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Menu labelling for reducing energy ordered and consumed: What’s the evidence?

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Health Evidence hosted a 60 minute webinar examining the effectiveness of menu labelling on reducing energy consumption. Click here for access to the audio recording for this webinar: https://youtu.be/ju5uucv3dEE

Sofia Lourenço and Jodie Anne Littlewood from the Danish Cancer Society led the session and presented findings from their recent review:

Littlewood J, Lourenço S, Iversen C, & Hansen G. (2016).Menu labelling is effective in reducing energy ordered and consumed: A systematic review and meta-analysis of recent studies. Public Health Nutrition, 19(12), 2106-2121.
http://www.healthevidence.org/view-article.aspx?a=menu-labelling-effective-reducing-energy-ordered-consumed-systematic-review-meta-29695

Menu labelling is a tool to inform consumers of energy content of meals in the eating-out environment and help consumers make informed decisions. This review examines the effectiveness of menu labelling to reduce energy consumption. Fifteen studies, including 17, 859 participants are included in this review. Evidence suggests that menu labelling reduces overall energy consumed and ordered in the eating-out environment. This webinar examined the effectiveness of menu labelling to reduce energy consumed in the eating-out environment.

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Menu labelling for reducing energy ordered and consumed: What’s the evidence?

  1. 1. Welcome! Menu labelling for reducing energy ordered and consumed: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  2. 2. Poll Questions: Consent • Participation in the webinar poll questions is voluntary • Names are not recorded and persons will not be identified in any way • Participation in the anonymous polling questions is accepted as an indication of your consent to participate Benefits: • Results inform improvement of the current and future webinars • Enable engagement; stimulate discussion. This session is intended for professional development. Some data may be used for program evaluation and research purposes (e.g., exploring opinion change) • Results may also be used to inform the production of systematic reviews and overviews Risks: None beyond day-to-day living
  3. 3. After Today • The PowerPoint presentation and audio recording will be made available • These resources are available at: – PowerPoint: http://www.slideshare.net/HealthEvidence – Audio Recording: https://www.youtube.com/user/healthevidence /videos
  4. 4. What’s the evidence? Littlewood J, Lourenço S, Iversen C, & Hansen G. (2016). Menu labelling is effective in reducing energy ordered and consumed: A systematic review and meta-analysis of recent studies. Public Health Nutrition, 19(12), 2106-2121. http://healthevidence.org/view-article.aspx?a=menu- labelling-effective-reducing-energy-ordered-consumed- systematic-review-meta-29695
  5. 5. • Use CHAT to post comments / questions during the webinar – ‘Send’ questions to All (not privately to ‘Host’) • Connection issues – Recommend using a wired Internet connection (vs. wireless) • WebEx 24/7 help line – 1-866-229-3239 Participant Side Panel in WebEx Housekeeping
  6. 6. Housekeeping (cont’d) • Audio – Listen through your speakers – Go to ‘Communicate > Audio Broadcast’ • WebEx 24/7 help line – 1-866-229-3239
  7. 7. Poll Question #1 How many people are watching today’s session with you? A. Just me B. 2-3 C. 4-5 D. 6-10 E. >10
  8. 8. The Health Evidence™ Team Maureen Dobbins Scientific Director Heather Husson Manager Susannah Watson Project Coordinator Students: Emily Belita (PhD candidate) Jennifer Yost Assistant Professor Olivia Marquez Research Coordinator Emily Sully Research Assistant Liz Kamler Research Assistant Zhi (Vivian) Chen Research Assistant Research Assistants: Lina Sherazy Claire Howarth Rawan Farran
  9. 9. What is www.healthevidence.org? Evidence Decision Making inform
  10. 10. Why use www.healthevidence.org? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  11. 11. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
  12. 12. Stages in the process of Evidence-Informed Public Health National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
  13. 13. Poll Question #2 Have you heard of PICO(S) before? A. Yes B. No
  14. 14. Searchable Questions Think “PICOS” 1. Population (situation) 2. Intervention (exposure) 3. Comparison (other group) 4. Outcomes 5. Setting
  15. 15. How often do you use Systematic Reviews to inform a program/services? A. Always B. Often C. Sometimes D. Never E. I don’t know what a systematic review is Poll Question #3
  16. 16. Menu labelling can reduce energy ordered and consumed in the away-from-home food environment A. Strongly agree B. Agree C. Neutral D. Disagree E. Strongly disagree 16 Poll Question #4
  17. 17. Jodie Anne Littlewood Bachelor in Global Nutrition and Health, Danish Cancer Society Sofia Lourenço MSc, Senior Project Manager, Danish Cancer Society
  18. 18. Menu Labelling Review Menu labelling is effective in reducing energy ordered and consumed: A systematic review and meta-analysis of recent studies Jodie Anne Littlewood Sofia Lourenço Cecilie Lauberg Gitte Laub Hansen
  19. 19. Consequences of overweight Cardiovascular diseases Musculoskeletal diseases Cancer Mental disorders Type II diabetes BRAIN BREAST GALL BLADDER PANCREAS UTERUS BLOOD COLON & RECTUM KIDNEY LIVER ESOPHAGUS THYROID
  20. 20. Overweight in Denmark PERCENTAGE YEAR 47% 70%
  21. 21. What is Menu Labeling? Images: Pumpkin Loaf https://www.bostonglobe.com/lifestyle/2014/12/01/new-fda-rules-will-put-calorie-counts-menus/NcV6aDQYG73CswHGc3KGrM/story.html Bagel meal: http://www.miradamedia.com/blog/en/tag/digital-menu-board Menu: http://ottawa.ca/en/residents/public-health/healthy-living/nutrition/healthy-eating-programs-and-services/menu-labelling
  22. 22. Rationale for Menu Labelling • Increased frequency of eating or ordering out • People consume more calories when eating out • People underestimate energy content when eating out • Improves noticing of calorie information • Facilitates ‘calorie-enlightenment’ • Enables consumers to exercise personal responsibility and make informed food choices • Dissuades up-sizing • Encourages food reformulation • Consumer demand
  23. 23. Increased frequency of eating out 24 hour trading has increased 50-100% in some major chains https://www.wsj.com/articles/SB10001424127887324445904578286421615513846 🇺🇸 ⅙ meals now prepared outside the home – contributing to ≈ 20% of energy intake for women and 25% for men Department of Health: https://responsibilitydeal.dh.gov.uk/pledges/pledge/?pl=8🇬🇧 number of fast food outlets doubled between 1992-2002 Magnusson 2010: http://www.biomedcentral.com/1471-2458/10/662 🇦🇺 ⅓ of the food budget is spent on restaurant meals Statistics Canada: http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/famil132a-eng.htm 🇨🇦
  24. 24. People consume more calories when eating out ~ 2000 calories from 3 home-cooked meals... a single fast food meal... or a single drink Images: http://www.nytimes.com/interactive/2014/12/22/upshot/what-2000-calories-looks-like.html?abt=0002&abg=1
  25. 25. People underestimate the energy content of foods prepared outside the home CALORIES Nando’s 899 Feta and Avocado Wrap Grill’d 786 Garden Goodness Vege Burger in a gluten free bun KFC 565 Grilled Chicken Spicy Hot Twister Starbucks 562 Green Tea Crème Frappuccino (24oz.) McDonald’s 520 Caesar Salad with Crispy Chicken Sumo Salad 508 Chicken Caesar Salad (regular) Subway 480 6-inch Spicy Italian Boost Juice 475 Green Tea Mango Mantra Gloria Jean’s 446 Strawberry Fruzie (large) https://www.nandosperiperi.com/eat/menu https://www.grilld.com.au/menu/garden-goodness https://www.kfc.com.au/menu/twisters/spicy-hot-twister https://www.starbucks.com/menu/drinks/frappuccino-blended-beverages/tazo-green-tea-frappuccino-blended-cr%C3%A8me#size=11002682&milk=67&whip=125 http://www.mcdonalds.ca/ca/en/food/nutrition_centre.html#/ http://sumosalad.com/menu-category/made-to-order/ http://www.subway.com/en-us/menunutrition/menu/product?ProductId=4272&MenuCategoryId=1 https://www.boostjuice.com.au/wp-content/uploads/2017/02/Boost_Nutrition_Flyer.pdf http://www.gloriajeanscoffees.com/Drink%20Menu%20-%20Nutritional%20and%20Ingredient%20Info.pdf
  26. 26. ‘Calorie enlightenment’ Popcorn + soda + candy can be a day’s worth of calories… “if someone is selling a 2000 calorie ‘snack’, the least they can do is tell you.” Image and statement: https://www.youtube.com/watch?v=QifyoBvGt0k = = ~ 1200 calories
  27. 27. Improves noticing of calorie information Image: http://www.economist.com/blogs/babbage/2011/07/menu-labelling
  28. 28. Dissuades up-sizing Difference: 540 calories 110 calories 190 calories Upsizing total = 840 calories Energy values calculated from: https://www.bk.com/pdfs/nutrition.pdf Images: http://visual.ly/skinny-food-portion-sizes-portion-control-tips-prevent-weight-gain
  29. 29. Replacing fries and soda in kids meals with milk and apple can save 140 kcal Allowing consumers to now choose between a salad or fries in a meal deal, can help them save 340 kcal Introducing grilled chicken, reduced calories per purchase by 6% Reducing fat content of default milk to 2%, decreased average beverage calories by 14% Encourages food reformulation
  30. 30. Consumer demand 70 - 81% depending on type of food establishment https://cspinet.org/new/201206041.html 81% http://webarchive.nationalarchives.gov.uk/20120206100416/http://food.gov.uk/news/newsarchive/2008/jun/eatout 80% https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/04809141-ab56-48f3-bcda-0c53d895431c.pdf 90% support ML in fast food restaurants http://www.opha.on.ca/getmedia/ad9cb6f3-f165-4569-b2ee-734e75e1d740/OPHA-Position-Statement-on-Menu- Labelling.pdf.aspx?ext=.pdf 66% Aarup, L., Neilsen, E. & Pedersen T.S., 2013. Kalorier versus Joule : FDB/Coop. Report provided by The Danish Cancer Society 80% http://www.nielsen.com/us/en/insights/reports/2012/healthy-eating-trends-around-the-world.html 🇺🇸 🇬🇧 🇦🇺 🇨🇦 🇩 🇰🌎
  31. 31. Aim of the study P General population (mostly adults) I Exposure to ML C Comparing to absence of ML O Energy consumed, ordered or selected ML noticing S Real-world & Experimental settings Update the most recent evidence (studies published between 2012-2014): • Differences in energy consumed, ordered or selected • Compare real-world and experimental settings • Importance of noticing ML and ML format
  32. 32. Inclusion criteria • Peer-reviewed articles • Full text • In English • Primary studies • Reported the effects of ML, measured by differences in energy consumed, ordered or selected • Published after 1 January 2012
  33. 33. Literature search results Energy ordered n = 6 (menu items purchased) Energy selected n = 6 (hypothetical choice) Energy consumed n = 6 (actual portion eaten) 141 articles identified 15 articles retrieved for full-text review 0 identified from related citations or personal correspondence 126 excluded based on title and abstract •Non-relevant (n = 67) •Reported only effects of restaurant environment (n = 10) •Qualitative studies or did not measure behaviour change in kcal (n = 24) •Vending machines (n = 1) •Not primary studies (reviews or commentaries) (n = 11) •Duplicates (n = 13)
  34. 34. Data extraction & synthesis Systematic across-study comparisons based on: • Year & authors • Country • Aim • Study design • Sampling • Setting • Type of outcome reported (energy consumed, ordered or selected; nutrients; interpretative guidance; meal type; ML noticing rate) • Covariates • Results • Limitations of study design
  35. 35. Quality assessment scheme
  36. 36. Study characteristics & quality 17,859 participants
  37. 37. Systematic review results
  38. 38. Reductions in energy consumed, ordered or selected Outcome measured ✔ ? ✗ E Consumed (n=3) ✔✔ ✔ E Ordered (n=6) ✔ ✔ ✔ ? ? ✗ E Selected (n=6) ✔ ✔ ✔ ? ✗ ✗ ✔ Significant energy reduction ? Significant energy reductions in some groups ✗Non-significant or no energy reduction
  39. 39. The effects of ML in various settings Food establishment type Real-world setting (n=7) Experimental setting (n=8) Fast food (n=8) ✔ ✗ ✔ ✔ ✔ ✔ ✗ ✗ Table service restaurants (n=4) ✔ ✔ ? (depending on ML format) ? (depending on ML format) Café/coffee chain (n=1) ? (ML was effective in coffee chains but not food chains) Cafeteria (n=1) ✔ Snack (n=1) ✔ ✔ Significant energy reduction ? Significant energy reductions in some groups ✗Non-significant or no energy reduction
  40. 40. Significant energy reductions not likely when <70% of participants noticed Significant energy reductions likely when ≥70% noticed ML 20% 40% 60% 80% 100% 70% The effects of noticing ML
  41. 41. ML format - Interpretative guidance No information Calories only Calorie Traffic light Multi-Traffic light [None] CALORIES 480 CALORIES 480 MED CALORIES 480 MED FAT 23 (g) HIGH SUGAR 6 (g) LOW SODIUM 1220 (mg) HIGH Hammond et al. 2013: http://www.sciencedirect.com/science/article/pii/S0091743513003666
  42. 42. ML format – Interpretative guidance Dowray et al. 2013: http://www.sciencedirect.com/science/article/pii/S0195666312004655
  43. 43. ML format – Contextual guidance Menu: http://ottawa.ca/en/residents/public-health/healthy-living/nutrition/healthy-eating-programs-and-services/menu-labelling
  44. 44. Sociodemographic aspects Variances in: • BMI, • Ethnicity, • Age or • Socio-economic status had any particular influence on the effectiveness of ML.
  45. 45. Meta-analysis 12 out of 15 studies used for a meta-analysis: • Stratified by type of outcome – energy consumed, ordered or selected • Comparisons limited to controls (no labels) vs. energy-labels alone • Random-effects meta-analysis • Publication bias was assessed with funnel plots and Egger’s test • The I2 statistic was used to quantify the effect of heterogeneity
  46. 46. Meta-analysis findings Mean reduction = -419.5 kJ / 100.2 cal (P<0.0001) 95% CI [-613.25; -225.76 kJ]
  47. 47. Meta-analysis findings Mean reduction = -325.66 kJ / 77.8 cal (P<0.0005) 95% CI [-508.6; -142.7 kJ]
  48. 48. Meta-analysis findings Mean reduction = -313.16 kJ / 74.8 cal (P<0.0001) 95% CI [-453.14; -173.19 kJ]
  49. 49. Meta-analysis findings Mean reduction = -201.71 kJ / 48.18 cal (P<0.005) 95% CI [-343.66; -59.76 kJ]
  50. 50. Strengths & limitations Strengths: • Meta-analysis results – ML is effective • Focus on studies from 2012 – 2014 • Quality rating reflects differences between real-world and experimental settings Limitations: • Methodological shortcomings of the included studies • Meta-analysis include few studies • Publication bias tests are underpowered – it might not have been detected
  51. 51. Conclusion • ML is effective in reducing energy ordered and consumed, in real-world settings • ML is effective in various types of food-service outlets, positively affecting a large proportion of the population • Prominent and noticeable labeling of all menu items, with reference values, is important • ML is essential for consumers to make informed food choices • ML is an important overweight and obesity prevention tool
  52. 52. Menu labelling can reduce energy ordered and consumed in the away- from-home food environment A. Strongly agree B. Agree C. Neutral D. Disagree E. Strongly disagree Poll Question #5
  53. 53. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
  54. 54. Poll Question #6 The information presented today was helpful A.Strongly agree B.Agree C.Neutral D.Disagree E.Strongly disagree
  55. 55. What can I do now? Visit the website; a repository of over 5,000+ quality-rated systematic reviews related to the effectiveness of public health interventions. Health Evidence™ is FREE to use. Register to receive monthly tailored registry updates AND monthly newsletter to keep you up to date on upcoming events and public health news. Tell your colleagues about Health Evidence™: helping you use best evidence to inform public health practice, program planning, and policy decisions! Follow us @HealthEvidence on Twitter and receive daily public health review- related Tweets, receive information about our monthly webinars, as well as announcements and events relevant to public health. Encourage your organization to use Health Evidence™ to search for and apply quality-rated review level evidence to inform program planning and policy decisions. Contact us to suggest topics or provide feedback. info@healthevidence.org
  56. 56. Poll Question #7 What are your next steps? [Check all that apply] A. Access the full text systematic review B. Access the quality assessment for the review on www.healthevidence.org C. Consider using the evidence D. Tell a colleague about the evidence
  57. 57. Thank you! Contact us: info@healthevidence.org For a copy of the presentation please visit: http://www.healthevidence.org/webinars.aspx

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