Confidential: for Review Only (Over)Eating Out: an Observational Study of the Energy Content of Main Meals Served in Major UK Restaurant Chains
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BMJ Confidential: For Review Only (Over)Eating Out: An observational study of the energy content of main meals served in major UK restaurant chains Journal: BMJ Manuscript ID BMJ.2018.046276.R1 Article Type: Christmas research BMJ Journal: BMJ Date Submitted by the 18-Oct-2018 Author: Complete List of Authors: Robinson, Eric; University of Liverpool, Jones, Andrew; University of Liverpool Whitelock, Victoria; University of Liverpool Mead, Bethan; University of Liverpool Haynes, Ashleigh; University of Liverpool Keywords: eating out, obesity, food environment, restaurant food, kilocalories https://mc.manuscriptcentral.com/bmj Page 1 of 29 BMJ 1 1 2 3 4 1 (Over)Eating Out: An observational study of the energy content 5 6 7 2 of main meals served in major UK restaurant chains 8 9 10 3 11 Confidential: For Review Only 12 13 4 14 15 5 16 17 6 18 19 7 Eric Robinson1, Andrew Jones1, Victoria Whitelock1, Bethan R. Mead1 & Ashleigh Haynes1 20 21 22 8 23 24 9 1 Institute of Psychology, Health & Society, University of Liverpool, L69 7ZA, UK 25 26 10 27 28 29 11 Correspondence: Eric Robinson, Institute of Psychology, Health & Society, University of 30 31 12 Liverpool, L69 7ZA, UK. Email: [email protected] 32 33 13 34 35 36 14 37 38 15 39 40 16 41 42 17 43 44 45 18 46 47 19 48 49 20 50 51 52 21 53 54 22 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 2 of 29 2 1 2 3 23 Total Word Count: 3, 935 4 5 6 24 Key Words: food environment; eating out; restaurant food; kilocalories; obesity 7 8 25 What is already known on this topic? 9 10 26 Eating out of the home is common in the UK. 11 Confidential: For Review Only 12 27 The poor nutritional quality of ‘fast food’ has been well documented. 13 14 15 28 The energy content of traditional ‘sit down’ restaurants has received less attention. 16 17 29 18 19 30 What this study adds? 20 21 22 31 The average kcal content of main meals served in both fast food and sit down restaurants in the 23 24 32 UK is larger than public health recommendations. 25 26 33 The proportion of main meals in UK restaurant chains that meet public health recommendations 27 28 34 for kcals is smaller than the proportion of meals that have an excessive number of kcals. 29 30 31 35 Compared to fast food restaurants, there are more significantly more kcals on average in sit down 32 33 36 restaurant meals in the UK. 34 35 37 36 37 38 38 39 40 39 41 42 40 43 44 45 41 46 47 42 48 49 43 50 51 44 52 53 54 45 55 56 46 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 3 of 29 BMJ 3 1 2 3 47 4 5 6 48 7 8 49 Abstract 9 10 50 Objectives: Eating out of the home is common, but the kilocalorie (kcal) content of main meals 11 Confidential: For Review Only 12 served by major UK restaurant chains has not been examined. The objectives of this study were 13 51 14 15 52 to examine the kcal content of main meals served in major UK restaurant chains and compare the 16 17 53 kcal content of fast food and ‘sit down’ restaurant chains. 18 19 54 Design: Observational study. 20 21 22 55 Setting: Menu and nutritional information provided by major UK restaurant chains. 23 24 56 Method: During April to July 2018, websites were accessed and visits were made to restaurant 25 26 57 chains with 50 or more outlets in the UK. Menu items that constituted lunch or evening main 27 28 29 58 meal dishes were identified and the kcal content of these meals was extracted. Beverage kcals 30 31 59 were not included. 32 33 60 Main outcome measures: The mean kcal content of meals, the proportion of meals meeting 34 35 public health recommendations for kcal consumption (600kcals or less) and the proportion of 36 61 37 38 62 meals with an excessive kcal content (1000kcals or more). 39 40 63 Results: Main meals from twenty-seven restaurant chains (21 sit down, 6 fast food) were 41 42 64 sampled. The mean kcal content of all eligible restaurant meals (13,396 in total) was 977kcals 43 44 45 65 (95% CIs: 973 to 983), the percentage of all meals that met public health recommendations for 46 47 66 kcal content was low (10%) and smaller than the percentage of meals with an excessive kcal 48 49 67 content (42%). Compared to fast food restaurants, sit down restaurants offered significantly more 50 51 52 68 excessive calorific main meals, fewer main meals meeting public health recommendations and 53 54 69 on average 268 kcals more (95% Cis: 102.6 to 433.4) in main meals. 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 4 of 29 4 1 2 3 70 Conclusions: The kcal content of a large number of main meals in major UK restaurant chains is 4 5 6 71 excessive and only a minority meet public health recommendations. Although the poor 7 8 72 nutritional quality of fast food meals has been well documented, the kcal content of sit down 9 10 73 restaurant meals in the UK tends to be greater and is a cause for concern. 11 Confidential: For Review Only 12 Registration: The study protocol and analysis strategy was pre-registered on the Open Science 13 74 14 15 75 Framework (https://osf.io/w5h8q/). 16 17 76 18 19 77 Introduction 20 21 22 78 The prevalence of overweight and obesity has increased markedly across most of the 23 24 79 developed world1. Increases in energy intake caused by major changes to the food environment2 25 26 80 have been identified as a key factor explaining population level weight gain3 4. In the UK, meals 27 28 29 81 are consumed out of the home regularly; data collected from 2008-2012 showed that a quarter of 30 31 82 UK adults ate out once or more per week5. However, a more recent report from the UK Food 32 33 83 Standards Agency in 2016 indicates that eating out of the home may becoming more common, 34 35 with 39% of UK adults reporting eating out at least once per week6. A number of studies suggest 36 84 37 38 85 that people who eat out of the home more frequently are at increased risk of weight gain and 39 40 86 obesity7. ‘Fast food’ restaurants in particular have been highlighted as providing meals that are 41 42 87 low in nutritional quality8 9. There is also some evidence that a higher geographical density of 43 44 10 11 45 88 fast food restaurants is associated with increased risk of obesity . Because of this there have 46 47 89 been public health calls in the UK to limit where fast food restaurant outlets can operate12 13. 48 49 90 However, more traditional ‘sit down’ restaurants also contribute substantially to the out of home 50 51 14 52 91 dining market in the UK . 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj Page 5 of 29 BMJ 5 1 2 3 92 Recent public health recommendations made by Public Health England suggest that 4 5 6 93 adults should aim to consume 600 kilocalories (kcals) or less for their main lunch and dinner 7 8 94 meals to avoid excess daily energy intake and maintain a healthy body weight15. This is in part 9 10 95 motivated by Public Health England’s estimate that the average adult in the UK is consuming 11 Confidential: For Review Only 12 195 excess kcals per day15. Because the amount of energy a person consumes during a meal is 13 96 14 15 97 strongly influenced by the energy density and portion size of food served 16-19, meals provided to 16 17 98 consumers that are high in kcals promote excess energy intake and are problematic for public 18 19 99 health. However, public health action on improving the nutritional quality of food prepared 20 21 22 100 outside of the home has to date focused largely on encouraging the food industry to make 23 24 101 reductions to the kcal content of supermarket food20 and has not focused on the restaurant sector. 25 26 102 To date, there has been no examination of the number of kcals in main meals served by major 27 28 29 103 UK restaurant chains and it is therefore unclear whether consumers can adhere to public health 30 31 104 recommendations for meal kcal consumption when eating in these establishments. Moreover, 32 33 105 legislation has been passed which will result in kcal labelling of all food products sold by major 34 35 chain restaurants becoming mandatory in the US21. Similar legislation is currently being 36 106 37 38 107 considered by UK government, but mandatory kcal labelling will come at a financial cost to the 39 40 108 food industry which may cause challenges to legislation, as was the case in the US22. To address 41 42 109 such challenges it will be important to understand the extent to which major UK restaurant 43 44 45 110 chains are contributing to overconsumption by examining the typical kcal content of main meals 46 47 111 and the availability of main meals meeting public health recommendations for kcal consumption.