There is insufficient evidence that restaurant menu labeling policies are cost-effective strategies to reduce obesity and diet-related non-communicable diseases (NCDs). Evidence suggests that menu labeling has a modest effect on calories purchased and consumed. No review has been published on the effect of menu labeling policies on transnational restaurant chains globally. This study conducted a two-step scoping review to map and describe the effect of restaurant menu labeling policies on menu reformulation. First, we identified national, state, and municipal menu labeling policies in countries from global databases. Second, we searched four databases (i.e., PubMed, CINHAL/EBSCO, Web of Science, and Google Scholar) for peer-reviewed studies and gray-literature sources in English and Spanish (2000-2020). Step 1 identified three voluntary and eight mandatory menu labeling policies primarily for energy disclosures for 11 upper-middle and high-income countries, but none for low- or middle-income countries. Step 2 identified 15 of 577 studies that met the inclusion criteria. The analysis showed reductions in energy for newly introduced menu items only in the United States. We suggesr actions for governments, civil society organizations, and the restaurant businesses to develop, implement, and evaluate comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.
CONTEXT: The influence of food and beverage labeling (food labeling) on consumer behaviors, industry responses, and health outcomes is not well established.
EVIDENCE ACQUISITION: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Ten databases were searched in 2014 for studies published after 1990 evaluating food labeling and consumer purchases/orders, intakes, metabolic risk factors, and industry responses. Data extractions were performed independently and in duplicate. Studies were pooled using inverse-variance random effects meta-analysis. Heterogeneity was explored with I2, stratified analyses, and meta-regression; and publication bias was assessed with funnel plots, Begg's tests, and Egger's tests. Analyses were completed in 2017.
EVIDENCE SYNTHESIS: From 6,232 articles, a total of 60 studies were identified, including 2 million observations across 111 intervention arms in 11 countries. Food labeling decreased consumer intakes of energy by 6.6% (95% CI= -8.8%, -4.4%, n=31), total fat by 10.6% (95% CI= -17.7%, -3.5%, n=13), and other unhealthy dietary options by 13.0% (95% CI= -25.7%, -0.2%, n=16), while increasing vegetable consumption by 13.5% (95% CI=2.4%, 24.6%, n=5). Evaluating industry responses, labeling decreased product contents of sodium by 8.9% (95% CI= -17.3%, -0.6%, n=4) and artificial trans fat by 64.3% (95% CI= -91.1%, -37.5%, n=3). No significant heterogeneity was identified by label placement or type, duration, labeled product, region, population, voluntary or legislative approaches, combined intervention components, study design, or quality. Evidence for publication bias was not identified.
CONCLUSIONS: From reviewing 60 intervention studies, food labeling reduces consumer dietary intake of selected nutrients and influences industry practices to reduce product contents of sodium and artificial trans fat.
BACKGROUND: Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour.
OBJECTIVES: To assess the impact of nutritional labelling for food and non-alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption.
SEARCH METHODS: We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries.
SELECTION CRITERIA: Eligible studies: were randomised or quasi-randomised controlled trials (RCTs/Q-RCTs), controlled before-and-after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non-alcoholic drinks in real-world or laboratory settings.
DATA COLLECTION AND ANALYSIS: Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary.
MAIN RESULTS: We included 28 studies, comprising 17 RCTs, 5 Q-RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28).Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real-world settings, including purchases from vending machines (one cluster-RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q-RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta-analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD -46.72 kcal, 95% CI -78.35, -15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta-analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias.Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta-analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD -50 kcal, 95% CI -104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies.Six laboratory studies (four RCTs and two Q-RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta-analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI -0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies.There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high-energy foods) during a snack or meal. A meta-analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI -0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate.
AUTHORS' CONCLUSIONS: Findings from a small body of low-quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality.Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high-quality research in real-world settings is needed to enable more certain conclusions.Further high-quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status.
BACKGROUND: This systematic review (PROSPERO: CRD42015025276) employs a realist approach to investigate the effect of "real-world" policies targeting different aspects of the food environment that shape individual and collective nutrition.
OBJECTIVES: We were interested in assessing intermediate outcomes along the assumed causal pathway to "policy success", in addition to the final outcome of changed consumption patterns.
DATA SOURCES: We performed a search of 16 databases through October 2015, with no initial restriction by language.
STUDY ELIGIBILITY CRITERIA: We included all publications that reported the effect of statutory provisions aimed at reducing the consumption of energy-dense foods and beverages in the general population. We allowed all methodological approaches that contained some measure of comparison, including studies of implementation progress.
STUDY APPRAISAL AND SYNTHESIS METHODS: We reviewed included studies using the appraisal tools for pre-post and observational studies developed by the National Heart, Lung, and Blood Institute. Given the considerable heterogeneity in interventions assessed, study designs employed, and outcome measures reported, we opted for a narrative synthesis of results.
RESULTS AND IMPLICATIONS: Results drawn from 36 peer-reviewed articles and grey literature reports demonstrated that isolated regulatory interventions can improve intermediate outcomes, but fail to affect consumption at clinically significant levels. The included literature covered six different types of interventions, with 19 studies reporting on calorie posting on chain restaurant menus. The large majority of the identified interventions were conducted in the US. Early results from recent taxation measures were published after the review cut-off date but these suggested more favorable effects on consumption levels. Nevertheless, the evidence assessed in this review suggests that current policies are generally falling short of anticipated health impacts.
INTRODUÇÃO: a obesidade infantil é uma preocupação séria em matéria de saúde pública a nível internacional e são necessárias intervenções a nível populacional para apoiar escolhas alimentares saudáveis. As avaliações existentes da rotulagem do menu se concentraram predominantemente em adultos. No entanto, a infância e a adolescência são períodos distintos de desenvolvimento durante os quais são estabelecidos comportamentos alimentares e preferências alimentares a longo prazo. Embora alguns estudos tenham examinado o efeito da rotulagem do menu entre crianças e adolescentes, nenhuma revisão sintetizou essa evidência. OBJETIVO: Avaliar se a rotulagem do menu influencia a quantidade de calorias ordenadas por crianças e adolescentes (ou pais em nome da juventude) nos estabelecimentos alimentares, incluindo restaurantes e cafeterias. MÉTODOS: pesquisas bibliográficas abrangentes foram realizadas nos bancos de dados Medline, Scopus, PsycINFO, CINAHL, SocINDEX e Embase. Foram identificados onze estudos relevantes a partir de uma pesquisa inicial com 1.682 resultados. Os estudos foram avaliados utilizando uma ferramenta de avaliação de qualidade validada. RESULTADOS: Os exames de compras hipotéticas de alimentos em ambientes artificiais sugerem que a rotulagem do menu pode ser eficaz na redução de calorias compradas para ou por crianças e adolescentes. Estudos do mundo real são menos favoráveis, embora os estudos baseados na escola sejam geralmente positivos. Não está claro se os formatos contextuais ou interpretativos de rotulagem de menu são mais eficazes em comparação com a informação de calorias numéricas sozinho. CONCLUSÃO: Evidências que apoiem o impacto da rotulagem do menu na redução do conteúdo energético das escolhas alimentares para restaurantes e cafeterias feitas para crianças ou adolescentes são limitadas. Existe uma necessidade de estudos de alta qualidade realizados em configurações do mundo real.
A systematic review and meta-analysis determined the effect of restaurant menu labeling on calories and nutrients chosen in laboratory and away-from-home settings in U.S. adults. Cochrane-based criteria adherent, peer-reviewed study designs conducted and published in the English language from 1950 to 2014 were collected in 2015, analyzed in 2016, and used to evaluate the effect of nutrition labeling on calories and nutrients ordered or consumed. Before and after menu labeling outcomes were used to determine weighted mean differences in calories, saturated fat, total fat, carbohydrate, and sodium ordered/consumed which were pooled across studies using random effects modeling. Stratified analysis for laboratory and away-from-home settings were also completed. Menu labeling resulted in no significant change in reported calories ordered/consumed in studies with full criteria adherence, nor the 14 studies analyzed with ≤1 unmet criteria, nor for change in total ordered carbohydrate, fat, and saturated fat (three studies) or ordered or consumed sodium (four studies). A significant reduction of 115.2 calories ordered/consumed in laboratory settings was determined when analyses were stratified by study setting. Menu labeling away-from-home did not result in change in quantity or quality, specifically for carbohydrates, total fat, saturated fat, or sodium, of calories consumed among U.S. adults.
OBJECTIVE: Evidence on the effects of restaurant calorie labeling on consumer and restaurant behavior is mixed. This paper examined: (1) consumer responses to calorie information alone or compared to modified calorie information and (2) changes in restaurant offerings following or in advance of menu labeling implementation.
METHODS: Searches were conducted in PubMed, Web of Science, Policy File, and PAIS International to identify restaurant calorie labeling studies through October 1, 2016, that measured calories ordered, consumed, or available for purchase on restaurant menus. The reference lists of calorie labeling articles were also searched.
RESULTS: Fifty-three studies were included: 18 in real-world restaurants, 9 in cafeterias, and 21 in laboratory or simulation settings. Five examined restaurant offerings.
CONCLUSIONS: Because of a lack of well-powered studies with strong designs, the degree to which menu labeling encourages lower-calorie purchases and whether that translates to a healthier population are unclear. Although there is limited evidence that menu labeling affects calories purchased at fast-food restaurants, some evidence demonstrates that it lowers calories purchased at certain types of restaurants and in cafeteria settings. The limited data on modified calorie labels find that such labels can encourage lower-calorie purchases but may not differ in effects relative to calorie labels alone.
INTRODUCTION: Food pricing policies to promote healthy diets, such as taxes, price manipulations, and food subsidies, have been tested in different settings. However, little consensus exists about the effect of these policies on the availability of healthy and unhealthy foods, on what foods consumers buy, or on the impact of food purchases on consumer health outcomes. We conducted a systematic review of studies of the effect of food-pricing interventions on retail sales and on consumer purchasing and consumption of healthy foods and beverages.
METHODS: We used MEDLINE, Embase, PsycINFO, Web of Science, ClinicalTrials.gov, and the Cochrane Library to conduct a systematic search for peer-reviewed articles related to studies of food pricing policies. We selected articles that were published in English from January 2000 through December 2016 on the following types of studies: 1) real-world experimental studies (randomized controlled trials, quasi-experimental studies, and natural experiments); 2) population studies of people or retail stores in middle-income and high-income countries; 3) pricing interventions alone or in combination with other strategies (price promotions, coupons, taxes, or cash-back rebates), excluding studies of vending-machine or online sales; and 4) outcomes studies at the retail (stocking, sales) and consumer (purchasing, consumption) levels. We selected 65 articles representing 30 studies for review.
RESULTS: Sixteen pricing intervention studies that sought to improve access to healthy food and beverage options reported increased stocking and sales of promoted food items. Most studies (n = 23) reported improvement in the purchasing and consumption of healthy foods or beverages or decreased purchasing and consumption of unhealthy foods or beverages. Most studies assessed promotions of fresh fruits and vegetables (n = 20); however, these foods may be hard to source, have high perishability, and raise concerns about safety and handling. Few of the pricing studies we reviewed discouraged purchasing and consumption of unhealthy foods (n = 6). Many studies we reviewed had limitations, including lack of formative research, process evaluation, or psychosocial and health assessments of the intervention's impact; short intervention duration; or no assessment of food substitutions or the effects of pricing interventions on food purchasing and diets.
CONCLUSION: Pricing interventions generally increased stocking, sales, purchasing, and consumption of promoted foods and beverages. Additional studies are needed to differentiate the potential impact of selected pricing strategies and policies over others.
CONTEXTO: Embora o preço dos alimentos seja uma estratégia promissora para melhorar a dieta, o impacto prospectivo do preço dos alimentos na dieta não foi sistematicamente quantificado. OBJETIVO: Quantificar o efeito prospectivo das mudanças nos preços dos alimentos no consumo de dieta. DESIGN: Pesquisamos sistematicamente bases de dados on-line para estudos observacionais intervencionistas ou prospectivos de mudança de preços e dieta; Também procuramos estudos que avaliem a adiposidade como resultado secundário. Os estudos foram excluídos se os dados do preço fossem coletados antes de 1990. Os dados foram extraídos de forma independente e em duplicado. Os resultados foram agrupados usando o modelo de efeitos aleatórios da DerSimonian-Laird. As fontes pré-especificadas de heterogeneidade foram analisadas usando meta-regressão; E potencial para viés de publicação, por gráficos de funil, testes de Begg e Egger. RESULTADOS: De 3.163 resumos identificados, 23 estudos de intervenção e 7 coortes prospectivos com 37 armas de intervenção atingiram os critérios de inclusão. Nas análises agrupadas, uma diminuição de 10% no preço (ou seja, o subsídio) aumentou o consumo de alimentos saudáveis em 12% (IC 95% = 10-15%, N = 22 estudos / armas de intervenção), enquanto um aumento de 10% (ou seja, imposto ) Diminuiu o consumo de alimentos não saudáveis em 6% (IC 95% = 4-8%; N = 15). Por grupo de alimentos, os subsídios aumentaram a ingestão de frutas e vegetais em 14% (IC 95% = 11-17%; N = 9); E outros alimentos saudáveis, em 16% (IC 95% = 10-23%; N = 10); Sem efeitos significativos em bebidas mais saudáveis (-3%; IC 95% = -16-11%; N = 3). Cada aumento de preço de 10% reduziu o consumo de bebidas azucaradas em 7% (IC 95% = 3-10%; N = 5); Fast foods, em 3% (IC 95% = 1-5%; N = 3); E outros alimentos não saudáveis, em 9% (IC 95% = 6-12%; N = 3). Mudanças no preço das frutas e vegetais reduziram o índice de massa corporal (-0,04 kg / m2 por queda de preço de 10%, IC 95% = -0,08-0 kg / m2; N = 4); As mudanças de preços para bebidas açucaradas ou fast foods não alteraram significativamente o índice de massa corporal, com base em 4 estudos. A meta-regressão identificou a direção da mudança de preço (imposto vs. subsídio), número de componentes de intervenção, duração da intervenção e pontuação de qualidade do estudo como fontes significativas de heterogeneidade (heterogeneidade-P <0,05 cada). Não foram observadas evidências de viés de publicação. CONCLUSÕES: esses resultados prospectivos, em grande parte de estudos de intervenção, apoiam a eficácia de subsídios para aumentar o consumo de alimentos saudáveis; E tributação para reduzir a ingestão de bebidas e alimentos não saudáveis. O uso de subsídios e as intervenções multicomponentes combinadas parecem mais eficazes.
OBJETIVO: rotulagem Menu é uma ferramenta prática para informar os consumidores sobre o conteúdo energético de itens de menu e ajudar os consumidores a tomar decisões informadas no ambiente de comer-out, eo volume de estudos publicados recentemente sobre os seus efeitos está em expansão, tanto em termos quantitativos e geograficamente. O objetivo da presente revisão e meta-análise é a de considerar a evidência mais recente que avalia o efeito de rotulagem de menu referente a mudanças na energia consumida, encomendados ou seleccionados de ambos do mundo real e as configurações experimentais.
PROJETO: A revisão incluiu quinze peer-reviewed, artigos de texto completo publicados entre 2012 e 2014. metodológica informações pertinentes foi extraído de cada um dos estudos incluídos e um esquema de avaliação da qualidade foi aplicado para classificar os estudos, após o que foram realizadas as comparações entre sistemáticos-estudo. A metanálise foi realizada incluindo doze dos quinze estudos, e estratificada de acordo com o tipo de ambiente de pesquisa e os resultados: energia consumida, ordenada ou selecionado.
RESULTADOS: A avaliação produziu estudos categorizados por qualidade do estudo: bom (n 3), justo (n 9) e fracos (n 3). No geral nove estudos mostraram reduções estatisticamente significativas na energia consumida, ordenada ou selecionado. Três artigos relataram nenhum efeito de rotulagem menu. A meta-análise mostrou efeitos estatisticamente significativos de rotulagem do menu: energia total consumida foi reduzida por uma média de 419 · 5 kJ (100 · 2 kcal) e energia ordenados em configurações do mundo real diminuiu em uma média de 325 · 7 kJ (77 · 8 kcal).
Conclusão: A revisão apoia que a rotulagem do menu pode efetivamente reduzir energia ordenada e consumido no ambiente de alimentação fora de casa.
There is insufficient evidence that restaurant menu labeling policies are cost-effective strategies to reduce obesity and diet-related non-communicable diseases (NCDs). Evidence suggests that menu labeling has a modest effect on calories purchased and consumed. No review has been published on the effect of menu labeling policies on transnational restaurant chains globally. This study conducted a two-step scoping review to map and describe the effect of restaurant menu labeling policies on menu reformulation. First, we identified national, state, and municipal menu labeling policies in countries from global databases. Second, we searched four databases (i.e., PubMed, CINHAL/EBSCO, Web of Science, and Google Scholar) for peer-reviewed studies and gray-literature sources in English and Spanish (2000-2020). Step 1 identified three voluntary and eight mandatory menu labeling policies primarily for energy disclosures for 11 upper-middle and high-income countries, but none for low- or middle-income countries. Step 2 identified 15 of 577 studies that met the inclusion criteria. The analysis showed reductions in energy for newly introduced menu items only in the United States. We suggesr actions for governments, civil society organizations, and the restaurant businesses to develop, implement, and evaluate comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.
