Assessing the Nutritional Quality of Canadian Restaurant Foods

Beyond the Menu: Assessing the Nutritional Quality of Canadian Restaurant Foods

Sarah Alexina Barbara Murphy

A thesis submitted in conformity with the requirements for the degree of Master of Science (M.Sc.) Department of Nutritional Sciences University of Toronto

Beyond the Menu: Assessing the Nutritional Quality of Canadian Restaurant Foods

Sarah Alexina Barbara Murphy

Master of Science (M.Sc.)

Nutritional Sciences University of Toronto

2019 Abstract

One of the primary preventative measures of non-communicable diseases is a healthy diet. There is currently no oversight of the nutritional quality of foods served in the restaurant industry, meanwhile increasing numbers of Canadians eat outside the home on a regular basis. This thesis aimed to assess mean saturated fat, sodium, and sugar levels in restaurant foods in Canada, and to determine the proportion of menu items that would require one of Health Canada’s ‘high-in’ labels if applied to the restaurant sector. Analyzing data from 10,950 menu items from 96 chain establishments, this thesis represents the largest study of its kind in Canada. Our results showed the majority of menu items evaluated were high in nutrients of public health concern, and would require at least one ‘high-in’ label. This highlights the urgent need for more legislation and strategies to improve the nutritional quality of restaurant foods in Canada.

Acknowledgments

I’d like to take this opportunity to thank the many people who have been instrumental to the completion of this thesis and who have supported me throughout my journey as a graduate student.

First and foremost, a huge thank you to my supervisor Dr. Mary L’Abbé for giving me this incredible opportunity and supporting me throughout this adventure. It’s been an incredible privilege to work with someone so brilliant and I’ve learned so much from her along the way.

I am also immensely grateful to Mary Scourboutakos, who took me under her wing and introduced me to this great project, and Kacie Dickinson, who mentored me throughout my Masters. Both have been instrumental to the development of this thesis and I will always be indebted to them for all the kindness they have shown me.

A very special thank you to my committee members, Dr. Erin Hobin and Dr. Anthony Hanley, for taking the time to learn about my work and give me invaluable feedback on how to best develop it.

I would further like to thank my family, friends, and the rest of the L’Abbé lab for their continuous support throughout this process. I could never express enough how much of a difference they make to my life every day. A special thank you to Xulin Liu and Madyson Weippert, who volunteered to conduct the validation checks of my data and its categorizations.

This research was supported by a CIHR Project Operating Grant (201610PJI-152979). Their support makes research like mine possible and I am very grateful for their dedication to enabling upcoming researchers to make a difference in the world of health science research.

iii

Table of Contents

Abstract ...... ii

Acknowledgments ...... iii

Table of Contents ...... iv

List of Tables ...... vii

List of Figures ...... viii

List of Appendices ...... ix

List of Abbreviations ...... x

Chapter 1 ...... 1

Introduction ...... 1

1.1 Overall Rational ...... 1

Chapter 2 ...... 3

Background and Literature Review ...... 3

2.1 Restaurants and Public Health ...... 3

2.1.1 Food expenditure outside of the home ...... 3

2.1.2 Types of restaurant establishments ...... 3

2.1.3 Frequency of eating out, obesity, and diet quality ...... 3

2.1.4 Mechanistic links between restaurant food consumption and poor dietary intake ..5

2.1.5 Differences between sit-down and fast-food restaurants: frequency of consumption and nutrient intakes ...... 6

2.2 Levels of saturated fat, sodium, and sugar in restaurant foods ...... 6

2.2.1 Saturated fat in restaurant foods ...... 7

2.2.2 Sodium in restaurant foods...... 8

2.2.3 Sugar in restaurant foods ...... 9

2.3 Research and policies on menu labelling ...... 10 iv

2.3.1 Energy labelling ...... 10

2.3.2 Impact of energy labelling on consumer choice ...... 11

2.3.3 Impact on the nutrient composition of menu items ...... 12

2.3.4 Menu labelling beyond calories ...... 13

2.3.5 Health Canada’s Front-of-Pack ‘high-in’ labels ...... 15

2.4 Summary and literature gaps ...... 16

2.5 Thesis Objectives ...... 17

2.5.1 Objective 1 ...... 17

2.5.2 Objective 2 ...... 17

Chapter 3 ...... 18

Study 1 – A quantitative analysis of the saturated fat, sodium, and sugar levels in fast-food and sit-down restaurant menu items...... 18

3.1 Abstract ...... 18

3.2 Introduction ...... 18

3.3 Methods...... 20

3.4 Results ...... 21

3.5 Discussion ...... 28

3.6 Conclusion ...... 30

Chapter 4 ...... 31

Study 2 – Results of applying the Canadian proposed FOP labelling regulations to chain restaurant menu items ...... 31

4.1 Abstract ...... 31

4.3 Introduction ...... 32

4.4 Methods...... 33

4.5 Results ...... 34

4.6 Discussion ...... 37

4.7 Conclusion ...... 39 v

Chapter 5 ...... 40

Overall Discussion ...... 40

5.1 Synopsis ...... 40

5.2 General Discussion & Implications for Policy ...... 41

5.3 Future research ...... 44

5.4 Final Conclusions ...... 45

Chapter 6 ...... 47

References ...... 47

Chapter 7 ...... 58

Appendices ...... 58

7.1 Appendix A – Supplementary material accompanying Chapter 3: “A quantitative analysis of the saturated fat, sodium, and sugar content in Canadian fast-food and sit-down restaurant menu items” ...... 58

7.2 Appendix B – Supplementary material accompanying chapter 4: “Results of applying the Canadian proposed FOP labelling regulations to chain restaurant menu items” ...... 68

List of Tables

Chapter 3

Table 3.1. Levels of saturated fat, sodium, and sugar in Canadian restaurant menu items, by major category.

Table 3.2. Comparison of mean nutrient levels in Canadian fast food and sit down establishments, per serving.

Table 3.3. Comparison of nutrient levels in Canadian fast food and sit down establishments, per 100g.

Chapter 4

Table 4.1 Tabulation of DVs and FOP thresholds for each nutrient

Table 4.2: Proportion of menu items requiring 0, 1, 2, or 3 FOP symbols, FF vs SDR.

vii

List of Figures

Chapter 2 Figure 2.1: Example of NYC’s Salt Shaker logo (1a) and Australia’s Health Star Rating labels (1b). Figure 2.2. Proposed designs for Health Canada’s upcoming FOP labels Chapter 3 Figure 3.1. Boxplots of the interquartile ranges and median levels of saturated fat, sodium, and sugar in Canadian restaurant foods, per serving and per 100 grams. Chapter 4 Figure 4.1. Proportion of menu items requiring 0, 1, 2, or 3 FOP labels, overall and by category. Figure 4.2. Proportion of menus items requiring an FOP warning label for saturated fat, sodium, or sugar, overall and by category.

viii

List of Appendices

Appendix A – Supplementary material accompanying Chapter 3: “A quantitative analysis of the saturated fat, sodium, and sugar content in Canadian fast-food and sit-down restaurant menu items”

Appendix B - Supplementary material accompanying Chapter 4: “Proposed Front-of-Pack labelling legislation as applied to chain restaurant foods: a simulation study”

List of Abbreviations

BMI – Body Mass Index CI – Confidence Interval CVD – Cardiovascular disease DV – Daily Value FF – Fast-food establishment FOP – Front-of-Package Menu-FLIP – Menu Food Label Information Program NFt – Nutrition Facts Table HC – Health Canada HR – Hazard Ratio NCD – Non-communicable disease SDR – Sit-down restaurant SF – Saturated Fat UL – Upper Tolerance Limit WHO – World Health Organization

Chapter 1 Introduction 1.1 Overall Rational

Cardiovascular disease (CVD) is the second leading cause of death in Canada, accounting for almost one-third of all deaths annually.1,2 Hypertension, obesity, and type II diabetes are all major risk factors for CVD, with obesity affecting one quarter of Canadian adults and type 2 diabetes affecting one in ten.3-5 One of the primary preventative measures for all of these health conditions is eating a healthy diet, including minimizing consumption of saturated fat (SF), sodium, and sugars.6-11 In order to enable consumers to make informed choices, standardized Nutritional Facts tables (NFt) and full ingredients lists are required to be posted on food packages.12 However, these regulations do not apply to foods purchased from restaurants, which constituted 30% of Canadians’ food expenditure in 2018.13 The proportion of Canadians’ food expenditures dedicated to restaurant food items has been rising over the last five years, and as more and more people regularly eat food from outside the home, it is important to know how these foods contribute to dietary intake and health status.13-15 Currently, the only mandated nutrition labelling for menu items in Canada comes from the Ontario Healthy Menu Choices Act (2017), which requires the display of the item’s energy contents on the menus and menu boards of chain restaurants with ≥20 outlets provincially.16 However, energy content alone does not represent the nutritional quality of a food, and smaller chains and independent restaurants are still not legislated to post calorie information.

Research on the nutritional quality of Canadian restaurant foods is limited. Three studies have been published examining the sodium content of restaurant foods, one of which was a multi-national study on children’s menus that included Canada in its analysis, and not a comprehensive study of the Canadian market.17-19 The most recent study, which longitudinally compared sodium levels in restaurant items from 2010-2013, found no statistically significant change, with a mean sodium content of 917mg per serving in 2010 and 892mg per serving in 2013.20 While excess dietary sodium consumption is a critical contributor to hypertension and CVD, limiting intakes of SF and sugars is also important for managing and preventing the risk of non-communicable diseases as well. 9,21-26 To our knowledge, no previous research has assessed the overall SF or sugar content of Canadian restaurant foods. Two multinational studies including Canada examined SF, however one did not

1 2 provide a mean or median SF value for the Canadian items, and the other focused exclusively on children’s menus, with a sample of only 29 items.17,27 Sugar levels have only been examined in kid’s meals offered at restaurants in Canada, with results showing 50% of the items analyzed exceeded the World Health Organization’s (WHO) recommended daily free sugar intakes for children, but no analyses of sugar levels in restaurant foods beyond children’s items were found.20 Understanding the nutritional quality of foods will help inform policies for increased transparency in the restaurant industry, enabling Canadians to make healthier food choices, and ultimately promote the reformulation of menu items to improve the overall health status of Canadians.

This thesis therefore aims to expand our understanding of the levels of SF, sodium and sugars in Canadian restaurant foods. In Study 1, levels of SF, sodium and sugar in Canadian restaurant foods were assessed, overall and by menu category, and median levels by categories from different restaurant types (sit-down, fast-food) were compared. Levels were also compared to the recommended daily intakes for the three nutrients, and discussed in the context of previous literature, both in Canada and abroad. In Study 2, the thresholds established for Health Canada’s upcoming Front-of-Package (FOP) mandatory labelling legislation for packaged foods were applied to restaurant menu items to determine the proportions of restaurant foods that would require a ‘high-in’ label for each nutrient, as well as the proportions that would require multiple labels, if regulations for the packaged food sector were extended to restaurants. The results of these studies can be used to highlight menu categories and subcategories most in need of reformulation, and to develop policies to help inform consumer choice in the Canadian restaurant sector.

Chapter 2 Background and Literature Review 2.1 Restaurants and Public Health

2.1.1 Food expenditure outside of the home

Canadians spend on average almost 30% of their total food expenditure in restaurants, and this proportion has increased by approximately 20% since 2012.13 When examining what items are purchased in restaurants, 88% percent of the average food dollars spent are spent on full meals, while the other 12% are spent on snacks and beverages. A 2018 study found that Canadians consumed on average 4.6 meals a week outside the home, of which 40% came from fast-food restaurants or coffee shops, and 20% came from sit-down restaurants.28 Further to this, industry research found that 60% of Canadians consume restaurant foods at least once a week, with 31% consuming them more than once a week, and 7% consuming them daily.29 Collectively, these data demonstrate that restaurants are a significant contributor to the Canadian food environment, and the items served at these establishments are a potentially influential aspect of both the population’s dietary intakes and overall health.

2.1.2 Types of restaurant establishments

In the existing body of literature examining restaurant foods, restaurants are commonly distinguished as either fast-food establishments (FF) or sit-down/full-service restaurants (SDR). These types are defined by the degree of service offered, with FFs indicating a lack of table service, and SDRs indicating its presence. A traditional example of a FF would be McDonald’s, while one of a SDR would be Pizza Hut. The FF category also includes specialty establishments such as coffee shops like Starbucks and dessert chains such as Baskin Robbins, while SDRs tend to have a full menu, and although alcohol is usually not included in nutritional information published by restaurants, are also more likely to serve items such as beer, wine, and cocktails alongside its other menu offerings. As will be seen further on in this chapter, the majority of literature on restaurant foods has focused on FFs, while others have compared the two restaurant types.

2.1.3 Frequency of eating out, obesity, and diet quality

Systematic reviews have previously summarized research on the association between frequency of restaurant food consumption and obesity. Bezzera et al assessed 28 observational studies on eating

3 4 outside of the home and obesity, concluding that there was consistent evidence that eating at FFs on a regular basis (≥1 visit per week) was associated with an increase in body weight, but that the association with other types of restaurants was inconclusive.30 However, they noted that the variety in methodologies, food environments, as well as the inconsistent definitions of what constituted eating out of the home limited their ability to make comparisons between studies. Their findings relating to FFs were supported by the findings of Nago et al, whose systematic review of 15 prospective studies concluded that eating at FFs was associated with increased body weight over time, and that FF consumption positively predicted increased Body Mass Index (BMI) among adults.31 The authors stressed that future research should aim to be more comprehensive by including multiple sources of foods from outside the home, rather than focusing exclusively on FF establishments.

More recently, a prospective cohort study found eating at an FF establishment two or more times per week was significantly associated with being overweight and obese.32 However, another recent nine- year prospective cohort study in the US did not find a significant difference in either all-cause or cardiometabolic mortality between those who ate at restaurants frequently (including both restaurant types) and those who did not, but they also found that the energy, energy density, and energy from fat levels consumed were higher in those who reported to eat at restaurants three or more times a week.33

Most reviews have focused on adults, but some reports included children. One systematic review also concluded a positive association between eating FF and weight gain in adults, but not in children, despite it being associated with an increase in their energy intake.34 They suggested this may be due to children’s increased energy needs while growing up, but that developing a habit of eating fast food regularly could translate to weight gain when they reach adulthood. Dietary habits established during childhood and adolescence have been shown to significantly track into adulthood in previous studies.35,36

Overall, research has found a consistent positive association between the frequency of eating outside the home and obesity, particularly in the context of FFs. Various mechanistic links for this association have been proposed, as will be explored in the next section, although no definitive cause has been established, and the data for prospective cohorts and other health outcomes remains inconclusive.

2.1.4 Mechanistic links between restaurant food consumption and poor dietary intake

One of the main proposed explanations for the relationship between eating out and obesity is that the energy content of menu items may contribute to excess energy intakes, which overtime can lead to weight gain. Two recent papers examining the energy content of meals from chain restaurants found the majority were in excess of the 600 kcal per meal recommendation by public health authorities.37,38 The first, looking at 27 chain restaurants in the UK, found only 9% of restaurant meals in their sample met this recommendation and 47% contained ≥1000kcal per meal.37 The other found a similar trend from chain restaurants in five different countries.38 Both noted that SDR meals had significantly more energy-excessive meals on their menus than FFs, with Roberts et al finding that 94% of SDR meals compared to 72% of FF meals contained at least 600 kcal per meal. Further, another study found people who ate a meal from outside the home at least once a week had a significantly higher mean energy intake than those who ate out rarely.39

A longitudinal study of FF items in New Zealand found that portion sizes, energy content per serving, as well as energy density had all significantly increased from 2012-2016, by +5%, +14%, and +6%, respectively.40 Increased portion sizes at restaurants, along with their overall popularity, has been found to mirror increases in obesity rates over time.41,42 A 2018 systematic review found that larger portion sizes lead to increased consumption at meals, and explored various mechanisms behind this phenomenon, one of which is the single unit bias, where people assume that the portion served to them is what is appropriate to eat.43 An earlier study by the same researchers also established that larger portion sizes lead to larger bite sizes and increased eating rate, which lead to increased energy consumption.44 Reducing portion sizes may then be a viable target to help reduce the impact of restaurant foods on population health.

A Belgian study found that reducing the portion size of French fries by 20% led to a decreased intake without a decrease in satiety.45 However, when they polled the study participants, they found the majority (86%) noticed the change in portion size, and only a minority (32%) said they would accept a permanent reduction in the portion size. This was supported by another study that found smaller portion sizes negatively impacted consumers’ value perception of the food unless they did perceived the food to be of high quality.46 In the context of chain establishments, the authors suggested portion size reductions therefore may hurt their appeal, as foods from common chain restaurants are generally not perceived to be high-end. The possibility of consumer backlash against reduced portion sizes in

6 restaurants would be an obstacle to getting restaurants to make such changes for the sake of public health.

While most restaurants offer some healthier or less energy-dense options such as salads, an Australian study on purchasing habits at various McDonald’s outlets found that only 1% of orders were for these “healthy options”.47 Further research showed a significant inverse relationship between energy cost (dollar per kilojoule) and energy density (kilojoule per gram) in menu items, meaning that energy- dense foods tended to be cheaper per kilojoule than less-energy dense ones, making higher-calorie items often the more economical choice.48 A systematic review, including both research on both packaged and fast foods, concluded that reducing the price of healthier items led to an increased selection of those items, and that pushing establishments to reduce the cost of lower-density foods could have a positive impact on consumer choice.49

2.1.5 Differences between sit-down and fast-food restaurants: frequency of consumption and nutrient intakes

Past research has found consistent positive associations between eating out at FFs and weight gain, but not for other types of restaurants.30,50,51 However, a recent paper found the frequency of eating out at both FFs and SDRs was associated with a higher BMI, and with each meal eaten out of the home per week, an increase in average BMI by 0.8kg/m2 for FFs, and 0.6kg/m2 for SDRs was seen.52 Two other papers found that FFs items had significantly fewer mean calories (33%) than items from SDRs, and that a larger proportion of items from SDRs were excessive in calories than those from FFs.37,38 These studies contradict the idea that FF menu items are less healthy than other types of restaurants. Investigating differences between the nutrient contents of foods served at these types of establishments beyond calories may help elucidate why FF items have a stronger association with weight gain than SDR items if they tend to be lower in calories.

2.2 Levels of saturated fat, sodium, and sugar in restaurant foods

In addition to excess energy content, restaurants foods are characterized by high levels of sodium and SF due to the nature of food preparation methods, such as deep frying, of many foods. Beyond calories, many public health authorities identify these nutrients, along with added sugars, as nutrients to limit for a healthier diet, as each of them have been associated with a variety of negative health outcomes. These nutrients are also those often targeted by FOP labelling schemes and reformulation

7 initiatives to alert consumers to products high in these nutrients.53-58 This section will review the literature on each of these nutrients in the context of the restaurant sector.

2.2.1 Saturated fat in restaurant foods

SF consumption has been found to increase risk of CVD, specifically myocardial infarctions and strokes.59-61 Some recent meta-analyses have questioned whether SF has a substantial impact on heart health, however it remains the recommendation of health organizations to limit them from the diet.2,6,62-64 A 2015 Cochrane review of the literature on SF consumption and CVD concluded that there was moderate evidence that a long-term reduction in SF reduced the risk of cardiovascular events by 17%.21 They noted that replacing SF with polyunsaturated fats appeared to have the most significant protective effect, while replacing them with carbohydrates was less effective. This supports what was found by three other systematic reviews on the topic.23,63,65 These papers note that while significant reductions in CVD risk are found when SF intake is replaced with polyunsaturated fats (PUFAS), higher SF levels were not directly linked to increased CVD or stroke risk, and that the source of the SF may also be an important factor.65

Previous research has found high SF levels in restaurant items. Urban et al assessed SF levels in restaurant foods through two different studies, one examining three products (large french fries, cheeseburgers and grilled chicken sandwiches) and the other examining four products (the three aforementioned plus the addition of regular cola) from three unnamed major restaurant chains in the United States, comparing levels from 2000-2013 in the former and 1997-2013 in the latter.66,67 They found no significant changes to SF levels over the fourteen-year period in their sample, however the small sample size greatly limits these studies’ generalizability. Another study by Bruemmer et al found that 50% of menu items analyzed from King County, Washington, exceeded SF targets, and a systematic review from 2017 reported that US consumers consume 20-35% of their total fat intakes from restaurant food items.68,69 Only one paper was found to have examined SF content of Canadian restaurant foods as part of a multi-national comparison of SF levels in international chains, with no studies having looked at Canada exclusively.27 The study did not provide an overall average SF value for Canadian menu items, and included data from only seven chain restaurants, meaning it may also not have been representative of the entire sector. More comprehensive research of SF levels in Canadian restaurant foods is needed to establish current levels and develop targets for improvement.

2.2.2 Sodium in restaurant foods.

Excessive sodium intake has been strongly linked to an increase in blood pressure, a leading risk factor for stroke and heart disease.70-73 One paper found hypertension to be associated with a 2.5 higher risk of heart attack within a ten-year time frame.74 A 2013 Cochrane review concluded that a modest reduction in sodium intake sustained for at least one month leads to a significant decrease in blood pressure in both hypertensive and normotensive individuals.70 They noted that initiatives to reduce sodium intake in the population could have a significant effect on public health, and reduce the burden of cardiovascular diseases on the healthcare system over time. They also noted that while achieving the current recommendations of reducing sodium intake to 2,000-2400mg per day would have positive benefits, aiming to reduce it further to around 1,200mg of sodium would be a better long-term goal. These results were supported by two other systematic reviews published around the same time period.22,71

A paper most recently published as part of the INTERMAP study found no other nutrients consumed alongside sodium attenuated its effect on blood pressure, further emphasizing its singular and significant contribution to this risk factor, and solidifying the assertion that reducing sodium levels could have a direct and significant benefit on reducing blood pressure.75 To date, sodium reduction targets have been established in Canada for packaged foods, but not restaurant foods.76 Meanwhile in the US and the UK, targets have been set for both packaged and restaurant foods.77,78 However, a US- based committee from Institute of Medicine (IOM) concluded voluntary reductions in sodium are ineffective; suggesting the best way to make a population-wide reduction would be through mandatory regulation.79

The only research on sodium levels in menu items in Canadian restaurants was conducted by Scourboutakos et al, comparing 2010 and 2013 levels, and results show no significant changes in the average amount of sodium.19 The proportion of foods (around 10%) containing over the Upper Tolerance Limit (UL) of sodium (per serving) also had not changed. In the US, the aforementioned Urban et al study in the SF section also examined sodium, and found that from 1997-2013, while 18% of menu items decreased in sodium, another 33% increased.66 Another US study by Jacobson et al tracking 73 US chain restaurants found an overall 3% increase in sodium levels from 2005-2011, indicating levels were marginally increasing.80 These findings were supported by a study by Hearst et al who found sodium levels in the US had increased over a 14 year period through their assessment of the Health Eating Index (HEI)-score for menu items, although raw values were not provided.81

However, a comparative study of sodium levels from six major chains in six different countries (Australia, Canada, France, New Zealand, UK, and USA) found substantial variation in mean sodium levels depending on the country, indicating that Canada therefore requires its own research in order to obtain an accurate assessment of sodium levels in Canadian restaurant foods.82

A survey on public support of sodium regulation in 2014 found that 56% of US consumers supported government restrictions on sodium, and 81.5% supported sodium reduction policies, indicating that the public recognized the negative impact of sodium and would be supportive of government initiatives to reduce sodium in the food supply.83 A clinical study by Patel et al on product formulation and consumer acceptance also found that US consumers rated moderately modified recipes of popular restaurant dishes as acceptable. These modifications include reductions of up to 210 calories, 20 grams of total fat and 8 grams of SF, as well as up to 1,970 mg of sodium per serving, showing that healthier reformulations, including significant reductions in sodium, in the FF industry can be done in a way that does not negatively impact taste.84 Six restaurant partners were involved in the study so that exact recipes (which are proprietary) could be used and modified to enhance the validity of the results. These studies demonstrate the feasibility of sodium reduction in restaurant foods without diminishing taste or the product’s appeal to consumers.

2.2.3 Sugar in restaurant foods

Research has shown individuals consuming higher amounts of added sugars have a higher risk of obesity, diabetes, hypertension, dental caries, and CVD.9,10,25,26 However, a recent systematic review has emphasized that these associations may be due to added sugars being a source of excessive calories, rather than anything inherent in the sugars.85 Regardless, increased overall sugar intake is significantly associated with an increase in body weight, and vice versa, even after sensitivity analyses.10 A prospective cohort study in the United States also found a significant association between added sugar consumption and CVD mortality risk, with those consuming between 10%-24% of their calories from sugar having a 1.30 (Confidence Interval (CI): 1.09-1.55) hazard ratio (HR) and those consuming ≥25% a 2.75 (CI 1.40-5.42) HR compared to those consuming less than 10% of their calories from added sugars.26 Due to these associations, and sugars being one of the primary sources of excessive energy in the diet, it makes sense to target their reduction in the food supply to help tackle the obesity epidemic and obesity-related conditions. As of 2015, an average of 26% of Canadian’s daily energy intakes were reported to have come from total sugars, an increase from 21% in 2004.86 Sugary beverages, primarily soft drinks, have been highlighted as top sources of sugars in most

Canadians’ diets, along with items with naturally-occurring sugars such as fruit.86 Food items such as sugar-sweetened beverages (SSBs), which provide little nutrition and for which sugars provide the majority of the calories, are often the focus of studies and policies to reduce both sugar and energy intakes in both adults and children.85,87

Public Health England identified reformulation in restaurant foods to be one of their eight priority areas for reducing added sugar consumption, however research on average sugar levels in restaurant foods is sparse.88 One previous study was found analyzing added sugar levels from restaurant foods by Rehm and Drewnoski using NHANES data, which indicated that US children were consuming less fats, sodium and sugar from fast-food sources compared to previous years.89 However, they suggested this was more likely an indication of a reduction in fast-food consumption on a national level in the US, rather than a reflection of improvements in nutritional quality at these establishments.89 The paper did not involve an examination of the nutritional values of the foods themselves. Two studies from New Zealand and Australia included sugar levels in their assessments of restaurant foods, both finding elevated sugar levels, with Chand et al highlighting the high mean sugar content (56g per serving) of regular beverage items from FF establishments, and Dunford et al noting that some FF salads, which may often been perceived as the healthier options by consumers, also contained up to 40g per serving.90,91 A Canadian study examined sugar levels in children’s meals from restaurants and found over 50% exceeded the WHO proposed daily maximum limit and 19% exceeded the current one (22.5g and 45g, respectively, based on values for a 4-8 year old).20 However, they did not examine the rest of the menu. The scarcity of information on average sugar levels in restaurant foods hinders the ability to create targets and policies to improve the nutritional quality of restaurant foods and make a public health impact. An overall analysis of average sugar levels in restaurant foods as well as which categories have the highest levels is a necessary starting point to begin working towards improvements.

2.3 Research and policies on menu labelling

2.3.1 Energy labelling

Energy labelling is the most common form of menu labelling, where the energy content of each menu item, either in kilocalories or kilojoules, is published on the menu alongside each item’s name or description. Mandatory energy labelling has been implemented in Ontario, the US, and five states in Australia (New South Wales, South Australia, the Australian Capital Territory, Queensland, and

Victoria), and is currently under review by the Australian and UK governments for national implementation.16,92-94 There are two main ways menu labelling is purported to lead to improved health outcomes: the first is through influencing consumer choice, and the second is by influencing restaurants to reduce the energy contents of high-energy menu items, or encouraging restaurants to offer lower-energy alternatives.

2.3.2 Impact of energy labelling on consumer choice

Research into the effectiveness of energy labelling on consumer choice has shown mixed results, although recent reviews have concluded a small but positive effect on the amount of calories ordered. A Cochrane review of calorie labelling in menu items concluded that including energy information on menus results in a statistically significant reduction in calories ordered, however they noted the evidence was based on few studies of low quality, and that further high quality studies were needed. Another recent meta-analysis of various types of food labelling, including but not exclusive to menu labelling, also concluded that labelling significantly reduced consumer intake of energy and total fat.95 However, earlier literature, including one meta-analysis and four systematic reviews, overall did not find a significant impact on consumer choice in studies done in a real world setting, with studies either finding no or only a small reduction in calories ordered.96-101 One of the systematic reviews focused exclusively on the impact of calorie labelling on the choices of children and adolescents, and noted school cafeterias to be an exception, as menu labelling in that setting has been shown to have positive effect on student choice.97 While the evidence on energy labelling and reductions in calories ordered was weak, authors of the Cochrane review found no negative impact, and several suggested it to be a useful addition to multi-pronged strategies to help combat obesity.95,98,101,102

Many of the papers also noted that there was no consensus on the most effective design or format for menu labelling, and the designs used were inconsistent across studies.96-98 One systematic review found that labelling with calories alone did not reduce calories ordered, but calories along with contextual or interpretive information did.101 However, Shangguan et al’s meta-analysis proposed that the type of labelling used may be less important than whether or not there was a label.95 More research into the various formats of menu labels, along with more consistent interventions across studies, could lead to more concrete results and help inform the implementation of future menu labelling schemes.

When surveyed, the vast majority of consumers in the US supported the implementation of energy labelling, although the preferred format of the labels varied between simple calories (35%), percent of

12 recommended daily energy intake (39%), and physical activity equivalents (26%).103 A survey polling actual usage of menu labelling found 52% of the almost 24,000 participants reported that they used menu labelling to inform their choices when available.104 People who reported using menu labelling were more likely to be obese or overweight individuals, and who also reported already engaging in other healthy behaviors such as exercising, avoiding soft drinks, and consuming more fruits and vegetables. While these results suggest that menu labelling may not alter the behavior of someone not already engaging in activities to improve their health, it does suggest that it can be useful to those motivated to make better choices and improve their health. If menu-labelling is to be part of a broad approach to combat obesity, the fact that it is used by those who are overweight and trying to engage in healthier behaviors is a positive sign it could help achieve this goal. However, as this study was observational and based on self-reported responses, an intervention study is needed to determine if menu labelling objectively changed people’s behaviors, and who would be most affected.

2.3.3 Impact on the nutrient composition of menu items

Research on the impact of menu labelling on product reformulation is scarce compared with research on its impact on consumer choice. The only Canadian research paper published on menu labelling and reformulation evaluated the early impact of the Ontario Healthy Menu Choices Act; however, results suggest no significant change in calories or serving sizes immediately following implementation.105 A study assessing the impact of the energy labelling legislation in New South Wales Australia also did not find that the introduction of energy labelling significantly decreased the energy contents of menu items from the top five chains in the area, up to four years after its implementation.106 However, two menu-labelling studies conducted in the United States did report significant reductions in the energy, SF, and sodium contents both in the thirty days following implementation as well as at 18 months.69,107

It should be noted the two studies showing a significant difference focused exclusively on entrées, while the two that did not achieve significance included all standard menu items except beverages. Differences in the types of products analyzed make it difficult to compare results. While one of the papers that included all standard menu items did break down their results into categories, the categorizations were focused around types of foods (ex. burgers, salads, breakfast) rather than by meal type (entrée, side, starters).106 Differences in inclusion criteria and item categorizations, along with varied geographical regions, time frames, and sample sizes, may account for the differences in outcomes and reduce comparability.

Overall, results concerning product reformulation are mixed, possibly due to inconsistent study designs hindering comparisons, and the limited number of studies available. Further research is needed to demonstrate the reproducibility and reliability of the results. However, caloric labelling also does not present information on the other nutritive aspects of the food, and it cannot be assumed that the impact of caloric labelling and those of other nutrients, or a holistic symbol indicating the overall healthfulness of a food, would be the comparable.

2.3.4 Menu labelling beyond calories

Menu labelling policies involving more than calories are less common, with the only currently implemented programs being New York City’s salt shaker logos (see Figure 2.1a), which indicate whether a menu item contains ≥2300mg of sodium per serving, and Philadelphia’s menu labelling legislation, which requires that calories, SF, trans fat, sodium and carbohydrate values be listed next to each item on the menu.108,109 No papers analyzing the impact of New York City’s logos on either consumer choice of product reformulation were found at the time of this thesis. One study was found assessing the impact of Philadelphia’s menu labelling ordinance, which conducted customer surveys and collected transaction receipts from several outlets of the same establishment, comparing results at Philadelphia outlets with labelling to those at outlets outside of Philadelphia, without labelling.110 They found that food labelling was associated with healthier food choices, with a mean of 151 fewer calories, 224mg less sodium, and 3.7g less SF when compared to the choices of customers at unlabeled restaurants. However, they noted that while 76% of users surveyed reported they noticed the labels, only 26% reported actively using them to inform their choices, and that label users appeared not to understand the recommended intakes for the labelled nutrients. A lack of education on what the label numbers signify in terms of daily recommendations could impede the effectiveness of the labels.

Figure 2.1: Example of NYC’s Salt Shaker logo (1a) and Australia’s Health Star Rating labels (1b).108,111

An Australian study simulated the application of their government’s voluntary FOP labelling system – called the Health Star Rating (HSR) system, which was designed to be applied to packaged foods, to menu items from 13 FF chains in Australia.112 This system assesses food items both on its content of negative nutrients, such as SF, sodium, and sugars, as well as positive nutrients such as fiber and protein, to obtain a healthfulness rating of 0.5 to 5.0 stars, as shown above (Figure 2.1b). They found that overall fast foods had a similar mean HSR to packaged food items from the same categories (with a mean rating of 2.5 stars in fast foods, compared to 2.6 stars in packaged foods), and concluded that the HSR system was able to evaluate the nutritional quality of restaurant foods comparably to packaged foods. They suggested that the system could be extended to restaurant foods, and there could be significant advantages to having a consistent standardized labelling system across the food sector. This was backed up by an evaluation of the HSR system in retail stores, which found consumer understanding and usage of the labels to select healthier foods was increasing with the increased prevalence of the labels, and that public sentiment was positive.113 While they did not evaluate the effectiveness of these labels in terms of consumer choice, a more recent study did, evaluating how adding HSR labels to menus effected consumer choice compared to no labels, simple energy labels, or the presence of both energy and HSR labels.114 They found that the presence of both an HSR label and energy led to consumers selecting items with a significantly (p=0.024) healthier mean HSR score than when presented with either no label or simple energy labels, while the HSR label alone led a non- significant increase in healthier selections. They concluded the HSR could be a useful tool for consumers to help make healthier choices, especially when presented alongside mandatory energy labels.

Some further studies have been done assessing the effectiveness of menu labelling formats in influencing consumer choice, especially compared to calorie-only conditions. Here in Canada, a quasi- experimental study found that adding a Heart and Stroke Foundation Health Check logo beside menu items that were lower in fats and sodium, and higher in fiber and protein, lead to significantly (p<0.05) less saturated fat and carbohydrates, and more protein and fiber ordered by consumers, although most participants did not recall seeing the logo after ordering.115 These results are supported by another study that compared menu labelling formats, which found that while calorie labeling lead to a reduction in calories ordered, providing full nutrition facts tables or health-related claims lead to

15 reductions in other nutrients, such as carbohydrates and calories from fat.116 Further, an online Canadian study found conducted among 3080 participants examined the impact of adding a sodium label to menus alongside calories found consumers ordered an average of 171-384mg (p<0.0001) less sodium compared to those who only saw calorie information, depending on the type of establishment.117 However, an Irish study simulating the implementation of several icon-based menu labels indicating a variety of health claims (ex. “cholesterol friendly”, “weight friendly”, etc) in partnership with 11 food establishments did not find a significant change in sales for items awarded an icon compared to items without an icon.118 The authors suggest that the lack of consumer familiarity with the logos may have reduced their effectiveness, and that any menu labelling initiative should be implemented alongside an education campaign to increase consumer awareness and understanding of the labels.

Overall, there is a dearth of research into the effectiveness of alternative menu labelling initiatives displaying more than energy content, particularly in relation to active menu labelling legislations. There is also a lack of data on the effectiveness of applying of existing FOP labelling systems used in packaged foods, which consumers would already be familiar with, to the restaurant sector.

2.3.5 Health Canada’s Front-of-Pack ‘high-in’ labels

The Canadian government has proposed regulations mandating FOP ‘high-in’ labels for packaged foods that contain high levels of sodium, SF, and/or sugar.56 Similar labels for packaged foods have already been introduced in Chile, and research has found such warning labels to be effective at influencing consumer choices, particularly among middle- and upper-SES households.119-123 While the proposed regulations would not apply to restaurants menus, this type of label could be useful in restaurants as it would bring consistency with packaged foods. The ‘high-in’ labels also already account for meal-sized dishes sold in grocery stores, which have a higher cutoff than individual foods (see tabulation under 3.2.1), making it easy to apply the system to both full meals and non-meal items from restaurants. This system would enable consumer choice to avoid items high in nutrients of concern to them, which is currently not possible to do due to the lack of information provided in restaurants.

Figure 2.2. Proposed designs for Health Canada’s upcoming FOP labels.124 2.4 Summary and literature gaps

To summarize, there is a paucity of literature on the nutritional quality of restaurant foods in Canada, with no data on average levels of SF or sugar levels in restaurant foods outside of children’s menus, specifically kid’s meals, and no sodium data within the past six years.19,20,27 Data published internationally suggest that levels of these nutrients are high in restaurant foods and have shown little change over the past two decades.66,81,91,125 However, multinational comparison studies show wide variation in the nutrient levels of the same food items between countries, suggesting research specific to Canada is necessary to be able to inform public policy and initiatives to improve the healthfulness of our food supply.17,27,82 Restaurant foods make up a significant proportion of Canadian’s dietary intakes, and frequent consumption of foods from outside of the home, particularly from FFs, have been associated with adverse health outcomes such as obesity.13,30,31 Restaurant menu items should therefore be included in policies and programs aimed at tackling obesity and improving the healthfulness of Canadian’s food choices to optimize their effectiveness.

Health Canada’s proposed ‘high-in’ FOP labels for SF, sodium, and sugars in packaged foods provides an opportunity to examine their application on menu items in restaurants.56 A similar warning label for sodium has already been implemented in New York City, and research applying Australia’s FOP labelling system to restaurant items suggested symbols such as the HSR can be reliably used to assess menu items similarly to how it is used to evaluate packaged foods.108,112 Australian researchers concluded having a consistent standardized labelling system across the entire food supply could have significant benefits on consumer understanding and use, as well as population health.112 While research on the effectiveness of menu labelling has been inconclusive, the vast majority of the literature focuses

17 on energy labelling, rather than the broader range of nutrients of public health concern.96-99,102 The only paper published on an implemented menu labelling scheme involving more than calories found the labels to reduce the levels of calories, sodium, and SF ordered.110 Similar results have also been found by other studies assessing the effectiveness of various menu labelling schemes in experimental rather than real-world conditions.115-117,120 However, it is not known what proportion of menu items would require such labels if they were applied, and there is no consensus on the most effective format of these labels to impact consumer choice.

The objectives of this thesis aimed to address some of these literature gaps, and to facilitate future research on the topic.

2.5 Thesis Objectives

The main goal of this thesis was to establish baseline data on the nutritional quality of restaurant foods sold in Canada to encourage and inform the creation of public policy for foods sold at these establishments. This overall goal was broken into two primary research objectives:

2.5.1 Objective 1

The first objective of this thesis was a) to determine the sodium, SF, and sugar levels in chain restaurant foods in Canada and b) to compare the levels of these nutrients in FF and SDR establishments. The hypothesis was that restaurant items in Canada would be high in SF, sodium, and sugars. It was also hypothesized that SDR establishments would contain higher mean levels of these nutrients compared to comparable foods from FF establishments, given that prior research has shown higher mean energy levels; differences, however, could be mediated by portion size.

2.5.2 Objective 2

To assess what proportion of menu items would require one or more Health Canada FOP ‘high-in’ warning label if the proposed FOP regulations were extended to restaurant foods, and how these labels would be distributed across menu categories. Building on the hypotheses for Objective 1 that restaurant menu items will be high in the three nutrients of interest, I hypothesize that a large proportion of menu items would also require a Health Canada FOP label for each of the nutrients evaluated, and a majority of menu items will require at least one of the three.

Chapter 3 Study 1 – A quantitative analysis of the saturated fat, sodium, and sugar levels in fast-food and sit-down restaurant menu items. 3.1 Abstract

Introduction: The nutritional quality of restaurant foods in Canada is currently not monitored, and limited research has evaluated the nutrient contents of these foods. Given the increasing proportion of foods consumed outside the home from these establishments, this study aimed to assess levels of nutrients of public health concern in Canadian restaurant foods.

Methods: Mean levels of SF, sodium, and total sugars of 10,950 food and beverage products from 96 national chain restaurants in Canada were assessed. Data are presented by food categories, and levels in FF and SDR establishments are compared.

Results: Overall levels of SF, sodium and sugar were high. Entrées contained on average 54% of the total daily value for sodium (1259mg per serving) and just under half (45%) of the total daily value of SF (9.0g per serving). Beverages and Desserts had high levels of total sugars (mean 43g and 32g per serving, respectively), but tended to be low in sodium. Side dishes tended to have the lowest levels of sugars, SF, sodium and calories per serving. SDR items had significantly (P≤0.0001) higher levels of SF and sodium overall, although FF items had higher average sugar levels due to the higher number of Beverage and Dessert items.

Conclusion: Levels of nutrients of concern in Canadian restaurant foods are excessive among most food categories. As frequency of restaurant food consumption rises, policies to promote reformulation and increase transparency of these items’ nutritional content are important to reduce their negative impact on public health.

3.2 Introduction

It is well documented that excess intakes of sodium, SF, and sugars are associated with poor health outcomes and intakes should be limited. 9,24,26,70,126-130 On average, Canadians spent 30.4% of their food budget in restaurants in 2018, a proportion that has increased by 1-2% annually over the last five years.13,14 It is therefore increasingly important to understand the nutritional quality of foods purchased

18 19 outside the home. As of 2017 in Ontario, major chains (≥20 outlets) are required to display calories on their menus, however the release of all other nutritional information remains voluntary.12,131 This is contrary to the US, where disclosure of full nutrient levels is required, along with the labelling of items’ caloric contents on menus.92

Research is very limited on the levels of sodium, SF, and sugars found in restaurant foods in Canada. Previous Canadian research found elevated sodium levels across menu items with a mean of 892±679mg/serving of sodium in 2013, which had not significantly improved since 2010.19 A smaller study focusing on kid’s meals found 50% of them exceeded recommended maximum sugar intakes.20 No other research has evaluated sugar levels in Canadian restaurant foods beyond children’s items, and SF has only been reported in multi-national comparison studies, which were limited in the amount of data they reported on each country included.17,27 One of these also focused exclusively on children’s meals, while the other reported Canada to have neither the highest nor the lowest SF levels among the countries evaluated.

More extensive research has been done in the United States looking at sodium and SF levels in restaurant foods, but not at sugars.67,81,125 A longitudinal study assessing changes in the nutritional quality of menu items from eight popular chains from 1997-2010, using the Healthy Eating Index, found the overall nutritional quality of foods and beverages was poor and had not improved over the period of study.81 Further research found most large-sized restaurant meals exceeded the daily upper limits for SF and sodium intakes, and longitudinal changes in sodium were inconsistent across food types and establishments.67,80,125 These results suggest an overall low nutritional quality of restaurant foods and no evidence it is improving. However, menu items from different countries have been found to have significantly different nutritional compositions, despite being from the same chains, and cannot be generalized from one country to another.27

Most of the literature on eating outside of the home distinguishes between two types of restaurants – fast food establishments (FF) and sit-down restaurants (SDR), defined by the presence or absence of table service. Most literature concerning the nutritional quality of restaurant foods has focused exclusively on FFs.17,27,67,81 However, research that looked at both types of restaurants found SDRs to have higher mean energy and sodium levels than FFs.19, 37,38,125 Given that SDRs represent a significant proportion of the restaurant industry, including them in assessments of the nutritional quality of menu items is necessary to get an accurate representation of the restaurant sector.

The objectives of this paper were to: a) evaluate the sodium, SF, and sugar levels in chain restaurant foods in Canada; and b) compare the levels of these nutrients in FF and SDR establishments. These analyses will provide a comprehensive evaluation of these nutrients in the restaurant sector.

3.3 Methods

Sampling of restaurant information. Restaurants with ≥20 Canadian outlets were eligible for inclusion, following methods used in previous Canadian analyses, using data publicly available on restaurants’ Canadian websites. 19, 132 In the case of four establishments where a country-specific website was not available, the North American version of the website was used. Of the 197 eligible establishments, identified using The 2016 Directory of Restaurants and Fast-Food Chains in Canada, 90 published this information at the time of collection (May-June, 2016).132 Further, data from four restaurants that had ≥20 locations during previous collections (2010 and 2013) but had now dropped below the threshold, and one establishment previously listed as a single entity with ≥20 locations that has since been split into two, were also collected to enable longitudinal comparisons. This brings the total sample to 96 establishments available for analysis, representing market share of 75% of FFs and 40% of all restaurants in Canada, including 84% of the top 50 chains.133 A table of included restaurants along with the number of outlets and menu items analyzed can be found in Supplementary Table 3.1 in Appendix A.

Data Extraction and validation. Nutrition information was retrieved from each website and entered into a database called Menu-FLIP.19 Items were categorized by major category (starter, entrée, side, dessert, or beverage) and by subcategory (e.g. entrées further divided into pizzas, burgers, etc). Serving sizes listed in ounces or milliliters were converted to grams, using density conversion factors derived from the Canadian Nutrient File.134 Duplicates were removed, however items sold in multiple sizes (such as small, medium, or large beverages) were included as separate items to represent the entirety of options on the menu. Restaurants were classified by establishment type (FF or SDR, Supplementary Table 3.1). Researchers not involved in the data analysis (see acknowledgements) checked 10% of the nutrient values and categorizations for accuracy; inconsistencies (less than 3%) were resolved through consensus. Extreme value checks, where outliers were verified, and Atwater calculation checks were also completed.

Final Sample. A total of 10,950 items were analyzed. Some establishments did not provide all nutrients; the total n for each nutrient were as follows: n=10,415 (95.1% of the total sample) for SF,

21 n=10,859 (99.1%) for sodium, and n=10,458 (95.5%) for total sugars. Serving sizes were available for 9,093 (83.0%) of the sample. It should be noted some establishments provided nutritional information for a limited number of items (Supplementary Table 3.1) which may not be representative of their complete menu. Analyses were therefore performed by category, rather than by establishment.

Information on individual condiments, sauces, and add-on items that would not be ordered on their own (for example, avocado or cucumber slices to add to a sandwich), were omitted. In cases where an item, such as a salad, might be listed without dressing and with multiple potential sauces, independent combination items were created combining the values of the salads with the dressings. This follows what was done in previous Canadian research.19

Statistical Analysis. All statistics were performed using SPSS version 25.0.18 Descriptive statistics were calculated overall, by category and by subcategory, for sodium, SF, and total sugars. Sodium was reported in milligrams, while sugars, and SF are reported in grams. All three main variables were analyzed per stated serving size and per 100g, when serving sizes were available.

Results were compared to percent daily values (DV%) used on Canadian Nutrition Facts tables to indicate the proportion of one’s total daily intake of a nutrient each serving represents.135,136 As the data were not normally distributed, Mann-Whitney U-tests were run to assess whether there were significant differences between the median nutrient levels per food category/subcategory depending on restaurant type.

3.4 Results

The total number of items evaluated consisted of 10,950 foods, including entrées (52% of the sample), beverages (19%), side dishes (13%), desserts (11%), and starters (5%). Table 3.1 presents mean and median SF, sodium and sugar levels by serving size and per 100g.

Nutrient Levels Per Serving. Entrées had the highest levels of SF and sodium per serving, while beverages had the highest sugar contents. Entrées had the highest content per serving of SF (mean 9.0g, CI: 8.8-9.3) and sodium (1259mg, 1170-1282) followed by Desserts for SF (7.2g, 6.7-7.7) and Starters for sodium (1250mg, 1162-1336). Beverages had the highest sugar levels per serving (43g, 42- 45), followed by desserts (32g, 31-34). Median nutrient content per serving with quartiles are presented in Figure 3.1, and a more detailed breakdown of nutrient levels by subcategories can be found in Supplementary Tables 3.2 & 3.3.

Nutrient Levels Per 100 grams. Desserts had the highest mean SF levels per 100g (5.1g, 4.8-5.3), and Starters the highest sodium (464mg, 441-487), with Entrées being the second highest in both nutrients per 100g (3.2g, 3.1-3.2, for SF; 434mg, 427-440, for sodium). Desserts had higher sugar contents per 100g than Beverages, with means of 22g (22, 23) and 10g (10, 10), respectively. For all nutrients, mean values tended to be greater than the median values, both per serving size or per 100g.

Table 3.1. Levels of saturated fat, sodium, and sugar in Canadian restaurant menu items, by major category Saturated Fat (g) Sodium (mg) Sugar (g) Category n Mean ±95 CI Median ±95 CI n Mean ±95 CI Median ±95 CI n Mean ±95 CI Median ±95 CI Per Serving Overall 10415 7.0 6.8, 7.1 4.5 4.5, 5.0 10859 859 841, 878 580 570, 600 10458 17 17, 18 7 7, 8 Beverage 1728 2.5 2.3, 2.7 0.1 0.1, 0.2 2043 130 124, 135 100 98, 110 2045 43 42, 45 38 37, 40 Desserts 1150 7.2 6.7, 7.7 4.5 4.5, 5.0 1198 260 347, 273 210 200, 230 1194 32 31, 34 23 22, 23 Entrées 5582 9.0 8.8, 9.3 6.0 6.0, 7.0 5626 1259 1170, 1282 1002 980, 1030 5344 8 8, 9 5 5, 6 Sides 1412 3.6 3.4, 3.9 2.0 2.0, 2.5 1446 680 648, 713 531 505, 570 1345 5 4, 5 3 2, 3 Starters 543 7.9 7.1, 8.7 4.2 3.7, 5.0 546 1250 1163, 1336 920 870, 1010 530 6 6, 7 3 3, 4 Per 100g Overall 8585 2.7 2.7, 2.8 2.2 2.2, 2.3 9030 317 311, 322 308 301, 315 8728 7 6, 7 3 3, 3 Beverages 1575 0.6 0.5, 0.7 0.0 0.0, 0.0 1891 34 32, 35 21 19, 25 1894 10 10, 10 9 9, 10 Desserts 994 5.1 4.8, 5.3 4.5 4.1, 4.8 1042 195 186, 205 145 127, 164 1038 22 22, 23 22 22, 23 Entrées 4382 3.2 3.1, 3.2 2.9 2.9, 3.0 4426 434 427, 440 414 408, 421 4216 3 3, 3 2 2, 2 Sides 1188 2.0 1.9, 2.2 1.3 1.2, 1.4 1222 380 361, 398 349 336, 360 1138 3 3, 3 2 2, 2 Starters 446 2.8 2.6, 3.1 2.1 1.8, 2.3 449 464 441, 487 433 402, 465 442 2 2, 3 2 1, 2 Table 3.1 presents the number of items per category included in each analysis, along the means and medians with their confidence intervals. Means are provided per serving as well as per 100g, the latter accounts for how portion size impacts the means of each category.

Figure 3.1. Boxplots of the interquartile range and median levels of saturated fat, sodium, and sugar in Canadian restaurant foods, per serving and per 100 grams. Per Serving Per 100g Saturated Fat (g)

Sodium (mg)

Sugar (g)

Comparison to DVs. Overall content of SF, sodium and sugar were high, with the average Entrée item containing over half (1259mg/serving, 54%) of the total daily value (DV) for sodium and just under half (9g/day, 45%) of the total daily value for SF. Beverages and Desserts tended to have very high total sugar content (median 38% DV and 23% DV in a single serving, respectively), but were low in sodium. Side dishes had the lowest sugar, SF, sodium and calorie content per serving.

FF/SDR Comparison. Both per serving (Table 3.2) and per 100g (Table 3.3), items from SDRs had higher mean and median levels of sodium and SF overall, while items from FFs had significantly higher sugar contents. By category, items from SDRs had higher median sodium and SF levels per serving for Desserts, Entrées, and Starters. Median SF and sugar contents for Sides between establishment types were equivalent, and comparisons per serving were not statistically different from each other (p=0.32 for SF, p=0.279 for sugars). While the trends were generally the same per serving size and per 100g, the scale of the differences were much smaller when evaluated per 100g, with SDR median SF and sodium levels at 200% and 210% of FF median per serving respectively, but 150% and 127% of the FF median per 100g. The difference in median sugar levels between items from FFs and SDRs however was greater when evaluated per 100g than per serving (with the SDR median being 75% of the FF median per serving, vs. only 56% per 100g).

Table 3.2. Comparison of mean nutrient levels in Canadian fast food and sit down establishments, per serving

1 1 Relative Fast Food Establishments (n =71) Sit-Down Establishments (n =25) FF vs proportion SDR of median, Category n2 Mean ±95 CI Median ±95 CI n2 Mean ±95 CI Median ±95 CI P-value SDR to FF3 Saturated Fat (g) Overall 6107 5.0 4.9, 5.2 3.5 3.5, 4.0 4308 9.7 9.4, 10.0 7.0 7.0, 8.0 ≤0.0001 200 Beverages 1543 2.6 2.3, 2.8 0.2 0.2, 0.3 185 1.7 0.9, 2.5 0.0 0.0, 0.0 ≤0.0001 0 Desserts 893 5.3 4.9, 5.6 4.0 4.0, 4.5 257 13.9 12.6, 15.3 12.0 9.0, 14.0 ≤0.0001 300 Entrées 2776 6.9 6.6, 7.1 5.0 5.0, 6.0 2806 11.2 10.8, 11.5 9.0 9.0, 10.0 ≤0.0001 180 Sides 816 3.5 3.2, 3.8 2.0 2.0, 2.5 596 3.9 3.4, 4.3 2.0 2.0, 2.5 0.32 100 Starters 79 2.6 1.9, 3.3 2.0 2.0, 2.5 464 8.8 7.9, 9.7 5.0 4.6, 6.3 ≤0.0001 250 Sodium (mg) Overall 6530 653 632, 674 420 400, 440 4329 1170 1137, 1202 880 848, 920 ≤0.0001 210 Beverages 1858 133 127, 138 110 104, 120 185 103 76, 130 30 25, 45 ≤0.0001 27 Desserts 935 231 218, 244 190 170, 210 263 364 329, 400 320 261, 370 ≤0.0001 168 Entrées 2808 1113 1074, 1153 910 890, 950 2818 1405 1364, 1446 1135 1100, 1178 ≤0.0001 125 Sides 850 728 688, 768 611 580, 650 596 612 558, 666 400 360, 460 ≤0.0001 65 Starters 79 731 630, 832 790 720, 840 467 1337 1239, 1435 1050 930, 1179 ≤0.0001 133 Sugar (g) Overall 6217 21 20, 21 8 8, 9 4241 13 12, 13 6 6, 7 ≤0.0001 75 Beverages 1860 45 43, 46 39 38, 41 185 29 25, 32 26 23, 28 ≤0.0001 67 Desserts 937 28 26, 29 22 22, 23 257 49 45, 53 43 41, 47 ≤0.0001 195 Entrées 2594 6 6, 6 4 4, 5 2750 11 10, 11 6 6, 7 ≤0.0001 150 Sides 750 4 4, 5 3 2, 3 595 5 4, 6 3 3, 4 0.279 120 Starters 76 2 2, 3 1 1, 3 454 7 6, 8 4 4, 5 ≤0.0001 400 Table 3.2 presents the means and medians per serving for each category when separated by establishment types. P-values comparing category medians between FF and SDR establishments, calculated with Mann-Whitney U-tests, are provided. Boldface indicates statistical significance (p<0.05) (or appropriate value). Boldface indicates statistical significance (p<0.05) (or appropriate value). 1 Number of restaurant chains for that restaurant type 2 Number of menu items by category for each nutrient 3 Shows the SDR median as a relative proportion of the FF median (SDR/FF*100).

Table 3.3. Comparison of nutrient levels in Canadian fast food and sit down establishments, per 100g Fast Food Establishments (n1=71) Sit-Down Establishments (n1=25) Relative proportion FF vs SDR of median, Category n2 Mean ±95 CI Median ±95 CI n2 Mean ±95 CI Median ±95 CI P-value SDR to FF3 Saturated Fat (g) Overall 5374 2.4 2.4, 2.5 1.8 1.7, 1.9 3211 3.2 3.1, 3.3 2.7 2.6, 2.8 ≤0.0001 150 Beverages 1465 0.6 0.6, 0.7 0.0 0.0, 0.1 110 0.4 0.1, 0.6 0.0 0.0, 0.0 ≤0.0001 -- Desserts 781 4.6 4.3, 4.9 3.7 3.3, 4.2 213 6.8 6.2, 7.3 5.9 5.4, 6.8 ≤0.0001 160 Entrées 2357 3.0 2.9, 3.1 2.9 2.8, 3.0 2025 3.3 3.2, 3.4 2.9 2.8, 3.0 0.003 100 Sides 697 2.0 1.8, 2.1 1.3 1.2, 1.5 491 2.1 2.1, 1.8 1.2 1.1, 1.4 0.397 92 Starters 74 2.3 1.5, 3.0 1.4 1.0, 2.0 372 2.9 2.7, 3.2 2.2 1.8, 2.8 0.001 157 Sodium (mg) Overall 5798 287 281, 294 273 262, 286 3232 369 360, 378 348 339, 356 ≤0.0001 127 Beverages 1781 33 32, 35 23 20, 27 110 39 27, 52 12 10, 18 ≤0.0001 53 Desserts 823 204 192, 216 141 118, 194 219 163 147, 179 150 130, 162 0.072 106 Entrées 2389 463 455, 472 451 442, 459 2037 398 389, 408 374 365, 387 ≤0.0001 83 Sides 731 401 383, 419 362 350, 379 491 348 310, 386 301 268, 339 ≤0.0001 83 Starters 74 519 453, 585 452 409, 545 375 454 429, 478 431 393, 465 0.042 95 Sugar (g) Overall 5521 8 8, 8 4 4, 4 3207 4 4, 5 2 2, 2 ≤0.0001 56 Beverages 1784 10 10, 10 9 9, 10 110 8 7, 9 9 7, 10 0.046 101 Desserts 825 22 22, 23 22 22, 23 213 23 21, 24 23 21, 25 0.647 104 Entrées 2194 3 2, 3 2 2, 2 2022 3 3, 3 2 2, 2 0.169 100 Sides 647 3 2, 3 2 1, 2 491 3 3, 4 2 2, 2 0.05 113 Starters 71 2 1, 2 1 0, 2 371 2 2, 3 2 1, 2 0.003 136 Table 3.3 presents the means and medians per 100g for each category when separated by establishment types. P-values comparing category medians between FF and SDR establishments, calculated with Mann-Whitney U-tests, are provided. Boldface indicates statistical significance (p<0.05) (or appropriate value). 1 Number of restaurant chains for that restaurant type 2 Number of menu items by category for each nutrient 3 Shows the SDR median as a relative proportion of the FF median (SDR/FF*100).

Beverage/Dessert Sensitivity Analyses. As the items with the highest sugar contents were confined to the beverage and dessert categories, and 91% and 78% of those categories were from FFs, a sensitivity analysis was run to determine whether these categories drove the higher sugar contents of the average FF menu item. When omitting both beverages and desserts from the comparisons, the median sugar level per serving in SDR items was 167% that of the FF median, a full reversal of the original analysis where SDR appeared lower in median sugar level. When omitting desserts, median sugar levels were equivalent between restaurant types, but the exclusion of beverages resulted in SDR establishments having higher median sugar levels per serving l by 120%. Per 100g, removing either beverages or desserts separately from the analysis resulted in FF items remaining significantly (p<0.0001) higher in sugar than SDR items. However, removing both beverages and desserts eliminated the significant difference between the two (p=0.111). These results can be seen in Supplementary Table 3.4.

3.5 Discussion

This paper reports the most up-to-date data on sodium, SF, and sugar levels present in menu items in the Canadian restaurant sector. Overall, levels of these nutrients tend to be high per serving, and many items contained almost half of the recommended daily value for either SF, sodium, or sugars. Entrées and Starters had the highest amounts of sodium and SF, while Desserts and Beverages had the highest sugar content. Side dishes overall had the lowest levels of the nutrients evaluated, which may partially be attributed to smaller serving sizes, as seen when values were examined per 100g. Means values tended to be greater than median values, both per serving and per 100g, highlighting the skewed distribution of the data, further displayed in Figure 3.1.

Our results are consistent with previous literature. A 2014 review of the nutritional content of restaurant foods in the US found starters contained the highest mean levels of sodium and SF (sugars were not evaluated), and fewer than 3% of entrées were within the recommended limits of either nutrient.137 A recent evaluation of sodium in US menu items found a mean of 758mg/serving among 5,186 menu items, which had not changed significantly since 2012-2016.125 Importantly, these levels are lower than those found in Canada, which were 892mg mean sodium in a study of 2,198 items in 2013, and 859mg per serving in the present study of 10,859 menu items.19 The similar means from our study of 2016 restaurant foods and those of Scourboutakos et al indicate there have not been significant reductions in sodium levels of Canadian menu items since 2013. This differs from packaged foods, which have shown modest sodium reductions since the release of Canadian sodium targets in 2010.138

28 29

SF levels in Canadian restaurants foods have only briefly been examined in two multi-national comparison studies, one of which focused exclusively on children’s menu items, and another which did not report overall means or medians.17,27 Some longitudinal studies in the United States have included SF in their analyses, finding modest decreases in the SF content over time, but mean levels remained elevated, particularly for entrées.67,81 Bruemmer et al reported 13.7g±10 mean SF for 1,641 entrées in King’s County, Washington, while studying the effects of a menu-labelling legislation on nutritional quality.69 This value is much higher than the mean of 9.0g/serving for entrées found in our study, but the extremely localized sampling used in the King’s County study makes it difficult to compare to one at a national scale like the present one. Bruemmer et al’s results are however comparable to levels found by Wu & Sturm in 2012, from a national US sample >28,000 menu items, which found a mean SF level of 12g/serving in entrées, 16g/serving in starters, and 4g/serving in sides.137 They did not examine beverages and desserts. By category, these levels all exceed what was found in the present study (9.0g, 7.9g, and 3.6g, respectively). This may represent a regional difference in either SF levels or serving sizes between the US and Canada.

Literature on sugar levels in restaurant foods are equally scarce. Previous Canadian research calculated the proportions of added sugars in children’s meals, and found the average amount of added sugar (25±0.36g) exceeded WHO recommended daily sugar intakes.20 Two papers from Australia and New Zealand looking at popular FF chains included sugars in their analyses, one found beverages were high in sugars (mean 56g/serving, compared to 43g found in the present study) and the other noted some salads contained up to 40g/serving.90,91 No other North American research investigating sugar levels in restaurant foods were found. Our study therefore provides a baseline of mean sugar levels, overall and by category, in a North American context for future studies to compare to.

Literature examining the relationship between frequency of eating out and health outcomes have found that frequent eating at FFs had a significant association with obesity, type II diabetes, and heart disease, but either no association or a modest one for SDRs.30,50-52 Despite this, research examining the nutritional quality of restaurant foods has found higher mean energy and sodium levels in SDR items than FF items, with larger portion sizes being proposed as a potential explanation.19,37,38,125 Our results show SDRs in Canada also have higher median sodium and SF than FF establishments, as well as higher sugar levels in Entrées and Starters. However, these differences cannot be fully explained by portion size, as the nutrient density of SDR items remained significantly higher for these nutrients even when assessed per 100g.

Limitations. Only 46% of eligible establishments (≥20 outlets) published nutritional information online at the time of collection. However, data were available for most of the largest chains by market share in Canada. A US study found nutrient levels were significantly lower in establishments that voluntarily published their nutritional information online, compared to those that only made it available upon request.137 This suggests our results may underestimate actual levels. A policy mandating transparency from chain restaurants in Canada would allow for the inclusion of all eligible restaurants, as required in the US.92 The quality of the data in the study was dependent on the accuracy of the data collected, as validating nutrient composition of menu items was beyond the scope of this study. Some items may have had artificially low contents due to low reported serving sizes, such as pizzas reported by slice when served as the whole pizza, or the absence of sauces and condiments from the nutritional information of items they are served with. Should disclosure of nutritional information from restaurants become mandatory, standardized serving sizes and reporting standards may be necessary to ensure information reflects the actual nutritional quality of items as typically consumed.

Future Directions. Tracking these nutrients longitudinally will be necessary to determine whether conditions are improving in response to initiatives such as the Canadian Sodium Reduction Strategy, or if reformulation will occur primarily in the packaged food sector, as has been seen to date.76,138 Furthermore, Health Canada has proposed a mandatory ‘high-in’ FOP warning labels for all prepackaged foods containing >15% DV (30%DV for meals) of sodium, SF or sugar per serving.56 Analyzing menu items in the context of these regulations could help emphasize the prevalence of unhealthy foods in the restaurant sector, and encourage more attention to improving the healthfulness of these foods.

3.6 Conclusion

Canadian restaurant foods are currently high in sodium, SF, and total sugars across menu categories. Sector-wide reductions in these nutrients, through both reformulation and reductions in serving sizes, are necessary to decrease excessive consumption of these nutrients and to help reduce risk of non- communicable diseases such as obesity, hypertension, and CVD. Increased policy action targeting product reformulation and disclosure of nutritional information in restaurants should be encouraged.

Chapter 4 Study 2 – Results of applying the Canadian proposed FOP labelling regulations to chain restaurant menu items 4.1 Abstract

Background. Restaurants are subject to far less regulation than packaged foods when it comes to disclosing nutritional information. However, this sector is increasingly prominent in consumers’ food purchase and consumption habits. Health Canada has proposed a new mandatory front-of-package (FOP) warning label system for packaged foods, which if applied to restaurant foods could help consumers avoid foods high in nutrients of public health concern.

Objective. This study assessed the proportion of menu items that would be required to carry these symbols if they were applied to the restaurant sector.

Design. Nutritional data for food and beverage menu items (n=10,950) were collected from the websites of restaurants with ≥20 Canadian outlets in 2016. Each item was assessed according to Health Canada’s FOP thresholds for saturated fat, sodium, and sugar to determine whether they would require a warning symbol if the regulations were extended to restaurant foods.

Results. Of all eligible menu items, 79% would require at least one FOP symbol, with 48% requiring at least two. In terms of nutrients, ≥47% of all items would require a sodium or saturated fat warning. 79% of all beverages and desserts would require a sugar warning. Proportions from fast-food and sit- down establishments were generally similar overall, although differed somewhat when examined by nutrient.

Conclusions. These results show the majority of restaurant foods to be high in nutrients of public health concern, thus there is an urgent need for regulations that apply to both packaged and restaurant foods to improve their nutritional quality and assist consumers in making healthier choices.

31 32

4.3 Introduction

Health Canada is currently developing regulations for mandatory, front-of-package (FOP) labelling for packaged food and beverage items in the retail sector that are high in (≥15% Daily Value (DV) saturated fat, sodium, or sugar, as described in Canada Gazette 1 (CG1).56 With Canadians spending 30.4% of their food dollars in restaurants in 2018, and 54% of Canadians reporting they eat out at least once a week, restaurants are a significant contributor to Canadian diets, but are frequently overlooked in terms of nutrition regulations.13,139 Currently, chain restaurants in Canada are not required to disclose nutritional information, with the exception of calories in some establishments in Ontario, nor ingredient lists, and will be exempt from the upcoming FOP labelling regulations.16,56 Restaurant foods are however acknowledged in Health Canada’s updated Food Guide, which encourages people to choose healthier menu options.140 This is inherently difficult for consumers given the lack of quantitative information available to inform consumer choices. Consumers may assume certain choices to be healthy, such as salads, soups, and sandwiches, however many of these items can be high in saturated fat, sodium, and/or sugar, with levels comparable to those found in some burgers or pizzas.91

Simple FOP warning symbols such as the ones proposed for packaged foods could easily be applied to menus and menu boards to give consumers the ability to quickly and easily make more informed choices when eating away from the home. This has already been done for sodium in the city of New York, where a logo depicting a salt shaker framed by a yield-sign appears next to the item name on menus of restaurants with ≥15 outlets, if the sodium content of the food meets or exceeds a threshold of 2300mg.108 The currently proposed FOP symbols will already apply to many packaged foods that are comparable to items purchased in chain restaurants, such as pizzas, chicken fingers, deserts, and frozen meals.56 Extending a version of Health Canada’s FOP labelling to menu items could help consumers choose the ‘healthier menu option’ by avoiding items high in saturated fat, sodium and/or sugar.

The objective of this paper was to apply the published thresholds designed for a prepackaged FOP labels to menu items from restaurant chains in Canada, in order to assess what proportion of menu items would be required to carry one or more FOP symbols if the regulations were applied to the restaurant sector.

4.4 Methods

Study Sample. This study was conducted using data from the 2016 collection of Menu-FLIP, a database containing nutritional information for restaurants with ≥20 Canadian outlets.19,132 Publicly available nutrition information published on restaurants’ websites was collected. Of the 197 eligible establishments, 90 published this information at the time of data collection (May-June, 2016). Further, data from four restaurants (Applebee’s, Flying Wedge Pizza, Mmmuffins, Pizza Salvatore) that had ≥20 locations during previous Menu-FLIP collections (2010 and 2013) but have now dropped below the threshold, as well as one establishment that was previously listed as a single entity with ≥20 locations and has since been split into two (Mr. Greek Mediterranean Grill, and Mr. Greek Express), were also collected for the purpose of enabling longitudinal comparisons. This brings a total sample of 96 establishments available for analysis, representing, by market share, 75% of FF establishments and 40% of all restaurants, including 84% of the top 50 chains.133 Items were categorized by category (starter, entrée, side, dessert, or beverage), and by restaurant type, defined by presence or absence of table service (sit-down or fast-food, respectively). Ten percent of values and categories were verified by third-party researchers (see acknowledgements) and any inconsistencies (<3%) were resolved through consensus. Extreme value checks and Atwater calculations were also conducted. Data for individual condiments, sauces, as well as toppings were omitted from the final sample, as these are not directly ordered and consumed as stand alone menu items.

Final Sample. A total n of 10,950 menu items were eligible for analysis in this study, however as some establishments did not provide complete nutritional information for all items, the total n for each nutrient was as follows: n=10,415 (95% of the total sample) for saturated fat, n=10,859 (99%) for sodium, and n=10,458 (96%) for total sugars. The breakdown of the sample by category was: entrées (52% of the sample), beverages (19%), side dishes (13%), desserts (11%), and starters (5%). The total n for the combined analyses (only assessing items providing values for all three nutrients) was 10,062 (92%).

Items Automatically Classified as Not Requiring a Label. Following the guidelines published in Canada Gazette 1 (CG1), all fresh/canned/frozen fruits and vegetables, and plain milks qualified for exemptions, meaning that they were automatically classified as not requiring an FOP symbol, regardless of whether they would exceed the threshold for one of the nutrients of interest. These mainly consisted of items like fresh fruit cups that exceeded the sugar thresholds, or 2% milks that

34 exceeded the saturated fat threshold. Items for which it was not clear that there was no added sodium, saturated fat or sugars to the dish (ex. a side of “Seasonal Vegetables”) and that exceeded one or more of these thresholds were not exempted.

Assessment by Thresholds. FOP cut-offs for sodium, saturated fat, and sugars were applied to all items to assess the proportion of items that would require a ‘high-in’ symbol if Health Canada extended its FOP labelling to menus. The standard 15% DV cut-off (see table) was applied to all categories except entrées, which were assessed following the 30% DV cut-off designated for frozen and prepackaged meals. As per CG1 published by Health Canada, nutritional information for any items with a reported serving size below 50g were adjusted to 50g for the analysis. These cut-offs are described in Table 1. An analysis combining individual nutrient assessments was also completed, to determine the proportion of items that would require one, two, or all three of the FOP warning symbols.

Table 4.1. Tabulation of DVs and FOP thresholds for each nutrient, per serving1 Thresholds Sodium Saturated Fat2 Sugars DV3 2300mg 20g 100g FOP Cut-off for 15% DV (345mg) 15%DV (3g) 15% DV (15g) all categories except Entrées FOP Cut-off 30% DV (690mg) 30%DV (6g) 30% DV (30g) applied to Entrées 1Assessments were done by either stated serving size in the place of the reference amounts used for packaged foods, or by 50g if the stated value was <50g. 2Although referred to as the threshold for saturated fat, the results were calculated using the sum of saturated and trans fats, as per the FOP criteria, unless trans information was not provided 3 DV= Daily Value, as described by Health Canada 135

Statistical Analysis. Thresholds were applied to all menu items. Results were analyzed with SPSS to calculate the proportions that met or exceeded the criteria for an FOP symbol, along with 95% confidence intervals. 141

4.5 Results

Overall, 79% of all restaurant menu items would require at least one ‘high-in’ warning symbol. Of these, 31% would require one of the three symbols, 43% would require two, and 6% would require all three, as shown in Figure 4.1. The distribution of these among food category and subcategory is

35 described in Supplementary Table 4.1 in Appendix B. The majority of items that would require all three came from the Dessert and Starter categories, with the most notable subcategory being Milkshakes & Floats, almost half of which would require all three warning symbols. The difference in the overall proportion of items requiring ≥1 symbols between sit-down and fast-food establishments was minor, with the sit-down restaurant proportion being higher by 2.4%, but varied more widely when compared by category, as shown in Table 4.2.

FIGURE 4.1: Proportion of menu items requiring 0, 1, 2, or 3 FOP labels, overall and by category.

100

80 70 60 50 40 30 20 10 0 Overall Beverage Dessert Entrée Side Starter

No Labels One Label Two Labels Three Labels

Figure 4.1 shows the proportion of menu items that would require one or more FOP labels, using a n=10,062.

Table 4.2: Proportion of menu items requiring 0, 1, 2, or 3 FOP symbols, FF vs SDR. 95% One 95% Two 95% Three 95% No Label Confidence Symbol Confidence Symbols Confidence Symbols Confidence Category N (%1) Interval (%1) Interval (%1) Interval (%1) Interval Fast-Food Establishments Overall 5821 22.3 21.2, 23.4 37.6 36.4, 38.9 36.1 34.8, 37.3 4.0 3.5, 4.5 Beverage 1538 16.0 14.2, 17.9 59.0 56.6, 61.5 20.0 18.1, 22.1 4.9 3.9, 6.1 Dessert 883 8.0 6.4, 10.0 35.3 32.2, 38.5 44.7 41.5, 48.0 11.9 9.9, 14.2 Entrée 2594 32.5 30.7, 34.3 24.5 22.9, 26.2 41.8 39.9, 43.7 1.3 0.9, 1.8 Side 730 17.4 14.8, 20.3 40.1 36.6, 43.7 40.0 36.5, 42.6 2.5 1.5, 3.8 Starter 76 14.5 7.9, 23.6 56.6 45.4, 67.3 28.9 19.7, 9.8 0.0 0.0, 0.0 Sit-Down Restaurants Overall 4241 19.9 18.7, 21.1 21.3 20.1, 22.6 51.3 49.8, 52.8 7.5 6.7, 8.3 Beverage 185 26.5 20.5, 33.2 63.8 56.7, 70.5 6.5 3.6, 10.7 3.2 1.4, 6.6 Dessert 257 4.3 2.3, 7.3 11.7 8.2, 16.0 41.6 35.7, 47.7 42.4 36.5, 48.5 Entrée 2750 19.6 18.1, 21.1 17.1 15.8, 18.6 58.4 56.6, 60.3 4.8 4.1, 5.7 Side 595 17.4 14.8, 20.3 40.1 36.6, 43.7 40.0 36.5, 43.6 2.5 1.5, 3.8 Starter 454 14.5 7.9, 23.6 56.6 45.4, 67.3 28.9 19.7, 39.8 0 0.0, 0.0 1Percentages include exemptions which were counted as being below threshold no matter the values, as described in the methods section of this paper, and are reported by row

By nutrient, 50% of all items would carry a saturated fat warning and 47% a sodium one, while 29% would require a sugar warning (Figure 4.2). The Desserts and Starters categories had the highest proportions of items requiring a saturated fat symbol, while Entrées and Starters had the highest proportion of items requiring a warning symbol for sodium. Of desserts and beverages served in restaurants, 79% and 80% respectively would require a sugar warning. These results are described with a full subcategory breakdown in Supplementary Table 4.2. When examined by nutrient, 22% more items from fast-food type establishments would require a sugar warning, while 21% more of sit-down establishment items would require a saturated fat or sodium warning. The differences in outcomes between the two restaurant types by category and subcategory can be found in Supplementary Table 4.3.

Figure 4.2. Proportion of menus items exceeding the threshold for a FOP warning label for saturated fat, sodium, or sugar, overall and by category.

100 90 80 70 60 50 40 30 20 10 0 Side Side Side Entrée Entrée Entrée Starter Starter Starter Overall Overall Overall Dessert Dessert Dessert Beverage Beverage Beverage Saturated Fat Sodium Sugar

Exceeds Threshold

4.6 Discussion

Our results highlight that high levels of saturated fat, sodium, and sugar are pervasive across restaurant foods, with the majority of items containing an excess of at least one of the three nutrients when assessed accordingly to the high-in thresholds developed by Health Canada for packaged foods. Given that more Canadians are consuming foods purchased in these settings, this is an issue of urgent public health concern. As labelling requirements for packaged foods continue to be expanded to encourage

37 38 reduced consumption of these nutrients, the extension of these regulations to include restaurant foods should be considered to provide consumers with an equal ability to make informed choices regardless of where they purchase their foods.

Our results are supported by previous literature evaluating the nutritional content of restaurant foods, which have consistently found elevated levels of these nutrients in menu items in a variety of countries.19,20,27,66,81,91,125,137 However, previous research on menu labelling has focused almost exclusively on the impact of calorie labelling, rather than nutrient-focused ‘high-in’ warning symbols like the ones explored in this paper, as that is the most common form of menu labelling implemented.96-99 Only one paper evaluating the effectiveness of a menu labelling initiative disclosing more than just calories was found in the literature: a 2013 study of consumer response to Philadelphia’s implementation of a menu labelling law, which required full-service restaurants to label sodium, fat, and carbohydrate content on menus.110 It’s results showed the labelling to be associated with a mean reduction of 151 calories, 224mg of sodium, and 3.7g saturated fat ordered compared to those ordered from unlabeled establishments. No papers evaluating the New York City’ salt shaker logos, the most comparable menu labelling scheme to the one trialed in this paper, were found at the time of this study.

Only two other papers have described the simulation of a FOP labelling scheme applied to restaurant foods, using Australia’s Health Star Rating (HSR) system.112,114 This system differs from Canada’s FOP symbols in that it factors in positive nutrients like protein and fibre along with the negative nutrients targeted in this study to obtain a composite rating of an item on a range of 0.5 to 5.0 stars.111 The first paper found menu items in their study’s sample received a mean HSR of 2.5 out of 5.0 stars, comparable to what was found for packaged foods.112 They concluded the model was effective in evaluating restaurant foods, and that with a few adaptions to suit the restaurant environment, such a system could be effectively implemented on menus. The second paper further found the presence of HSR labels alongside energy labelling positively impacted consumer choice.114 Overall, research on nutritional labelling beyond calories in restaurant foods is very scarce, but those that are available conclude it has the potential to have a beneficial impact on public health and should be considered as part of public health strategies to inspire healthy eating.

As only 90/197 (46%) of establishments with ≥20 locations in Canada published public nutritional information at the time of collection, and some establishments did not publish complete data on all the

39 nutrients examined in this study, our results may be limited in their generalizability to the full restaurant sector, although this study did capture 84% of the largest fast food chains by market share. It’s unknown how the inclusion of further data would impact the results of this study and may limit the generalizability of our study. The accuracy of our results also depends on the accuracy of the data provided by the restaurant chains, as without regulation there is no monitoring of the values these establishments provide. Furthermore, some results may be biased by the portion sizes establishments choose to report by, as while packaged foods now have to adjust their nutritional values to a standardized reference amount, no such values have been developed for restaurant foods.142 For example, some restaurants report a portion of pizza as being a single slice, while others report nutrition for the entire pizza. This may lead to similar items being scored differently. Mandating the release of nutritional information from restaurants, as is done in the US, and establishing reference amounts for restaurant foods to ensure standardized reporting of nutritional information would greatly enhance the accuracy of future research.92

4.7 Conclusion

In conclusion, the majority of menu items from major restaurant chains would require at least one FOP ‘high-in’ symbol if they were included in the regulations introduced by Health Canada. These results show the urgent need for strategies and regulations to improve the nutritional quality of restaurant foods and help inform consumers on which products will be the healthier choices. The current FOP symbols under development could be a viable way to do this on menus and menu boards, similarly to what has been done in New York City. Future research into the validity of nutritional information provided by restaurants, as well as consumer response to adding this type of labelling to menus, could help enhance the results of this study.

Chapter 5 Overall Discussion 5.1 Synopsis

This thesis aimed to address the lack of literature on the nutritional quality of restaurant foods in a Canadian context, and to establish mean levels of SF, sodium, and total sugars in Canadian menu items. It also aimed to simulate the application of Health Canada’s FOP labelling scheme in restaurant foods to assess how many products would require a label if the legislation were extended beyond packaged foods.

Study 1 found that mean levels of sodium and SF were high across menu items, with entrées containing on average over half (54.7%) of the UL for sodium (2300mg) and 45% of the maximum daily value for SF (20g). Starters tended to be marginally lower in all three nutrients compared to Entrées. Side dishes and Beverages tended to have the lowest levels of SF and sodium, per serving and per 100g, however beverages had the highest mean sugar contents per serving, and the second highest per 100g. Desserts were high in SF and sugar, both per serving and per 100g, but low in sodium. Items from SDRs had higher mean sodium and SF contents than items from FFs, both per serving and per 100g, indicating the difference is not solely down to a difference in portion sizes. Study 1 also highlighted the lack of publicly available nutritional information from restaurants, with only 46% of eligible restaurants publishing their nutritional information at the time of collection, and the lack of standardization in how that information is presented when available, leading to incomplete data for a number of items.

Study 2 found 78.8% of eligible menu items would require at least one FOP label, compared to 61.7% of packaged foods.143 Further, 42.5% of all menu items would require two labels, and 5.5% would require all three, including 18.8% of desserts. By nutrient, 50.1% and 52.2% of all menu items would require a SF or sodium label respectively, while 28.6% would require a sugar label. However, 79.9% and 79.0% of all beverages and desserts would require a sugar label. The overall proportion of items requiring one or more labels differed by only 2.4% percent when comparing SDRs and FFs. As a greater proportion of menu items are excessive in the nutrients targeted by Health Canada’s ‘high-in’ labels than packaged foods, it is illogical from a public health perspective to omit them from initiatives to reduce Canadian’s intakes of these nutrients. The high proportion of menu items that would require

41 a FOP warning label should alert authorities to the urgent need to improve nutritional quality in the restaurant sector.

These findings will be discussed in the context of their implications for future policy development in the following sections.

5.2 General Discussion & Implications for Policy

Studies 1 and 2 highlight not only that mean and median levels of nutrients of public health concern are high in Canadian restaurant foods, but that the vast majority of items surpass government thresholds that would require them to carry a warning label if they were held to the same standards as packaged foods. These results are consistent with the previous literature on the topic, and represent both the largest study of its kind conducted in Canada and among the largest conducted worldwide, in terms of both the number of establishments and menu items included. This thesis particularly adds to the literature in its coverage of SF and sugar levels across the restaurant food supply in Canada, which to this date have not been previously examined. Further, the results relating to FF and SDR establishments highlight that SDR menu items tend to have higher levels of nutrients of concern than FF ones, and that future research and public health initiatives targeting the restaurant sector should include both types to be most effective, rather than focusing solely on FF establishments.

Health Canada’s new food guide mentions making healthier choices in restaurants and engaging in mindful eating as ways to improve one’s diet, however they have yet to take any action to ensure that the restaurant sector provides adequate information to enable consumers to make informed and healthier choices.140 This thesis shows that only a minority of eligible restaurants (46%) published nutritional information at the time of data collection. There was also a wide variance in how nutritional information is reported by those who choose to do so, with some publishing only partial nutritional facts (such as releasing total fat values but not saturated or trans fat), some omitting sides and sauces served with the meal from their calculations which may misrepresent the nutritional profile of the meal as served, and some reporting lower serving sizes than what is served (such as reporting values per one slice of pizza or per one chicken wing when an entire pizza or basket of wings is served). These issues make it difficult not only for consumers to correctly gauge what they are eating, but also for researchers to properly compare restaurant offerings in terms of nutritional quality, as those that report values for the full amount served appear to have worse nutritional quality than those who do not. The mandatory disclosure of a full nutritional facts table, either online or in store, along with standardized

42 serving sizes similar to the reference amounts established for packaged foods, would resolve these issues and greatly improve the ability to hold restaurants accountable for what they serve.

Some policies on menu labelling have already been developed at the provincial level, and could be used as a basis for implementing a national policy. British Columbia has developed a voluntary scheme called the Informed Dining program, which has restaurants post their full nutritional information in a standardized format online for consumers to access and make informed choices.144 While voluntary schemes not been shown to be effective, making this program mandatory and extending this voluntary program nationally would bring Canada in line with implemented policy in the United States, which has already legislated the release of nutritional information from chain restaurants as part of the Affordable Care Act.92 Similarly, an amendment of Ontario’s Healthy Menu Choices Act, which mandates energy labelling on chain restaurant menus, to include the nutrients covered in Health Canada’s FOP labelling legislation could also help improve public health.16 Timing its implementation to coincide with the appearance of the FOP labels in packaged foods would provide Canadians with a systematic and standardized way of identifying foods to limit across the entire food supply. Adjusting and extending existing policies to the restaurant sector may be easier than implementing new ones, and any expansion of nutritional transparency in the restaurant sector could be highly beneficial to increasing consumer awareness of the nutritional quality of the products they are consuming.

Some establishments in the sector have already voluntarily pledged to improve the nutritional quality of their items and their transparency in one way or another. For example, Subway has pledged to reduce the sodium levels in their foods globally, and McDonald’s has pledged to improve the nutritional quality of its Happy Meals, and to only market Happy Meals meeting certain nutrition criteria (e.g. ≤600kcal, 10% calories from SF, 650mg sodium, and 10% calories from added sugar) to children by 2022.145,146 However, an Australian assessment found that while its top chains all pledged to publish their nutritional information, only 5/11 chains evaluated reported having taken any steps to reduce levels of nutrients of concern in their offerings.147 Introducing formal, mandatory government policies to reduce the levels of these nutrients in restaurant foods may be necessary to prompt restaurants to take action.

The inclusion of sugars in this analysis helped highlight the excessive amounts of sugar found in many of the beverage offerings on Canadian restaurant menus, which has not been previously explored. Sugar-sweetened beverages have been widely researched in relation to obesity risk, with systematic

43 reviews finding an overall positive association between habitual consumption and incidence of obesity, and sugary beverages were found to be the top sources of sugars in Canadians’ diets in 2015.86,148,149 The average beverage evaluated in this thesis contained 43g of sugar per serving. Subcategories such as milkshakes, juices/smoothies, and soft drinks contained an average 82g, 56g, and 46g of sugar per serving respectively, representing even higher proportions of the recommended maximum total sugar intake of 100g per day.136 The presence of large and extra-large sized beverage items may be responsible for some of these results, as beverages are not the highest in sugar content per 100g. Introducing policies to restrict larger sized beverage options, as was previously proposed in New York City, as well as targeting beverages sold in chain establishments for sugar reductions could have a significant benefit to reducing excessive sugar intakes among the Canadian population.150

As discussed in Sections 2.3 and 4.5, there is also a paucity of studies examining the effect of menu labelling on product reformulation and consumer behavior, particularly examining labelling schemes involving more than just caloric labelling. As nutrient-focused labelling schemes become more prevalent worldwide in the packaged foods sector through FOP labels (such as Nutriscore in France, Traffic Light Labelling in the UK, Health Star Ratings in Australia and New Zealand, Warning Labels in Chile, and soon FOP ‘high-in’ labels in Canada), extending such schemes to restaurant foods makes sense to get a more complete evaluation of our food supply and to provide consumers with a systematic way to assess their food, regardless of which retail sector it comes from.53,56,58,111,121 Our study simulates the application of an FOP label to menu items, similarly to how Dunford et al simulated HSR in Australian restaurant foods, but did not test consumer response to such labelling as done by Kerin et al and Niven et al as it was beyond the scope of its objectives.112,114,118 Given that so little has been published regarding the application of FOP labels to menu items, it is hoped that our contributions to the literature will prompt more attention to this area of research, both by policy makers and researchers who will continue to address the considerable literature gaps on this topic.

This thesis has some further limitations, primarily those examined in the discussion sections of the individual study chapters (3.5 and 4.5). Notably, the incomplete sample (i.e. only 46% of eligible establishments publishing information at the time of data collection) hindering generalizability, and the lack of standardization in reported serving sizes and inconsistent inclusion of condiments and sides in entrées, leading to large variances. Further, the lack of sales data means we do not know which items are most popular or most commonly consumed from each establishment, giving equal weight to all items regardless of what proportion of sales they make up. Integrating sales data could help identify

44 and target popular items that are high in one or more nutrient of public health concern, and therefore would have the greatest impact if their nutritional quality was improved.

Another notable limitation is the lack of alcoholic beverages represented in our sample. Alcoholic beverages are currently exempt from disclosing nutritional information in Canada, and were not provided in any of the collected nutritional information for this study. However, beverages such as beers, wines, and cocktails are commonly consumed at restaurants alongside meals. It is unknown how the inclusion of these items may have altered our results for the Beverage category, and overall nutrient intakes of consumers eating outside the home. This gap in nutritional transparency laws further hinders our ability to properly assess nutritional quality in restaurants, and may mislead consumers on how much they may be consuming in one sitting. Modifying nutritional labelling regulations to represent the entire food supply, including menu items and alcoholic beverages, is critical to providing consumers with the ability to make informed choices in all aspects of their dietary intakes.

5.3 Future research

This thesis provides a baseline which future researchers can use to track changes in the levels of these nutrients in restaurant foods as consumers continue to spend an increasing proportion of their budgets on items from this sector. The two studies described in this thesis were both cross-sectional; a longitudinal study of how nutrient levels in Canadian restaurant foods have changed over time, as well as additional data collection cycles would provide Canadians with an up-to-date overview of the nutritional quality of restaurant foods they are consuming. The only longitudinal study published in Canada on the changes in these nutrient levels in restaurant foods tracked sodium levels from 2010- 2013, and did not find any significant change.19 It is possible this time period was not sufficient to detect changes, or that increased effort has been put in by restaurants in recent years since to improve the quality of their offerings, although the sodium results found in the present study suggest 2016 sodium levels remain similar to those found in 2013. Conducting a larger longitudinal study, covering a longer time period and more nutrients than just sodium, may help elucidate any changes occurring in the restaurant food supply over time.

Furthermore, a study on consumer acceptance and usage regarding menu labelling, particularly using nutrient-focused labels such as Health Canada’s FOP labels or other FOPs created in other jurisdictions, would greatly enhance the literature. Studies testing various formats of menu labels to

45 identify the most intuitive option for consumers to use would also be necessary, as an optimal format has not been identified. If current FOP labels applied to packaged foods are extended to restaurant foods, design modifications to render the labels recognizable when printed in a smaller size alongside a line of text on a menu will be necessary for feasibility of implementation. Similar symbols are already commonly used by restaurants to represent when an item is vegetarian, spicy, or contains nuts, to alert people with dietary restrictions or food sensitivities. Using such symbols as a basis to simplify FOP labels for menu labelling could make it easier for restaurants to add them to their menus without overhauling their layouts, and still be both intuitive and informative for consumers.

Research by Patel et al tested how reducing calories, SF, sodium in various menu items to various degrees would affect consumer response, and found that modest to moderate reductions in sodium and fat levels in common menu items were considered acceptable to consumers.84 However, Vermote et al found that while reducing the portion sizes of French fries by 20% reduced caloric intake, the majority of consumers both noticed the reduction and indicated they would not approve of the reduction being permanent.45 Testing gradual reductions in portion sizes, or the acceptability of smaller reductions in portion sizes, such as 10% instead of 20%, in a variety of items could help determine the best adjustments restaurants could make to reduce consumers caloric and nutrient intakes without hurting consumer acceptance. Based on the results of this thesis, testing consumer acceptance of portion size reductions in beverages could be particularly beneficial, as portion sizes were found to be partially responsible for the excessive sugar levels per serving in the Beverage category. Identifying to what degree beverage sizes could be reduced without backlash could help encourage establishments to make such adjustments.

5.4 Final Conclusions

In conclusion, the restaurant sector is under-researched and under-regulated compared to the packaged food sector, and the majority of menu items tend to be excessive in at least one of SF, sodium, and sugar. Further, current labelling requirements for the Canadian restaurant sector lag behind those of packaged foods as well as restaurant foods in the US. Extending Health Canada’s upcoming FOP labels to restaurant menu items could be a good way to address this gap, as well as to highlight the prevalence of restaurant foods excessive in these nutrients. Our results show a higher proportion of restaurant items would qualify for a FOP warning label than packaged foods, emphasizing the urgent need for more regulation in this sector to enable informed decision making, and to encourage product

46 reformulation towards healthier items. As the government continues to develop public health initiatives to curb obesity and increase consumer awareness of the nutritional quality of the foods they are consuming, greater attention needs to be paid to the restaurant sector to ensure their effectiveness.

Chapter 6 References

1. Government of Canada. Heart disease - heart health. Retrieved from: https://www.canada.ca/en/public-health/services/diseases/heart-disease-heart-health.html. Accessed 2018-10-29.

2. Heart & Stroke Foundation. Saturated Fat, Heart Disease, And Stroke. heartandstroke.ca: Heart & Stroke Foundation; 2015.

3. National Heart L, and Blood Institute (NIH),. Listen to Your Heart: Learn About Heart Disease. Retrieved from: https://www.nhlbi.nih.gov/health-topics/education-and-awareness/heart- truth/listen-to-your-heart.

4. Network CO. Obesity in Canada. Retrieved from: http://www.obesitynetwork.ca/obesity-in- canada. Accessed 2018-01-12.

5. Diabetes Canada. Diabetes statistics in Canada. 2017. Retrieved from: http://www.diabetes.ca/how-you-can-help/advocate/why-federal-leadership-is- essential/diabetes-statistics-in-canada. Accessed 2017-10-29.

6. Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr. 2010;91(3):535-546.

7. Mensink RP, Zock PL, Kester ADM, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003;77:1146-1155.

8. Zhou L, Stamler J, Chan Q, et al. Salt intake and prevalence of overweight/obesity in Japan, China, the United Kingdom, and the United States: the INTERMAP Study. Am J Clin Nutr. 2019;0:1-7.

9. Te Morenga L, Howatson AJ, Jones RM, Mann J. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. Am J Clin Nutr. 2014;100:65-79.

10. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ. 2013;346(7891):12.

11. Mente A, de Koning L, Shannon HS, Anand SS. A Systematic Review of the Evidence Supporting a Causal Link Between Dietary Factors and Coronary Heart Disease. Arch Intern Med. 2009;169(7):659-669.

12. Canadian Food Inspection Agency. Nutrition labelling: general requirements. Retrieved from: http://www.inspection.gc.ca/food/labelling/food-labelling-for-industry/nutrition- labelling/general-requirements/eng/1386946331880/1386946333349. Accessed 2019-05-14.

47 48

13. Statistics Canada. Average household food expenditure by province. 2018. Retrieved from: http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/famil132a-eng.htm. Accessed 2019-06-15.

14. Charlebois S, McGuinty E, Keselj V, et al. Canada's Food Price Report. Dalhousie University, University of Guelph; 2019.

15. Garriguet D. Canadian's Eating Habits. Health Reports. 2007;18(2):17-32.

16. Government of Ontario. Healthy Menu Choices Act, 2015, S. O. 2015, c. 7, Sched 1. In: Ontario Go, ed. 15h07. Toronto: Queen's Printer for Ontario; 2015.

17. Hobin E, White C, Li Y, Chiu M, O'Brien MF, Hammond D. Nutritional quality of food items on fast-food 'kids' menus': comparisons across countries and companies. Public Health Nutr. 2014;17(10):2263-2269.

18. Scourboutakos MJ, L'Abbé MR. Sodium levels in Canadian fat food and sit-down restaurants. Can J Public Health. 2013;104(1):e2-e8.

19. Scourboutakos MJ, L'Abbe MR. Changes in sodium levels in chain restaurant foods in Canada (2010-2013): a longitudinal study. CMAJ Open. 2014;2(4):E343-351.

20. Scourboutakos MJ, Semnani-Azad Z, L'Abbe MR. Added sugars in kids' meals from chain restaurants. Prev Med Rep. 2016;3:391-393.

21. Hooper L, Martin N, Abdelhamid A, Davey Smith G. Reduction in saturated fat intake for cardiovascular disease. Cochrane Database Syst Rev. 2015(6):CD011737.

22. Aburto NJ, Ziolkovska A, Hooper L, Elliott P, Cappuccio FP, Meerphol JJ. Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ. 2014;346(7903):13.

23. Mozaffarian D, Micha R, Wallace S. Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2010;7(3):e1000252.

24. Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006;114:82-96.

25. Louie JC, Tapsell LC. Association between intake of total vs added sugar on diet quality: a systematic review. Nutr Rev. 2015;73(12):837-857.

26. Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R, Hu FB. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med. 2014;174(4):516-524.

27. Ziauddeen N, Fitt E, Edney L, Dunford E, Neal B, Jebb SA. Variability in the reported energy, total fat and saturated fat contents in fast-food products across ten countries. Public Health Nutr. 2015;18(16):2962-2969.

28. Wiggers D, Vanderlee L, White CM, Reid JL, Minaker L, Hammond D. Food sources among young people in five major Canadian cities. Can J Public Health. 2018.

29. Holroyd J. Canada's Restaurant Industry: Putting jobs and economic growth on the menu. Canadian Restaurant and Foodsenders Association;2010.

30. Bezerra IN, Curioni C, Sichieri R. Association between eating out of home and body weight. Nutr Rev. 2012;70(2):65-79.

31. Nago ES, Lachat CK, Dossa RA, Kolsteren PW. Association of out-of-home eating with anthropometric changes: a systematic review of prospective studies. Crit Rev Food Sci Nutr. 2014;54(9):1103-1116.

32. Jiao J, Moudon AV, Kim SY, Hurvitz PM, Drewnowski A. Health Implications of Adults' Eating at and Living near Fast Food or Quick Service Restaurants. Nutr Diabetes. 2015;5:e171.

33. Kant AK, Graubard BI. A prospective study of frequency of eating restaurant prepared meals and subsequent 9-year risk of all-cause and cardiometabolic mortality in US adults. PLoS One. 2018;13(1):e0191584.

34. Rosenheck R. Fast food consumption and increased caloric intake: a systematic review of a trajectory towards weight gain and obesity risk. Obes Rev. 2008;9(6):535-547.

35. Mikkilä V, Räsänen L, Raitakari OT, Pietinen P, Viikari J. Consistent dietary patterns identified from childhood to adulthood: The Cardiovascular Risk in Young Finns Study. Br J Nutr. 2005;93:923-931.

36. Movassagh EZ, Baxter-Jones ADG, Kontulainen S, Whiting SJ, Vatanparast H. Tracking dietary patterns over 20 years from childhood through adolescence into young adulthood: the Saskatchewan Pediatric Bone Minteral Accrual Study. Nutrients. 2017;9:990.

37. Robinson E, Jones A, Whitelock V, Mead BR, Haynes A. (Over)eating out at major UK restaurant chains: observational study of energy content of main meals. BMJ. 2018;363:k4982.

38. Roberts SB, Das SK, Suen VMM, et al. Measured energy content of frequently purchased restaurant meals: multi-country cross sectional study. BMJ. 2018;363:k4864.

39. Goffe L, Rushton S, White M, Adamson A, Adams J. Relationship between mean daily energy intake and frequency of consumption of out-of-home meals in the UK National Diet and Nutrition Survey. Int J Behav Nutr Phys Act. 2017;14(1):131.

40. Eyles H, Jiang Y, Blakely T, et al. Five year trends in the serve size, energy, and sodium contents of New Zealand fast foods: 2012 to 2016. Nutr J. 2018;17(1):65.

41. Mazidi M, Speakman JR. Higher densities of fast-food and full-service restaurants are not asscoiated with obesity prevalence. Am J Clin Nutr. 2017(106):603-613.

42. Powell LM, Nguyen BT. Fast-Food and Full-Service Restaurant Consumption Among Children and Adolescents: Effect on Energy, Beverage, and Nutrient Intake. JAMA Pediatr. 2013;167(1):14-20.

43. Almiron-Roig E, Navas-Carretero S, Emery P, Martinez JA. Research into food portion size: methodological aspects and applications. Food Funct. 2018;9(2):715-739.

44. Almiron-Roig E, Tsiountsioura M, Lewis HB, Wu J, Solis-Trapala I, Jebb SA. Large portion sizes increase bite size and eating rate in overweight women. Physiol Behav. 2015;139:297- 302.

45. Vermote M, Versele V, Stok M, et al. The effect of a portion size intervention on French fries consumption, plate waste, satiety and compensatory caloric intake: an on-campus restaurant experiment. Nutr J. 2018;17(1):43.

46. Ge L, Almanza B, Behnke C, Tang C. Will reduced portion size compromise restuarant customer's value perception? . Int J Hosp Manag. 2018;70:130-138.

47. Wellard L, Glasson C, Chapman K. Sales of healthy food choices at fast food restaurants in Australia. Health Promot J Aust. 2012;23(1):37-41.

48. Wellard L, Havill M, Hughes C, Watson WL, Chapman K. Energy-dense fast food products cost less: an observational study of the energy density and energy cost of Australian fast foods. Aust N Z J Public Health. 2015;39(6):544-545.

49. Afshin A, Peñalvo JL, Del Gobbo L, et al. The prospective impact of food pricing on improving dietary consumption: A systematic review and meta-analysis. PLoS ONE. 2017;12(3).

50. Close MA, Lytle LA, Viera AJ. Is frequency of fast food and sit-down restaurant eating occasions differentially associated with less healthful eating habits? Prev Med Rep. 2016;4:574-577.

51. Larson N, Neumark-Sztainer D, Laska MN, Story M. Young adults and eating away from home: associations with dietary intake patterns and weight status differ by choice of restaurant. J Am Diet Assoc. 2011;111(11):1696-1703.

52. Bhutani S, Schoeller DA, Walsh MC, McWilliams C. Frequency of eating out at both fast-food and sit-down restaurants was associated with high body mass index in non-large metropolitan communities in Midwest. Am J Health Promot. 2018;32(1):75-83.

53. Department of Health. Guide to creating a front of pack (FoP) nutrition label for pre-packed products sold through retail outlets. In: Health Do, ed. United Kingdom2016.

54. Corvalan C, Reyes M, Garmendia ML, Uauy R. Structural responses to the obesity andnon- communicable diseases epidemic: the Chilean Law of Food Labeling and Advertising. Obes Rev. 2013;14(S2):79-87.

55. Haut Conseil de la Santé Publique. Information sur la qualité nutritionelle des produicts alientaires. In: Publique HCdlS, ed2015.

56. Canada Gazette. Regulations Amending Certain Regulations Made Under the Food and Drugs Act (Nutrition Symbols, Other Labelling Provisions, Partially Hydrogenated Oils and Vitamin D). . Canada Gazette Part 1. Vol 152. Ottawa2018:248-500.

57. Australian Health Ministers' Advisory Council. Guide for industry to the health star rating calculator. In: Council. AHMA, ed2018.

58. Santé Publique France. Usage regulation for the "Nutri-Score" logo. In: France SP, ed2018.

59. Chiu S, Williams PT, Krauss RM. Effects of a very high saturated fat diet on LDL particles in adults with atherogenic dyslipidemia: A randomized controlled trial. PLoS One. 2017;12(2):e0170664.

60. Sun Y, Neelakantan N, Wu Y, Lote-Oke R, Pan A, van Dam RM. Palm Oil Consumption Increases LDL Cholesterol Compared with Vegetable Oils Low in Saturated Fat in a Meta- Analysis of Clinical Trials. J Nutr. 2015;145(7):1549-1558.

61. Seo T, Qi K, Chang C, et al. Saturated fat-rich diet enhances selective uptake of LDL cholesteryl esters in the arterial wall. J Clin Invest. 2005;115(8):2214-2222.

62. Chowdhury R, Warnakula S, Kunutsor S, et al. Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis. Ann Intern Med. 2014;160:398-406.

63. Sacks FM, Lichtenstein AH, Wu JHY, et al. Dietary Fats and Cardiovascular Disease: A Presidential Advisory From the American Heart Association. Circulation. 2017;136(3):e1-e23.

64. World Health Organization. Preventing chronic disease: a vital investment: WHO global report. 2005. Retrieved from: https://apps.who.int/iris/bitstream/handle/10665/43314/9241563001_eng.pdf?sequence=1. Accessed: 2019-05-22.

65. Nettleton JA, Brouwer IA, Geleijnse JM, Hornstra G. Saturated Fat Consumption and Risk of Coronary Heart Disease and Ischemic Stroke: A Science Update. Ann Nutr Metab. 2017;70(1):26-33.

66. Urban LE, Roberts SB, Fierstein JL, Gary CE, Lichtenstein AH. Temporal trends in fast-food restaurant energy, sodium, saturated fat, and trans fat content, United States, 1996-2013. Prev Chronic Dis. 2014;11:E229.

67. Urban LE, Roberts SB, Fierstein JL, Gary CE, Lichtenstein AS. Sodium, saturated fat, and trans fat content per 1,000 kilocalories: temporal trends in fast-food restaurants, United States, 2000-2013. Preventing Chronic Disease. 2014;11:140335.

68. Kraak VI, Englund T, Misyak S, Serrano EL. A novel marketing mix and choice architecture framework to nudge restaurant customers toward healthy food environments to reduce obesity in the United States. Obes Rev. 2017;18(8):852-868.

69. Bruemmer B, Krieger J, Saelens BE, Chan N. Energy, saturated fat, and sodium were lower in entrees at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in King County, Washington. J Acad Nutr Diet. 2012;112(8):1169-1176.

70. He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ. 2013;346:f1325.

71. Whelton PK, Appel LJ, Sacco RL, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation. 2012;126(24):2880-2889.

72. Health Canada. Sodium intakes of Canadians in 2017. In: Canada H, ed. Canada2018.

73. Muntzel M, Drueke T. A comprehensive review of the salt and blood pressure relationship. . Am J Hypertens. 1992;5:1S-42S.

74. Vasan RS, Larson MG, Leip EP, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345(18):1291-1297.

75. Stamler J, Chan Q, Daviglus ML, et al. Relation of Dietary Sodium (Salt) to Blood Pressure and Its Possible Modulation by Other Dietary Factors: The INTERMAP Study. Hypertension. 2018;71(4):631-637.

76. Health Canada. Sodium reduction strategy for Canada: recommendations of the Canadian Sodium Working Group. Ottawa: Health Canada;2010.

77. Food and Drug Administration. Draft Guidance for Industry: Target Mean and Upper Bound Concentrations for Sodium in Commercially Processed, Packaged, and Prepared Foods for Voluntary Sodium Reduction Goals. In: Labeling OoNaF, ed2016.

78. Public Health England. Salt Reduction Targets for 2017. In: Public Health England, ed. London2017.

79. IOM (Institute of Medicine). Strategies to reduce sodium intake in the United States. Washington, D. C.: IOM (Institute of Medicine);2010.

80. Jacobson MF, Havas S, McCarter R. Changes in Sodium Levels in Processed and Restaurant Foods, 2005 to 2011. JAMA Intern Med. 2013;173(14):1285-1291.

81. Hearst MO, Harnack LJ, Bauer KW, Earnest AA, French SA, Michael Oakes J. Nutritional quality at eight U.S. fast-food chains: 14-year trends. Am J Prev Med. 2013;44(6):589-594.

82. Dunford E, Wu JHY, Wellard-Cole L, et al. The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction. CMAJ. 2012;184(4):1023-1031.

83. Patel SM, Gunn JP, Tong X, Cogswell ME. Consumer sentiment on actions reducing sodium in processed and restaurant foods, ConsumerStyles 2010. Am J Prev Med. 2014;46(5):516-524.

84. Patel AA, Lopez NV, Lawless HT, Njike V, Beleche M, Katz DL. Reducing calories, fat, saturated fat, and sodium in restaurant menu items: Effects on consumer acceptance. Obesity. 2016;24(12):2497-2508.

85. Khan TA, Sievenpiper JL. Controversies about sugars: results from systematic reviews and meta-analyses on obesity, cardiometabolic disease and diabetes. Eur J Nutr. 2016;55(Suppl 2):25-43.

86. Langlois K, Garriguet D, Gonzalez A, Sinclair SE, Colapinto CK. Change in total sugars conusmption among Canadian children and adults. Statistics Canada Health Reports. 2019;30(1):10-19.

87. Lane H, Porter K, Estabrooks P, Zoellner J. A Systematic Review to Assess Sugar-Sweetened Beverage Interventions for Children and Adolescents across the Socioecological Model. J Acad Nutr Diet. 2016;116(8):1295-1307 e1296.

88. Public Health England. Sugar Reduction: from evidence to action. London: Public Health England;2015.

89. Rehm CD, Drewnowski A. Trends in Consumption of Solid Fats, Added Sugars, Sodium, Sugar-Sweetened Beverages, and Fruit from Fast Food Restaurants and by Fast Food Restaurant Type among US Children, 2003–2010. nutrients. 2016;8(12):804.

90. Chand A, Eyles H, Mhurchu CN. Availability and accessibility of healthier options and nutrition information at New Zealand fast food restaurants. Appetite. 2012;58:227-233.

91. Dunford E, Webster J, Barzi F, Neal B. Nutrient content of products served by leading Australian fast food chains. Appetite. 2010;55:484-489.

92. Food and Drug Administration. Food Labeling; Nutrition Labeling of Standard Menu Items in Restaurants and Similar Retail Food Establishments; Calorie Labeling of Articles of Food in Vending Machines; Final Rule. Vol 79: Food and Drug Administration; 2014:71155-71259.

93. Government of Australia. Consulation paper: Review of fast food menu labelling schemes. In: Secretariat FR, ed2018.

94. Government of the United Kingdom. Consultation on mandating calorie labelling in the out-of- home sector. In: Care DoHS, ed2018.

95. Shangguan S, Afshin A, Shulkin M, et al. A Meta-Analysis of Food Labeling Effects on Consumer Diet Behaviors and Industry Practices. Am J Prev Med. 2018.

96. Cantu-Jungles TM, McCormack LA, Slaven JE, Slebodnik M, Eicher-Miller HA. A Meta- Analysis to Determine the Impact of Restaurant Menu Labeling on Calories and Nutrients (Ordered or Consumed) in U.S. Adults. Nutrients. 2017;9(10).

97. Sacco J, Lillico HG, Chen E, Hobin E. The influence of menu labelling on food choices among children and adolescents: a systematic review of the literature. Perspect Public Health. 2017;137(3):173-181.

98. Long MW, Tobias DK, Cradock AL, Batchelder H, Gortmaker SL. Systematic Review and Meta-analysis of the Impact of Restaurant Menu Calorie Labeling. Am J Public Health. 2015;105(5):e11-e24.

99. Swartz JJ, Brazton D, Viera AJ. Calorie menu labeling on quick-service restaurant menus: an updated systematic review of the literature. Int J Behav Nutr Phys Act. 2011;8:135.

100. Bleich SN, Economos CD, Spiker ML, et al. A Systematic Review of Calorie Labelingand Modified Calorie Labeling Interventions:Impact on Consumer and Restaurant Behavior. Obesity. 2017;25(12).

101. Sinclair SE, Cooper M, Mansfield ED. The Influence of Menu Labeling on Calories Selected or Consumed: A Systematic Review and Meta-Analysis. J Acad Nutr Diet. 2014;114(9):1375- 1388.

102. Crockett RA, King SE, Martea TM, et al. Nutritional labelling for healthier food or non- alcoholic drink purchasing and consumption. Cochrane Database Syst Rev. 2018(2).

103. Bleich SN, Pollack KM. The publics’ understanding of daily caloric recommendations and their perceptions of calorie posting in chain restaurants. BMC Public Health. 2010;10(121).

104. Bowers KM, Suzuki S. Menu-labeling usage and its association with diet and exercise: 2011 BRFSS Sugar Sweetened Beverage and Menu Labeling module. Prev Chronic Dis. 2014;11:130231.

105. Scourboutakos MJ, Orr S, Hobin E, Murphy SA, Manson H, L'Abbe MR. Assessing the Early Impact of Menu-Labeling on Calories in Chain Restaurants in Ontario, Canada. Am J Prev Med. 2019;56(6):e195-e203.

106. Wellard-Cole L, Goldsbury D, Havill M, et al. Monitoring the changes to the nutrient composition of fast foods following the introduction of menu labelling in New South Wales, Australia: an observational study. Public Health Nutr. 2018;21(6):1194-1199.

107. Pulos E, Leng K. Evaluation of a Voluntary Menu-Labeling Program in Full-Service Restaurants. Am J Public Health. 2010;100(6):1035-1039.

108. Department of Health and Mental Hygiene. National Salt Reduction Initiative: Sodium Warning Rule in NYC Chain Restaurants. 2015; Retrieved from: https://www1.nyc.gov/site/doh/health/health-topics/national-salt-reduction-initiative.page. Accessed: 2019-05-14.

109. Philadelphia Department of Public Health. The Philadelphia Code: § 6-308 - Menu Labeling Requirements for Chain Establishments. In: Health PDoP, ed2010.

110. Auchincloss AH, Mallya GG, Leonberg BL, Ricchezza A, Glanz K, Schwarz DF. Customer responses to mandatory menu labeling at full-service restaurants. Am J Prev Med. 2013;45(6):710-719.

111. Government of Australia. Health Star Rating System Style Guide, Version 5. 2017. Retrieved from: http://www.healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/style- guide. Accessed: 2019-05-14.

112. Dunford EK, Wu JHY, Wellard-Cole L, et al. A comparison of the Health Star Rating system when used for restaurant fast foods and packaged foods. Appetite. 2017;117:1-8.

113. Maganja D, Buckett K, Stevens C, Flynn E. Consumer choice and the role of front-of-pack labelling: the Health Star Rating system. Public Health Res Pract. 2019;29(1):e2911909.

114. Niven P, Morley B, Dixon H, et al. Effects of health star labelling on the healthiness of adults' fast food meal selections: An experimental study. Appetite. 2019;136:146-153.

115. White CM, Lillico HG, Vanderlee L, Hammond D. A voluntary nutrition labeling program in restaurants: Consumer awareness, use of nutrition information, and food selection. Prev Med Rep. 2016;4:474-480.

116. Streletskaya NA, Amatyakul W, Rusmevichientong P, Kaiser HM, Liaukonyte J. Menu- Labeling Formats and Their Impact on Dietary Quality. Agribusiness. 2016;32(2):175-188.

117. Scourboutakos MJ, Corey PN, Mendoza J, Henson SJ, L'Abbé MR. Restaurant menu labelling: Is it worth adding sodium to the label? Can J Public Health. 2014;105(5):e354-e361.

118. Kerins C, Cunningham K, Finucane FM, Gibson I, Jones J, Kelly C. Effects of an icon-based menu labelling initiative on consumer food choice. Perspect Public Health. 2017;137(1):45-52.

119. Khandpur N, de Morais Sato P, Amaral Mais L, et al. Are Front-of-Package Warning Labels More Effective at Communicating Nutrition Information than Traffic-Light Labels? A Randomized Controlled Experiment in a Brazilian Sample. nutrients. 2018;10:688-703.

120. Goodman S, L. V, Acton R, Mahamad S, Hammond D. The impact of front-of-package label design on consumer understanding of nutrient amounts. Nutrients. 2018;10:1624-1636.

121. Modifica Decreto Supremo N° 977 de 1996, Reglamento Sanitario de los Alimentos. Diario Oficial de la República de Chile 2015.

122. Correa T, Fierro C, Reyes M, Carpentier FRD, Taillie LS, Corvalan C. Responses to the Chilean law of food labeling and advertising: exploring knowledge, perceptions and behaviors of mothers of young children. Int J Behav Nutr Phys Act. 2019;16(1):1-10.

123. Tórtora G, Machín L, Ares G. Influence of nutritional warnings and other label features on consumers' choice: Results from an eye-tracking study. Food Res Int. 2019;119:605-611.

124. Health Canada. Consultation on proposed front-of-package labelling. 2018; Retrieved from: https://www.canada.ca/en/health-canada/programs/consultation-front-of-package-nutrition- labelling-cgi.html. Accessed: 2018-10-11.

125. Wolfson JA, Moran AJ, Jarlenski MP, Bleich SN. Trends in sodium content of menu items in large chain restaurants in the US. Am J Prev Med. 2018;54(1):28-36.

126. Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low sodium diet versus high sodium diet on bloodpressure, renin, aldosterone, catecholamines, cholesterol,and triglyceride (Review). Cochrane Database Syst Rev. 2017;4:CD004022.

127. Brunstrom M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med. 2018;178(1):28-36.

128. Prentice AM, Jebb SA. Fast foods, energy density and obesity: a possible mechanistic link. Obes Rev. 2003;4(4):187-194.

129. Zong G, Li Y, Wanders AJ, et al. Intake of individual saturated fatty acids and risk of coronary heart disease in US men and women: two prospective longitudinal cohort studies. BMJ. 2016;355:i5796.

130. Allen NB, Zhao L, Liu L, et al. Favorable cardiovascular health, compression of morbidity and healthcare costs: forty year follow-up of the CHA (Chicago Heart Association Detection Project in Industry). Circulation. 2017;135:1693-1701.

131. Government of Ontario. Guide to Menu Labelling Requirements. Retrieved from: https://www.ontario.ca/document/guide-menu-labelling-requirements. Accessed: 2019-05-12.

132. Monday Report on Retailers. The 2016 directory of restaurants and fast-food chains in Canada. In: Toronto : Monday Report on Retailers c-, ed. Directory of restaurant and fast food chains in Canada. 2016.

133. Brand Shares | Local - Latest Owner | Historical | % breakdown. Euromonitor International; 2016. Accessed 04/26/2019.

134. Health Canada. Canadian Nutrient File (CNF). 2012. Retrieved from: http://webprod3.hc- sc.gc.ca/cnf-fce/index-eng.jsp.

135. Government of Canada. Percent daily value. Retrieved from: https://www.canada.ca/en/health- canada/services/understanding-food-labels/percent-daily-value.html. Accessed: 2019-05-11.

136. Government of Canada. Sugars. Retrieved from: https://www.canada.ca/en/health- canada/services/nutrients/sugars.html - he. Accessed: 2019-05-21.

137. Wu HW, Sturm R. What's on the menu? A review of the energy and nutritional content of US chain restaurant menus. Public Health Nutr. 2013;16(1):87-96.

138. Health Canada. Sodium reduction in processed foods in Canada: an evaluation of progress toward voluntary targets from 2012 to 2016. In: Canada H, ed. Ottawa2018.

139. Statistics Canada. Eating Out: How often and why? In: Canada S, ed: Government of Canada; 2019.

140. Health Canada. Choosing healthy menu options. In: Canada H, ed. Canada's Food Guide: Government of Canada; 2019.

141. IBM SPSS Statistics for MacIntosh, Version 25.0. [computer program]. Armonk, NY: IBM Corp; 2017.

142. Health Canada. Nutrition Labelling: Table of Reference Amounts. In: Canada H, ed. Ottawa: Government of Canada; 2016:1-93.

143. Christoforou A, Bernstein JT, L'Abbé MR. Examining the impact of proposed mandatory front- of-package 'high-in' symbols in the Canadian prepackaged food supply. Unpublished manuscript. 2019.

144. Health Families BC. Informed Dining. 2012. Retreived from: https://www.healthyfamiliesbc.ca/home/informed-dining. Accessed 2019-05-30.

145. Our Commitment. Subway. 2019. Retrieved from: https://www.subway.com/en- CA/AboutUs/SocialResponsibility/OurOverallCommitment. Accessed 2019-07-10.

146. McDonald's Commitment fo Families: Global Happy Meal Goals. Retrieved from: https://corporate.mcdonalds.com/content/dam/gwscorp/scale-for-good/Global Happy Meal Goals_7_24_18_Final.pdf. Accessed 2019-07-10.

147. Sacks G, Robinson E. Inside our quick service restaurants: assessment of company policies and commitments related to besity prevention and nutrition. Melbounre: Deakin University; 2018.

148. Luger M, Loafontan M, Bes-Ratrollo M, Winzer E, Yumuk V, Farpour-Lambert N. Sugar- Sweetened Beverages and Weight Gain in Children and Adults: A Systematic Review from 2013 to 2015 and a Comparison with Previous Studies. Obes Facts. 2017;10:674-693.

149. Malik VS, Shulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84:274-288.

150. Pigott J. Matter of New York Statewide Coalition of Hispanic Chambers of Commerce v New York City Dept. of Health & Mental Hygiene, 23 NY3d 681. New York State Law Reporting Bureau; 2014.

Chapter 7 Appendices 7.1 Appendix A – Supplementary material accompanying Chapter 3: “A quantitative analysis of the saturated fat, sodium, and sugar content in Canadian fast-food and sit-down restaurant menu items”

Supplementary Table 3.1: List of Included Establishments n Outlets in n Menu Items # RESTAURANTS FF/SDR 20161 Included 1 241 Pizza FF 74 40 2 A&W FF 820 102 3 Applebee's4 SDR 172 236 4 Arby's FF N/A1 64 5 Baskin Robbins FF 93 60 6 Baton Rouge SDR 29 80 7 BentoSushi (formerly Bento Nouveau) FF 43 34 8 Booster Juice FF 286 104 9 Boston Pizza SDR 343 399 10 Burger King FF 291 138 11 Captain George's Fish and Chips FF 27 1 12 Coffee Time FF 125 131 13 Country Style FF 424 109 14 Dagwood Sandwiches and Subs FF 21 154 15 Dairy Queen FF 85 306 De Dutch Pannekoek House 16 Restaurant SDR 22 289 17 Denny's SDR 49 223 18 Domino's Pizza FF 384 40 19 Earl's Restaurant SDR 58 130 20 East Side Mario's SDR 79 176 21 Edo Japan FF 106 83 22 Fatburger FF 41 52 23 Flying Wedge Pizza FF 102 42 24 Freshii FF 74 41 25 Freshly Squeezed FF 53 39 26 Freshslice FF 74 4 27 Good Earth Coffeehouse and Bakery FF 45 176

58 59

28 Greco Pizza Donair FF 100 81 29 Harvey's FF 259 101 30 Hero Certified Burger FF 56 10 31 Jack Astors SDR 38 71 32 Joey's Restaurant SDR 60 63 33 Jugo Juice FF 135 59 34 Kelsey's SDR 70 135 35 KFC FF 638 70 36 La Cremiere FF 60 104 37 Little Caesars FF 180 21 38 Lone Star Texas Grill SDR 22 91 39 Manchu Wok FF 71 30 40 Mary Browns FF 94 110 41 McDonald's FF 1417 262 42 Mike's Restaurant SDR 74 368 43 Milestone's SDR 50 105 44 Mmmuffins FF 142 113 45 Montana's SDR 97 147 46 Mr. Greek Express FF 123 75 47 Mr. Greek Mediterannean Grill SDR 93 82 48 Mr. Mike's Steakhouse and Bar SDR 27 107 49 Mr. Sub FF 308 65 50 Mrs. Vanelli's FF 36 48 51 Mucho Burrito FF 76 45 52 New Orleans Pizza FF 43 75 53 New York Fries FF 121 33 54 Opa! Souvlaki of Greece FF 88 88 55 Orange Julius FF 41 97 56 Panago FF 184 236 57 Papa John's Pizza4 FF 74 61 58 Pita Pit FF 182 38 59 Pizza 73 FF 102 91 60 Pizza Delight SDR 82 116 61 Pizza Hotline FF 23 13 62 Pizza Hut SDR 395 559 63 Pizza Nova FF 148 12 64 Pizza Pizza FF 631 132 65 Pizza Salvatore FF 122 110 66 Pizzaiolo FF 30 51 67 Pizzaville FF 75 28 68 Popeye's Chicken and Biscuits FF 76 75

69 Prime Pubs (Fion MacCools) SDR 31 80 70 Quiznos FF 392 100 71 Robin's Donuts FF 144 79 72 Scores Rotisserie SDR 42 154 73 Second Cup FF 350 106 74 Shoeless Joe's SDR 37 137 75 Smitty's Restaurant SDR 100 177 76 South St. Burger Co. FF 32 43 77 Starbucks FF 878 315 78 Subway FF 3100 132 79 Swiss Chalet SDR 214 105 80 Taco Bell4 FF 182 239 81 Taco Del Mar4 FF 45 280 82 Taco Time FF 128 41 83 TCBY FF 85 35 84 Teriyaki Experience FF 102 103 85 The Extreme Pita FF 178 44 86 The Great Canadian Bagel FF 25 87 87 The Keg SDR 86 151 88 Tim Hortons FF 4000 192 89 Topper's Pizza FF 36 23 90 Treats FF 57 34 91 Van Houtte FF 51 29 92 Waves Coffee FF 37 396 93 Wendy's FF 367 105 94 White Spot Legendary Restaurant SDR 63 150 95 White Spot Triple O's FF 43 59 96 Yogen Fruz FF 181 123 Total 20795 10950 1 All data on outlet numbers in the above table were taken from the Directory of Restaurant & Fast Food Chains in Canada. “Not available” indicates the outlet number was not provided in the directory. 2Restaurants listed with <20 locations were included due having had ≥20 outlets during a previous Menu-FLIP collection (in 2010 or 2013) and were therefore collected in the interest of enabling longitudinal comparisons 3Mr Greek Restaurants Inc. was reported as a single entity in the Directory's listings in earlier collections, and when combined consistently has ≥20 outlets. However, they provide separate nutritional information for their Mr. Greek Mediterranean Grill and Mr. Greek Express outlets, which are SDR and FF-style, respectively. Given that FF versus SDR comparisons are a key part of this study, they are kept separate in the database.

Supplementary Table 3.2. Levels of saturated fat, sodium, and sugar in Canadian menu items per serving, by category and subcategory Category Saturated Fat (g) Sodium (mg) Sugar (g) n Mean ±95 CI Median ±95 CI n Mean ±95 CI Median ±95 CI n Mean ±95 CI Median ±95 CI Overall 10415 7.0 6.8, 7.1 4.5 4.5, 5.0 10859 859 841, 878 580 570, 600 10458 17 17, 18 7 7, 8 Beverage 1728 2.5 2.3, 2.7 0.1 0.1, 0.2 2043 130 124, 135 100 98, 110 2045 43 42, 45 38 37, 40 Beverage- Coffee/Teas 624 2.4 2.2, 2.7 1.0 1.0, 2.0 847 140 134, 147 135 130, 140 850 29 28, 30 26 25, 28 Beverage- Flavoured Milk 48 6.4 4.7, 8.0 4.5 3.5, 6.0 88 219 200, 238 202 180, 218 88 37 33, 40 35 29, 38 Beverage- Juices/Smoothie 473 0.7 0.6, 0.9 0.0 0.0, 0.0 496 84 73, 95 42 40, 46 494 56 54, 59 52 50, 55 Beverage-Kids 48 1.9 0.4, 3.4 0.0 0.0, 0.0 48 61 42, 81 35 25, 75 48 28 23, 34 27 26, 32 Beverage- Milkshakes/Floa 14.0, ts 135 14.9 13.8, 16.0 15.0 17.0 164 321 292, 350 300 272, 340 166 82 78, 87 76 72, 86 Beverage-Plain Milk 12 2.6 1.8, 3.4 3.0 3.0, 4.0 12 120 105, 136 120 120, 180 12 13 11, 15 12 12, 20 Beverage-Soft Drinks 380 0.1 0.0, 0.1 0.0 0.0, 0.0 380 76 69, 82 65 60, 70 380 46 42, 50 47 42, 51 Beverage-Water 8 0.0 0.0, 0.0 0.0 0.0, 0.0 8 0 0, 0 0 0, 0 7 0 0, 0 0 0, 0 Desserts 1150 7.2 6.7, 7.7 4.5 4.5, 5.0 1198 260 347, 273 210 200, 230 1194 32 31, 34 23 22, 23 Dessert-Cookies 94 6.1 5.2, 6.9 5.0 5.0, 6.0 100 216 177, 256 135 130, 170 94 21 17, 24 17 15, 19 Dessert-Donuts 126 6.0 5.1, 6.9 5.0 5.0, 6.8 126 297 260, 334 274 251, 290 126 17 14, 19 15 14, 17 Dessert-Frozen Desserts 407 6.1 5.4, 6.8 4.0 3.5, 5.0 410 126 112, 140 70 65, 85 417 35 32, 38 22 22, 23 Dessert-Kids 34 5.5 3.8, 7.3 4.0 3.5, 5.0 37 119 80, 157 75 60, 92 37 20 15, 25 13 12, 23 Dessert-Misc. 5 0.2 -0.3, 0.8 0.0 0.0, 0.0 5 11 -12, 34 2 0, 43 5 16 -2, 35 8 7, 40 Dessert-Muffins 125 2.2 1.9, 2.5 2.0 2.0, 2.5 157 402 376, 428 370 360, 410 157 31 29, 32 28 27, 30 Dessert-Other Baked Goods 359 11.2 10.2, 12.1 8.0 7.0, 9.0 363 368 341, 394 320 300, 350 358 39 36, 43 31 28, 35 980, Entrées 5582 9.0 8.8, 9.3 6.0 6.0, 7.0 5626 1259 1170, 1282 1002 1030 5344 8 8, 9 5 5, 6 Entrée- 1050, Breakfast 603 11.5 10.8, 12.2 10.0 9.6, 11.0 603 1226 1293, 1435 1110 1170 599 16 14, 18 8 7, 10 13.2, 1170, Entrée-Burgers 292 15.0 14.0, 16.1 14.1 16.0 292 1364 1052, 1427 1212 1282 292 9 9, 10 8 8, 9 Entrée-Hot 130, Dogs 19 9.7 7.8, 11.6 9.0 8.0, 12.0 19 1240 1052, 1427 1190 1280 19 5 4, 6 5 5, 6 Entrée-Kids 222 5.9 5.3, 6.6 4.5 4.0, 5.4 222 729 680, 778 665 640, 710 220 6 5, 7 4 3, 4

61 62

1140, Entrée-Meat 356 13.3 12.3, 14.4 10.0 9.4, 11.0 357 1415 1324, 1506 1220 1317 326 10 9, 11 5 5, 6 850, Entrée-Misc. 48 10.7 8.6, 13.1 9.0 6.0, 15.0 48 1369 1102, 1637 1170 1508 48 15 10, 20 8 5, 12 Entrée-Other 1230, Baked Goods 16 12.6 10.4, 14.9 12.5 9.8, 16.0 16 1546 1259, 1834 1587 1980 16 6 4, 9 6 5, 7 1272, Entrée-Pasta 290 10.3 8.6, 12.1 7.0 6.5, 9.0 293 1440 1350, 1530 1377 1432 231 10 9, 11 8 8, 10 Entrée-Pizza 1576 7.2 6.7, 7.6 4.5 4.5, 5.0 1576 992 923, 1061 580 570, 610 1516 5 5, 5 3 3, 4 1290, Entrée-Poultry 368 9.8 8.8, 10.7 7.0 6.5, 9.0 372 1985 1800, 2171 1460 1580 356 11 9, 13 5 5, 6 1150, Entrée-Poutine 34 12.2 10.1, 14.3 10.7 9.2, 14.7 34 2095 1613, 2578 1840 2380 34 8 6, 11 6 5, 9 Entrée-Salad 400 7.2 6.7, 7.6 6.0 6.0, 7.0 425 987 929, 1046 930 850, 990 399 10 9, 11 7 7, 8 Entrée- Sandwiches/Wr 1300, aps 897 8.3 7.9, 8.8 7.0 7.0, 8.0 905 1536 1485, 1588 1344 1420 871 7 7, 8 6 6, 7 1070, Entrée-Seafood 199 8.5 7.1, 9.8 5.0 4.5, 8.0 201 1336 1261, 1456 1210 1290 179 8 6, 11 6 6, 8 1189, Entrée-Soup 20 9.7 6.1, 7.2 10.8 5.0, 12.0 20 1500 1261, 1740 1466 1720 20 11 8, 14 10 6, 13 Entrée- 890, Tacos/Burritos 197 6.6 6.1, 7.2 5.0 5.0, 6.0 198 1035 951, 1119 950 1030 191 4 4, 5 3 3, 4 Entrée- 967, Vegetables 45 5.2 3.1, 7.3 3.0 1.5, 5.0 45 1296 1065, 1527 1272 1500 27 14 9, 18 12 5, 19 Sides 1412 3.6 3.4, 3.9 2.0 2.0, 2.5 1446 680 648, 713 531 505, 570 1345 5 4, 5 3 2, 3 Side-Bagels 54 1.2 0.7, 1.8 0.5 0.3, 1.0 81 501 468, 535 480 440, 541 74 5 4, 5 4 4, 5 Side-Breads 108 4.1 3.1, 5.1 2.1 1.8, 3.0 108 614 497, 731 386 344, 430 107 4 3, 5 2 1, 4 Side-Breakfast 46 2.6 1.8, 3.4 2.0 1.0, 3.0 46 557 370, 744 410 300, 560 46 7 4, 10 2 2, 12 860, Side-Fries 232 6.3 5.4, 7.2 3.5 3.0, 4.0 232 1161 1046, 1276 970 1140 229 4 3, 5 1 1, 2 Side-Fruit 18 0.3 -0.1, 0.6 0.0 0.0, 0.0 18 22 10, 35 14 5, 20 18 23 16, 31 19 16, 24 Side-Kids 66 1.3 0.9, 1.7 1.0 1.0, 1.6 66 290 217, 362 225 65, 322 65 4 2, 5 2 2, 4 Side-Meat 26 5.9 0.9, 1.7 4.0 3.0, 10.0 26 843 578, 1107 760 598, 914 21 6 1, 12 3 1, 6 Side-Misc. 160 3.8 2.9, 4.6 2.3 2.0, 3.0 160 639 534, 745 469 448, 560 150 5 4, 6 3 3, 4 Side-Other Baked Goods 22 4.3 2.7, 5.9 3.0 1.5, 8.0 22 403 329, 478 380 330, 510 22 8 5, 11 4 3, 14 Side-Pasta 18 4.2 0.8, 7.6 1.3 0.3, 3.0 18 396 221, 571 305 260, 490 16 3 2, 6 4 1, 5 Side-Potatoes (non-fried) 68 5.0 3.8, 6.1 3.5 2.0, 6.0 68 559 459, 659 520 410, 600 67 3 2, 4 2 2, 3 Side-Poultry 88 4.3 3.4, 5.2 3.0 3.0, 3.8 88 922 777, 1066 735 630, 910 87 3 2, 5 1 1, 2

Side-Rice 43 1.7 0.8, 2.6 0.2 0.2, 1.0 43 522 354, 691 380 252, 590 40 2 1, 3 1 1, 2 Side-Salad 161 2.7 2.2, 3.2 2.0 1.5, 3.0 168 413 360, 467 355 280, 409 159 5 4, 6 3 3, 4 Side-Seafood 41 2.6 1.7, 3.6 2.0 1.5, 4.1 41 654 472, 835 490 400, 710 40 3 2, 5 2 1, 4 Side-Soup 186 2.8 2.4, 3.3 2.0 1.5, 2.5 186 870 824, 915 835 800, 870 131 5 4, 5 4 4, 6 Side-Vegetables 75 2.4 1.4, 3.4 0.5 0.0, 1.5 75 305 228, 381 2000 106, 300 73 4 3, 5 3 3, 4 870, Starters 543 7.9 7.1, 8.7 4.2 3.7, 5.0 546 1250 1163, 1336 920 1010 530 6 6, 7 3 3, 4 840, Starter-Breads 33 9.8 7.0, 12.6 8.0 4.7, 15.0 33 1318 1039, 1597 1130 1770 33 6 4, 8 4 3, 9 1170, Starter-Cheese 13 13.5 8.9, 18.1 12.1 8.0, 20.0 13 1890 1201, 2579 1710 3010 13 6 2, 11 4 2, 9 295, Starter-Dips 23 10.5 6.5, 14.4 9.0 3.5, 15.0 23 906 509, 1303 820 1430 23 4 2, 6 3 1, 6 1100, Starter-Fries 21 12.2 8.5, 15.9 12.0 4.9, 19.0 21 1602 1221, 1982 1280 2470 21 10 4, 16 3 2, 19 1270, Starter-Meat 31 14.1 9.3, 18.9 12.7 5.0, 19.0 31 1893 1367, 2418 1560 2320 28 8 5, 12 5 3, 10 1444, Starter-Misc. 59 16.6 12.6, 20.6 11.0 8.7, 18.0 60 2204 1840, 2568 1784 2300 59 10 7, 12 8 5, 11 480, Starter-Poultry 120 7.3 5.8, 8.8 4.0 2.5, 6.0 120 1203 1006, 1400 668 1220 111 7 5, 9 2 2, 5 Starter-Salad 31 3.7 2.7, 4.8 3.1 2.8, 4.5 31 480 335, 625 370 260, 520 31 5 4, 6 5 5, 9 764, Starter-Seafood 63 5.0 3.7, 6.4 3.6 2.5, 4.5 64 1160 979, 1340 1057 1310 62 6 4, 8 3 2, 9 Starter-Soup 139 3.5 2.8, 4.2 2.0 2.0, 3.0 139 857 782, 931 810 780, 870 139 4 3, 5 3 3, 4 Starter- 670, Vegetables 10 6.9 1.9, 11.9 4.9 1.5, 9.0 11 1483 821, 2144 995 2440 10 8 3, 12 7 4, 8 Data are reported as means and medians with their 95% confidence intervals, per serving.

Supplementary Table 3.3. Levels of saturated fat, sodium, and sugar in Canadian menu items per 100g, by category and subcategory Saturated Fat (g) Sodium (mg) Sugar (g)

Category n Mean ±95 CI Median ±95 CI n Mean ±95 CI Median ±95 CI n Mean ±95 CI Median ±95 CI Overall 8585 2.7 2.7, 2.8 2.2 2.2, 2.3 9030 317 311, 322 308 300, 315 8728 7 6, 7 3 3, 3 Beverage 1575 0.6 0.5, 0.7 0.0 0.0, 0.0 1891 34 32, 35 21 19, 25 1894 10 10, 10 9 9, 10 Beverage- Coffee/Teas 577 0.6 0.5, 0.7 0.4 0.2, 0.5 800 40 38, 42 41 40, 44 803 8 7, 8 8 7, 8 Beverage-Flavoured Milk 46 1.8 1.3, 2.2 1.1 1.0, 1.6 86 65 60, 70 60 57, 62 86 11 10, 11 11 10, 12 Beverage- Juices/Smoothies 413 0.1 0.1, 0.2 0.0 0.0, 0.0 437 18 15, 22 9 8, 9 435 12 11, 13 10 10, 11 Beverage-Kids 48 0.8 0.3, 1.4 0.0 0.0, 0.0 48 25 16, 34 10 7, 24 48 10 8, 12 10 8, 11 Beverage- Milkshakes/Floats 122 3.3 3.0, 3.5 3.3 2.9, 3.6 151 79 73, 85 72 70, 81 153 21 20, 22 20 19, 22 Beverage-Plain Milk 12 1.0 0.7, 1.3 1.2 1.1, 1.2 12 43 40, 45 41 40, 47 12 5 5, 5 5 4, 5 Beverage-Soft Drinks 352 0.0 0.0, 0.0 0.0 0.0, 0.0 352 13 12, 14 12 12, 13 352 8 7, 9 11 10, 11 Beverage-Water 5 0.0 0.0, 0.0 0.0 0.0, 0.0 5 0 0, 0 0 0.0, 0.0 5 0 0, 0 0 0, 0 Desserts 994 5.1 4.8, 5.3 4.5 4.1, 4.8 1042 195 186, 205 145 127, 164 1038 22 22, 23 22 22, 23 9.3, 9.3, Dessert-Cookies 78 9.9 10.6 10.4 10.6 84 324 292, 356 316 309, 340 78 33 31, 35 35 34, 36 Dessert-Donuts 75 6.8 6.1, 7.5 6.7 5.9, 7.7 75 357 335, 379 379 347, 400 75 22 21, 24 22 20, 24 Dessert-Frozen Desserts 399 3.2 2.9, 3.5 2.5 1.8, 3.0 402 71 65, 77 61 55, 65 409 20 19, 20 21 21, 22 Dessert-Kids 30 4.8 2.9, 3.5 5.0 2.9, 5.3 33 102 75, 129 83 76, 105 33 19 15, 23 19 16, 23 -0.0, Dessert-Misc. 4 0.0 0.0 0.0 0.0, 0.0 4 3 -4, 9 1 0, 9 4 26 -18, 70 16 7, 67 Dessert-Muffins 103 1.8 1.5, 2.0 1.7 1.3, 1.9 135 321 299, 342 310 301, 328 135 23 22, 24 23 22, 24 Dessert-Other Baked Goods 305 7.0 6.5, 7.5 6.2 5.6, 6.9 309 241 223, 259 216 196, 232 304 23 22, 24 24 22, 25 Entrées 4382 3.2 3.1, 3.2 2.9 2.9, 3.0 4426 434 427, 440 414 408, 421 4216 3 3, 3 2 2, 2 Entrée-Breakfast 497 3.4 3.2, 3.6 3.1 2.9, 3.3 497 369 352, 385 360 340, 381 497 4 4, 5 3 2, 3 Entrée-Burgers 254 4.7 4.4, 5.0 5.0 4.7, 5.2 254 446 427, 463 437 410, 453 254 3 3, 3 3 3, 3 Entrée-Hot Dogs 18 5.8 5.0, 6.7 5.8 4.6, 6.9 18 751 704, 798 731 702, 801 18 3 3, 3 3 3, 3 Entrée-Kids 179 3.7 3.2, 4.1 3.0 2.5, 3.5 179 434 406, 461 424 372, 480 177 3 2, 3 2 2, 2 Entrée-Meat 310 3.8 3.5, 4.1 3.0 2.5, 3.5 311 366 344, 389 345 324, 358 280 2 2, 3 1 1, 1

64 65

Entrée-Misc. 38 3.3 2.6, 4.0 3.0 2.3, 3.7 38 492 295, 688 311 255, 388 38 4 2, 6 2 1, 3 Entrée-Other Baked Goods 12 3.7 3.1, 4.4 3.9 2.4, 5.0 12 496 417, 576 503 390, 592 12 2 1, 4 2 1, 3 Entrée-Pasta 270 2.0 1.7, 2.3 1.4 1.0, 1.7 273 278 263, 293 270 353, 291 211 2 2, 2 2 2, 2 Entrée-Pizza 1038 3.6 3.5, 3.6 3.6 1.8, 3.7 1038 466 458, 474 460 456, 469 1038 3 3, 3 2 2, 2 Entrée-Poultry 331 2.6 2.4, 2.8 2.2 2.0, 2.6 335 505 476, 534 451 420, 491 319 3 2, 3 1 1, 1 Entrée-Poutine 14 3.1 2.5, 3.8 3.6 1.8, 3.7 14 255 208, 302 254 192, 282 14 2 1, 3 1 1, 2 Entrée-Salad 312 2.0 1.7, 2.2 1.7 1.6, 1.8 337 271 254, 288 259 245, 274 311 3 3, 3 2 2, 2 Entrée- Sandwiches/Wraps 773 3.0 2.8, 3.1 2.6 2.5, 2.7 781 573 556, 590 529 518, 541 749 2 2, 3 2 2, 2 Entrée-Seafood 176 2.4 2.0, 2.9 1.5 1.0, 1.9 178 342 312, 376 316 282, 350 156 2 2, 2 1 1, 2 Entrée-Soup 17 2.2 1.3, 3.1 2.2 1.6, 3.0 17 351 304, 393 353 317, 381 17 3 2, 3 2 2, 3 Entrée- Tacos/Burritos 105 2.8 2.7, 3.1 2.7 2.3, 3.0 106 415 390, 439 410 390, 442 104 2 2, 2 2 2, 2 Entrée-Vegetables 38 0.9 0.5, 1.2 0.6 0.3, 0.8 38 279 241, 317 292 250, 317 21 3 2, 5 3 2, 4 Sides 1188 2.0 1.9, 2.2 1.3, 1.2, 1.4 1222 380 361, 398 349 336, 360 1138 3 3, 3 2 2, 2 Side-Bagels 34 1.2 0.7, 1.8 1.0, 0.4, 1.2 61 417 385, 448 393 363, 420 54 5 4, 5 4 3, 5 Side-Breads 85 3.4 2.9, 4.0 3.1 2.5, 3.6 85 553 489, 616 516 489, 560 85 3 2, 4 2 2, 3 Side-Breakfast 41 2.6 1.7, 3.5 1.8 0.5, 3.3 41 463 306, 620 425 218, 466 41 4 2, 6 2 2, 3 Side-Fries 192 2.1 1.9, 2.4 1.4 1.3, 1.8 192 419 385, 453 418 373, 471 191 2 1, 2 0 0, 1 -0.0, Side-Fruit 16 0.1 0.3 0.0 0.0, 0.0 16 13 2, 23 8 4, 11 16 13 10, 15 11 11, 14 Side-Kids 51 1.5 0.7, 2.2 0.7 0.5, 1.2 51 265 192, 338 204 78, 324 51 4 2, 7 1 1, 2 Side-Meat 20 3.1 1.7, 4.4 1.8 1.5, 2.3 20 447 340, 553 376 345, 500 16 3 0, 6 2 1, 2 Side-Misc. 125 2.9 2.3, 3.4 1.8 1.5, 2.3 125 454 404, 503 467 353, 535 118 4 3, 4 3 2, 4 Side-Other Baked Goods 20 5.9 3.5, 8.3 4.6 1.8, 8.8 20 486 394, 577 492 411, 611 20 7 4, 9 5 4, 7 Side-Pasta 16 1.8 0.2, 3.5 0.8 0.1, 1.8 16 296 140, 452 206 155, 314 14 2 1, 2 1.8, 0, 2 Side-Potatoes (non- fried) 51 1.9 1.4, 2.4 1.4 1.0, 2.5 51 249 199, 298 250 157, 334 50 1 1, 1 1 1, 1 Side-Poultry 76 2.3 2.0, 2.6 2.2 1.8, 2.6 76 548 494, 603 497 455, 600 75 2 1, 2 1 0, 1 Side-Rice 39 0.7 0.4, 1.0 0.1 0.1, 0.5 39 249 171, 327 211 147, 280 36 1 1, 1 1 0, 1 Side-Salad 140 1.5 1.3, 1.7 1.2 1.0, 1.5 147 250 224, 276 228 203, 282 138 4 3, 4 2 2, 3 Side-Seafood 40 2.8 0.3, 5.3 1.1 0.5, 1.7 40 597 219, 975 377 339, 438 39 3 1, 5 2 1, 3

Side-Soup 173 1.2 1.0, 1.4 0.9 0.6, 1.0 173 345 325, 364 328 317, 345 127 2 2, 2 2 1, 2 Side-Vegetables 69 1.2 0.7, 1.7 0.4 0.0, 0.6 69 200 149, 252 109 71, 204 67 3 2, 3 2 2, 4 Starter 446 2.8 2.6, 3.1 2.1 1.8, 2.3 449 464 441, 487 433 402, 465 442 2 2, 3 2 1, 2 Starter-Breads 31 3.8 2.8, 4.9 3.2 2.7, 4.4 31 524 479, 570 529 482, 569 31 2 2, 3 2 1, 2 5.1, 6.1, 734, 566, Starter-Cheese 10 8.0 10.9 6.6 12.1 10 962 1190 1050 1292 10 2 1, 4 1 1, 3 Starter-Dips 22 7.1 4.6, 9.7 6.0 3.5, 9.1 22 482 399, 565 472 374, 521 22 3 1, 4 2 1, 3 Starter-Fries 18 3.1 2.2, 4.1 3.3 1.8, 4.0 18 404 320, 489 365 293, 494 18 3 1, 5 1 0, 1 Starter-Meat 27 3.7 2.5, 4.8 3.3 1.9, 4.5 27 510 431, 600 497 489, 564 24 2 1, 3 2 1, 3 Starter-Misc. 43 3.8 3.0, 4.5 3.6 2.7, 4.5 44 549 477, 631 540 480, 561 43 2 2, 3 2 2, 2 Starter-Poultry 80 3.0 2.6, 3.4 3.1 2.5, 3.6 80 527 469, 584 526 461, 590 80 3 2, 4 1 1, 2 Starter-Salad 25 1.8 1.3, 2.3 1.5 1.2, 2.4 25 237 178, 296 203 180, 281 25 3 2, 3 2 2, 3 Starter-Seafood 61 2.0 1.6, 2.4 1.5 1.3, 18 62 474 400, 548 418 381, 504 60 2 1, 3 1 1, 2 Starter-Soup 122 1.3 1.0, 1.6 0.9 0.4, 1.1 122 372 339, 404 348 419, 368 122 2 1, 3 1 1, 2 Starter-Vegetables 7 3.4 0.1, 6.9 1.0 0.7, 9.5 8 501 228, 774 422 219, 811 7 3 1, 5 3 1, 8 Data are reported as means and medians with their 95% confidence intervals, per serving.

Supplementary Table 3.4. Sensitivity analysis of removing beverage and dessert data on mean sugar (g) levels in Canadian fast food and sit down establishments Fast Food Establishments (n1=71) Sit-Down Establishments (n1=25)

Relative proportion of median, Category n2 Mean ±95 CI Median ±95 CI n2 Mean ±95 CI Median ±95 CI P-value SDR to FF3 Per serving All Categories 6217 21 20, 21 8 8, 9 4241 13 12, 13 6 6, 7 ≤0.0001 75 Omitting desserts 5280 19 19, 20 6 6, 7 3984 10 10, 11 6 5, 6 ≤0.0001 100 Omitting beverages 4357 10 10, 11 5 5, 6 4056 12 11, 12 6 6,7 ≤0.0001 120 Omitting beverages and desserts 3420 5 5, 6 3 3, 4 3799 9 9, 10 5 5, 6 ≤0.0001 167 Per 100g All Categories 5521 8 8, 8 4 4, 4 3207 4 4, 5 2 2, 2 ≤0.0001 56 Omitting desserts 4696 5 5, 6 3 3, 3 2994 3 3, 3 2 2, 2 ≤0.0001 67 Omitting beverages 3737 7 7, 7 3 2, 3 3097 4 4, 5 2 2, 2 ≤0.0001 67 Omitting beverages and desserts 2912 3 2, 3 2 2, 2 2884 3 3, 3 2 2, 2 0.111 100 Data are reported as means and medians with their 95% confidence intervals, per serving. 1 Number of restaurant chains for that restaurant type 2 Number of menu items by category for each nutrient 3 Shows the SDR median as a relative proportion of the FF median (SDR/FF*100).

7.2 Appendix B – Supplementary material accompanying chapter 4: “Results of applying the Canadian proposed FOP labelling regulations to chain restaurant menu items” Supplementary Table 4.1: Proportion of menu items requiring 0, 1, 2, or 3 FOP warning symbols, by category and subcategory. 95% 95% 95% 95% Confidenc Confidenc No Labels Confidence One Label Confidence Two Labels e Three Labels e Category n (%1) Interval (%1) Interval (%1) Interval (%1) Interval Overall 10,062 21.3 21.3, 22.1 30.8 29.9, 31.7 42.5 41.5, 43.4 5.5 5.0, 5.9 Beverage 1,723 17.1 15.4, 19.0 59.5 57.2, 61.8 18.6 16.8, 20.5 4.8 3.8, 5.8 Beverage-Coffee/Teas 624 23.4 20.2, 26.8 46.6 42.7, 50.6 28.2 24.8, 31.8 1.8 0.9, 3.0 Beverage-Flavoured Milk 48 0.0 0.0, 0.0 29.2 17.8, 43.0 62.5 48.4, 75.1 8.3 2.9, 18.6 Beverage-Juices/Smoothies 471 3.8 2.4, 5.8 87.9 84.7, 90.6 7.6 5.5, 10.3 0.6 0.2, 1.7 Beverage-Kids 48 18.8 9.7, 31.4 66.7 52.7, 78.7 14.6 6.8, 26.5 0.0 0.0, 0.0 Beverage-Milkshakes/Floats 133 0.0 0.0, 0.0 1.5 0.3, 4.7 51.1 43.7, 59.5 47.4 39.0, 55.8 100.0, Beverage-Plain Milk 12 100.0 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Beverage-Soft Drinks 380 27.1 22.8, 31.7 71.8 67.2, 76.2 0.8 0.2, 2.1 0.3 0.0, 1.2 100.0, Beverage-Water 7 100.0 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Desserts 1140 7.2 5.8, 8.8 30.0 27.4, 32.7 44.0 41.2, 46.9 18.8 16.6, 21.1 Dessert-Cookies 94 4.3 1.5, 9.8 24.5 16.6, 33.8 64.9 54.9, 74.0 6.4 2.7, 12.7 Dessert-Donuts 126 24.6 17.7, 32.6 24.6 17.7, 32.6 31.7 24.1, 40.2 19.0 12.9, 26.6 Dessert-Frozen Desserts 399 6.0 4.0, 8.7 47.6 42.8, 52.5 38.8 34.2, 43.7 7.5 5.2, 10.4 Dessert-Kids 33 24.2 12.2, 40.6 27.3 14.4, 43.9 42.4 26.8, 59.3 6.1 1.3, 18.1 Dessert-Misc. 5 50.0 20.9, 90.6 40.0 9.4, 79.1 0.0 0.0, 0.0 0.0 0.0, 0.0 Dessert-Muffins 125 0.8 0.1, 3.7 24.0 17.2, 32.0 54.4 45.7, 62.9 20.8 14.4, 28.5 Dessert-Other Baked Goods 358 3.1 1.6, 5.3 15.9 12.4, 20.0 45.8 40.7, 51.0 35.2 30.4, 40.2 Entrées 5344 25.8 24.7, 27.0 20.7 19.6, 21.8 50.3 49.0, 51.7 3.1 2.7, 3.6 Entrée-Breakfast 599 8.0 6.0, 10.4 19.4 16.4, 22.7 64.4 60.5, 68.2 8.2 6.2, 10.6 Entrée-Burgers 292 4.1 2.3, 6.9 17.1 13.1, 21.8 77.7 72.7, 82.2 1.0 0.3, 2.7 Entrée-Hot Dogs 19 0.0 0.0, 0.0 10.5 2.3, 29.7 89.5 70.3, 97.7 0.0 0.0, 0.0 Entrée-Kids 220 37.7 29.8, 42.4 35.9 29.8, 42.4 25.5 20.0, 31.5 0.9 0.2, 2.9 Entrée-Meat 326 5.2 3.2, 8.0 23.0 18.7, 27.8 64.7 59.4, 69.8 7.1 4.6, 10.2 68 69

Entrée-Misc. 48 16.7 8.2, 29.0 20.8 11.2, 33.8 50.0 36.2, 63.8 12.5 5.4, 24.0 Entrée-Savoury Baked Goods 16 0.0 0.0, 0.0 12.5 2.7, 34.4 87.5 65.6, 97.3 0.0 0.0, 0.0 Entrée-Pasta 231 10.4 6.9, 14.8 22.5 17.5, 28.2 64.5 58.2, 70.5 2.6 1.1, 5.3 Entrée-Pizza 1516 58.3 55.8, 60.8 6.8 5.6, 8.1 33.4 31.1, 35.8 1.5 0.9, 2.1 Entrée-Poultry 356 14.0 10.7, 17.9 29.8 25.2, 34.7 49.2 44.0, 54.3 7.0 4.7, 10.0 Entrée-Poutine 34 8.8 2.5, 21.7 5.9 1.2, 17.6 82.4 67.2, 92.3 2.9 0.3, 12.9 Entrée-Salad 399 26.8 22.6, 31.3 23.6 19.6, 27.9 46.6 41.8, 51.5 3.0 1.7, 5.0 Entrée-Sandwiches/Wraps 871 6.5 5.0, 8.3 31.7 28.7, 34.8 59.8 56.5, 63.0 2.0 1,2, 3.0 Entrée-Seafood 179 15.6 10.9, 21.5 38.0 31.1, 45.2 45.8 38.6, 53.1 0.6 0.1, 2.6 Entrée-Soup 20 0.0 0.0, 0.0 25.0 10.2, 46.4 75.0 52.6, 89.8 0.0 0.0, 0.0 Entrée-Tacos/Burritos 191 28.8 22.7, 35.5 28.8 22.7, 35.5 42.4 35.6, 49.5 0.0 0.0, 0.0 Entrée-Vegetables 27 18.5 7.4, 35.9 40.7 23.9, 59.4 40.7 23.9, 59.4 7.4 2.6, 16.7 Sides 1325 24.5 22.3, 26.9 36.3 33.7, 38.9 36.7 34.1, 39.3 2.5 1.8, 3.4 Side-Bagels 54 7.4 2.6, 16.7 85.2 74.0, 92.7 7.4 2.6, 16.7 0.0 0.0, 0.0 Side-Breads 107 30.8 22.7, 40.0 31.8 23.5, 41.0 36.4 278, 45.8 0.9 0.1, 4.3 Side-Breakfast 46 26.1 15.1, 40.0 32.6 20.4, 46.9 39.1 26.0, 53.5 2.2 0.2, 9.7 Side-Fries 229 16.6 12.2, 21.8 22.3 17.3, 28.0 55.5 49.0, 61.8 5.7 3.2, 9.2 Side-Fruit 18 61.1 38.3, 80.6 38.9 19.4, 61.7 0.0 0.0, 0.0 0.0 0.0, 0.0 Side-Kids 65 53.8 41.8, 65.6 35.4 24.6, 47.4 10.8 4.9, 20.0 0.0 0.0, 0.0 Side-Meat 21 9.5 2.0, 27.2 23.8 9.7, 44.6 61.9 40.7, 80.1 4.8 0.5, 20.2 Side-Misc. 150 25.3 18.9, 42.7 34.0 26.8, 41.8 38.7 31.2, 46.6 2.0 0.6, 5.2 Side-Other Baked Goods 22 9.1 1.9, 26.1 50.0 30.2, 69.8 36.4 18.9, 57.1 4.5 0.5, 19.3 Side-Pasta 16 31.3 13.1, 55.6 42.8 22.2, 67.4 25.0 9.1, 49.1 0.0 0.0, 0.0 Side-Potatoes (non-fried) 67 19.4 11.3, 30.0 43.3 31.9, 55.2 35.8 25.1, 47.7 1.5 0.2, 6.8 Side-Poultry 87 11.5 6.1, 19.4 28.7 20.0, 38.8 56.3 45.8, 66.4 3.4 1.0, 8.9 Side-Rice 40 37.5 23.8, 52.9 50.0 35.0, 65.0 12.5 4.9, 25.2 0.0 0.0, 0.0 Side-Salad 159 37.7 30.5, 45.4 23.9 17.8, 31.0 34.0 26.9, 41.6 4.4 2.0, 8.4 Side-Seafood 40 27.5 15.6, 42.5 42.5 28.1, 57.9 30.0 17.6, 45.2 0.0 0.0, 0.0 Side-Soup 131 1.5 0.3, 4.8 57.3 48.7, 65.5 39.7 31.6, 48.2 1.5 0.3, 4.8 Side-Vegetables 73 46.6 35.5, 58.0 37.0 26.6, 48.4 16.4 9.3, 26.2 0.0 0.0, 0.0 Starters 530 11.1 8.7, 14.0 26.4 22.8, 30.3 52.1 47.8, 56.3 10.4 8.0, 13.2

Starter-Breads 33 9.1 2.6, 22.3 15.2 6.0, 30.1 69.7 52.9, 83.2 6.1 1.3, 18.1 Starter-Cheese 13 0.0 0.0, 0.0 7.7 0.8, 30.7 76.9 50.3, 93.0 15.4 3.3, 40.9 Starter-Dips 23 21.7 8.8, 41.3 26.1 11.7, 46.1 52.2 32.5, 71.3 0.0 0.0, 0.0 Starter-Fries 21 0.0 0.0, 0.0 9.5 2.0, 27.2 71.4 50.3, 87.1 19.0 6.8, 39.2 Starter-Meat 28 7.1 1.5, 21.0 3.6 0.4, 15.5 67.9 49.5, 82.8 21.4 9.5, 38.9 Starter-Misc. 59 1.7 0.2, 7.6 11.9 5.5, 21.9 7.8 55.2, 78.6 18.6 10.3, 29.9 Starter-Poultry 111 23.4 16.3, 31.9 14.4 8.8, 21.8 47.7 38.6, 57.0 14.4 8.8, 21.8 Starter-Salad 31 35.5 20.5, 53.0 6.5 1.4, 19.1 58.1 40.6, 74.1 0.0 0.0, 0.0 Starter-Seafood 62 11.3 5.2, 20.9 32.3 21.6, 44.5 41.9 30.3, 54.4 14.5 7.4, 24.8 Starter-Soup 139 2.2 0.6, 5.6 56.1 47.8, 64.2 38.8 31.0, 47.1 2.9 1.0, 6.7 Starter-Vegetables 10 10.0 1.1, 38.1 20.0 4.4, 50.3 60.0 30.4, 84.7 10.0 1.1, 38.1 1Percentages include exemptions which were counted as being below threshold no matter the values, as described in the methods section of this paper, and are reported by row.

Supplementary Table 4.2 Proportion of menus items requiring an FOP warning symbols for saturated fat, sodium, or sugar, by major category and subcategory Saturated Fat (g) Below Thresholds 95% Confidence Exceeds Thresholds 95% Confidence Category n (%1) Intervals (%1) Intervals Overall 10,415 49.9 48.9, 50.9 50.1 49.1, 51.1 Beverage 1728 75.7 75.7, 73.6 24.3 22.3, 26.4 Beverage-Coffee/Teas 624 66.5 62.7, 70.1 33.5 29.9, 37.3 Beverage-Flavoured Milk 48 27.1 16.1, 40.7 72.9 59.3, 83.9 Beverage-Juices/Smoothies 473 93.2 90.7, 95.2 6.8 4.8, 9.3 Beverage-Kids 48 81.3 68.6, 90.3 18.8 9.7, 31.4 Beverage- Milkshakes/Floats 135 1.5 0.3, 4.7 98.5 95.3, 99.7 Beverage-Plain Milk 12 100.0 100.0, 100.0 0.0 0.0, 0.0 Beverage-Soft Drinks 380 99.5 98.3, 99.9 0.5 0.1, 1.7 Beverage-Water 8 100.0 100.0, 100.0 0.0 0.0, 0.0 Desserts 1150 32.4 29.8, 35.2 67.6 64.8, 70.2 Dessert-Cookies 94 7.4 3.4, 14.1 92.6 85.9, 96.6 Dessert-Donuts 126 33.3 25.6, 41.9 66.7 58.1, 74.4 Dessert-Frozen Desserts 407 45.0 40.2, 49.8 55.0 50.2, 59.8 Dessert-Kids 34 29.4 16.2, 45.9 70.6 54.1, 83.8 Dessert-Misc. 5 100.0 100.0, 100.0 0.0 0.0, 0.0 Dessert-Muffins 125 69.6 61.2, 77.1 30.4 22.9, 38.8 Dessert-Other Baked Goods 359 10.9 8.0, 14.4 89.1 85.6, 92.0 Entrées 5582 44.7 43.4, 46.0 55.3 54.0, 56.6 Entrée-Breakfast 603 24.9 21.6, 28.4 75.1 71.6, 78.4 Entrée-Burgers 292 17.1 13.1, 21.8 82.9 78.2, 86.9 Entrée-Hot Dogs 19 10.5 2.3, 29.7 89.5 70.3, 97.7 Entrée-Kids 222 59.0 52.5, 65.3 41.0 34.7, 47.5 Entrée-Meat 356 20.5 16.6, 24.9 79.5 75.1, 83.4 Entrée-Misc. 48 31.3 19.5, 45.2 68.8 54.8, 80.5

71 72

Entrée-Savoury Baked Goods 16 0.0 0.0, 0.0 100.0 100.0, 100.0 Entrée-Pasta 290 44.5 38.8, 50.2 55.5 49.8, 61.2 Entrée-Pizza 1576 63.9 61.5, 66.2 36.1 33.8, 38.5 Entrée-Poultry 368 42.1 36.2, 47.2 57.9 52.8, 62.8 Entrée-Poutine 34 14.7 5.8, 29.3 85.3 70.7, 94.2 Entrée-Salad 400 44.0 39.2, 48.9 56.0 51.1, 60.8 Entrée-Sandwiches/Wraps 897 38.9 35.8, 42.1 61.1 57.9, 64.2 Entrée-Seafood 199 52.3 45.3, 59.1 47.7 40.9, 54.7 Entrée-Soup 20 25.0 10.2, 46.4 75.0 53.6, 89.8 Entrée-Tacos/Burritos 197 54.3 47.3, 61.2 45.7 38.8, 52.7 Entrée-Vegetables 45 77.8 64.2, 88.0 22.2 12.0, 35.8 Sides 1412 58.0 55.4, 60.6 42.0 39.4, 44.6 Side-Bagels 54 90.7 80.9, 96.4 9.3 3.6, 19.1 Side-Breads 108 56.5 47.1, 65.6 43.5 34.4, 52.9 Side-Breakfast 46 56.6 42.2, 70.1 43.5 29.9, 57.8 Side-Fries 232 41.4 35.2, 47.8 58.6 52.2, 64.8 Side-Fruit 18 100.0 100.0, 100.0 0.0 0.0, 0.0 Side-Kids 66 84.8 74.8, 91.9 15.2 8.1, 25.2 Side-Meat 26 38.5 21.8, 57.6 61.5 42.4, 78.2 Side-Misc. 160 56.9 49.1, 64.4 43.1 35.6, 50.9 Side-Other Baked Goods 22 45.5 26.3, 65.7 54.5 34.3, 73.7 Side-Pasta 18 66.7 43.7, 84.7 33.3 15.3, 56.3 Side-Potatoes (non-fried) 68 47.1 35.5, 58.8 52.9 41.2, 64.5 Side-Poultry 88 42.0 32.1, 52.5 58.0 47.5, 67.9 Side-Rice 43 83.7 70.7, 92.4 16.3 7.6, 29.3 Side-Salad 161 56.5 48.8, 64.0 43.5 36.0, 51.2 Side-Seafood 41 68.3 53.2, 80.9 31.7 19.1, 46.8 Side-Soup 186 61.3 54.2, 68.1 48.7 31.9, 45.8 Side-Vegetables 75 69.3 58.4, 87.8 30.7 21.1, 41.7 Starters 543 37.6 33.6, 41.7 62.4 58.3, 66.4 Starter-Breads 33 69.3 58.3, 78.9 30.7 21.1, 41.7

Starter-Cheese 13 7.7 0.8, 30.7 92.3 69.3, 99.2 Starter-Dips 23 26.1 11.7, 46.1 73.9 52.9, 88.3 Starter-Fries 21 19.0 6.8, 39.2 81.0 60.8, 93.2 Starter-Meat 31 19.4 8.5, 35.6 80.6 64.4, 91.5 Starter-Misc. 59 13.6 6.6, 24.0 86.4 76.0, 93.4 Starter-Poultry 120 41.7 33.1, 50.6 58.3 49.4, 66.9 Starter-Salad 31 35.5 20.5, 53.0 64.5 47.0, 79.5 Starter-Seafood 63 42.9 34.5, 50.7 57.1 44.8, 68.8 Starter-Soup 139 57.6 49.3, 65.5 42.4 34.5, 50.7 Starter-Vegetables 10 30.0 9.3, 60.6 70.0 39.4, 90.7 Sodium (mg) Overall 10,859 47.1 46.2, 48.0 52.9 52.0, 53.8 Beverage 2043 94.5 93.5, 95.4 5.5 4.6, 6.5 Beverage-Coffee/Teas 847 97.8 96.6, 98.6 2.2 1.4, 3.4 Beverage-Flavoured Milk 88 93.2 86.5, 97.1 6.8 2.9, 13.5 Beverage-Juices/Smoothies 496 96.0 94.0, 97.4 4.0 2.6, 6.0 Beverage-Kids 48 100.0 100.0, 100.0 0.0 0.0, 0.0 Beverage- Milkshakes/Floats 164 61.6 54.0, 68.8 38.4 31.2, 46.0 Beverage-Plain Milk 12 100.0 100.0, 100.0 0.0 0.0, 0.0 Beverage-Soft Drinks 380 98.9 97.5, 99.6 1.1 0.4, 2.5 Beverage-Water 8 100.0 100.0, 100.0 0.0 0.0, 0.0 Desserts 1198 70.9 68.2, 73.4 29.1 26.6, 31.8 Dessert-Cookies 100 89.0 81.8, 94.0 11.0 6.0, 18.2 Dessert-Donuts 126 72.2 64.0, 79.5 27.8 20.5, 36.0 Dessert-Frozen Desserts 410 92.4 89.6, 94.7 7.6 5.3, 10.4 Dessert-Kids 37 91.9 79.9, 97.7 8.1 2.3, 20.1 Dessert-Misc. 5 100.0 100.0, 100.0 0.0 0.0, 0.0 Dessert-Muffins 157 34.4 27.3, 42.1 65.6 57.9, 72.7 Dessert-Other Baked Goods 363 54.4 49.2, 59.5 45.6 40.5, 50.7 Entrées 5626 31.8 30.6, 33.0 68.2 67.0, 69.4 Entrée-Breakfast 603 20.9 17.8, 24.3 79.1 75.7, 82.2

Entrée-Burgers 292 8.6 5.8, 12.2 91.4 87.8, 94.2 Entrée-Hot Dogs 19 0.0 0.0, 0.0 100.0 100.0, 100.0 Entrée-Kids 222 54.5 47.9, 61.0 45.5 39.0, 52.1 Entrée-Meat 357 19.6 15.7, 24.0 80.4 76.0, 84.3 Entrée-Misc. 48 25.0 14.5, 38.5 75.0 61.5, 85.5 Entrée-Savoury Baked Goods 16 12.5 2.7, 34.4 87.5 65.6, 96.3 Entrée-Pasta 293 15.0 11.3, 19.4 85.0 80.6, 88.7 Entrée-Pizza 1576 61.2 58.7, 63.6 38.8 36.4, 41.3 Entrée-Poultry 372 20.2 16.3, 24.5 79.8 75.5, 83.6 Entrée-Poutine 34 8.8 2.5, 21.7 91.2 78.3, 97.5 Entrée-Salad 425 35.1 30.6, 39.7 64.9 60.3, 69.4 Entrée-Sandwiches/Wraps 905 7.8 6.2, 9.7 92.2 90.3, 93.8 Entrée-Seafood 201 22.9 17.5, 29.1 77.1 70.9, 82.5 Entrée-Soup 20 0.0 0.0, 0.0 100.0 100.0, 100.0 Entrée-Tacos/Burritos 198 35.4 28.9, 42.2 64.6 57.8, 71.1 Entrée-Vegetables 45 22.2 12.0, 35.8 77.8 64.2, 88.0 Sides 1446 32.2 29.8, 34.6 67.8 65.4, 70.2 Side-Bagels 81 19.8 12.2, 29.4 80.2 70.6, 87.8 Side-Breads 108 40.7 31.8, 50.2 59.3 49.8, 68.2 Side-Breakfast 46 45.7 31.9, 59.9 54.3 40.1, 68.1 Side-Fries 232 19.4 14.7, 24.8 80.6 75.2, 85.3 Side-Fruit 18 0.0 0.0, 0.0 100.0 100.0, 100.0 Side-Kids 66 62.1 50.1, 73.1 37.9 26.9, 49.9 Side-Meat 26 26.9 12.9, 45.7 73.1 54.3, 87.1 Side-Misc. 160 33.8 26.8, 41.3 66.3 58.7, 73.2 Side-Other Baked Goods 22 36.4 18.9, 57.1 63.6 42.9, 81.1 Side-Pasta 18 50.0 28.4, 71.6 50.0 28.4, 71.6 Side-Potatoes (non-fried) 68 35.3 24.7, 47.1 64.7 52.9, 75.3 Side-Poultry 88 14.8 8.5, 23.3 85.2 76.7, 91.5 Side-Rice 43 46.2 32.2, 61.2 53.5 38.8, 67.8 Side-Salad 168 48.8 41.3, 56.3 51.2 43.8, 58.7

Side-Seafood 41 29.3 17.1, 44.2 70.7 55.8, 82.9 Side-Soup 186 1.1 0.2, 3.4 98.9 96.6, 99.8 Side-Vegetables 75 65.3 54.1, 75.4 34.7 24.6, 45.9 Starters 546 14.8 82.0, 88.0 85.2 12.0, 18.0 Starter-Breads 33 9.1 2.6, 22.3 90.9 77.7, 97.4 Starter-Cheese 13 0.0 0.0, 0.0 100.0 100.0, 100.0 Starter-Dips 23 43.5 25.0, 63.5 56.5 36.5, 75.0 Starter-Fries 21 0.0 0.0, 0.0 100.0 100.0, 100.0 Starter-Meat 31 6.5 1.4, 19.1 93.5 80.9, 98.6 Starter-Misc. 60 5.0 1.4, 12.7 95.0 87.3, 98.6 Starter-Poultry 120 30.0 22.4, 38.6 70.0 61.4, 77.6 Starter-Salad 31 41.9 25.9, 59.4 58.1 40.6, 74.1 Starter-Seafood 64 12.5 6.1, 22.2 87.5 77.8, 93.9 Starter-Soup 139 3.6 1.4, 7.7 96.4 92.3, 98.6 Starter-Vegetables 11 9.1 1.0, 35.3 90.9 64.7, 99.0 Sugar (g) Overall 10,458 71.4 71.4, 72.3 28.6 27.7, 29.5 Beverage 2045 20.1 18.5, 21.9 79.9 78.1, 81.5 Beverage-Coffee/Teas 850 28.5 25.5, 31.6 71.5 68.4,74.5 Beverage-Flavoured Milk 88 10.2 5.3, 17.8 89.8 82.2, 94.8 Beverage-Juices/Smoothies 494 5.5 3.7, 7.7 94.5 92.3, 96.3 Beverage-Kids 48 22.9 12.8, 36.2 77.1 63.8, 87.2 Beverage- Milkshakes/Floats 166 0.0 0.0, 0.0 100.0 100.0, 100.0 Beverage-Plain Milk 12 100.0 100.0, 100.0 0.0 0.0, 0.0 Beverage-Soft Drinks 380 27.3 23.1, 32.0 72.6 68.0, 76.9 Beverage-Water 7 100.0 100.0, 100.0 0.0 0.0, 0.0 Desserts 1194 21.0 18.8, 23.4 79.0 76.6, 81.2 Dessert-Cookies 94 30.9 22.2, 40.7 69.1 59.3, 77.8 Dessert-Donuts 126 49.2 40.6, 57.9 50.8 42.1, 59.4 Dessert-Frozen Desserts 417 13.9 10.8, 17.5 86.1 82.5, 89.2 Dessert-Kids 37 51.4 35.7, 66.8 48.6 33.2, 64.3

Dessert-Misc. 5 60.0 20.9, 90.6 40.0 9.4, 79.1 Dessert-Muffins 157 1.3 0.3, 4.0 98.7 96.0, 99.7 Dessert-Other Baked Goods 358 21.8 17.8, 26.4 78.2 73.6, 82.2 Entrées 5344 95.2 94.6, 95.7 4.8 4.3, 5.4 Entrée-Breakfast 599 82.5 79.3, 85.4 17.5 14.6, 20.7 Entrée-Burgers 292 98.6 96.8, 99. 1.4 0.5, 3.2 Entrée-Hot Dogs 19 100.0 100.0, 100.0 0.0 0.0, 0.0 Entrée-Kids 220 97.7 95.1, 99.1 2.3 0.9, 4.9 Entrée-Meat 326 91.7 88.4, 94.3 8.3 5.7, 11.6 Entrée-Misc. 48 85.4 73.5, 93.2 14.6 6.8, 26.5 Entrée-Savoury Baked Goods 16 100.0 100.0, 100.0 0.0 0.0, 0.0 Entrée-Pasta 231 97.4 94.7, 98.9 2.6 1.1, 5.3 Entrée-Pizza 1516 98.5 97.9, 99.1 1.5 0.9, 2.1 Entrée-Poultry 356 90.2 86.8, 92.9 9.8 7.1, 13.2 Entrée-Poutine 34 97.1 87.1, 99.7 2.9 0.3, 12.9 Entrée-Salad 399 95.5 93.1, 97.2 4.5 2.8, 6.9 Entrée-Sandwiches/Wraps 871 97.6 96.4, 98.5 2.4 1.5, 3.6 Entrée-Seafood 179 96.8 94.8, 99.2 2.2 0.8, 5.2 Entrée-Soup 20 100.0 100.0, 100.0 0.0 0.0, 0.0 Entrée-Tacos/Burritos 191 100.0 100.0, 100.0 0.0 0.0, 0.0 Entrée-Vegetables 27 92.6 78.3, 98.4 7.4 1.6, 21.7 Sides 1345 93.2 91.7, 94.4 6.8 5.6, 8.3 Side-Bagels 74 98.6 93.9, 99.9 1.4 0.1, 6.1 Side-Breads 107 96.3 91.4, 98.7 3.7 1.3, 8.6 Side-Breakfast 46 80.4 67.3, 89.9 19.6 10.1, 32.7 Side-Fries 229 89.1 84.6, 92.6 10.9 7.4, 15.4 Side-Fruit 18 61.1 38.3, 80.6 38.9 19.4, 61.7 Side-Kids 65 95.4 88.2, 98.7 4.6 1.3, 11.8 Side-Meat 21 95.2 79.8, 99.5 4.8 0.5, 20.2 Side-Misc. 150 91.3 86.0, 95.1 8.7 4.9, 14.0 Side-Other Baked Goods 22 81.8 62.4, 93.5 18.2 6.5, 37.6

Side-Pasta 16 100.0 100.0, 100.0 0.0 0.0, 0.0 Side-Potatoes (non-fried) 67 98.5 93.2, 99.8 1.5 0.2, 6.8 Side-Poultry 87 93.1 86.3, 97.1 6.9 2.9, 13.7 Side-Rice 40 100.0 100.0, 100.0 0.0 0.0, 0.0 Side-Salad 159 92.5 87.5, 95.8 7.5 4.2, 12.4 Side-Seafood 40 97.4 88.9, 99.67 2.5 0.3, 11.1 Side-Soup 131 97.7 94.0, 99.4 2.3 0.6, 6.0 Side-Vegetables 73 97.3 91.5, 99.4 2.7 0.6, 8.5 Starters 530 87.7 84.7, 90.3 12.3 9.7, 15.3 Starter-Breads 33 93.9 81.9, 98.6 6.1 1.3, 18.1 Starter-Cheese 13 84.6 59.1, 96.7 15.4 3.3, 40.9 Starter-Dips 23 100.0 100.0, 100.0 0.0 0.0, 0.0 Starter-Fries 21 71.4 50.3, 87.1 28.6 12.9, 49.7 Starter-Meat 28 78.6 61.1, 90.5 21.4 9.5, 38.9 Starter-Misc. 59 78.0 66.2, 87.0 22.0 13.0, 33.8 Starter-Poultry 111 82.0 73.1, 88.3 18.0 11.7, 25.9 Starter-Salad 31 100.0 100.0, 100.0 0.0 0.0, 0.0 Starter-Seafood 62 83.9 73.3, 91.4 16.1 8.6, 26.7 Starter-Soup 139 96.4 92.3, 98.6 3.6 1.4, 7.7 Starter-Vegetables 10 90.0 61.9, 98.9 10.0 1.1, 38.1 1Percentages include exemptions which were counted as being below threshold no matter the values, as described in the methods section of this paper, and are reported by row.

Supplementary Table 4.3: Proportion of menu items requiring 0, 1, 2, or 3 FOP labels by subcategory, fast-food restaurants

Fast Food Establishments

95% 95% 95% 95% No Labels Confidence Confidence Confidence Confidence Category N n (%1) Interval One Label (%1) Interval Two Labels (%1) Interval Three Labels (%1) Interval Overall 10,062 5821 22.3 21.2, 23.4 37.6 36.4, 38.9 36.1 34.8, 37.3 4.0 3.5, 4.5 Beverage 1723 1538 16.0 14.2, 1.9 59.0 56.6, 61.5 20.0 18.1, 22.1 4.9 3.9, 6.1 Beverage- Coffee/Teas 624 598 22.2 19.0, 25.7 46.5 42.5, 50.5 29.4 25.9, 33.2 1.8 1.0, 3.2 Beverage- Flavoured Milk 48 40 20.0 9.9, 34.2 62.5 47.1, 76.2 17.5 8.2, 31.3 0.0 0.0, 0.0 Beverage- Juices/Smoothies 471 404 2.2 1.1, 4.0 88.6 85.2, 91.4 8.4 6.0, 11.4 0.7 0.2, 2.0 Beverage-Kids 48 40 2.0 9.9, 34.2 62.5 47.1, 76.2 17.5 8.2, 31.3 0.0 0.0, 0.0 Beverage- Milkshakes/Floats 133 119 0.0 0.0, 0.0 0.8 0.1, 3.9 51.3 42.3, 60.1 47.9 39.1, 56.8 Beverage-Plain Milk 12 4 100.0 100.0, 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Beverage-Soft Drinks 380 329 26.7 22.2, 31.7 72.0 67.0, 76.7 0.9 0.3, 2.4 0.3 0.0, 1.4 Beverage-Water 7 4 100.0 100.0, 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Desserts 1140 883 8.0 6.4, 10.0 35.3 32.2, 38.5 44.7 41.5, 48.0 11.9 9.9, 14.2 Dessert-Cookies 94 88 4.5 1.6, 10.4 25.0 16.9, 34.8 67.0 56.8, 76.2 3.4 1.0, 8.8 Dessert-Donuts 126 120 25.8 18.6, 34.2 25.8 18.6, 34.2 41.6 23.9, 40.3 16.7 10.8, 24.1 Dessert-Frozen Desserts 399 351 6.3 4.1, 9.2 51.3 46.1, 56.5 36.8 31.8, 41.9 5.7 3.6, 8.5 Dessert-Kids 33 7 42.9 13.9, 76.5 28.6 6.5, 64.8 28.6 6.5, 64.8 0.0 0.0, 0.0 Dessert-Misc. 5 4 75.0 28.4, 97.2 25.0 2.8, 71.6 0.0 0.0, 0.0 0.0 0.0, 0.0 Dessert-Muffins 125 122 0.8 0.1, 3.8 23.8 16.9, 31.9 54.9 46.1, 63.5 20.5 14.1, 28.3 Dessert-Other Baked Goods 358 191 3.7 1.7, 7.1 24.6 18.9, 31.1 52.4 45.3, 59.4 19.4 14.3, 25.4 Entrées 5344 2594 32.5 30.7, 34.3 24.5 22.9, 26.2 41.8 39.9, 43.7 1.3 0.9, 1.8 Entrée-Breakfast 599 219 14.2 10.0, 19.2 26.0 20.6, 32.1 59.8 53.2, 66.1 0.0 0.0, 0.0 Entrée-Burgers 292 160 6.3 3.3, 10.8 22.5 16.6, 29.4 70.6 63.2, 77.3 0.6 0.1, 2.9 Entrée-Hot Dogs 19 18 0.0 0.0, 0.0 11.1 2.4, 31.1 88.9 68.9, 97.6 0.0 0.0, 0.0

Entrée-Kids 220 67 53.7 41.8, 65.3 32.8 22.5, 44.6 13.4 6.9, 23.1 0.0 0.0, 0.0 Entrée-Meat 326 68 7.4 2.9, 15.4 23.5 14.7, 34.6 69.1 7.5, 79.1 0.0 0.0, 0.0 Entrée-Misc. 48 25 24.0 10.7, 42.9 32.0 16.4, 51.5 40.0 22.7, 59.4 4.0 0.4, 17.2 Entrée-Savoury Baked Goods 16 10 0.0 0.0, 0.0 20.0 4.4, 50.3 80.0 49.7, 95.6 0.0 0.0, 0.0 Entrée-Pasta 231 36 27.8 15.3, 43.7 25.0 13.2, 40.7 47.2 31.7, 63.2 0.0 0.0, 0.0 Entrée-Pizza 1516 805 66.5 63.1, 69.7 7.0 5.4, 8.9 24.0 21.1, 27.0 2.6 1.7, 3.9 Entrée-Poultry 356 131 23.7 17.0, 31.5 36.6 28.8, 45.1 38.9 30.9, 47.4 0.8 0.1, 3.5 Entrée-Poutine 34 32 9.4 2.7, 23.0 6.3 1.3, 18.6 84.4 69.1, 93.8 0.0 0.0, 0.0 Entrée-Salad 399 166 31.3 24.6, 38.7 19.9 14.4, 26.4 47.0 39.5, 54.6 1.8 0.5, 4.7 Entrée- Sandwiches/Wraps 871 613 8.8 6.8, 11.2 40.8 36.9, 44.7 49.3 45.3, 53.2 1.1 0.5, 2.2 Entrée-Seafood 179 55 21.8 12.5, 34.0 58.2 45.0, 70.5 20.0 11.1, 31.9 0.0 0.0, 0.0 Entrée-Soup 20 7 0.0 0.0, 0.0 57.1 23.5, 86.1 42.9 13.9, 76.5 0.0 0.0, 0.0 Entrée- Tacos/Burritos 191 171 31.6 25.0, 38.8 29.8 23.3, 37.0 38.6 31.5, 46.0 0.0 0.0, 0.0 Entrée-Vegetables 27 11 27.3 8.3, 56.5 63.6 24.8, 86.3 9.1 1.0, 35.3 0.0 0.0, 0.0 Sides 1325 730 17.4 14.8, 20.3 40.1 36.6, 43.7 40.0 36.5, 43.7 2.5 1.5, 3.8 Side-Bagels 54 53 7.5 2.6, 17.0 84.9 73.5, 92.6 7.5 2.6, 17.0 0.0 0.0, 0.0 Side-Breads 107 50 26.0 15.4, 39.3 30.0 18.7, 43.6 42.0 29.1, 55.8 2.0 0.2, 9.0 Side-Breakfast 46 10 40.0 15.3, 69.6 30.0 9.3, 60.6 30.0 9.3, 60.6 0.0 0.0, 0.0 Side-Fries 229 138 18.1 12.4, 25.2 24.6 18.0, 32.3 55.1 46.7, 63.2 2.2 0.6, 5.7 Side-Fruit 18 8 75.0 40.8, 94.4 25.0 5.6, 59.2 0.0 0.0, 0.0 0.0 0.0, 0.0 Side-Kids 65 8 37.5 11.9, 70.5 62.5 29.5, 88.1 0.0 0.0, 0.0 0.0 0.0, 0.0 Side-Meat 21 8 12.5 1.4, 45.4 12.5 1.4, 45.4 75.0 40.8, 94.4 0.0 0.0, 0.0 Side-Misc. 150 97 15.5 9.3, 23.6 35.1 26.1, 44.9 46.4 36.7, 56.3 3.1 0.9, 8.0 Side-Other Baked Goods 22 20 10.0 2.1, 28.4 50.0 29.3, 70.7 35.0 17.2, 56.8 5.0 0.5, 21.1 Side-Pasta 16 6 16.7 1.9, 55.8 33.3 .7, 71.4 50.0 16.7, 83.3 0.0 0.0, 0.0 Side-Potatoes (non-fried) 67 20 30.0 13.6, 51.7 40.0 21.1, 61.6 30.0 13.6, 51.7 0.0 0.0, 0.0 Side-Poultry 87 74 12.2 6.2, 21.0 25.7 16.8, 36.4 59.5 48.1, 70.1 2.7 0.6, 8.4 Side-Rice 40 14 42.9 20.3, 68.1 35.7 15.1, 61.5 21.4 6.4, 46.9 0.0 0.0, 0.0 Side-Salad 159 69 23.2 14.5, 34.1 30.4 20.5, 41.9 37.7 26.9, 49.4 8.7 3.7, 17.0

Side-Seafood 40 19 36.8 18.2, 59.1 52.6 31.2, 73.4 10.5 2.3, 29.7 0.0 0.0, 0.0 Side-Soup 131 118 1.7 0.4, 5.3 59.3 50.3, 67.9 37.3 29.0, 46.2 1.7 0.4, 5.3 Side-Vegetables 73 18 38.9 19.4, 61.7 50.0 28.4, 71.6 11.1 2.4, 31.1 0.0 0.0, 0.0 Starters 530 76 14.5 7.9, 23.6 56.6 45.4, 67.3 28.9 19.7, 39.8 0.0 0.0, 0.0 Starter-Breads 33 2 50.0 6.1, 93.9 50.0 6.1, 93.9 0.0 0.0, 0.0 0.0 0.0, 0.0 Starter-Cheese 13 3 0.0 0.0, 0.0 0.0 0.0, 0.0 100.0 100.0, 100.0 0.0 0.0, 0.0 Starter-Dips 23 3 33.3 3.9, 82.3 66.7 17.7, 96.1 0.0 0.0, 0.0 0.0 0.0, 0.0 Starter-Fries 21 0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Starter-Meat 28 3 100.0 100.0, 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Starter-Misc. 59 5 0.0 0.0, 0.0 40.0 9.4, 79.1 60.0 20.9, 90.6 0.0 0.0, 0.0 Starter-Poultry 111 17 29.4 12.2, 53.0 35.3 16.3, 58.9 35.3 16.3, 58.9 0.0 0.0, 0.0 Starter-Salad 31 0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Starter-Seafood 62 5 40.0 9.4, 79.1 40.0 9.4, 79.1 20.0 2.3, 62.9 0.0 0.0, 0.0 Starter-Soup 139 39 0.0 0.0, 0.0 76.9 62.1, 87.9 23.1 12.1, 37.9 0.0 0.0, 0.0 Starter-Vegetables 10 0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 1Percentages include exemptions which were counted as being below threshold no matter the values, as described in the methods section of this paper, and are reported by row.

Supplementary Table 4.4: Proportion of menu items requiring 0, 1, 2, or 3 FOP labels by subcategory, sit-down restaurants Sit Down Restaurants

95% One 95% 95% Three 95% No Labels Confidence Label Confidence Two Labels Confidence Labels Confidence Category N n (%1) Interval (%1) Interval (%1) Interval (%1) Interval 424 Overall 10,062 1 19.9 18.7, 21.1 21.3 20.1, 22.6 51.3 49.8, 52.8 7.5 6.7, 8.3 Beverage 1723 185 26.5 20.5, 33.2 63.8 56.7, 70.5 6.5 3.6, 10.7 3.2 1.4, 6.6 Beverage- Coffee/Teas 624 26 50.0 31.6, 68.4 50.0 31.6, 68.4 0.0 0.0, 0.0 0.0 0.0, 0.0 Beverage- Flavoured Milk 48 8 62.5 29.5, 88.1 37.5 11.9, 70.5 0.0 0.0, 0.0 0.0 0.0, 0.0 Beverage- Juices/Smoothies 471 67 13.4 6.9, 23.1 83.6 73.4, 91.0 3.0 0.6, 9.2 0.0 0.0, 0.0 Beverage-Kids 48 8 12.5 1.4, 45.4 87.5 54.6, 98.6 0.0 0.0, 0.0 0.0 0.0, 0.0 Beverage- Milkshakes/Floats 133 14 0.0 0.0, 0.0 7.1 0.8, 28.8 50.0 5.9, 74.1 42.9 20.3, 68.1 Beverage-Plain Milk 12 8 100.0 100.0, 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Beverage-Soft Drinks 380 51 29.4 18.3, 42.8 70.6 57.2, 81.7 0.0 0.0, 0.0 0.0 0.0, 0.0 Beverage-Water 7 3 100.0 100.0, 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Desserts 1140 257 4.3 2.3, 7.3 11.7 8.2, 16.0 41.6 35.7, 47.7 42.4 36.5, 48.5 Dessert-Cookies 94 6 0.0 0.0, 0.0 16.7 1.9, 55.8 33.3 7.7, 71.4 50.0 16.7, 83.3 Dessert-Donuts 126 6 0.0 0.0, 0.0 0.0 0.0, 0.0 33.3 7.7, 71.4 66.7 28.6, 92.3 Dessert-Frozen Desserts 399 48 4.2 0.9, 12.7 20.8 11.2, 33.8 54.2 40.2, 67.7 20.8 11.2, 33.8 Dessert-Kids 33 26 19.2 7.7, 37.1 26.9 12.9, 45.7 46.2 28.2, 64.9 7.7 1.6, 22.5 100.0, Dessert-Misc. 5 1 0.0 0.0, 0.0 100.0 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Dessert-Muffins 125 3 0.0 0.0, 0.0 33.3 3.9, 82.3 33.3 3.9, 82.3 33.3 3.9, 82.3 Dessert-Other Baked Goods 358 167 2.4 0.8, 5.6 6.0 3.1, 10.4 38.3 31.2, 45.8 53.3 45.7, 60.7 284 Entrées 5344 4 19.6 18.1, 21.1 17.1 15.8, 18.6 58.4 56.6, 60.3 4.8 4.1, 5.7

81 82

Entrée-Breakfast 599 380 4.5 2.7, 6.9 15.5 12.2,19.4 67.1 62.3, 71.7 12.9 9.8, 16.5 Entrée-Burgers 292 132 1.5 0.3, 4.8 10.6 6.2, 16.7 86.4 79.7, 91.4 1.5 0.3, 4.8 100.0, Entrée-Hot Dogs 19 1 0.0 0.0, 0.0 100.0 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Entrée-Kids 220 153 30.7 23.8, 38.3 37.3 29.9, 45.1 30.7 23.8, 38.3 1.3 0.3, 4.1 Entrée-Meat 326 258 4.7 2.6, 7.7 22.9 18.1, 28.3 63.6 57.6, 69.3 8.9 5.9, 12.9 Entrée-Misc. 48 23 8.7 1.9, 25.1 8.7 1.9, 25.1 60.9 40.6, 78.6 21.7 8.8, 41.3 Entrée-Savoury Baked Goods 16 6 0.0 0.0, 0.0 0.0 0.0, 0.0 100.0 100.0, 100.0 0.0 0.0, 0.0 Entrée-Pasta 231 195 7.2 4.2, 11.4 22.1 16.7, 28.3 67.7 60.9, 74.0 3.1 1.3, 6.2 Entrée-Pizza 1516 711 49.1 45.4, 52.8 6.6 5.0, 8.6 44.2 40.5, 47.8 0.1 0.0, 0.7 Entrée-Poultry 356 225 8.4 5.3, 12.6 25.8 20.4, 31.8 55.1 48.6, 61.5 10.7 7.1, 15.2 Entrée-Poutine 34 2 0.0 0.0, 0.0 0.0 0.0, 0.0 50.0 6.1, 93.9 50.0 6.1, 93.9 Entrée-Salad 399 233 23.6 18.5, 29.4 26.2 20.9, 32.1 46.4 40.0, 52.8 3.9 1.9, 6.9 Entrée- Sandwiches/Wrap s 871 258 1.2 0.3, 3.1 10.1 6.8, 14.2 84.9 80.1, 88.9 3.9 2.0, 6.8 Entrée-Seafood 179 124 12.9 7.9, 19.6 29.0 21.6, 37.4 57.3 48.5, 65.7 0.8 0.1, 3.7 Entrée-Soup 20 13 0.0 0.0, 0.0 7.7 0.8, 30.7 92.3 69.3, 99.2 0.0 0.0, 0.0 Entrée- Tacos/Burritos 191 20 5.0 0.5, 21.1 20.0 7.2, 40.8 75.0 52.6, 89.8 0.0 0.0, 0.0 Entrée-Vegetables 27 16 12.5 2.7, 34.4 25.0 9.1, 49.1 62.5 38.3, 82.6 0.0 0.0, 0.0 Sides 1325 595 33.3 29.6, 37..1 31.6 28.0, 35.4 32.6 28.9, 36.4 2.5 1.5, 4.0 100.0, Side-Bagels 54 1 0.0 0.0, 0.0 100.0 100.0 0.0 0.0, 0.0 0.0 0.0, 0.0 Side-Breads 107 57 35.1 23.7, 48.0 33.3 22.2, 46.2 21.6 20.7, 44.3 0.0 0.0, 0.0 Side-Breakfast 46 36 22.2 11.1, 37.6 33.3 19.7, 49.5 41.7 26.7, 57.9 2.8 0.3, 12.3 Side-Fries 229 91 14.3 8.3, 22.5 18.7 11.7, 27.6 56.0 45.8, 65.9 11.0 5.8, 18.6 Side-Fruit 18 10 40.0 15.3, 69.6 50.0 22.4, 77.6 10.0 1.1, 38.1 0.0 0.0, 0.0 Side-Kids 65 57 14.9 6.9, 27.0 44.7 31.1, 58.9 38.3 25.4, 52.6 2.1 0.2, 9.5 Side-Meat 21 13 7.7 0.8, 30.7 46.2 22.1, 71.7 38.5 16.5, 65.0 7.7 0.8, 30.7 Side-Misc. 150 53 43.4 30.7, 56.8 32.1 20.7, 45.3 24.5 14.5, 37.2 0.0 0.0, 0.0

Side-Other Baked Goods 22 2 0.0 0.0, 0.0 50.0 6.1, 93.9 50.0 6.1, 93.9 0.0 0.0, 0.0 Side-Pasta 16 10 40.0 15.3, 69.6 50.0 22.4, 77.6 10.0 1.1, 38.1 0.0 0.0, 0.0 Side-Potatoes (non-fried) 67 47 14.9 6.9, 27.0 44.7 31.1, 58.9 38.4 25.4, 52.6 2.1 0.2, 9.5 Side-Poultry 87 13 7.7 0.8, 30.7 46.2 22.1, 71.7 38.5 16.5, 65.0 7.7 0.8, 30.7 Side-Rice 40 26 34.6 18.7, 53.7 57.7 38.7, 59.1 7.7 1.6, 22.6 0.0 0.0, 0.0 Side-Salad 159 90 48.9 38.7, 59.1 18.9 11.9, 27.9 31.1 22.3, 41.2 1.1 0.1, 5.1 Side-Seafood 40 21 19.0 6.8, 39.2 33.3 6.3, 54.6 47.6 27.7, 68.1 0.0 0.0, 0.0 Side-Soup 131 13 0.0 0.0, 0.0 38.5 16.5, 65.0 61.5 35.0, 83.5 0.0 0.0, 0.0 Side-Vegetables 73 55 49.1 36.2, 62.1 32.7 21.5, 45.8 18.2 9.7, 29.9 0.0 0.0, 0.0 Starters 530 454 10.6 8.0, 13.7 21.4 17.8, 25.3 55.9 51.4, 60.5 12.1 9.4, 15.4 Starter-Breads 33 31 6.5 1.4, 19.1 12.9 4.5, 27.8 74.2 57.1, 87.0 6.5 1.4, 19.1 Starter-Cheese 13 10 0.0 0.0, 0.0 10.0 1.1, 38.1 70.0 39.4, 90.7 20.0 4.4, 5.30 Starter-Dips 23 20 20.0 7.2, 40.8 20.0 7.3, 40.8 60.0 38.4, 78.9 0.0 0.0, 0.0 Starter-Fries 21 21 0.0 0.0, 0.0 9.5 2.0, 27.2 71.4 50.3, 87.1 19.0 6.8, 39.2 Starter-Meat 28 26 0.0 0.0, 0.0 3.8 0.4, 16.6 73.1 54.3, 87.1 23.1 10.3, 41.5 Starter-Misc. 59 54 1.9 0.2, 8.3 9.3 3.6, 19.1 68.5 55.4, 79.7 20.4 11.3, 32.5 Starter-Poultry 111 94 22.3 14.8, 31.5 10.6 5.6, 18.0 50.0 40.0, 60.0 17.0 10.5, 25.6 Starter-Salad 31 31 35.5 20.5, 53.0 6.5 1.4, 19.1 58.1 40.6, 74.1 0.0 0.0, 0.0 Starter-Seafood 62 57 8.8 3.4, 18.2 31.6 20.7, 44.3 43.9 31.5, 56.8 15.8 8.1, 26.8 Starter-Soup 139 100 3.0 0.9, 7.8 48.0 38.4, 57.7 45.0 35.5, 54.8 4.0 1.4, 9.2 Starter-Vegetables 10 10 10.0 1.1, 38.1 20.0 4.4, 50.3 60.0 30.4, 84.7 10.0 1.1, 38.1 1Percentages include exemptions which were counted as being below threshold no matter the values, as described in the methods section of this paper, and are reported by row