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Eating-Out: A Study of the Nutritional Quality of Canadian Chain Restaurant Foods and Interventions to Promote Healthy Eating by Mary J. Scourboutakos A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Department of Nutritional Sciences University of Toronto © Copyright by Mary J. Scourboutakos 2016 Eating-Out: A Study of the Nutritional Quality of Canadian Chain Restaurant Foods and Interventions to Promote Healthy Eating Mary J. Scourboutakos Doctor of Philosophy Department of Nutritional Sciences University of Toronto 2016 Abstract Canadians are increasingly eating outside-the-home. At the outset of this thesis there were no data on the nutritional quality of Canadian chain restaurant foods, the Sodium Working Group’s plan to monitor sodium reductions in the food supply was abandoned, and despite interest and numerous bills, there was no existing menu-labelling legislation in Canada. The specific objectives of this thesis were to 1) investigate the nutritional quality of the Canadian chain restaurant food supply; 2) explore consumers’ use of menu-labelling; and 3) test the potential of alternative forms of labelling in non-chain restaurant settings. Objective 1 was investigated by developing and analyzing a national database of over 9000 menu-items from Canadian fast-food and sit-down chain restaurants which was created in 2010. There was wide variation in calorie levels within each restaurant and food category; furthermore, portion size, as opposed to calorie density, was the most important driver of this variation. Sodium levels in menu items often exceed daily recommendations and despite reported efforts by the restaurant sector to improve, as of 2013, reductions were minimal. Objective 2 used an online, national consumer survey to test three menu-labelling treatments (calories; calories and sodium; and calories, sodium and serving size labelling). The effect of labelling on consumer choice varied depending on the restaurant setting, however, overall, labelling sodium in addition to calories led consumers to choose meals with significantly less sodium. There was no additional benefit from adding serving size information. ii Objective 3 was examined in a quasi-experimental, population-level nutrition labelling/education intervention study in a campus cafeteria. Results showed that this intervention could modestly increase fruit and vegetable consumption, and decrease sugar- sweetened beverage consumption among University students. Overall, this thesis provides food supply and consumer data to inform public health policy debates around issues concerning food consumed outside-the-home. iii Dedication This thesis is dedicated to my Mom, who told me what a PhD was when I was twelve, and then encouraged me to do one. iv Acknowledgments In the summer following my second year of undergrad, I wrote down an idea for a research project… ―test healthy take-out food‖ …little did I know that two years later, Dr. Mary L’Abbé would propose a somewhat similar idea, that set me on a journey that ended up being more than I ever dreamed it would be. Throughout the journey, the famous quotation attributed to Sir Isaac Newton… ―If I have seen further than others it is because I have stood on the shoulders of giants‖ …has crossed my mind on numerous occasions, because there have been so many giants in my life, without whom, none of this would have been possible. Here I will attempt to acknowledge all of the special people on whose shoulders I stand… First and foremost, thank you to Dr. Mary L’Abbé. I can’t imagine what my life would be like if I hadn’t met you. Words cannot express how fortunate I feel for having had the privilege of being your student. Thank you for teaching and mentoring me, for being patient with me (especially in the early days), for encouraging and inspiring me, for supporting me and for giving me opportunities that exceeded my wildest dreams. So much of what I have achieved, I owe to you. Second, one of the greatest gifts I gained as part of this experience was my lab sisters, aka, the L’Abbé Lab girls, who journeyed with me. Each of you has brought so much to my life. I truly cherish the friendships we’ve formed and I feel so privileged to have shared this experience with you. Specifically, I must recognize my ―big sisters‖ JoAnne Arcand, Teri Emrich, Christina Wong and Alyssa Schermel. Thank you for nurturing me when I was a naive undergraduate who was way too excited and probably asked you far too many questions. Words cannot express how lucky I feel to have benefited from all of your wisdom, insight, advice and guidance. You have truly been the best role models I could have asked for. You pushed me and inspired me to achieve more than I ever could have without you. Additionally, thank you to the second generation of L’Abbé lab girls: Chelsea Murray, Mahsa Jessri, Mavra Ahmed, Jodi Bernstein, Sheida Noorhosseini, Marie-Eve Labonté, and Beatriz Franco Arellano. Thank you for listening to my never ending stories, my research rants, and for making Fitz 87 a very special place to be. An immense thanks is owed to my thesis committee members. First, thank you to Dr. Thomas Wolever for bringing scientific rigor to my committee meetings and for pushing my thinking and v my research to new levels. You have been an inspiration and I immensely appreciate the multi- year commitment you made to my academic development. Thank you to Dr. Catherine Mah for being a fantastic mentor right from the beginning. I truly appreciate the time you devoted to fostering my intellectual development. Thank you for challenging and encouraging me. I will never forget that you were a key agent in connecting me with the real policy world and so much more. Thank you to my examiners, Dr. Loren Vanderlinen and Dr. Alison Duncan who generously agreed to play this role, challenged me with their insight and helped me produce an even better finished product. Numerous professors have greatly shaped and contributed to this intellectual endeavour. Thank you to Dr. Paul Corey, for taking such a genuine interest in my work, for contributing your expertise so generously and for all the stimulating discussions about nutrition science. Dr. Gillian Einstein for pushing my thinking into new realms, for cheering me on, and for introducing me to the world of women’s health. Thank you to the late Dr. Sharon Parker who believed in me way back in my undergrad and who wrote countless reference letters on my behalf. Taking your fourth year course in my second year was an immense joy and the first taste that got me hooked on public health nutrition. The administrators in the Department of Nutritional Sciences are like angels that take care of all the DNS students. A special thanks is owed to Louisa Kung, Emelia D’Souza, Patrice Lee and Lucile Lo. I am indebted to numerous volunteers who have contributed to my research, notably, Zhila Semnani-Azad and Sahar Qassem who motivated me by enthusiastically entering data that led to some of the papers I am most proud of. As well, thank you to Sarah Murphy, Frank Mazza, and Andriana Chomka, who diligently spent many evenings with me, watching people make food selections. A special thanks is owed to the Victoria College community, especially Chef Nathan Barrett and Bill McFadden, for letting me into your cafeteria, for being so generous with your time, and for supporting my research. A huge thanks is owed to former Vic President Paul Gooch who has been my guardian angel since undergrad. Thank you for reading my column and seeing potential in me way back. You have opened so many doors for me and I am eternally grateful for your kindness and constant support. Throughout this journey, Massey College has been my home away from home. A huge thank you is owed to Former Master John Fraser for your wisdom, support, constant encouragement and ego pumping. But most of all, thank you for your dedication to creating such an inspiring and loving environment for graduate students. A special thanks to my Quadrangler mentors Elizabeth Wilson and David Scott, to Senior Fellows Dr. Aubie Angel for running the intellectually enriching Massey Grand Rounds which I learned so much from, and especially, vi Michael Valpy for being a constant source of encouragement and nutritional experimentation. Most importantly, thank you to my Junior Fellow friends who have inspired me and with whom I have shared so much of this journey. A special thanks is owed to the team at Toronto Public Health especially, Loren Vanderlinden and Dia Mamatis, also to MPP France Gelinas, who gave me the opportunity to use my research to inform policy. Thank you to all of the journalists who reported on our work and helped our message reach so many people. Thank you to all of the teachers I’ve had since Kindergarten who fostered my love of learning, to say the least. Especially Dr. Gabriel Ayyavoo, my high school science teacher, whose love for the science fair inspired me to pursue my first nutrition research project. I owe a huge thank you to the staff, students and professors in the department of Nutritional Sciences. A special thanks goes to Beatrice Boucher for being my mentor, Julie Mason, who has helped and inspired me throughout the years, and to Katie Hopperton who co-founded the DNS journal club with me, and whose insight I learned from at each of our meetings. Thank you to the friends that have supported me. Especially Jemy Joseph who has been a friend, mentor and constant source of inspiration for the past 13 years.

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