sodium reduction was important were more likely to have taken action to reduce sodium within the previous 30 days. Respondents who self-identified as consuming too much sodium were less likely to have taken action. The findings of the present study suggest that in addition to policy changes designed to reduce the sodium content of foods, there is a need to address the low levels of knowledge surrounding sources of excessive sodium in popular Canadian foods, the importance of a reduced intake of sodium and the availability of lower-sodium alternatives.
  • Article
    We assessed whether labeling restaurant menus with information on the nutrient content of menu items would cause customers to alter their ordering patterns. Six full-service restaurants in Pierce County, Washington, added nutrition information to their menus, and they provided data on entrée sales for 30 days before and 30 days after the information was added. We assessed the prelabeling versus postlabeling difference in nutrient content of entrées sold, and we surveyed restaurant patrons about whether they noticed the nutrition information and used it in their ordering. The average postlabeling entrée sold contained about 15 fewer calories, 1.5 fewer grams of fat, and 45 fewer milligrams of sodium than did the average entrée sold before labeling. Seventy-one percent of patrons reported noticing the nutrition information; 20.4% reported ordering an entrée lower in calories as a result, and 16.5% reported ordering an entrée lower in fat as a result. The concentration of calorie reduction among 20.4% of patrons means that each calorie-reducing patron ordered about 75 fewer calories than they did before labeling. Thus, providing nutrition information on restaurant menus may encourage a subset of restaurant patrons to significantly alter their food choices.
  • Article
    We assessed the impact of restaurant menu calorie labels on food choices and intake. Participants in a study dinner (n=303) were randomly assigned to either (1) a menu without calorie labels (no calorie labels), (2) a menu with calorie labels (calorie labels), or (3) a menu with calorie labels and a label stating the recommended daily caloric intake for an average adult (calorie labels plus information). Food choices and intake during and after the study dinner were measured. Participants in both calorie label conditions ordered fewer calories than those in the no calorie labels condition. When calorie label conditions were combined, that group consumed 14% fewer calories than the no calorie labels group. Individuals in the calorie labels condition consumed more calories after the study dinner than those in both other conditions. When calories consumed during and after the study dinner were combined, participants in the calorie labels plus information group consumed an average of 250 fewer calories than those in the other groups. Calorie labels on restaurant menus impacted food choices and intake; adding a recommended daily caloric requirement label increased this effect, suggesting menu label legislation should require such a label. Future research should evaluate menu labeling's impact on children's food choices and consumption.
  • Article
    Full-text available
    We examined the influence of menu calorie labels on fast food choices in the wake of New York City's labeling mandate. Receipts and survey responses were collected from 1,156 adults at fast-food restaurants in low-income, minority New York communities. These were compared to a sample in Newark, New Jersey, a city that had not introduced menu labeling. We found that 27.7 percent who saw calorie labeling in New York said the information influenced their choices. However, we did not detect a change in calories purchased after the introduction of calorie labeling. We encourage more research on menu labeling and greater attention to evaluating and implementing other obesity-related policies.
  • Article
    Full-text available
    In 2006, New York City's Health Department amended the city Health Code to require the posting of calorie counts by chain restaurants on menus, menu boards, and item tags. This was one element of the city's response to rising obesity rates. Drafting the rule involved many decisions that affected its impact and its legal viability. The restaurant industry argued against the rule and twice sued to prevent its implementation. An initial version of the rule was found to be preempted by federal law, but a revised version was implemented in January 2008. The experience shows that state and local health departments can use their existing authority over restaurants to combat obesity and, indirectly, chronic diseases.
  • Article
    A convenience sample of adolescents and adults who regularly eat at fast-food restaurants were recruited to participate in an experimental trial to examine the effect of nutrition labeling on meal choices. As part of this study, participants were asked to indicate how strongly they agreed or disagreed with 11 statements to assess reasons for eating at fast-food restaurants. Logistic regression was conducted to examine whether responses differed by demographic factors. The most frequently reported reasons for eating at fast-food restaurants were: fast food is quick (92%), restaurants are easy to get to (80%), and food tastes good (69%). The least frequently reported reasons were: eating fast food is a way of socializing with family and friends (33%), restaurants have nutritious foods to offer (21%), and restaurants are fun and entertaining (12%). Some differences were found with respect to the demographic factors examined. It appears that in order to reduce fast-food consumption, food and nutrition professionals need to identify alternative quick and convenient food sources. As motivation for eating at fast-food restaurants appears to differ somewhat by age, sex, education, employment status, and household size, tailored interventions could be considered.
  • Article
    Full-text available
    Eating away from home has increased in prevalence among US adults and now comprises about 50% of food expenditures. Calorie labeling on chain restaurant menus is one specific policy that has been proposed to help consumers make better food choices at restaurants. The present review evaluates the available empirical literature on the effects of calorie information on food choices in restaurant and cafeteria settings. Computer-assisted searches were conducted using the PUBMED database and the Google Scholar world wide web search engine to identify studies published in peer-review journals that evaluated calorie labeling of cafeteria or restaurant menu items. Studies that evaluated labeling only some menu items (e.g. low calorie foods only) were excluded from the review since the influence of selective labeling may be different from that which may be expected from comprehensive labeling. Six studies were identified that met the selection criteria for this review. Results from five of these studies provide some evidence consistent with the hypothesis that calorie information may influence food choices in a cafeteria or restaurant setting. However, results from most of these studies suggest the effect may be weak or inconsistent. One study found no evidence of an effect of calorie labeling on food choices. Each of the studies had at least one major methodological shortcoming, pointing toward the need for better designed studies to more rigorously evaluate the influence of point-of-purchase calorie labeling on food choices. More research is needed that meets minimum standards of methodological quality. Studies need to include behavioral outcomes such as food purchase and eating behaviors. Also, studies need to be implemented in realistic settings such as restaurants and cafeterias.
  • A number of studies, including the Danish adoption study, have shown that, in adults, the familial resemblance of obesity, as measured by the body mass index (weight in kg/(height in m)2), is mainly due to genes. The body mass index may reflect both fat and fat-free body mass. In this further analysis of the Danish adoption study, the degree of obesity was assessed by a silhouette score. There was a significant relationship in scores between the adult adoptees and their biological mothers and between the adoptees and their biological full siblings reared by the biological parents. Weaker, nonsignificant associations were found for the biological fathers and for the maternal and paternal half-siblings. There were no relationships in silhouette scoring between adoptees and adoptive parents. The results confirm the results of our previous analysis of body mass index. We conclude that human obesity is under genetic control, whereas the childhood family environment has little, if any, influence on obesity in adults. It is an important task for future research to identify the genes involved.
  • Article
    Despite widely held beliefs about increasing popularity of eating away-from-home and its possible contribution to increasing adiposity of the US population, there are little published data on this topic. To address this issue, we examined trends in frequency of consumption of commercially prepared (CP) meals reported by Americans aged > or =18 years, and its nutritional correlates. The data were from the National Health Interview Survey (NHIS) 1987 (n = 21,731), NHIS 1992 (n = 11,718), and the National Health and Nutrition Examination Survey (NHANES) 1999-2000 (n = 5,330). The information on CP meal consumption was obtained from questions included in the three surveys. The independent association of reported CP meal frequency with body mass index (BMI), and intakes of energy and macronutrients was examined using multiple linear regression methods. The mean reported number of CP meals per week was 2.5 in 1987 and 1992, and 2.8 in 1999-2000. In 1987, approximately 28% of the population reported 0 or <1 commercially prepared meal per week, decreasing to 24% in 1999-2000 (P for trend <0.0001). However, the proportion of the population reporting three or more weekly CP meals increased from 36% in 1987 to 41% in 1999-2000 (P for trend < or =0.0005). The odds of eating out at least one or more and three or more meals per week were 40% higher (95% CI 1.20-1.70) in 1999-2000 relative to 1987. The reported number of CP meals per week was positively associated with estimates of energy intake (P < or = 0.0001) in each survey. Self-reported and measured BMI were modestly associated with the reported number of weekly CP meals in women in 1999-2000 (P < or = 0.05). Our results confirm that in 1999-2000, more Americans ate out, and ate out more frequently than in 1987 and 1992. Higher eating-out frequency was associated with adverse nutritional consequences.
  • Article
    Full-text available
    Using self-refilling soup bowls, this study examined whether visual cues related to portion size can influence intake volume without altering either estimated intake or satiation. Fifty-four participants (BMI, 17.3 to 36.0 kg/m2; 18 to 46 years of age) were recruited to participate in a study involving soup. The experiment was a between-subject design with two visibility levels: 1) an accurate visual cue of a food portion (normal bowl) vs. 2) a biased visual cue (self-refilling bowl). The soup apparatus was housed in a modified restaurant-style table in which two of four bowls slowly and imperceptibly refilled as their contents were consumed. Outcomes included intake volume, intake estimation, consumption monitoring, and satiety. Participants who were unknowingly eating from self-refilling bowls ate more soup [14.7+/-8.4 vs. 8.5+/-6.1 oz; F(1,52)=8.99; p<0.01] than those eating from normal soup bowls. However, despite consuming 73% more, they did not believe they had consumed more, nor did they perceive themselves as more sated than those eating from normal bowls. This was unaffected by BMI. These findings are consistent with the notion that the amount of food on a plate or bowl increases intake because it influences consumption norms and expectations and it lessens one's reliance on self-monitoring. It seems that people use their eyes to count calories and not their stomachs. The importance of having salient, accurate visual cues can play an important role in the prevention of unintentional overeating.
  • Article
    To examine the temporal pattern of the number of eating occasions that occurred at home, at work and outside the home, and to examine the contribution of fat to energy and the contribution of 26 food groups to fat at home and outside the home. Food intake data were collected using a 7-day food diary from a random sample of 18-64-year-old adults from the Republic of Ireland (n=958). Respondents recorded the day, time and location of every eating occasion. The number of eating occasions was constant across the days of the week for meals consumed at home, whereas the number of eating occasions increased at weekends for meals outside the home. The contribution of fat to energy approximated the 35% recommendation at home from Monday to Friday, but increased above this on Saturday and Sunday. The contribution of fat to energy outside the home was always above the recommendation. The food groups that contributed most to fat were similar at home and outside the home. These included butter and full-fat spreads, fresh meat, meat products, meat dishes, biscuits, cakes and pastries, whole milk, and chips and processed potatoes. The contribution of fat to energy was above the recommendations when eating outside the home, regardless of day of the week. A number of food groups have been identified that contributed most to fat intake outside the home and these might be targeted in developing public health nutrition strategies to reduce fat intake.
  • Article
    This pilot study examined nutrition-related attitudes that may affect food choices at fast-food restaurants, including consumer attitudes toward nutrition labeling of fast foods and elimination of value size pricing. A convenience sample of 79 fast-food restaurant patrons aged 16 and above (78.5% white, 55% female, mean age 41.2 [17.1]) selected meals from fast-food restaurant menus that varied as to whether nutrition information was provided and value pricing included and completed a survey and interview on nutrition-related attitudes. Only 57.9% of participants rated nutrition as important when buying fast food. Almost two thirds (62%) supported a law requiring nutrition labeling on restaurant menus. One third (34%) supported a law requiring restaurants to offer lower prices on smaller instead of bigger-sized portions. This convenience sample of fast-food patrons supported nutrition labels on menus. More research is needed with larger samples on whether point-of-purchase nutrition labeling at fast-food restaurants raises perceived importance of nutrition when eating out.
  • Article
    Full-text available
    Requiring restaurants to present nutrition information on menus is under consideration as a potential way to slow the increasing prevalence of obesity. Using a survey methodology, we examined how accurately consumers estimate the nutrient content of typical restaurant meals. Based on these results, we then conducted an experiment to address how the provision of nutrition information on menus influences purchase intentions and reported preferences. For both the survey and experiment, data were analyzed using analysis of variance techniques. Survey results showed that levels of calories, fat, and saturated fat in less-healthful restaurant items were significantly underestimated by consumers. Actual fat and saturated fat levels were twice consumers' estimates and calories approached 2 times more than what consumers expected. In the subsequent experiment, for items for which levels of calories, fat, and saturated fat substantially exceeded consumers' expectations, the provision of nutrition information had a significant influence on product attitude, purchase intention, and choice. Most consumers are unaware of the high levels of calories, fat, saturated fat, and sodium found in many menu items. Provision of nutrition information on restaurant menus could potentially have a positive impact on public health by reducing the consumption of less-healthful foods.
  • Article
    Comprehension of food labels can be important for patients, including those with chronic illness, to help follow dietary recommendations. Patient comprehension of food labels was examined, along with the relationship of comprehension to their underlying literacy and numeracy skills. From June 2004 to April 2005, a cross-sectional study of 200 primary care patients was performed. A 24-item measure of food label comprehension was administered. Literacy was measured with the Rapid Estimate of Adult Literacy in Medicine (REALM), and numeracy with the Wide Range Achievement Test, third edition (WRAT-3). Most patients (89%) reported using food labels. While 75% of patients reported at least a high school education and 77% had 9th-grade literacy skills, only 37% had 9th-grade math skills. On average, patients answered 69% (standard deviation, 21%) of the food-label questions correctly. Common reasons for incorrect responses included misapplication of the serving size, confusion due to extraneous material on the food label, and incorrect calculations. For example, only 37% of patients could calculate the number of carbohydrates consumed from a 20-ounce bottle of soda that contained 2.5 servings. Higher comprehension of food labels was significantly correlated (all p values were less than 0.001) with higher income (rho=0.39), education (rho=0.49), literacy (rho=0.52), and numeracy (rho=0.67). Patients demonstrated deficits in understanding nutrition labels. Poor label comprehension was highly correlated with low-level literacy and numeracy skills, but even patients with higher literacy could have difficulties interpreting labels. Providers need to consider patients' literacy and numeracy when providing dietary recommendations. Opportunities may exist for the U.S. Food and Drug Administration to promote changes to make food labels more comprehensible.
  • Article
    Americans are increasingly eating out, but nutrition environments in restaurants are poorly understood. An observational measure was developed to assess factors believed to contribute to food choices in restaurants, including availability of more healthy foods, facilitators and barriers to healthful eating, pricing, and signage/promotion of healthy and unhealthy foods. Inter-rater and test-retest reliability were assessed in 217 sit-down and fast-food restaurants in four neighborhoods in 2004 and 2005. Inter-rater reliability was generally high, with most kappa values greater than 0.80 (range 0.27-0.97) and all percent-agreement values greater than 75% (77.6-99.5). Test-retest reliability was high, with most kappa values greater than 0.80 (0.46-1.0) and all percent-agreement values greater than 80% (80.4-100). There were several differences (p<0.05) between nutrition environment variables in sit-down versus fast-food restaurants, although neither restaurant type was consistently more healthful. Fast-food restaurants had greater healthy entrée and main-dish salad availability, but sit-down restaurants had a higher proportion of healthy main-dish salads and more healthy food and beverage items. Fast-food restaurants more often encouraged large portions, unhealthful eating, and overeating, and offered relative cost savings for combination meals, but were also more likely to provide nutrition information and highlight healthy options. Testing hypotheses about food environment influences on obesity and eating patterns requires psychometrically sound measurement of nutrition environments. This Nutrition Environment Measures Study restaurant assessment (NEMS-R) has evidence of reliability, and can discriminate restaurant types. The NEMS-R can be used in research and practice to characterize restaurant environments.
  • Article
    Full-text available
    This review of the obesity epidemic provides a comprehensive description of the current situation, time trends, and disparities across gender, age, socioeconomic status, racial/ethnic groups, and geographic regions in the United States based on national data. The authors searched studies published between 1990 and 2006. Adult overweight and obesity were defined by using body mass index (weight (kg)/height (m)(2)) cutpoints of 25 and 30, respectively; childhood "at risk for overweight" and overweight were defined as the 85th and 95th percentiles of body mass index. Average annual increase in and future projections for prevalence were estimated by using linear regression models. Among adults, obesity prevalence increased from 13% to 32% between the 1960s and 2004. Currently, 66% of adults are overweight or obese; 16% of children and adolescents are overweight and 34% are at risk of overweight. Minority and low-socioeconomic-status groups are disproportionately affected at all ages. Annual increases in prevalence ranged from 0.3 to 0.9 percentage points across groups. By 2015, 75% of adults will be overweight or obese, and 41% will be obese. In conclusion, obesity has increased at an alarming rate in the United States over the past three decades. The associations of obesity with gender, age, ethnicity, and socioeconomic status are complex and dynamic. Related population-based programs and policies are needed.
  • Article
    Full-text available
    Because the sizes of food portions, especially of fast food, have increased in parallel with rising rates of overweight, health authorities have called on fast-food chains to decrease the sizes of menu items. From 2002 to 2006, we examined responses of fast-food chains to such calls by determining the current sizes of sodas, French fries, and hamburgers at three leading chains and comparing them to sizes observed in 1998 and 2002. Although McDonald's recently phased out its largest offerings, current items are similar to 1998 sizes and greatly exceed those offered when the company opened in 1955. Burger King and Wendy's have increased portion sizes, even while health authorities are calling for portion size reductions. Fast-food portions in the United States are larger than in Europe. These observations suggest that voluntary efforts by fast-food companies to reduce portion sizes are unlikely to be effective, and that policy approaches are needed to reduce energy intake from fast food.
  • Article
    This study investigated the effect on energy intake of increasing the portion size of a food served as a discrete unit. A within-subject design with repeated measures was used. The sample comprised 75 young adults (37 females and 38 males) from a university community. Individuals ate lunch in the lab once a week for 4 weeks. Each week, they were served one of four sizes of a deli-style sandwich (6, 8, 10, or 12 inches), of which they could eat as much as they wanted. Energy intakes were determined for each meal, as were ratings of hunger and satiety before and after each meal. A linear mixed model with repeated measures was used. The influence of subject characteristics was examined using analysis of covariance. The portion size of the sandwich significantly influenced lunch intake for both males and females (P<.0001). The majority of individuals consumed the entire 6-inch sandwich. When served the 12-inch sandwich, compared with the 8-inch sandwich, females consumed 12% more energy (74 kcal) and males consumed 23% more energy (186 kcal). Despite these differences, ratings of hunger and fullness were not significantly different after eating the 12-inch and 8-inch sandwiches. These results suggest that increasing the portion size of a food served as a discrete unit leads to increased energy intake at a single meal without differentially influencing ratings of hunger and satiety. Dietitians should educate their clients about strategies to moderate the effect on intake of increased portions of high-calorie foods.
  • Article
    Full-text available
    We surveyed 7318 customers from 275 randomly selected restaurants of 11 fast food chains. Participants purchased a mean of 827 calories, with 34% purchasing 1000 calories or more. Unlike other chains, Subway posted calorie information at point of purchase and its patrons more often reported seeing calorie information than patrons of other chains (32% vs 4%; P<.001); Subway patrons who saw calorie information purchased 52 fewer calories than did other Subway patrons (P<.01). Fast-food chains should display calorie information prominently at point of purchase, where it can be seen and used to inform purchases.