A Review of Calorie Posting in the Workplace Setting

Transcription

1 A Review of Calorie Posting in the Workplace Setting Soracha Mc Kinley and Hazel Dolan HEALTH SCIENCE AND NUTRITION DEPARTMENT OF NURSING AND HEALTH SCIENCE ATHLONE INSTITUTE OF TECHNOLOGY

2 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. 1

3 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 2

4 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 3

5 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 4

6 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 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. 5

7 Great Britain introduced calorie posting on a voluntary basis in 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 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 6

8 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 7

9 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 8

10 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 9

11 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. 10

12 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 oneday 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 crosssectional 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 years) who consumed at least one main meal in the two hospital staff canteens were recruited. Reported mean intakes 11

13 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 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 12

14 at different intervals, 3 4 months, 7 9 months and months. The findings from this intervention are to be published in 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, employees were randomly selected to take part in the survey at baseline and at endpoint. The dietary recording 13

15 methods used to collect the data were personal face-to-face interview and selfadministrated 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 14

16 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 15

17 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 16

18 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 17

19 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 who were also regular customers of the chosen canteens was 18

20 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 selfadministrated 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 19

21 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 An intervention took place in two hospital cafeterias in to target 20

22 the staff s energy and nutrient intake. It involved both male and female aged 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 21

23 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 22

24 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, 23

25 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. 24

26 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 25

27 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. 26

28 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. 27

29 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. 28

30 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. 29

31 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 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 Ellison, B., Lusk, J., & Davis, D. (2014). The Impact of Restaurant Calorie Labels on Food Choice: Results from a field experiment. Economic Inquiry (ISSN ) 52 (2), pp Falk Müller-Riemenschneider, T. R. (2008). Health-economic burden of obesity in Europe. European Journal of Epidemiology. pp 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