Energy, Saturated Fat, and Sodium Were Lower in Entrées at Chain
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RESEARCH Original Research Energy, Saturated Fat, and Sodium Were Lower in Entrées at Chain Restaurants at 18 Months Compared with 6 Months Following the Implementation of Mandatory Menu Labeling Regulation in King County, Washington Barbara Bruemmer, PhD, RD; Jim Krieger, MD, MPH; Brian E. Saelens, PhD; Nadine Chan, PhD, MPH ARTICLE INFORMATION ABSTRACT Article history: Background Policies on menu labeling have been proposed as a method to improve the Accepted 17 April 2012 food environment. However, there is little information on the nutrient content of chain Available online 14 June 2012 restaurant menu items and changes over time. Keywords: Objective To evaluate the energy, saturated fat, and sodium content of entrÊes 6 and 18 Food labeling months post-implementation of restaurant menu labeling in King County of Washing- Restaurants ton State for items that were on the menu at both time periods, and across all items at 6 Energy intake and 18 months and to compare energy content to recommendations provided by the 2005 Dietary Guidelines for Americans. Copyright © 2012 by the Academy of Nutrition Setting Eligible restaurants included sit-down and quick-service chains (eg, burgers, and Dietetics. pizza, sandwiches/subs, and Tex-Mex) subject to King County regulations with four or 2212-2672/$36.00 doi: 10.1016/j.jand.2012.04.019 more establishments. One establishment per chain was audited at each time period. Statistical analyses Hypothesis one examined entrÊes that were on the menu at both time periods using a paired t test and hypothesis two compared quartiles at 6 months to the distribution at 18 months using a Mantel-Haentzel odds ratios and 95% CIs, and a Cochrane-Armitage test for trend. The content of entrÊes at 18 months was compared with one-third (assuming three meals per day) of the nutrient intake recommendations for adults provided by the 2005 Dietary Guidelines for Americans. Results The audit included 37 eligible chains of 92 regulated chains. Energy contents were lower (all chains Ϫ41, sit down Ϫ73, and quick service Ϫ19; paired t tests PϽ0.0001) for entrÊes that were on the menu at both time periods. There was a significant trend across quartiles for a decrease in energy, saturated fat, and sodium for all entrÊes at sit-down chains only. At 18 months entrÊes not designated for children exceeded 56%, 77%, and 89% of the energy, saturated fat, and sodium guidelines, respectively. Conclusions Modest improvements in the nutrient content of sit-down and quick-ser- vice restaurant entrÊes occurred but overall levels for energy, saturated fat, and sodium are excessive. J Acad Nutr Diet. 2012;112:1169-1176. NVIRONMENTAL APPROACHES THAT ADDRESS SOURCES tion sizes contributing to excess energy intake,8–12 but of excess energy are a promising option to address the there are inconsistencies in study results possibly due to obesity epidemic.1,2 Studies have reported associations observational study designs and lack of controls. Recom- Ebetween various aspects of the away-from-home food mendations for labeling at the point of purchase are based environment and obesity, including a positive association be- on the assumption that increased awareness will lead to tween the frequency of consumption of fast food and obesity,3 healthier choices which, through sales patterns, will influ- increases in body weight, 4–6 and increases in total energy and ence the energy value of menu items.2,13–17 Public health percent fat intake4 and between the frequency of consumption agency jurisdictions, including King County, Washington; of fast food that is primarily burgers and french fries and over- New York City; and others were early implementers of reg- weight and obesity.7 In addition, children who eat more fast ulations requiring the posting of energy content and other food have a higher intake of energy compared with children nutrient information in national restaurant chains. Subse- who do not consume fast food.8 Theories that link food quently menu labeling became a federal mandate as part of eaten away from home to obesity often focus on large por- the Patient Protection and Affordable Care Act.18 © 2012 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1169 RESEARCH Table 1. Energy, saturated fat, and sodium levels used in the paired analysis for entrées present on menus at 37 chain restaurantsa at both 6 mo (May to July 2009) and at 18 months (May to July 2010) postimplementation of menu labeling regulation in King County, Washington Chain category Entrées (n) 6-mo post 18-mo post Differenceb 4™™™™™™™™™™™™™™™™™ meanϮstandard deviation ™™™™™™™™™™™™™™™3 Energy (kcal) All 1,771 818Ϯ407 777Ϯ388 Ϫ41Ϯ156* Sit down 704 1,044Ϯ438 970Ϯ425 Ϫ73Ϯ217* Quick service 1,067 668Ϯ304 650Ϯ300 Ϫ19Ϯ91* Burger 217 748Ϯ360 739Ϯ348 Ϫ10Ϯ60*** Pizza 212 624Ϯ241 622Ϯ248 Ϫ2Ϯ77 Sandwich/sub 347 628Ϯ217 605Ϯ220 Ϫ23Ϯ106* Tex-Mex 291 690Ϯ367 657Ϯ359 Ϫ33Ϯ97* Saturated fat (g) All 1,641 14.3Ϯ9.9 13.7Ϯ10.0 Ϫ0.7Ϯ3.8* Sit down 703 17.8Ϯ11.3 16.4Ϯ11.3 Ϫ1.4Ϯ4.8* Quick service 938 11.8Ϯ7.7 11.6Ϯ7.6 Ϫ0.1Ϯ2.7 Burger 196 10.9Ϯ7.3 10.5Ϯ6.9 Ϫ0.5Ϯ3.0*** Pizza 189 16.2Ϯ9.3 16.1Ϯ9.2 Ϫ0.1Ϯ2.9 Sandwich/sub 307 10.3Ϯ5.4 10.3Ϯ5.4 0.1Ϯ2.5 Tex-Mex 246 10.8Ϯ8.1 10.7Ϯ7.9 Ϫ0.2Ϯ2.6 Sodium (mg) All 1,669 1,841Ϯ1,038 1,733Ϯ965 Ϫ108Ϯ541* Sit down 703 2,134Ϯ1,226 1,905Ϯ1,138 Ϫ231Ϯ727* Quick service 966 1,628Ϯ813 1,608Ϯ796 Ϫ18Ϯ2 Burger 200 1,378Ϯ581 1,346Ϯ546 Ϫ35Ϯ166** Pizza 211 1,841Ϯ1,177 1,865Ϯ1,126 24Ϯ445 Sandwich/sub 308 1,656Ϯ656 1,642Ϯ674 Ϫ12Ϯ300 Tex-Mex 247 1,614Ϯ715 1,562Ϯ695 Ϫ47Ϯ310*** aAll chains nϭ37, sit down chains nϭ11, quick-service chains nϭ26, burger chains nϭ6, pizza chains nϭ9, sandwich/sub nϭ6, and Tex-Mex nϭ5. bDifference calculated as values at 18 mo minus values at 6 mo; thus, a negative value indicates the entrée’s energy content decreased during the study period. *P Ͻ0.0001. **PϽ0.01. ***PϽ0.05. The effectiveness of menu labeling in restaurants is uncer- menu items would be reformulated to improve their nutrient tain and preliminary evaluations have yielded mixed re- profiles with less energy, less saturated fat, and less sodium, sults.19–25 However, many studies have focused solely on cus- and second that the nutrient profiles of overall menus would tomer choices (eg, through receipt data collection) and the improve through both reformulation and menu changes. corresponding energy or other nutrient content of these These hypotheses were tested across restaurant chains. The choices, without examining whether the restaurants changed study also examined the distribution of energy in entrÊes re- the availability and energy content of their menu items over lated to a national reference standard. time, perhaps in response to menu labeling. To our knowl- edge, no evaluation of the effect of restaurant menu labeling METHODS on menu nutrition content has been conducted. To address this gap in the literature, we conducted an audit Study Design of menu items to describe changes that occurred following We compared entrÊe items available at one establishment of implementation of menu labeling regulation in King County. eligible national restaurant chains at two time periods (6 Our study assessed changes in energy, saturated fat, and so- months and 18 months) following the implementation of dium in entrÊes 6 months and 18 months postimplementa- mandatory menu labeling at the point of purchase. This re- tion of the regulations to test two hypotheses. First, individual search was exempt from Institutional Review Board review. 1170 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS August 2012 Volume 112 Number 8 RESEARCH Table 2. Quartile distributions for energy, saturated fat, and sodium levels for all entrées at 37 chain restaurantsa at6mo (May to July 2009) and 18 mo (May to July 2010) postimplementation of labeling regulation in King County, Washington % Distribution % Distribution at 6 mo post- at 18 mo post- Nutrient Nutrient values implementation implementation Odds ratio 95% CI Energy (kcal) Sit down Quartile 4 Ն1,310 25 19 0.63 0.48–0.84* Quartile 3 1,011–1,309 25 23 0.79 0.60–1.05 Quartile 2 715–1,099 25 27 0.90 0.69–1.19 Quartile 1 Ͻ715 25 30 1.00 Quick service Quartile 4 Ն840 25 24 0.84 0.67–1.05 Quartile 3 620–839 26 25 0.83 0.66–1.03 Quartile 2 460–619 25 24 0.86 0.69–1.08 Quartile 1 Ͻ460 24 27 1.00 Saturated fat (g) Sit down Quartile 4 Ն25.0 25 21 0.66 0.50–0.87* Quartile 3 16.5–24.0 25 21 0.67 0.51–0.89 Quartile 2 10.0–16.4 25 26 0.83 0.63–1.09 Quartile 1 Ͻ10.0 25 31 1.00 Quick service Quartile 4 Ն15.3 25 21 1.00 0.78–1.29 Quartile 3 10.0–15.2 28 21 1.01 0.79–1.29 Quartile 2 6.0–9.9 26 26 1.01 0.79–1.30 Quartile 1 Ͻ6.0 21 31 1.00 Sodium (mg) Sit down Quartile 4 Ն2,685 25 20 0.63 0.48–0.84* Quartile 3 1,926–2,684 25 21 0.69 0.52–0.92 Quartile 2 1,236–1,925 25 28 0.90 0.69–1.18 Quartile 1 Ͻ1,236 25 31 1.00 Quick service Quartile 4 Ն2,050 25 26 1.03 0.81–1.30 Quartile 3 1,480–2,049 25 27 1.07 0.85–1.36 Quartile 2 1,050–1,479 25 22 0.91 0.72–1.16 Quartile 1 Ͻ1,050 25 25 1.00 aAll chains nϭ37, sit down chains nϭ11, and quick service chains nϭ26.