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On today’s menu:

Lana Vanderlee & David HammondCPHA Annual MeetingMay 28, 2014

Evaluation of a

menu labelling

initiative in

hospital

cafeterias in

Ottawa, Canada.

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1. Mancino et al. Separating what we eat from where: Measuring the effect of food away from home on diet quality. Food Policy 2009;34(6):557-562. 2. Pereira MA et al. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. The Lancet 2005;365(9453):36-42. 3. French SA, Harnack L, Jeffery RW. Fast food restaurant use among women in the Pound of Prevention study: dietary, behavioral and demographic

correlates. International Journal of Obesity & Related Metabolic Disorders 2000;24(10).4. Industry Canada Office of Consumer Affairs. Chapter 9 – Consumer Spending. https://www.ic.gc.ca/eic/site/oca-bc.nsf/eng/ca02117.html#a95.

Food consumed away from homehas poor nutritional value1

Increased consumption of fast food associated with becoming overweight or obese.2,3

One quarter of the Canadian food dollar is spent on food away from home.4

Background

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Menu labelling is currently mandatory in several US jurisdictions

United States will implement menu labelling federally in 2014 – via Patient Protection and Affordable Care Act

Canada has no mandatory menu labelling– Informed Dining voluntary program in BC – Government of Ontario announced Healthy Eating

Decisions Made Easy Act

Background

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Evidence for menu labelling is mixed

Reviews suggest little impact at a population level5,6,7

• Some impact upon population subgroups• Impact varies upon settings

Little literature examining menu labeling in a Canadian context

Background

5. Kiszko KM, Martinez OD, Abrams C, Elbel B. The influence of calorie labeling on food orders and consumption: a review of the literature. J Comm Health. DOI 10.1007/s10900-014-9876-06. Swartz JJ, Braxton D, Viera AJ. Calorie menu labeling on quick-service restaurant menus: an updated systematic review of the literature. Int J Beh Nutr Phys Act. 2011, 8:1357. Harnack LJ, French SA. Effect of point-of-purchase calorie labeling on restaurant and cafeteria food choices: a review of the literature. Int J Beh Nutr Phys Act. 2008, 5:51

The Ottawa Hospital Menu Labelling Program

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Developed by Nutrition and Foodservices team with support from clinical nutrition team and external experts.

Identified an opportunity to implement a new menu labelling program with digital menu boards during renovations at the Civic hospital

Intervention components 5 digital menu boards with nutritional values for

calories, sodium, saturated fat and total fat.

7 Information provided for most food items

Civic Cafeteria Jan 2011

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Intervention components

Health logo for items that meet the developed nutritional standards.

Educational campaign at the entrance to the seating area.

Removal of deep fryers and increase in healthier options.

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Civic General DifferencePaninis 408 625 +217Entrée 435 553 +118Grill 447 536 +89Salad Bar 494 568 +74Sandwiches 470 519 +49Soups 120 120 0Pizzas 402 400 -2Breakfast 332 277 -55

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Jan/2011– Food selection across sites (kcal)

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General Cafeteria Jan 2011

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General Cafeteria Sept 2012

Advertisements on menu boards Sept 2012

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20 seconds of ads, 20 seconds of nutrition information

CivicDisplays

January

Study timeline

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August/September

Wave 1

GeneralDisplaysSeptember

November/December

Wave 2

2011 2012

Wave 1 Wave 2

Civic x xGeneral 0 x

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2, 085 exit interviews– Wave 1 n=1,003– Wave 2 n=1,082

10 minute intercept survey• Food ordered in the cafeteria• Noticing and use of menu labelling

Methods

Nutritional analysis of food ordered and consumed

Nutrition information obtained from The Ottawa Hospital Nutrition Services (using C-Bord)

Several estimations made:• Items from the salad bar• Items lacking adequate description

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Methods

Analysis

3 primary outcomes• Noticing nutrition information• Using nutrition information• Nutrient consumption

Regression models used to test differences• Wave• Site

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Analysis

Socio-demographics • age, gender, ethnicity, income, education, BMI

Consumer and behavioural demographics • consumer type, frequency of visiting the

cafeteria, use of nutrition labels when shopping for food, frequency of eating out, self-reported general health, and dieting behaviour in the previous year

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Results

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Sample description

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Civic GeneralWave 1

n=497Wave 2

n=511Wave 1

n=506Wave 2

n=571

Mean age (yrs) 44.9 47.1 44.9 45.3

55+ yrs 26% 31% 28% 31%

‘White’ * 76% 82% 74% 78%

Female 59% 61% 61% 60%

High income* 49% 43% 38% 41%

Staff* 58% 55% 53% 51%

Overweight/obese

53% 56% 49% 50%

General Civic

Did you notice any nutrition information anywhere in the cafeteria?

36%

80%

54%63%

W1 W2W1 W2

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Significant change in noticing nutrition information between sites over time X2= 61.2, p<0.001

Wave 2 Noticing

cc c

30% 33%27% 32%

11%

27%14%

20%

Did the nutrition information influence what you selected for your meal?Overall sample

n=2,085Among those who noticed

n=1,210

General Civic General CivicW1 W2 W1 W2 W1 W2 W1 W2

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There was a significant change in use of nutrition information between sites over time X2=11.5 , p=0.001

c

Wave 2 Use

cc

General CivicW1 W2 W1 W2

Calories consumed

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There was a significant change in calorie consumption between sites over time X2= 5.7, p=0.017

Wave 2 Nutrient Consumption

610 kcal

482 kcal

598 kcal533 kcal

c

General CivicW1 W2 W1 W2

Saturated Fat consumed

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Wave 2 Nutrient Consumption

General CivicW1 W2 W1 W2

Total fat consumed

7.3 g4.9 g6.7 g 5.5 g

25.1 g

15.5 g

23.1 g18.6 g

General CivicW1 W2 W1 W2

Sodium consumed

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Wave 2 Nutrient Consumption

c

1395 mg

1074 mg1244 mg

1171 mg

CivicW1 W2

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Calorie consumption lower among those who reported using nutritional labelling p=0.009

500 kcal573 kcal

Used labelling

Didn’t use labelling

Wave 1 & 2

Use of nutrition information more common among:Those who are not of ‘White’ ethnicity p<0.001

Those who usually or always use nutrition information when shopping for food p<0.001

Those with improved general health p=0.027

Hospital staff compared to patients p=0.003

Socio-demographic correlates

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Support for menu labelling

3%Maybe

2%No

…in Ottawa Hospital cafeterias

95%Yes

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4%Maybe

5%No

91%Yes

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Support for menu labelling

…in all fast-food and other chain restaurants

Preferred menu labels

71% want calories

55% want fat

48% want sodium

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Conclusions

Indicates a positive impact of menu labelling

Importance of noticing information

Magnitude of impact

Nutrition content and product reformulation

Few socio-demographic differences 31

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Additional support provided by:

Acknowledgements

Funding for the project provided by:

Stipend support to Lana Vanderlee funded by the CIHR Training Grant in Population Intervention for Chronic Disease Prevention: A Pan-Canadian Program (Grant #53893)

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Questions?

Lana Vanderlee PhD candidate

School of Public Health and Health Systems

University of Waterloo

Email: lana.vanderlee@uwaterloo.ca

Tel: 519-888-4567 ext. 31066