Calorie Menu Labeling on Quick-Service Restaurant Menus: an Updated Systematic Review of the Literature Jonas J Swartz1*, Danielle Braxton2 and Anthony J Viera1,3
Total Page：16
File Type：pdf, Size：1020Kb
Swartz et al. International Journal of Behavioral Nutrition and Physical Activity 2011, 8:135 http://www.ijbnpa.org/content/8/1/135 REVIEW Open Access Calorie menu labeling on quick-service restaurant menus: an updated systematic review of the literature Jonas J Swartz1*, Danielle Braxton2 and Anthony J Viera1,3 Abstract Nutrition labels are one strategy being used to combat the increasing prevalence of overweight and obesity in the United States. The Patient Protection and Affordable Care Act of 2010 mandates that calorie labels be added to menu boards of chain restaurants with 20 or more locations. This systematic review includes seven studies published since the last review on the topic in 2008. Authors searched for peer-reviewed studies using PUBMED and Google Scholar. Included studies used an experimental or quasi-experimental design comparing a calorie- labeled menu with a no-calorie menu and were conducted in laboratories, college cafeterias, and fast food restaurants. Two of the included studies were judged to be of good quality, and five of were judged to be of fair quality. Observational studies conducted in cities after implementation of calorie labeling were imprecise in their measure of the isolated effects of calorie labels. Experimental studies conducted in laboratory settings were difficult to generalize to real world behavior. Only two of the seven studies reported a statistically significant reduction in calories purchased among consumers using calorie-labeled menus. The current evidence suggests that calorie labeling does not have the intended effect of decreasing calorie purchasing or consumption. Keywords: Calorie label, menu label, nutrition information, restaurant label, Patient Protection and Affordable Care Act, obesity, food away from home, fast food Introduction home in the US diet [4,5] may be contributing to poor As part of the Patient Protection and Affordable Care health [6,7]. Food away from home now accounts for Act of 2010, lawmakers passed a requirement that all over 30% of daily caloric intake and 50% of yearly food chain restaurants with 20 or more locations include cal- spending [4-6]. This trend is concerning because foods orie information on all menus. If enacted, the policy will consumed away from home typically have more calories, require these restaurants to list at the very least the cal- fat and sodium than foods prepared in the home [4]. orie information in the foods and beverages they serve. Frequent consumption of food away from home has also This new legislation builds upon efforts already under- been linked to higher rates of overweight and obesity wayinsomestatestoprovideconsumerswithmore [8,9]. information about the foods they purchase away from In an effort to address the role of food away from the home [1]. home in the overweight and obesity epidemic, several Menu labeling is one of many policy approaches that states, cities and counties have passed menu labeling has been proposed to address the increasing prevalence laws starting with New York City in 2006. The New of overweight and obesity in the United States [2,3]. In York City law required restaurants with 15 or more particular, researchers and policymakers have begun to locations to list calorie information for each item on the focus on how the increasing reliance on food away from menu in a prominent location both on menu boards and menus and began enforcement in 2008. Shortly thereafter, in 2010, Congress passed the Patient Protec- * Correspondence: [email protected] 1Public Health Leadership Program, Gillings School of Global Public Health, tion and Affordable Care Act which included a national University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Full list of author information is available at the end of the article © 2011 Swartz et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Swartz et al. International Journal of Behavioral Nutrition and Physical Activity 2011, 8:135 Page 2 of 8 http://www.ijbnpa.org/content/8/1/135 menu labeling law for all restaurants with 20 or more appraisal criteria. The instrument required assessment locations [1,10]. of a variety of study procedures including study design, Though momentum has gathered behind menu label- randomization, blinding, minimization of selection bias, ing policies as a tool for combatting overweight and minimization of measurement bias, and minimization of obesity, evidence to support its efficacy is less robust. In confounding bias. For each applicable variable, two a 2008 review, Harnack and French were able to identify authors (JS and AV) independently assessed each article only six studies that tested the effects of calorie labeling and assigned scores of 2 for good, 1 for fair and 0 for on consumer choice [5]. They concluded that from the poor. To achieve a quality rating of good, studies had to current evidence, the effects of calorie labeling appeared have an average score greater than or equal to 1.5 and to be weak or inconsistent [5]. However, they also noted could not receive scores of 0 for any individual variable. major methodological flaws in each of the studies [5]. An average score less than or equal to 0.5 was consid- In this systematic review, we update Harnack and ered to indicate a study with poor quality. Studies with French’s findings with more recent evidence. The pur- scores in between were considered fair quality studies. pose of this paper is to use current literature to answer We excluded the randomization category for observa- the question of whether calorie labeling on menus at tional studies. After independently scoring each article, restaurants and cafeterias has an effect on consumer the two raters conferred to discuss any discrepancy in purchasing and eating behaviors. overall quality rating. Methods Results Search strategy Search results The most recent review of the literature was published The initial search produced 164 citations on PUBMED. in 2008 and included articles published through 2006. One author (JS) screened titles for relevance and further In the current search, conducted in August 2011, we examined 32 abstracts. Eighteen articles underwent full sought studies with publication dates from 2006-August text review, after which 12 articles were excluded. One 2011. We used PUBMED and Google Scholar World article was included from a hand search. Seven articles Wide Web search engines to identify relevant studies. met the inclusion and exclusion criteria described above Initial PUBMED searches with MeSH terms including (Figure 1). “food labeling”, “fast foods” and “choice behavior” yielded few results. We therefore broadened our search Study design to include the following keywords: “calorie labeling”, Included articles reported on studies conducted in two “menu labeling” and “point-of-purchase labeling”.We different types of settings; five articles reported on nat- supplemented our findings with hand searches from the ural experiments of calorie menu label implementation reference lists of articles and reviews [7,11-15]. in real world settings [6,16-19] and two involved researcher manipulated variables in laboratory settings Article selection [20,21] (Table 1). To be included, studies must have used an experimental or quasi-experimental design comparing a calorie- Study quality labeled menu with a no-calorie menu. This review All studies included in this review had methodological includes studies conducted in laboratories, college cafe- shortcomings. Despite these limitations, two studies were terias, and fast food restaurants. Only studies that mea- judged by the two raters to be of good quality [19,20] and sured purchasing behavior or consumption of ready-to- five to be of fair quality [6,16-18,21] (Table 2). eat meals were included. Our search was restricted to English-language in peer-reviewed publications. The effect of calorie menu boards on calorie ordering and purchasing Data extraction All seven studies compared calorie ordering and pur- One author (JS) extracted standardized information chasing in two conditions: calorie label versus no calorie including study aims, study type, sample population, and label. Two studies reported that calorie menu labels outcomes in a spreadsheet to facilitate comparison and reduced the calories purchased [6,21], one reported sig- synthesis. The table also included information about nificant reductions in calories purchased at some chains methodological strengths and weaknesses of the studies. (but not others)[16], three reported no effect on calories purchased [17,18,20] and one reported a slight increase Quality assessment in calories purchased [19]. Quality was graded with the assistance of an instrument Among the observational studies, Elbel et al. found developed by the investigators based on standard critical that in New York City, purchasing behavior of children Swartz et al. International Journal of Behavioral Nutrition and Physical Activity 2011, 8:135 Page 3 of 8 http://www.ijbnpa.org/content/8/1/135 examining data for each chain individually, they found a 164 Titles identified reduction in mean calories purchased for three chains ’ 132 Titles excluded: (McDonald s 829 vs. 785 calories, P = 0.02; Au Bon Pain - 62 Published before 2006 555 vs. 475 calories, P < 0.001; KFC 927 vs. 868 calories, 70 Unrelated - P < 0.01), no significant difference for 7 chains (Burger 32 Abstracts pulled for King, Wendy’s, Popeye’s, Domino’s, Pizza Hut, Papa review John’s, Taco Bell), and an increase for one chain (Sub- way 749 vs. 882, P < 0.001)[16]. The study did not 14 Abstracts excluded: - 7 Non-experimental include a control population. - 6 Assessing consumer knowledge or Though it was a small change, Finkelstein et al. did preferences - 1 Assessing consumer observe a small, statistically significant (but we do not awareness think clinically significant) increase in calories purchased per transaction after calorie labels were added to menus 18 Full text articles in King County, WA [19].