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

BackgroundCalorie labeling is mandated in restaurant chains with ≥20 locations nationwide, but the effect of labeling on the nutritional quality of purchased meals in fast-food settings is unclear, especially for adolescents and children.ObjectiveTo estimate the effect of calorie menu labeling on the nutrient content and composition of fast-food meal purchases in McDonald’s restaurants vs control restaurants.DesignFrom 2010 to 2014, customers were sampled during repeated visits to McDonald’s restaurants, which voluntarily labeled menus with calorie information in 2012, and 5 control fast-food restaurant chains that had not labeled their menus over the study period.Participants/settingRestaurant receipts and questionnaires were collected from 2883 adults, 2131 adolescents, and 433 children in 4 New England cities.Main outcome measuresSaturated fat, sugar, sodium, and fiber content of purchased meals, as well as nutrient densities (ie, nutrient content adjusted for total calories), were calculated after linking purchases to nutrition data from restaurant websites.Statistical analysesDifference-in-differences analyses and linear mixed models were used to examine whether calorie labeling in McDonald’s was associated with changes in nutrient content and nutrient density of purchased meals separately in adults, adolescents, and children.ResultsAfter implementation of calorie labeling at McDonald’s, adult meals contained on average 4.0% fewer calories from sugar (95% confidence interval: −7.5 to −0.5), but 1.8% more calories from saturated fat (95% confidence interval: 0.7 to 2.9) compared with control chains. The fiber content of children’s purchased meals was lower at McDonald’s after calorie labeling (change = −1.4 g, 95% confidence interval: −2.5 to −0.3). Calorie labeling was not associated with changes in nutrient quality of adolescent meals.ConclusionsCalorie labeling at McDonald’s was associated with a possibly small positive change in the nutritional quality of meals in adults but not in adolescents or children. Efforts are needed to improve the nutritional quality of restaurant meals.     

Changes in Awareness and Use of Calorie Information After Mandatory Menu Labeling in Restaurants in King County,Washington

Objectives. We examined population-level impact on customer awareness and use and explored potential disparities in outcomes regarding the King County, Washington, regulation requiring chain restaurants to provide calorie information.Methods. We analyzed 2008 to 2010 Behavioral Risk Factor Surveillance System data from 3132 English-speaking King County residents aged 18 years and older who reported eating at a regulated chain. We used regression models to assess changes in calorie information awareness and use from prepolicy to postpolicy implementation by customer demographics, health status, and restaurant type.Results. Calorie information awareness and use increased significantly from 2008 to 2010. Unadjusted analyses indicated that the proportion who saw and used calorie information tripled, from 8.1% to 24.8%. Fully adjusted analyses confirmed significant increases. After policy implementation, White, higher income, and obese respondents had greater odds of seeing calorie information. Women, higher income groups, and those eating at a fast-food versus a sit-down chain restaurant were more likely to use this information.Conclusions. Significant increases in calorie information awareness and use following regulation support the population-wide value of this policy. However, improvements varied across race, income, and gender.In recent years, policymakers and public health practitioners have implemented policies such as posting calorie and other nutrition information at restaurants to help curb epidemic levels of obesity.1,2 King County, Washington, implemented its menu-labeling regulation on January 1, 2009—the second jurisdiction in the United States to do so after New York City. The regulation requires chain restaurants to provide calorie, saturated fat, carbohydrate, and sodium information.3To date, research on the impact of menu-labeling policies has focused on pre–post changes in calorie information awareness and calories in food purchased among patrons intercepted at regulated chain restaurants using surveys, receipt data, or both.4–10 These studies may not provide an accurate population-level estimate of menu-labeling awareness and use and are not ideal for examining whether impact varies across demographic subgroups. We report on countywide and subpopulation changes in menu-labeling awareness (i.e., seeing calorie information) and use (i.e., using calorie information) before and after policy implementation and examine heterogeneity in outcomes across subpopulations.     

Consumer awareness of fast-food calorie information in New York City after implementation of a menu labeling regulation

Objectives. We assessed consumer awareness of menu calorie information at fast-food chains after the introduction of New York City''s health code regulation requiring these chains to display food-item calories on menus and menu boards.Methods. At 45 restaurants representing the 15 largest fast-food chains in the city, we conducted cross-sectional surveys 3 months before and 3 months after enforcement began. At both time points, customers were asked if they had seen calorie information and, if so, whether it had affected their purchase. Data were weighted to the number of city locations for each chain.Results. We collected 1188 surveys pre-enforcement and 1229 surveys postenforcement. Before enforcement, 25% of customers reported seeing calorie information; postenforcement, this figure rose to 64% (P < .001; 38% and 72%, weighted). Among customers who saw calorie information postenforcement, 27% said they used the information, which represents a 2-fold increase in the percentage of customers making calorie-informed choices (10% vs 20%, weighted; P < .001).Conclusions. Posting calorie information on menu boards increases the number of people who see and use this information. Since enforcement of New York''s calorie labeling regulation began, approximately 1 million New York adults have seen calorie information each day.In 2008, after a series of court challenges by the restaurant industry, New York City became the first jurisdiction in the United States to require restaurant chains to post calorie information on menus and menu boards. Adopting this regulation was part of a broader New York City Health Department public health response to rising rates of overweight and diabetes. These efforts draw on 2 decades of research that suggests a direct link between the growth of chain restaurant industries—both fast food and casual dining—and rising rates of obesity.^1–4 US fast-food sales increased exponentially between 1970 and 2000, from $6 billion to $110 billion.⁵ During the same time, obesity rates among US adults doubled; one third of US adults now meet the criteria for obesity, and another third are considered overweight.⁶Research examining changes in individual dietary patterns confirms that fast-food consumption is associated with increased body mass index⁷ and increased calorie intake.⁸ On days when they report eating fast food, adults consume 205 more calories, and children and adolescents consume 155 more calories than on days when they do not eat fast food.⁸ Choices at fast-food chains typically consist of high-calorie foods⁹ served in large portions.¹⁰ However, most consumers may not be aware of the high calorie content of such items because such information is often not easily accessible in fast-food establishments. Additionally, consumers have been found to consistently underestimate the calories in foods prepared outside of the home^11,12; even nutritionists and other health professionals underestimate the calories in typical chain restaurant foods.¹³Two studies have shown that few customers report seeing calorie information when it is provided in less accessible formats (e.g., posters, pamphlets) or after the point of purchase.^14,15a Prominent placement of calorie information on menus and menu boards was proposed in New York City to assure that customers have ready access to calorie information when they make menu selections. In December 2006, New York City approved the nation''s first regulation requiring calorie labeling in certain fast-food restaurants. That requirement, effective July 1, 2007, was overturned by a US District Court^15b in September 2007. An amended regulation was approved in January 2008 and became effective March 31, 2008. The amended regulation requires restaurant chains with 15 or more locations nationwide to post calorie counts on menus, menu boards, and item tags.¹⁶ Calories must be posted clearly and conspicuously, adjacent or in close proximity to the item name, using a font and format that are at least as prominent as the price or item name.The city began issuing violations for noncompliance in May 2008; full enforcement, including levying of fines, began on July 18, 2008. Because a lawsuit initiated by the New York State Restaurant Association was pending at the time the regulation went into effect, most restaurants waited until the enforcement date for financial penalties to begin posting calorie information. However, some chains began posting as early as 2007. A New York City Health Department study that we conducted before the city''s Board of Health 2006 regulation became effective found that most customers left fast-food chains without seeing any calorie information despite industry claims that restaurants were making substantial efforts to convey such information.^14a Fewer than 4% of fast-food customers reported seeing calorie information. This percentage did not include customers at the fast-food chain Subway, which had posted calorie information for a select number of items before the posting requirement went into effect. The earlier study also found that 1 in 3 lunchtime customers purchased food containing more than 1000 calories at the lunchtime meal,⁹ which accounted for more than half of the 2000-calorie daily intake recommendation for most adults.Immediately preceding and following the full enforcement (with levying of fines) of the calorie-labeling regulation, we assessed the impact of the regulation on customers’ awareness of calorie information and their report of its use in making food choices. The rationale that calorie information may help guide healthier choices was supported by data collected at Subway restaurant chains. Subway customers who reported seeing calorie information and using that information in making their food choices purchased 99 fewer calories than did customers who said they had not seen the calorie information.^14a     

Purchasing behavior and calorie information at fast-food chains in New York City, 2007

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.     

Comparison of Fast-Food and Non-Fast-Food Children's Menu Items

ObjectiveCompare the macronutrient content of children's meals sold by fast-food restaurants (FFR) and non-fast-food restaurants (NFF).DesignAll restaurants within the designated city limits were surveyed. Non-fast-food children's meals were purchased, weighed, and analyzed using nutrition software. All fast-food children's meals were recorded, with nutrient content information obtained from their respective commercial Web sites.SettingCommunity in southeastern United States.Participants33 restaurants, 10 FFR and 23 NFF.Main Outcome Measure(s)Total weight, total calories, fat, saturated fat, protein, carbohydrates, and fiber.AnalysisPaired t tests, 1-way analysis of variance, and general linear model analyses.ResultsOverall mean percentage of calories from fat for children's meals at FFR was 37.5%, and 40.5% at NFF. Significant differences (P < .01) existed between FFR and NFF, with FFR providing smaller servings, fewer calories, and less total fat, saturated fat, protein, carbohydrates, and fiber. When analyzing only with the highest calorie option side, controlling for portion size, no differences remained except saturated fat.Conclusions and ImplicationsFast-food restaurants offered smaller children's portion sizes and lower-fat options. These results have implications for restaurants, parents, children, and nutrition educators.     

Inviting consumers to downsize fast-food portions significantly reduces calorie consumption

Policies that mandate calorie labeling in fast-food and chain restaurants have had little or no observable impact on calorie consumption to date. In three field experiments, we tested an alternative approach: activating consumers' self-control by having servers ask customers if they wanted to downsize portions of three starchy side dishes at a Chinese fast-food restaurant. We consistently found that 14-33 percent of customers accepted the downsizing offer, and they did so whether or not they were given a nominal twenty-five-cent discount. Overall, those who accepted smaller portions did not compensate by ordering more calories in their entrées, and the total calories served to them were, on average, reduced by more than 200. We also found that accepting the downsizing offer did not change the amount of uneaten food left at the end of the meal, so the calorie savings during purchasing translated into calorie savings during consumption. Labeling the calorie content of food during one of the experiments had no measurable impact on ordering behavior. If anything, the downsizing offer was less effective in changing customers' ordering patterns with the calorie labeling present. These findings highlight the potential importance of portion-control interventions that specifically activate consumers' self-control.     

The effect of providing nutritional information about fast-food restaurant menus on parents' meal choices for their children

BACKGROUND/OBJECTIVESTo encourage healthier food choices for children in fast-food restaurants, many initiatives have been proposed. This study aimed to examine the effect of disclosing nutritional information on parents'' meal choices for their children at fast-food restaurants in South Korea.SUBJECTS/METHODSAn online experimental survey using a menu board was conducted with 242 parents of children aged 2-12 years who dined with them at fast-food restaurants at least once a month. Participants were classified into two groups: the low-calorie group (n = 41) who chose at least one of the lowest calorie meals in each menu category, and the high-calorie group (n = 201) who did not. The attributes including perceived empowerment, use of provided nutritional information, and perceived difficulties were compared between the two groups.RESULTSThe low-calorie group perceived significantly higher empowerment with the nutritional information provided than did the high-calorie group (P = 0.020). Additionally, the low-calorie group was more interested in nutrition labeling (P < 0.001) and considered the nutritional value of menus when selecting restaurants for their children more than did the high-calorie group (P = 0.017). The low-calorie group used the nutritional information provided when choosing meals for their children significantly more than did the high-calorie group (P < 0.001), but the high-calorie group had greater difficulty using the nutritional information provided (P = 0.012).CONCLUSIONSThe results suggest that improving the empowerment of parents using nutritional information could be a strategy for promoting healthier parental food choices for their children at fast-food restaurants.     

Where Are Kids Getting Their Empty Calories? Stores,Schools, and Fast-Food Restaurants Each Played an Important Role in Empty Calorie Intake among US Children During 2009-2010

Consumption of empty calories, the sum of energy from added sugar and solid fat, exceeds recommendations, but little is known about where US children obtain these empty calories. The objectives of this study were to compare children's empty calorie consumption from retail food stores, schools, and fast-food restaurants; to identify food groups that were top contributors of empty calories from each location; and to determine the location providing the majority of calories for these key food groups. This cross-sectional analysis used data from 3,077 US children aged 2 to 18 years participating in the 2009-2010 National Health and Nutrition Examination Survey. The empty calorie content of children's intake from stores (33%), schools (32%), and fast-food restaurants (35%) was not significantly different in 2009-2010. In absolute terms, stores provided the majority of empty calorie intake (436 kcal). The top contributors of added sugar and solid fat from each location were similar: sugar-sweetened beverages, grain desserts, and high-fat milk1 from stores; high-fat milk, grain desserts, and pizza from schools; and sugar-sweetened beverages, dairy desserts, french fries, and pizza from fast-food restaurants. Schools contributed about 20% of children's intake of high-fat milk and pizza. These findings support the need for continued efforts to reduce empty calorie intake among US children aimed not just at fast-food restaurants, but also at stores and schools. The importance of reformed school nutrition standards was suggested, as prior to implementation of these changes, schools resembled fast-food restaurants in their contributions to empty calorie intake.     

Evaluating the Impact of Menu Labeling on Food Choices and Intake

Objectives. We assessed the impact of restaurant menu calorie labels on food choices and intake.Methods. 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.Results. 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.Conclusions. 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.Poor diet is a major public health concern.^1,2 One policy that might help improve diet quality, which has been implemented in New York City and is being considered by other cities and states, requires chain restaurants to post kilocalorie (calorie) information on menus and menu boards. The aim of menu labels is to inform consumers about foods consumed outside the home, which account for approximately half of total food expenditures.³ The rationale is that (1) food purchased outside the home is higher in calories, of poorer nutritional quality, and served in larger portions, which promotes overconsumption^4–7; (2) the frequency of fast food consumption is associated with greater levels of body fat⁸ and overweight⁹; (3) people, including trained nutritionists,¹⁰ have great difficulty estimating the calories in restaurant meals¹¹; and (4) most consumers support calorie labeling on restaurant menus^12,13 and nearly half report it would inform their food choices.¹⁴The restaurant industry has lobbied hard against proposed regulations, suing New York City, San Francisco, and Santa Clara for attempting to enact labeling requirements, although these suits were unsuccessful. One industry claim is that at least some restaurants make nutrition information available via some combination of in-store brochures, posters, and the Internet. However, the information is often not readily accessible¹⁵ and only 0.1% of consumers seek it out.¹⁶ Given the prominence of this issue and the strong opposition of industry, it is important to test the impact of calorie labels on food choices and consumption. Studies bearing on this matter have produced mixed findings^17–29 and have either failed to examine calorie labels on chain restaurant menus, offered study participants a limited number of food items, or studied ordering behavior but not actual consumption and neglected to examine how nutrition information presented at one meal affects subsequent food intake. We designed the current study to test whether menu labeling influences the total calories ordered and consumed during a dinner meal as well as food consumed after the meal. We also aimed to assess whether the effects would be stronger if people were provided information about recommended daily caloric requirements.     

Secular Trends in Fast-Food Restaurant Use Among Adolescents and Maternal Caregivers From 1999 to 2010

Objectives. We examined trends from 1999 to 2010 in adolescents’ self-reported fast-food restaurant use alongside maternal reports of fast-food consumption and purchasing from restaurants for family meals.Methods. Middle- and high-school student participants from Minneapolis–St Paul, Minnesota, represented diverse ethnic/racial and socioeconomic backgrounds. Adolescents completed classroom-administered surveys and maternal caregivers responded by phone or mail.Results. The overall prevalence of frequent fast-food consumption, defined as 3 or more times per week, decreased from 1999 to 2010 among adolescents (1999: 25%; 2010: 19%; P < .001) and maternal caregivers (1999: 17%; 2010: 11%; P < .001), but sociodemographic disparities were apparent. For example, the prevalence of frequent fast-food consumption remained highest and did not significantly decrease among Black or Native American youths. The overall prevalence of frequent fast-food purchases for family meals did not significantly decrease; large decreases were observed only among Hispanic families (1999: 18%; 2010: 6%; P < .001).Conclusions. In light of previous findings linking frequent fast-food consumption to greater weight gain and poor nutrition, the observed decreases in consumption are encouraging and interventions are needed to address observed disparities.National data for adolescents and adults indicate that foods consumed away from home, as well as a growing proportion of those consumed at home, are frequently purchased at fast-food restaurants.1–3 These patterns are of public health concern as numerous studies have linked frequent consumption of fast food to weight gain and poor diets.4–6 In contrast to the nutritional consequences associated with fast food, research suggests that adolescents and parents who regularly eat together at mealtimes tend to have better diets.7–12 Despite some evidence of socioeconomic and racial/ethnic disparities in the healthfulness of foods prepared at home and served at family meals,13 this relationship between family meals and dietary intake likely represents greater exposure to healthful foods at shared mealtimes. Frequently purchasing fast food for family meals may compromise these nutrition-related benefits.14–18National data on adolescent dietary patterns also indicate that the proportion of energy from foods prepared at fast-food restaurants but consumed at home has increased in recent decades2; thus, it is important to examine whether parallel changes have occurred in the frequency of purchasing fast food for family meals. This information along with complementary data for adolescents and their parents on trends in overall fast-food consumption may have important implications for interventions. To the best of our knowledge, no previous studies have examined secular trends in purchasing fast food for family meals or secular changes in fast-food consumption among parents who serve as role models for their children. The most recent published data on secular changes in adolescent fast-food consumption do not describe trends beyond 2008.2,3We designed the current study to help fill these research gaps and guide the development of strategies to support adolescents and their families in sharing mealtimes while limiting consumption of foods prepared at fast-food restaurants. The aim was to examine secular trends in adolescent reports of fast-food consumption alongside maternal reports of their own fast-food consumption and purchasing for family meals. We examined trends from 1999 to 2010 in a large, diverse population-based sample, and therefore capture a period in which there was growing attention given to the large portions and high energy density of fast-food restaurant menu items.19,20 In addition, the diversity of the sample allowed for investigation of these trends by sociodemographic characteristics as any identified differences may be important to consider in the tailoring of interventions.     

Menu Labeling as a Potential Strategy for Combating the Obesity Epidemic: A Health Impact Assessment

Objectives. We conducted a health impact assessment to quantify the potential impact of a state menu-labeling law on population weight gain in Los Angeles County, California.Methods. We utilized published and unpublished data to model consumer response to point-of-purchase calorie postings at large chain restaurants in Los Angeles County. We conducted sensitivity analyses to account for uncertainty in consumer response and in the total annual revenue, market share, and average meal price of large chain restaurants in the county.Results. Assuming that 10% of the restaurant patrons would order reduced-calorie meals in response to calorie postings, resulting in an average reduction of 100 calories per meal, we estimated that menu labeling would avert 40.6% of the 6.75 million pound average annual weight gain in the county population aged 5 years and older. Substantially larger impacts would be realized if higher percentages of patrons ordered reduced-calorie meals or if average per-meal calorie reductions increased.Conclusions. Our findings suggest that mandated menu labeling could have a sizable salutary impact on the obesity epidemic, even with only modest changes in consumer behavior.During the past several decades, increased consumption of calorie-dense foods outside the home,^1–4 “supersizing” of food and beverage portions at large chain restaurants,^5,6 and an underestimation of caloric content by restaurant patrons^7,8 have contributed to the increase in the prevalence of obesity in the United States. Not surprisingly, during this same time period, obesity-related health conditions,^9,10 including diabetes, hypertension, fatty liver, sleep apnea, arthritis, and depression, and restaurant expenditures ($400 billion annually by consumers¹¹) have paralleled the trajectory of the obesity epidemic. These factors and others have made the failure to disclose nutrition content at the point of purchase a growing and significant public health concern. Whereas the Nutrition Labeling and Education Act of 1990 increased the availability of nutrition information on packaged foods, prepared foods at the point of purchase are exempt from such disclosures. At present, most fast-food and sit-down chain restaurants typically disclose nutrition information only upon request, via the Internet, or in a manner not readily visible to individuals placing their food orders on site (e.g., small-print table inserts, table tents, or brochures).¹¹Laws mandating the provision of calorie information at the point of purchase in large chain restaurants have garnered growing public and legislative support as a potential strategy for addressing the obesity epidemic.^12,13 This interest is reflected in the recent passage of menu-labeling ordinances in some jurisdictions, including New York City, New York; San Francisco, California; Multnomah County, Oregon; and King County, Washington. In California, Senate Bill (SB) 1420,¹⁴ introduced and passed in 2008, has received considerable national attention as it awaits implementation. When implemented, SB 1420 would require all restaurant chains across the state with 20 or more facilities to post calorie information next to each item on their menus and menu boards. An earlier version of the bill included restaurant chains with 15 or more facilities in the state, and required, in addition to the calorie information, the provision of information on saturated fat, sugar, and sodium content on menus (but not on menu boards).Despite this increased interest and legislative action, no published studies have sought to quantify the potential impact of menu labeling on the obesity epidemic. To address this gap, we conducted a health impact assessment of menu labeling, as specified in the original version of SB 1420, on population weight gain in Los Angeles County. Los Angeles County is the largest county in the United States, home to more than 10 million residents.     

Healthiness of US Chain Restaurant Meals in 2017

BackgroundGiven the popularity of restaurants as a meal source in the United States, it is important to understand the healthiness of their offerings.ObjectiveThis study’s purpose was to examine the healthiness of meals at national US chain restaurants in 2017 using the American Heart Association’s (AHA) Heart-Check meal certification criteria.DesignData for this cross-sectional study were obtained from MenuStat, an online database that includes nutrition information for menu items from the 100 restaurant chains with the largest sales in the United States in 2017. All possible meal combinations (meals defined as including an entrée and side item) were created at the 73 restaurants that reported nutrition information aligning with the AHA criteria: calories, total fat, saturated fat, trans fat, cholesterol, sodium, protein, and fiber.Main outcomes measureHealthy meal (0=did not meet AHA criteria; 1=did meet AHA criteria).Statistical analyses performedWe used χ² tests to compare the percent of restaurant meals and meal components compliant with each AHA criterion and the percent of restaurant meals and meal components meeting varying numbers of AHA criteria across restaurant service types (ie, fast food, full service, fast casual).ResultsAmong all restaurants, the median calories, total fat, saturated fat, cholesterol, and sodium of meals exceeded the AHA criteria. Fewer than 20% of meals met the saturated fat and sodium criteria; 22% of restaurant meals met zero to one AHA criteria, 50% met two to four AHA criteria, 20% met five to six AHA criteria, and 8% met all seven AHA criteria.ConclusionsGiven the popularity of restaurants as a source of meals, efforts are needed to improve the healthiness of restaurant meals.     

Fast-Food Optimal Defaults Reduce Calories Ordered,as Well as Dietary Autonomy: A Scenario-Based Experiment

BackgroundLow-calorie menu items as optimal defaults may encourage healthier choices when people eat out. Limited research has studied default effects from the restauranteurs’ perspective, as well as the public health perspective.ObjectiveTo examine the effects of optimal defaults on calories ordered, dietary autonomy, and visit intention in the context of a fast-food drive-through.DesignBetween-subjects randomized scenario-based experiment.Participants/settingIn all, 377 adults who lived in the United States were recruited through a crowdsourcing platform in July 2020.InterventionParticipants were asked to visualize ordering a combo meal in a fast-food drive-through. They were randomly assigned to order from 1 of 3 menu boards: (1) menu items available for combos by customer choice, (2) combos that included traditional high-calorie default items, or (3) combos that included low-calorie optimal defaults.Main outcome measuresDifferences in calories ordered among groups, dietary autonomy, and restaurant visit intention.AnalysisStatistical tests included multiple regression, Kruskal-Wallis, χ², and 1-way analysis of variance. Covariates such as education and sex were tested in regression models as potential confounders.ResultsCompared with the choice combo meals, optimal combo meals reduced calories ordered by consumers (?337 kcal, standard error = 19, P < .001), while traditional combos increased them (+132 kcal, standard error = 20, P < .001). No significant difference was found in visit intention. Dietary autonomy was affected by the optimal defaults (P = .025), even in participants with high health concern. Conversely, the traditional combo’s effect on dietary autonomy was moderated by health concern (B = ?0.26, P = .023), with only individuals with very high levels of health concern perceiving less autonomy.ConclusionsOptimal defaults provided a robust reduction in calories ordered but had implications for dietary autonomy.     

A spatial analysis of the association between restaurant density and body mass index in Canadian adults

Objective

To investigate the association between fast-food restaurant density and adult body mass index (BMI) in Canada.

Methods

Individual-level BMI and confounding variables were obtained from the 2007–2008 Canadian Community Health Survey master file. Locations of the fast-food and full-service chain restaurants and other non-chain restaurants were obtained from the 2008 Infogroup Canada business database. Food outlet density (fast-food, full-service and other) per 10,000 population was calculated for each Forward Sortation Area (FSA). Global (Moran's I) and local indicators of spatial autocorrelation of BMI were assessed. Ordinary least squares (OLS) and spatial auto-regressive error (SARE) methods were used to assess the association between local food environment and adult BMI in Canada.

Results

Global and local spatial autocorrelation of BMI were found in our univariate analysis. We found that OLS and SARE estimates were very similar in our multivariate models. An additional fast-food restaurant per 10,000 people at the FSA-level is associated with a 0.022 kg/m² increase in BMI. On the other hand, other restaurant density is negatively related to BMI.

Conclusions

Fast-food restaurant density is positively associated with BMI in Canada. Results suggest that restricting availability of fast-food in local neighborhoods may play a role in obesity prevention.     

Exploring the main and moderating effects of individual-level characteristics on consumer responses to sugar taxes and front-of-pack nutrition labels in an experimental marketplace

InterventionThis study examined whether the impacts of sugar taxes and front-of-pack (FOP) nutrition labels differ across socio-demographic subgroups.Research questionWhat are the main and moderating effects of individual-level characteristics on the nutrient content of participants’ purchases in response to varying taxation levels and FOP labels?MethodsData from an experimental marketplace were analyzed. A sample of 3584 Canadians aged 13 years and older received $5 to purchase an item from a selection of 20 beverages and 20 snack foods. Participants were shown products with one of five FOP labels and completed eight within-subject purchasing tasks with different tax conditions. Linear mixed models were used to estimate the main and moderating effects of 11 individual-level variables on the sugars, sodium, saturated fats, and calorie content of participants’ purchases.ResultsParticipants who were younger, male, and more frequent consumers of sugary drinks purchased products containing more sugars, sodium, saturated fats, and calories. Sex and age moderated the relationship between tax condition and sugars or calories purchased: female participants were more responsive than males to a tax that included fruit juice, and younger participants were more responsive to all sugar tax conditions than older participants. Reported thirst and education level also moderated the relationship between tax condition and calories purchased. No individual-level characteristics moderated the effects of FOP labels.ConclusionA small proportion (7 of 176) of the moderating effects tested in this study were significant. Sugar taxes and FOP labelling policies may therefore produce similar effects across key socio-demographic groups.Supplementary InformationThe online version contains supplementary material available at 10.17269/s41997-021-00475-x.     

Understanding Restaurant Healthfulness in Food Deserts

ObjectiveTo determine differences in restaurant environments between neighborhood and restaurant type to understand better a food desert's eating environments.MethodsThe Nutrition Environment Measures Survey for restaurants was used to assess restaurant healthfulness. Kruskal-Wallis compared healthy index scores, and Pearson chi-square compared individual items.ResultsHealthy index scores were consistently low across neighborhoods (total mean = 4.6 out of 23). Fast-food restaurants (mean = 5.7) were more healthful than sit-down restaurants (mean = 3.1). Individual comparisons showed more healthy eating facilitators (eg, nutrition information at point-of-purchase, P = 0.004) in food deserts and more available healthful items (eg, whole grain bread, P < 0.001) in the neighborhoods with high incomes.Conclusions and ImplicationsFindings indicate equities in restaurant environments across all neighborhoods but inequities across restaurant types, thus conclude the importance of restaurant type in understanding restaurant healthfulness. Policymakers can use these findings to develop healthy eating strategies in varying neighborhoods.     

Retailer Marketing Strategies and Customer Purchasing of Sweetened Beverages in Convenience Stores

BackgroundMarketing strategies for sweetened beverages (SBs) are pervasive across food retail. Yet few studies have examined how these strategies associate with planned and unplanned SB purchasing.ObjectiveThis study aimed to examine whether customers with greater exposure to SB retail marketing (eg, advertisements and product placement) were more likely to purchase an SB and whether this varied by customer characteristics.DesignThis was an observational, cross-sectional study using objective customer purchasing and store assessment data from convenience and other small food stores.Participants/settingParticipants were 1,604 food and beverage customers at 144 randomly sampled convenience and other small food stores in Minneapolis-St Paul, MN.ExposureMarketing strategies, including SB advertisements, placement, and shelf space were included.Main outcome measuresWe determined the probability of customers purchasing ≥4 fluid ounces of a ready-to-drink sugar and/or artificially sweetened beverage.Statistical analyses performedAssociations between marketing strategies and purchasing were estimated using mixed regression models, controlling for customer characteristics and accounting for customers nested within stores.ResultsFifty-six percent of customers purchased an SB; 14% also specified that it was an unplanned purchase. Customers were more likely to purchase an SB when exterior advertisements (P < .001) and advertisements hanging from the ceiling (P < .001) that promoted SBs were present. Customers with moderate and high cumulative exposure to SB marketing were significantly more likely to purchase SBs (51.2% and 54.9%, respectively) than those with lower exposure (34%); this effect was particularly salient for men. There were no significant associations between retail marketing strategies and unplanned purchases.ConclusionsFindings demonstrate that feasible and sustainable approaches are required from policy makers, retailers, and public health professionals to shift store environments away from cues that promote unhealthy beverage selections. Given that numerous retail actors are invested in the availability, promotion, and sales of SBs, changing the predominance of SB marketing in convenience stores will likely be challenging and require cross-sector collaboration.