Soracha Mc Kinley and Hazel Dolan HEALTH SCIENCE AND NUTRITION DEPARTMENT OF NURSING AND HEALTH SCIENCE ATHLONE INSTITUTE OF TECHNOLOGY

A Review of Calorie Posting in the Workplace Setting

1

Abstract

The aim of this literature review is to investigate the impact of calorie posting in the

workplace including the hospital setting. Both national and international research

studies conducted on this topic are included in this review and positive short term

effects are clear in almost all studies. However, the long term effects have yet to be

elucidated particularly since calorie posting is a relatively new initiative. The research

would indicate that combining the caloric information clearly and at point of choice

combined with consumer education provided the best results. Calorie posting is a

potential tool in reducing obesity.

2

Introduction

Obesity is the medical term used to describe the state of being overweight to the

point where it is harmful to health (WHO, 2015). Carrying such a large amount of

weight may have health implications to an individual, physically and psychologically.

The World Health Organisation (WHO) has reported that more than 1.4 billion adults,

20 years of age and older, are either overweight or obese. Of these overweight

adults, over 200 million men and nearly 300 million women are obese (WHO, 2008).

Currently in Ireland 25% of the adult population is obese and 37% are overweight.

Furthermore, four out of five people over the age of fifty are either overweight or

obese and 27% of Irish females and 16% of Irish males under the age of 20 are in

the overweight or obese category (Leahy et al, 2014).

Obesity has long been recognised as a major cause of chronic illnesses. In addition

to the negative health implications and reduced quality of life, the economic burden

of obesity and the health implications that arise from obesity has been increasing

steadily, not only in Ireland and Europe, but worldwide (Muller – Riemenschneider et

al, 2008). It is well recognised that obesity is a complex issue and at present there is

no clear strategy for treating obesity at the population level and reversing the obesity

epidemic. Multilevel approaches may prove beneficial and calorie menu labelling is

one approach to addressing the obesity crisis.

European public health professionals and stakeholders agree that nutrition labelling

is “a main tool for preventing increasing rates of obesity and unhealthy diets” (OECD,

2008). Consumers demand more information about food products including contents,

characteristics of the food, safety information on ingredients, ethical concerns,

potential allergens and the nutrition information. Following on from this, calorie

3

posting is a general term used for providing nutritional information on available food

options in public food outlets. Displaying calorie content on menus in food outlets

aims to provide the consumer with nutritional information allowing them to make an

educated decision about their food choice.

Best practice for calorie menu labelling

Calorie menu labelling should be implemented following best practice principles to

ensure that information is provided in a consistent and effective manner. The

following principles were devised by the Food Standard Authority of Ireland (FSAI) in

the report on calories on menus in Ireland (Reilly, 2012).

Calorie information must be displayed on all food and drink items

Display calorie information at the „point of choice‟ – where options are

displayed

Calorie information must be in terms in terms of portion/meal size

Display information about recommended daily calorie intake for the average

person

View and attitudes towards menu calorie labelling

In June 2012, the Food Safety Authority of Ireland published a report on the views

and attitudes towards displaying calorie information on menus in Ireland. Both

consumer and stakeholders were encouraged to give their opinion on the matter.

Each individual was given an information booklet providing information on obesity in

Ireland, calorie menu labelling in other countries and what to expect from the

4

implementation. Surveys were used to collect the responses over a four week

period. The consumer questionnaires were used to collect information on

participant‟s background, where calorie labelling should be implemented, how

calories should be presented, whether consumers felt that the information would be

trustworthy, whether calories should be put on alcoholic drinks and whether calorie

posting should be mandatory for large food businesses. There were 3,130 responses

from consumers. Over 95% were in favour of the implementation of calorie posting.

The main reason given was calorie posting allows the consumer to make informed

choices when purchasing food and drink from food service outlets.

Stakeholders information was also collected though surveys. Questions were based

on the four best practice recommendations on calorie posting. In this instance, just

over 50% of the stakeholders were in favour of calorie posting. Reasons given were

concerns about effects on business, cost and implementation. However, most

implied that calorie posting was acceptable once nutritional help was provided to

them.

“The national consultation indicated that as long as adequate support is provided

calorie menu labelling will be welcomed by all stakeholders in Ireland.” (Reilly, 2012)

Calorie posting is becoming more popular in public food outlets, due to public

demand and government legislation. Findings from the FSAI, (2012) demonstrated

that over 95% of consumers are in favour of calorie menu labelling in food outlets.

There were many reasons for this, the main one being that the consumer is allowed

to make a personal informed food choice. Other reasons included the empowerment

the information gives to the consumer and the right to be informed on what we are

5

eating. (Reilly, 2012) Eating outside of the home is becoming more popular due to

convenience and leisure.

“24% of calories are eaten outside the home. Recent data show that 18-64 year olds

consume 24% of their total energy from food and drink outside the home.” (IUNA,

2011)

The introduction of calorie labelling may contribute to tackling the obesity crisis in a

small but effective way. By educating the public about the food they are eating, it

allows a person to make a personal decision on their own health and lifestyle

choices. One comment from a consumer who completed the FSAI, (2012) report

suggested that calorie labelling is more important in sandwich bars and staff

canteens as these are the places where people eat regularly compared to a pub or

restaurant. This is an extremely valid point as some workers consume their main

meals for the day within the workplace setting.

“Nutritional labelling on menus has been proposed as a method to educate the

general public on the nutritional content of food items prepared away from home.”

(Vanderlee & Hammond, 2013)

Calorie posting was first introduced in the United States in 2003 on a voluntary basis.

In 2008, legislation was introduced in New York for calorie menu labelling to be

mandatory in food chain outlets. It requires the outlets to display the amount of

calories in each of the food and beverages available to the public (Bollinger et al,

2010). Part of Australia have also introduced a similar system and public food chains

which have 20 or more outlets are required to provide the number of kilojoules in a

dish. This practice has now been implemented in many food chains both nationally

and internationally.

6

Great Britain introduced calorie posting on a voluntary basis in 2009. The Food

Safety Authority in Britain developed a pilot scheme to investigate the outcome of

introducing this system into public businesses and twenty one UK companies

participated in this intervention. An evaluation was conducted by an independent

research company, which assessed consumers understanding and usability, along

with business costs. The results showed that implementing calorie information is

possible and issues which arise during the initial set up period can be overcome.

Consumers suggested that visibility, understanding and consumer engagement had

an impact on their inclination to use the calorie information. It allowed them to make

healthier choices when eating out whilst enjoying some of their favourite foods. The

consumers felt empowered by this (Ibrahim et al, 2011). This work was then

continued by the UK Department of Health. Eventually in 2011, „out of home calorie‟

labelling was launched. By the end of 2011, thirty eight food companies with 5,000

outlets were participating in displaying the calorie information (Reilly, 2012).

Northern Ireland also participated in a similar scheme to Great Britain in 2012. Nine

large food companies volunteered to take part in a 6 month pilot scheme. The calorie

information was posted in one or more of their food outlets, following the best

practice principles. The University of Ulster assisted in this scheme by calculating the

calorie information for the participating food businesses (Reilly, 2012). The aims of

the scheme were, firstly, to provide consumers with calorie information at the point of

choice, so as to give them the opportunity to choose a healthier option. It was also

put in place to encourage catering businesses to improve the nutritional content of

the food they served. Businesses were asked to display calorie information clearly at

the point of choice and to show the calories per portion, item or meal, so that

customers could use the information when making their food choices. Businesses

7

were also requested to display the estimated average requirement for calories so the

consumers could compare their intake (Ray et al, 2013).

In 2013, the FSA commissioned the Policy Studies Institute in London to carry out an

evaluation of the pilot scheme and published the findings in a report. Views from the

caterers and consumers were considered. Data from the scheme was collected

through interviews with the businesses and other stakeholders, a workshop with the

business stakeholders, interviews with consumers and focus groups with the public

also. The objectives of the report were to investigate the following:

1. Examine the rationale for food catering businesses participating in the

scheme, including for businesses of different types and sizes.

2. Explore the practical implications for food catering businesses of participating

in the scheme, including implementation challenges and perceived effects of

the scheme on the business.

3. Investigate consumer awareness, understanding of, and views on, calorie

labelling in catering outlets.

4. Examine the role of calorie information in decision-making for consumers

when eating outside the home.

5. Identify improvements to the Calorie wise scheme, from the experiences of

businesses and consumers that could be taken forward in any future national

rollout (Ray et al, 2013).

The findings from the evaluation are as follows: Responses from the businesses

stated that they got involved in order to improve public health, remain competitive

and be prepared for future legislation. The biggest challenge for businesses was

8

found to be acquiring the caloric information and that this was both time and cost

consuming. Findings from the focus group research indicated that most views from

consumers were positive. It was stated that it was building a trust between business

and consumer. A minority of views were negative for reasons including the issue that

consumers did not want to see this information when eating out for a treat. However,

overall usage of calorie information was low. Many individuals who were using the

information were currently on weight loss diets. Statements from the public explained

that nutritional labelling was more likely to be used in supermarkets rather than in

restaurants as it was perceived to be more important to eat healthy at home.

As a result of this evaluation the authors, recommended support for businesses

including setting up communication strategies for businesses, more support for

calculating calories and promote guidance for displaying the information. For the aid

of consumers, the information will have to be simple, clear and accessible (Ray et al,

2013). Engaging businesses and consumers more effectively should prove to have a

more beneficial effect on the implementation.

Calorie posting has already been implemented in certain restaurants and fast-food

outlets across Ireland and worldwide. In addition this concept is being extended to

other settings. The introduction of calorie posting into the workplace could be

beneficial in terms of education and changing people‟s food choices. The core aim is

to improve the health of the public by providing them with the essential information

needed for making a food choice.

Effectiveness of menu calorie labelling in restaurants and other food

establishments

9

Three major reviews on the effect of menu labelling in restaurants and other food

service establishments have been published (Larson and Story 2009; Swartz et al,

2011; Sinclair et al, 2014). Larson and Story (2009) reported an increase in the

selection of healthier menu items in several studies. In contrast, the review by

Swartz et al (2011) concluded that calorie labelling does not have the intended effect

of decreasing calorie purchasing or consumption. The most recent systematic review

reported that menu labelling with calories alone did not have an effect on decreasing

calories selected or consumed. However the addition of contextual or interpretive

nutrition information on menus appeared to assist consumers in the selection and

consumption of fewer calories (-67 kcal and -81 kcal, respectively). Some

researchers have questioned these small reductions in calorie intake and whether

this is a substantial reduction- replacing soft drinks consumed with a meal with water

would have a greater impact on caloric intake (Ellison et al, 2014).

However, some studies have found that calorie posting alone has a greater impact

on calorie consumption compared with other „traffic light‟ labelling and calorie posting

with including other nutrients. In a study conducted in Canada by Hammond et al

(2013), 635 adults over the age of 18 were asked to choose a free meal from

Subway (1 sandwich, 1 side and 1 drink) and was given 1 of 4 menus all containing

the same foods. The menus were allocated at random. One menu had no nutritional

information, one had calories only printed beside the item, another had the calories

displayed in the traffic light system and the last menu included calories, fat, sodium

and sugar amounts all presented in the traffic light system. After the subjects had

their meal each individual was asked for information on their socio demographic

background, recall of nutrition information from the menu, perceived influence of the

information, calorie knowledge, calories ordered and calories consumed. The

10

findings showed that recall of information was higher in all experimental conditions

compared to the no information menu with 24.4% of participants able to recall the

calories they ordered within 50 calories of a difference and this was highest from the

calorie only menu group.

“When presented with this longer list of nutrients participants were less likely to recall

the calorie content of their meal compared to when menus displayed calories only.”

(Hammond et al, 2013).

The calorie amounts of ordered meals were not significantly different across menu

labelling conditions, however, participants with the calorie only menus consumed

significantly fewer calories. In comparison to the traffic light system, displaying

calories numerically may be more beneficial (Hammond et al, 2013). This study

demonstrates that calorie labelling increases awareness of food choices. Presenting

calories alone may avoid confusion to the consumer. This study also highlights the

importance of measuring calories consumed in these types of studies as many

studies measure food ordered only. This may of importance when assessing the

impact of menu labelling policies.

Dietary Intervention in the Workplace setting

Menu and calorie labels are in competition with other important factors at the point of

purchase. Environmental, social and situational determinants will impact on the

decision making process and although nutrition can influence food choice, this differs

between and within individuals depending on the context. Understanding and

applying nutrition information also requires a high level of health and functional

literacy.

11

It has been recognised that the workplace may be an ideal setting to promote

healthy behaviours since most individuals spend two-thirds of their waking hours at

work (WHO, 2008). A systematic review carried out by Geaney et al, (2013) studied

the effectiveness of workplace interventions in relation to dietary modifications. To be

eligible for inclusion, the interventions must have included either changes in the

dietary content of food, changes in portion size, changes in food choices available or

an education aspect. Six studies met the criteria including 3 from the United States,

1 from Brazil, 1 from the Netherlands and 1 from Belgium. Each intervention varied

from 3 months to 12 months. Data on participants, intervention design, setting, and

duration, outcome, and outcome measures was collected from all of the studies and

the six studies consisted of 8,443 participants in total. Modifications from the studies

involved food preparation alterations, increased fruit and vegetables availability,

increased availability of low fat products, taste tests on healthier foods and education

programs. Four of the studies used food frequency questionnaires, one used one-

day food diaries and one used surveys to measure dietary intakes of the individuals.

The findings suggest that nutrition education and multi-component workplace dietary

interventions have a positive effect on dietary behaviours, especially fruit and

vegetable consumption however, due to the duration of each study, it is unclear if the

improvements can be sustained over a long period of time (Geaney et al, 2013).

A pilot study in Ireland investigated the impact of a structured catering initiative on

food choices in a hospital workplace setting (Geaney et al, 2011). This was a cross-

sectional comparison study in two hospitals, one of which had implemented a

catering initiative designed to provide nutritious food while reducing sugar, fat and

salt intakes. Participants (n=100, aged 18-64 years) who consumed at least one

main meal in the two hospital staff canteens were recruited. Reported mean intakes

12

of total sugar, total fat, saturated fat and salt were significantly lower in the

intervention hospital when adjusted for age and gender. Findings from this pilot study

indicate that the workplace can play an important role in the promotion of healthy

food choices.

These researchers are currently assessing the effectiveness of diet interventions

which aim to reduce the levels of diet related diseases. The intervention is focused

on environmental dietary modification or nutrition education in the workplace.

(Geaney et al, 2013). The study is a clustered controlled trial with a total of 448

adults within the age range of 18 – 64 years. The subjects were selected from four

multinational manufacturing workplaces and the only requirement being that they ate

at least one meal from the workplace canteen every day. The workplaces were

divided into groups and each had a different intervention technique, as follows,

(a) Workplace A – Control, no intervention technique used.

(b) Workplace B – Nutrition education only provided to workers.

(c) Workplace C – Nutrition education and environmental modification provided.

(d) Workplace D – Environmental education provided only to workers.

The nutrition education provided for workers were group presentations, individual

nutrition consultations and detailed nutrition information. The environmental

modifications made in the canteen setting were restriction of fat, saturated fat, sugar

and salt, Increase of fibre, fruit and vegetables, discounted price for purchase of

fresh fruit, portion size control and strategic positioning of healthier foods at point of

purchase. The changes in dietary behaviours, the knowledge of nutrition and health

status measurements were obtained at baseline and are being monitored throughout

13

at different intervals, 3 – 4 months, 7 – 9 months and 13 – 16 months. The findings

from this intervention are to be published in 2015.

Several other studies have been conducted internationally examining the impact of

nutrition and education interventions in the workplace with mixed results.

Nutrition and education interventions

An intervention was completed in Denmark on eight blue collar worksites. It was a

six month participatory and empowerment based intervention study. The main aims

of the intervention were to examine the employee‟s dietary habits and the effects of

changes in the canteen nutrition environment. It also investigated possible

opportunities and the impacts of promoting healthy eating specifically with blue collar

workers. Worksites were randomly allocated to either an intervention group or a

control group. All worksites were offered a monthly news magazine which detailed

achievements at other worksites throughout the intervention period (Lassen et al,

2011). The intervention group were offered two kinds of hand-out materials; nutrition

quizzes and dinner mats. They were also repeatedly encouraged to initiate nutrition

related activities which would address both individual and environmental levels.

Regular meetings were also arranged with staff to engage all members of the

intervention, they were advised to set goals for the employees and work site and to

also tailor initiatives directly towards the canteen. The canteen staff were offered

education opportunities in order to provide the employees with sufficient knowledge.

In regards to the employee‟s dietary survey, 25 – 30 employees were randomly

selected to take part in the survey at baseline and at endpoint. The dietary recording

14

methods used to collect the data were personal face-to-face interview and self-

administrated food diaries over a four day period. The employees were encouraged

to take part in this process by receiving individual feedback on both food diaries and

a small prize for taking part, this was a lunchbox or backpack. A total of 229

participated in baseline interviews only. 201 participants completed both baseline

and endpoint interviews. Reasons for participants dropping out included leaving the

workplace and refusing to complete interviews. In regards to the canteen survey data

was collected by using individual level lunch intake data at baseline and endpoint.

Outcomes which were measured included changes in dietary habits, food diaries and

the canteens nutritional environment, changes were noted by analysing the

nutritional status of the individual‟s canteen lunch. The most nutritionally favourable

changes were observed in the intervention group. There was a median daily

decrease in fat intake and sweet intake. In contrast there was a median daily

increase in dietary fibre and fruit. The control group showed no overall significant

change in any food intake. The authors concluded that moderate positive changes

can be achieved in the workplace if the correct practices are used (Lassen et al,

2011).

Another intervention based in the Netherlands on worksites chose to direct attention

towards portion size rather than calories. Larger portion sizes can often increase a

consumer‟s food intake so by directly reducing the portion size it may therefore help

in reducing calorie intake. The main aim of the study was to assess whether offering

a smaller hot meal in addition to existing sizes would stimulate people to replace

their regular chosen portion size. In total 25 worksite cafeterias took part in the

intervention. These worksites consisted of 15 hospitals, 5 companies, 3 universities

and 2 police departments (Vermeer et al, 2011). The main techniques of the

15

intervention was offering smaller portion sizes and employing different pricing

techniques, proportional pricing which was pricing the meal at 65% of the existing

size and value sized pricing which was offering a lower price per unit for larger

portions than for smaller portions.

The 25 worksites were randomly allocated into one of three groups which were,

experimental 1 (9 sites), experimental 2 (8 sites) and control (8 sites). Experimental

site 1 intervention consisted of the offering of smaller portion sizes in addition to

existing sizes along with the use of proportional pricing. Experimental site 2

intervention consisted of adding a smaller portion to an assortment of portion sizes

and implementing value size pricing. The control site did not add any additional

portion sizes. The only difference between experimental sites 1 and 2 was the

pricing method offered. This was to assess whether there was any additional effects

of pricing. A display with pricing information was displayed in the cafeteria and staff

in experimental conditions were instructed to ask the consumers which size they

wanted. This was the only method of advertising that took place.

The daily sale figures from the canteens were collected daily one month before the

intervention and also throughout the intervention period. Data was also collected

through a screening questionnaire which assessed how frequently the participants

ate hot meals at the worksite cafeteria itself. There was also four online

questionnaires completed throughout the intervention period. This was to collect data

ranging from age, educational levels, body weight and regular eating behaviours.

Results from the intervention indicated that participants involved in the experimental

conditions had a positive attitude towards smaller portion sizes. No significant

differences in small meal sales were found between experimental sites 1 and 2. It

can be concluded that when offered a smaller portion size in addition to the existing

16

sizes available the consumers were inclined to replace their regular choice with this

option. The sales figures collected also indicate that the consumers did not

compensate their smaller option with other snacks such as fried food. For future

studies using these techniques it is recommended that they use a broader range for

more reliable results. On the basis of these results it is concluded that offering

smaller portion sizes did reduce overall food intake (Vermeer et al, 2011).

Calorie posting and contextual or interpretive nutrition information in the

workplace

A quasi-experimental study was completed in two Danish hospital cafeterias in

2014.This study was completed to assess the effect of a healthy labelling

certification i.e. the Keyhole Certification. Improving dietary intake and influencing

edible plate waste were the main aims. The intervention canteen in this experiment

was aiming to achieve the Keyhole certification and had at least half of their available

meals labelled as healthy. They had fixed prices on all food menus. In the control

hospital, there were no plans to become Keyhole certified and therefore made no

changes to the food availability. Also, the food in this canteen was priced by weight.

To measure the food intake and edible leftover food, photographs were taken before

and after food consumption. Background information surveys and food

questionnaires were also completed by the consumers to measure food satisfaction

(Lassen et al, 2014).

The intervention and control groups were not significantly different at baseline in

relation to energy intake or any of the examined nutrients or foods. At the six week

end point the intervention group showed significant changes in relation to dietary

17

intake. They were consuming, on average, 30% less energy, 20% less fat and

increased their fruit and vegetable consumption by 47%. After six months, a follow

up was completed and the intervention group were found to be consuming 16% less

energy, 16.8% less fat, and 54% more vegetables, which proved that the intervention

had a somewhat lasting effect. No significant changes were found in food

satisfaction or edible plate waste. The control hospital displayed no positive

nutritional effects. This study highlights that using a healthy labelling certification

program encourages both availability and awareness of healthy meal choices,

therefore improving dietary intake (Lassen et al, 2014).

A clustered randomized controlled trial study conducted in the Netherlands

investigated the effectiveness of labelling foods with choice nutrition logos on

influencing menu selection and behavioural determinants. Choice logos can be

found on a variety of brands in many supermarkets and food outlets. The logo is

assigned to products which meet certain criteria for sodium, added sugar, saturated

fats, trans-fats, fibre and energy (Vyth et al, 2011). The cafeterias were allowed to

assign the choice logo to freshly prepared foods. Catering managers working in

cafeterias are trained to prepare certain food to fit into the criteria. By increasing the

availability and labelling on products, they can facilitate employee selection of

healthier foods. In total 25 cafeterias took part in the intervention. Thirteen of the

cafeterias were classed as intervention cafeterias and used the choice logo to

promote healthier eating. Twelve cafeterias were used as the control group. They

used the same menu but without the use of the choice logo. The intervention was

completed over a three week period. Sales data was collected for nine weeks in

total. A questionnaire was also completed in order to gain insight into the behavioural

determinants of food choice. Employees from the largest intervention and control

18

cafeteria completed an online questionnaire before and after the intervention. It was

also used to measure the use of the choice logo. In earlier research, food choice

motives were found to be significant predictors of selection of foods with the choice

logo (Vyth et al, 2010).

No intervention effects were found in the sale of sandwiches, soups, snacks, fruits

and salads. No significant differences in behavioural determinants were found. No

significant effects on employee‟s lunchtime food choices were observed. There was

a positive association with the intention to eat healthy and attention to the provided

product information and self-reported consumption of choice logo foods. Work

cafeterias are potentially the most important venues to target as food consumption

during lunch time. The majority of the intervention population had a low intention to

eat healthier at baseline. Labelling might not be an intervention that suits the

motivational phase. Labelling healthy choices in work site cafeterias could be useful

to health conscious employees however extended health education would be

required to impact the choices of employees that are not health conscious (Vyth et

al, 2011).

A study completed in Belgium was based on the provision of simple point of

purchase information in university canteens. Universities are potentially the most

effective setting to promote healthier eating because of the target group available.

The main aims of the study was understanding the process by which point of

purchase nutrition information can have, effects on meal choice and therefore energy

intake (Hoefkens et al, 2012). They also wanted to examine whether information was

more effective in changing meal choice in specific sub groups. The study was a one

group pre-test – post-test design. A convenience sample of 224 students between

the ages of 17 – 35 who were also regular customers of the chosen canteens was

19

selected. This sample completed the baseline and the six month follow up surveys.

The energy intake from the canteen meals at baseline and follow up were calculated

as an average of three days. This information was collected through self-

administrated food records. Participants composed their meals by choosing one

protein, sauce, vegetable and carbohydrate. There were approximately 180 meal

combinations available. Each day in the canteens twelve meals were selected –

three best meal options for each of the components – these suggested meals were

then communicated to the participants. The meals were selected based on their

compliance of the meals contents of energy, sodium, saturated fat and veg portion

size. The nutrition information on these suggested meals consisted of a star rating.

For example when a meal complied with one of the recommendations it received one

star and so on. The top score for a meal was then four stars.

Participants who had a greater knowledge of nutrition and understanding of their

health had a greater understanding of the displayed nutrition information. This

resulted in more effective use of the provided information. Motivation to change their

diet and understanding of the information provided was required to make a change.

This could be a useful practice to apply to other interventions. There was also a

significant relationship between with the liking of the provided information and its

use. The results suggest that nutrition information interventions such as this will be

more effective when the information is “liked” by the target group combined with

educational practices. Increasing nutritional knowledge is key to changing

individual‟s choices (Hoefkens et al, 2012).

A cafeteria intervention study was completed in Boston on the food choices of

minority and low income employees. The purpose of the intervention was to test

whether a two phase point of purchase intervention improved the food choices

20

across all the socioeconomic and ethnic groups. The aim was to develop a labelling

strategy that would minimize cognitive demands at the point of purchase, this

concept would then improve nutritional choices among diverse populations. It was a

nine month longitudinal study that took place in the main cafeteria of Massachusetts

General Hospital Boston with a total of 4,642 employees. Intervention one consisted

of a traffic light style colour coded labelling system (Levy et al, 2012). Healthy items

marked with a green, unhealthy items marked with red. Intervention two consisted of

“choice architecture”, which was physically rearranging certain cafeteria items. The

green labelled food were made more accessible and red labelled foods were made

less accessible. Sales data was collected and analysed at baseline for 3 months and

the two- phase intervention was completed over a period of 6 months, the second

intervention being put in place after 3 months. Permanent signage was placed

throughout the cafeteria and a crew of dieticians were available for a temporary

period in order to explain the labelling intervention to employees.

Main findings from the study concluded that the Latino and black ethnic groups had a

higher percentage of red labelled foods at baseline analysis. Overall labelling

decreased sales on all red labelled food items, with red labelled beverages

decreasing the most. The “choice architecture” further decreased the sales of red

labelled items. Intervention effects were similar across all ethnic and socioeconomic

groups. Simple intervention techniques similar to this can positively affect food

choices. The simple techniques used improved healthy choices among all categories

(Levy et al, 2012). The use of dieticians on site along with simple labelling

techniques could play a major role in the success of the study.

One of the first studies on the effect of calorie posting interventions took place in

Philadelphia in 2003. An intervention took place in two hospital cafeterias in to target

21

the staff‟s energy and nutrient intake. It involved both male and female aged 21-65

years. The aim was to allow access to staff to healthier options and see how they

would respond.

“Modifying the food environment is a novel approach or facilitating changes in eating

behaviour, such as reductions in energy intake that might ultimately prevent weight

gain.” (Lowe et al, 2003)

Two groups were randomly allocated to the EC group (Environmental Change) or the

EC-Plus group (Environmental Change plus Energy Density Education and

Incentives). All of the participants were exposed to food choices where the energy

density of some foods were lowered (e.g. providing low fat mayonnaise, low fat

cheese, whole wheat buns etc.) and nutritional labels on all available foods in a

colour coded system. In addition to this, the EC-Plus group were given training on

how to reduce their energy intake. These sessions were based on the book

„Volumetrics‟ by Rolls & Barnett (2000) and each participant received a copy of this

book. The EC-Plus group were also given discounts on low energy dense foods as

an incentive. ID cards were used by staff to gather information on their purchases.

However there were some limitations to the study as technical faults arose for month

3, which meant not all information on purchases was recorded. Dietary recalls were

also conducted to assess whether food intake outside of the work setting had

changed.

Height, weight, waist circumference, body composition, blood lipids, blood pressure,

and cognitive restraint were all measured before and after the intervention. The

results found that meat intake decreased along with total energy intake and

percentage of energy fat in both groups in the workplace. Because of this, the

22

percentage of energy from carbohydrate intake increased in both groups (Lowe et al,

2003). The results showed no significant changes in either groups in relation to

weight or body fat and the 24 hour recalls did not demonstrate an effect on food

choices outside of the intervention. Waist circumference or blood lipid levels did not

improve either. Participants in both groups were found to have gained a small

amount of weight. This may be caused by the employees eating more less-nutritious

foods at home to make up for the reduction of calorie intake at work. This

intervention did lower the calorie intake of employees, within the workplace, however

no significant changes occurred with regards to any of the health parameters

measured. As the results from both groups were extremely similar, this study

showed that in this instance, the addition of education or financial incentives did not

contribute to improvements. In saying this, total energy and fat intake did reduce in

the workplace, implying that small interventions like this may have a positive effect in

the long term (Lowe et al, 2003).

A cross-sectional study conducted in Canada in 2013 also compared results from an

intervention study in two hospital cafeterias. The aim of this study was to examine

the impact of nutritional information on menus.

“Nutritional labelling on menus has been proposed as a method to educate the

general public on the nutritional content of food items prepared away from home.”

(Vanderlee & Hammond, 2013)

The control setting had limited nutritional information available in the cafeteria. They

displayed energy, sodium, saturated fat and total fat on small paper signs. The

experimental setting had health logos, education campaigns, including posters and

pamphlets, and healthier items highlighted on the menu for the consumers along

23

with the nutritional information at point of sale. There was also a selection of

healthier foods, for example, some foods were grilled rather than deep fried. Data

was collected over a 5 week period by trained interviewers at the exit of the cafeteria

and surveys were completed by the consumers at the end of the intervention.

The results showed that more consumers noticed the labels in the intervention

cafeteria (79.5% Vs 36.2%) and staff and females noticed more than visitors and

males. Energy, sodium and fat labels were most noticed in both control and

intervention settings. The consumers who were most influenced were those in the

intervention cafeteria (26.6% Vs 10.7%). Participants at the intervention site

consumed 21% less calories, 23% less sodium, 33% less saturated fat and 37% less

total fat. In relation to both groups, the individuals who noticed the labels consumed,

on average, 77 kcal less, 159mg less sodium and 4.8g less fat. 95% of individuals

asked agreed that calorie posting was a good idea. This intervention suggests that

calorie posting at point of choice increases awareness. Location and the highlighting

of the nutritional information is critical (Vanderlee & Hammond, 2013).

Additional Considerations

Calorie posting has received major attention as a potential tool in public health

nutrition policy (Bleich & Pollack, 2010). Overall many studies support the role of

menu calorie posting in educating the public and providing them with the appropriate

information when making food choices outside of the home. Some factors have been

highlighted in several studies. A study conducted in 2009 involving a phone survey

with 663 randomly selected adults of different ethnic groups examined the

effectiveness of calorie posting. They found that 78% of men and 69% of women,

24

who were moderately active, from America, were knowledgeable about energy

requirements. 60% of under-active adults underestimated energy requirements.

Whites were found to be more knowledgeable and confident about calorie

information. Blacks, Hispanics and women reported to be more likely to select lower

calorie foods in chain restaurants where calorie information was provided. 68% of

Americans were in favour of the implementation of mandatory calorie information on

the menus at point of purchase, this being significantly higher with blacks, Hispanics

and women.

Additionally providing calorie information allows the already health conscious

individuals to make an informed decision when eating out of the home. Studies have

shown that individuals who are knowledgeable about nutrition and health are more

likely to benefit from calorie posting (Gracia et al, 2007).

Menu labelling will likely encourage consumers to eat more healthily some of the

time. The introduction of the calorie posting as part of public health nutrition policy

could help in improving and changing the public‟s eating habits. Particularly in

restaurant settings, consumers often fail to recognise the high calorie content of

most meal options (Block & Roberto, 2014). People are therefore more likely to

overeat when eating outside the home as they don‟t consider exact contents of a

meal when they themselves are not cooking or preparing it. Giving consumers

usable calorie information at point of purchase could increase awareness of food

choices. From previous discussed studies it was found that the majority of

consumers would like to know what they are eating and also that the menu labelling

can encourage people to order and consume less calories than normal (Block &

Roberto, 2014). However while many potential benefits do exist there is a major gap

in understanding the long term effects because of a lack of long-term data.

25

No studies were found to provide an estimate of the economic value of nutritional

information on restaurant or canteen menus. In 2009 it was found that Americans

spend 42% of their income on purchasing food outside of the home (Ellison et al,

2014). Food intake outside of the home tends to be high in calories and low in

nutritional value. The introduction of nutritional labelling in restaurants and canteens

could work towards promoting healthier choices outside of the home. It was found in

a study completed in Oklahoma that when prices on menus were manipulated

according to caloric value along with nutritional information it did change the

individual‟s willingness to pay for said item (Ellison et al, 2014). Three menus were

used in a restaurant, control, two a traffic light coded menu and, three a numerical

display of calories. All prices on menus were then changed according to a “fat tax” or

a “thin subsidy”. The “fat tax” was placed on items which were more than 800

calories and it was an increase in price by 10%. The “thin subsidy” was placed on

items which were less than 400 calories and it was a decrease in price by 10%.

When the calorie labelling was present a negative relationship then existed between

the willingness to pay and the calories (Ellison et al, 2014). From a business point of

view the introduction of nutritional policies may have a negative effect on net returns.

However pricing policies are unlikely to produce the desired effect by itself, symbolic

and numerical displays of calorie contents are much more affective in influencing

consumer‟s choices.

Discussion

The existing research proves that clear, concise labelling at point of choice provides

the best results. Excess information was found to be off putting to consumers, as

26

shown in one of the Canadian studies. Interventions worked best when different

methods were combined, such as introducing calorie posting along with an

educational intervention, so that the consumer was provided with nutritional

knowledge. It was noted that people who are more knowledgeable about nutrition,

acknowledged and used the caloric information. Workplaces which were reaching for

a goal, such as obtaining „Keyhole‟ certification in Denmark, was found to be positive

and have a beneficial effect on consumers.

There were no significant differences in studies varying in ethnic or socio-economic

groups. However, this has not been extensively researched and additional research

needs to be conducted to cover populations from different backgrounds. In many

studies, those participants who are conscious of their nutrient intake are most likely

to use it information from calorie posting. Individuals who were concerned about

weight loss or their general health benefited most but the aim of calorie posting is to

tackle the population‟s obesity problem as a whole. Providing education on the topic

is seen to be beneficial and therefore, the overall underlying finding was that

combining calorie posting with an educational aspect provides the best results.

27

Summary of the research investigating the effectiveness of calorie posting in a

workplace setting

Preference, hunger and habitual ordering habits are important considerations when

people are making food choices and may act as potential barriers to the success of

calorie posting. These combined with the consumer‟s general lack of awareness in

relation to the calorie contents of restaurant and cafeteria food are major barriers

that need to be addressed before developing intervention techniques in the

workplace setting.

It is important to acknowledge that calorie labelling in a restaurant/canteen/work

setting may place the pressure of weight gain or weight reduction directly on the

consumer at place and time of purchase. It may cause anxiety and internal conflict

on one‟s self when purchasing high calorie food in public.

The workplace setting may provide a more favourable environment for behaviour

change. Users will have more regular access to information and may also be

provided with more opportunities to observe and act on the information.

Interventions which used menus that were overloaded with nutritional information

were found to have a negative effect. Consumers were unable to recall the

information and did not find it useful.

28

Health and functional literacy are important considerations. For this reason, calorie

posting in a workplace setting may be more beneficial as these factors can be

addressed in the intervention.

The existing research demonstrates that clear, concise labelling at point of choice

provides the best results. The consumer benefits when the information is in clear

sight and in an understanding context.

Many studies have shown that those concerned with weight loss benefited.

Motivated participants benefited more form these interventions. Motivation should be

addressed in the intervention approach.

Interventions worked best when different methods are combined, such as introducing

calorie posting along with an educational intervention, so that the consumer is

provided with nutritional knowledge. When the individual is empowered with the

knowledge, they have the opportunity to make an informed food choice.

Workplaces which were reaching for a goal, such as obtaining the „Keyhole‟

certification in Denmark, which is a healthy labelling certification, was found to be

positive and had a beneficial effect on consumers.

29

While the effects of calorie posting in the workplace were found to have worked,

many studies report no changes in weight measurements. This suggests that the

information was not being used outside of the intervention setting.

When assessing the impact of menu labelling policies it is important to consider

measuring consumption and not just food ordering as there may be a difference.

Long term studies are required to examine if any changes are maintained and

extended outside of the work environment.

30

References

Alliance, I. U. (2011). National Adult Nutrition Survey Summary Report.

Bleich, S, N., Pollack, K, M. (2010). The Public‟s Understanding of Daily Caloric

Recommendations and their Perceptions or Calorie Posting in Chain Restaurants.

BMC Public Health. 10(121)

Block, J, P & Roberto, C, A. (2014). Potential Benefits of Calorie Labelling in

Restaurants. The Journal of the American Medical Association. 312(9), pp. 887 –

888.

Bollinger, B., Leslie, P., & Sorensen, A. (2010). Calorie posting in chain restaurants

(No. w15648). National Bureau of Economic Research.

Drewnowski, A., & Darmon, N. (2005). Food choices and diet costs: an economic

analysis. The Journal of nutrition. 135(4), pp. 900-904.

Ellison, B., Lusk, J., & Davis, D. (2014). The Impact of Restaurant Calorie Labels on

Food Choice: Results from a field experiment. Economic Inquiry (ISSN 0095-2583)

52 (2), pp. 666-681.

Falk Müller-Riemenschneider, T. R. (2008). Health-economic burden of obesity in

Europe. European Journal of Epidemiology. pp. 409-599.

Geaney, F., Di Marrozzo, J, S., Kelly, C., Fitzgerald, A, P., Harrington, J, M., Kirby,

A., McKenzie, K., Greiner, B., Perry, I, J., (2013). The Food Choice at Work Study:

effectiveness of complex workplace dietary interventions on dietary behaviours and

diet related disease risk – study protocol for a clustered controlled trial. Biomed

Central. 14(370), pp. 1 – 14.

31

Geaney, F., Harrington, J., Fitzgerald, A, P., Perry, U. (2011). The impact of a

workplace catering initiative on dietary intakes of salt and other nutrients: A pilot

study. Public Health Nutrition. 14(8), pp. 1345-1349.

Geaney, F., Kelly, C., Greiner, B, A., Harrington, J, M., Perry, I, J., Beirne, P. (2013).

The effectiveness of workplace dietary modification interventions: A systematic

review. Preventive Medicine. 57, pp. 438-447.

Hammond, D., Goodman, S., Hanning, R., & Daniel, S. (2013). A randomized trial of

calorie labelling on menus. Preventive Medicine. 57, pp. 860-866.

Hoefkens, C., Pieniak, Z., Van Camp, J., Verbeke, W. (2012). Explaining the effects

of a point-of-purchase nutrition-information intervention in university canteens: a

structural equation modelling analysis. International journal of behavioural nutrition

and physical activity. (9)111.

Ibrahim, U., Earl, R., Hooper, P., & Turner, G. (2011). Health Works: A look inside

eating-out. British Hospitality Association. pp. 14. Available at:

http://www.bha.org.uk/wordpress/wp-

content/uploads/2013/08/BHAHealthReportAdobePrint.pdf [Accessed: 23 Feb 2015]

Lassena, A, D., Beckb, D, A., Leedob, E., Andersenc, E, W., Christensena, T.,

Mejborna, H., Thorsena, A, V., & Tetensa, I. (2014). Effectiveness of offering healthy

labelled meals in improving the nutritional quality of lunch meals eaten in a worksite

canteen. Appetite. 75, pp. 128-134.

Lassen, A, D., Thorsen, A, V., Sommer, H, M., Fagt, S., Trolle, E., Biltoft- Jensen, A.,

Tetens, I. (2011). Improving the diet of employees at blue collar worksites: results

from the food at work intervention study. Public health nutrition. 14(06) pp.965-974

32

Leahy, S., Nolan, A., O' Connell, J., & Kenny, R, A. (2014). Obesity in an Ageing

Society. The Irish Longitudinal Study on Ageing 2014.

Levy, D, E., Riis, J., Sonnenberg, L, M., Barraclough, S, J., Thorndike, A, N. (2012).

Food Choices of Minority and Low-Income Employees – A Cafeteria Intervention.

American Journal of Preventitave Medicine. 43(3), pp. 240-248.

Lowe, M, R., Tappe, K, A., Butryn, M, L., Annunziato, R, A., Coletta, M, C., Ochner,

C, N., & Rolls, B, J. (2010). An intervention study targeting energy and nutrient

intake in worksite cafeterias. Eating Behaviors. 11, pp. 144-151.

Lowenstein, G. (2011). Confronting reality: pitfalls of calorie posting. The American

Journal of Clinical Nutrition. 93(4), pp. 679-680.

Müller-Riemenschneider, F., Reinhold, T., Berghöfer, A., & Willich, S. N. (2008).

Health-economic burden of obesity in Europe. European journal of epidemiology.

23(8), pp. 499-509.

Organisation for Economic Co-operation and Development. (2008). Promoting

sustainable consumption - good practices in OECD countries.

Raj, M., Kumar, R., (2010) Obesity in children and adolescents. The Indian Journal

of Medical Research. 132(5), pp. 598-607.

Ray, K., Clegg, S., Davidson, R., & Vegeris, S. (2013). Evaluation of Caloriewise: A

Northern Ireland pilot of the display of calorie information in food catering

businesses. Policy Studies Institute. pp. 1

Reilly, A. (2012). Calories on Menus in Ireland. The Food Safety Authority of Ireland.

33

Sinclair, S, E., Cooper, M., Mansfield, E, D. (2014). The Influence of Menu Labelling

on Calories Selected or Consumed: A Systematic Review and Meta – Analysis.

Journal of the Academy of Nutrition and Dietetics. 114(9), pp 1375 – 1388.

Vanderlee, L., & Hammond, D. (2013). Does nutrition information on menus impact

food choice? Comparisons across two hospital cafeterias. Public Health Nutrition.

17(6), pp. 1393-1402.

Vermeer, W, M., Steenhuis, I, H, M., Leeuwis, F, H,. Heymans, M, W., Seidell, J, C.

(2011). Small portion sizes in worksite cafeterias: do they help consumers to reduce

their food intake. International journal of obesity. 35(9). Pp.1200-1207

Vyth, E, L., Steenhuis, I, H., Heymans, M, W., Roodenburg, A, J., Brug, J., Seidell, J,

C. (2011). Influence of Placement of a Nutrition Logo on Cafeteria Menu Items on

Lunchtime Food Choices at Dutch Work Siteurnal of the American Dietetic

Association. 111(1) pp. 131-136.

World Health Organization. (2000). Obesity: preventing and managing the global

epidemic (No. 894). World Health Organization.

World Health Organisation (2008). 2008-2013 Action plan for the global strategy for

the prevention and control of noncommunicable diseases. WHO.

World Health Organization. (2015). Obesity. Available at:

http://www.who.int/topics/obesity/en/ [Accessed: 28 Jan 2015]

35

Table 1. Nutrition interventions in the workplace

Study Location

Study Type Aims/Objectives Intervention What they measured

Results/outcome

Ireland

Ireland – Cork Workplace

Clustered controlled trial completed in a workplace setting

To assess the effectiveness of diet interventions

To develop a long term dietary change on participants

Investigate motives behind employees food choice

Evaluate and compare alternative intervention methods

Four workplaces using different techniques

A – control

B – nutrition education provided

C – nutrition education and environmental modification

D – environmental modification only

Nutrition education - monthly group presentations, individual consultations, detailed nutrition information, traffic light coded system on food in canteen. Environmental modification - restrictions on fat, saturated fat, sugar and salt. Increase of fibre, fruit and veg, portion size control, discounted prices on fresh fruit and strategic positioning at point of purchase.

Measurements obtained at baseline and measured throughout at intervals. Changes in dietary behaviour. Knowledge of nutrition and health status measurements

Ongoing

36

Europe

Denmark 1 Worksite

“food at work” study 6 month participatory and empowerment based intervention study. Worksites

Examine employees‟ dietary habits and effect of changes in the canteen nutrition environment. Investigate opportunities and impacts of promoting healthy eating in worksites.

Worksites were randomly allocated to either

1- Intervention group – offered two kinds of hand-out materials and repeatedly encouraged to initiate nutrition related activities

1- Control group – no additional support or information provided.

Measurements included: changes in employees dietary habits with the use of a food diary. At baseline and end-point the canteen nutritional environment was monitored with the use of nutritional analysis. Participants also completed a dietary survey.

Several positive nutritional effects were observed in the intervention group, including a decrease in fat intake and an increase in dietary fibre and fruit and veg. Moderate positive changes are possible in workplace settings.

37

Denmark 2 Hospital

Quasi-experimental study design in 2 hospital cafeterias

To study the effect of a healthy labelling certification in improving dietary intake and influencing edible plate waste.

2 hospital cafeterias. 1. Intervention group.

Goal to achieve the Denmark keyhole certification. At least half of the meals healthy labelled and fixed prices on all menus.

2. Control hospital. No plan to become keyhole certified and priced food by weight.

Food intake and edible plate waste was measured. Food was photographed and weighed before and after consumption. Food satisfaction was measured by questionnaires.

Intervention group showed significant decrease in fat and energy intake but no significant changes in food satisfaction or plate waste. No positive changes in control group.

Netherlands 1 Workplace

Clustered Randomized Controlled Study, cafeterias in the workplace

Investigate the effectiveness of choice logo influence (choice logos being placed on food items which fit in specific criteria for sodium, added sugar, saturated fats, trans fat, fibre and energy)

13 cafeterias – experimental 12 cafeterias – control All using the same/similar menus with only difference being use of choice logo.

Intervention was completed over 3 weeks. Sales data was collected over 9 weeks. A questionnaire was completed on the behavioural determinants of food choice. Questionnaires were used to measure the use of the choice logo.

No significant differences in behavioural determinants were found. No significant effects on employee‟s lunchtime choices were found. Labelling healthy choices in workplaces may be beneficial to health conscious employees, extended health education would be required to impact on employees who do not fit this criteria.

38

Netherlands 2 Worksite

Longitudinal randomized controlled trial in Dutch worksite cafeterias.

To assess whether offering smaller hot meal portions stimulates people to replace their larger meal. Assess impact of introducing a smaller portion size. Assess impact of pricing strategies.

Worksites were randomly allocated to:

2- Experimental 1 – smaller portions offered with existing and proportionate pricing

3- Experimental 2 – smaller portions offered and value size pricing.

Control – only existing sizes available

Daily sales of meals were monitored (1 month before intervention and 3 months throughout intervention) Screening questionnaire completed Online questionnaires completed throughout Participants were also asked about attitudes to portion size

Ratio of smaller portion sizes in relation to larger portion sizes scales were 10.2% No effect of proportional pricing found. Participants in experimental conditions had a positive attitude towards smaller portions being offered.

39

Belgium University

One group pre-test – post-test design. University Canteen setting

To understand the process by which point of purchase nutrition information can have an effect on meal choice and energy intake.

Participants were informed about purpose of study only. Participants could compose their meal by choosing 1 protein, 1 sauce, 1 veg, and 1 carbohydrate. Approx.: 180 combinations available Each day a selection of 12 meals (made of the best components) were communicated. Provided was a 3-star rating for components and a descriptor of nutrients that did not comply with recommendations.

Participants completed a 3 day food diary. Questionnaires were self-administered at baseline and at follow up

Significant relationship with liking of information and its use was found. Participants that had a greater knowledge and understanding of nutrition showed more effective use of provided information. Increasing students‟ motivation to change their diet is recommended.

40

Philadelphia Hospital

Hospital Cafeteria - Intervention techniques

Allow access to healthier options and observe response of staff members. Target staffs energy and nutrient intake

2 groups 1- EC group

(environmental change)

2- EC – plus (environmental change and education and incentives.)

All participants were exposed to energy density of foods being lowered. Nutritional labelling on available foods with colour coded system. EC – plus were additionally provided with training on how to reduce energy intake and given discounts on low energy dense foods as incentive.

ID cards of staff were used to gather information of changes in dietary intake. Measurements at baseline and after intervention: height, weight, waist circumference, body composition, blood lipids, blood pressure, cognitive restraints. Dietary recalls (24hrs) conducted to note change in diet outside of workplace.

(Results from both groups) Meat intake decreased. Total energy intake decreased. Percentage of energy fat decreased. Carbohydrate intake increased. Body fat, waist circumference and blood lipids did not improve. Recalls did not prove to show changes in diet outside of workplace. No significant changes in relation to weight and body fat. Total energy and fat intake did reduce in workplace only.

41

Canada Hospital

Cross Sectional Study, comparison of 2 hospital cafeterias

Examine the impact of nutritional information on menus

2 settings 1- Control setting,

limited information available. Displayed energy, sodium, total fat and saturated fat on small paper signs.

2- Experimental setting, health logos on food items, education campaigns, healthier options highlighted on menus and nutritionally information at point of purchase.

Data was collected over a period of 5 weeks. Interviews were conducted at exit of cafeteria. Surveys were also completed by consumers at the end of intervention.

More consumers noticed signs and labels in intervention cafeteria.

The experiment site consumed less calories, sodium, saturated fat and total fat.

In relation to both groups the individuals who noticed labels consumed less calories, sodium and fat.

Calorie posting and labelling at point of purchase increased awareness.

42

North America Food Outlets

Systematic Review and Meta – analysis

Determine whether format of nutritional information affects selection and consumption of calories in food services

Calorie posting on menus along with the use of contextual and/or interpretive information. Ex. Posting recommended calorie intakes or use of colour codes systems on menus

Two reviewers screened titles and abstracts for appropriate articles.

Menus with calorie posting alone did not have intended effect of decreasing calories consumed

Overall women were more likely to use provided information

Findings support the inclusion of contextual/interpretive information along with calorie posting.

43