Calorie Labeling Research Articles

The impact of ‘on-pack’ pictorial health warning labels and calorie information labels on drink choice: A laboratory experiment

Sugar-sweetened beverages (SSBs) are one of the largest added sugar sources to diets in the UK and USA. Health warning labels reduce hypothetical selection of SSBs in online studies but uncertainty surrounds their impact on selection of drinks for consumption. Calorie information labels are also promising but their impact on SSB selection is unclear. This laboratory study assessed the impact on SSB selection of ‘on-pack’ labels placed directly on physical products: i.a pictorial health warning label depicting an adverse health consequence of excess sugar consumption; and ii.calorie information labels. Potential moderation of any effects by socio-economic position (SEP) was also examined. Participants - 401 adults, resident in England, approximately half of whom were of lower SEP and half of higher SEP, were asked to select a drink from a range of two non-SSBs and four SSBs (subsequent to completing a separate study assessing the effects of food availability on snack selection). The drinks included ‘on-pack’ labels according to randomisation: Group 1: pictorial health warning label on SSBs; Group 2: calorie information label on all drinks; Group 3: no additional label. The primary outcome was the proportion of participants selecting an SSB. Compared to not having additional labels (39%), neither the pictorial health warning label (40%) nor calorie information labels (43%) affected the proportion of participants selecting an SSB. Lower SEP participants (45%) were more likely to select an SSB compared to those of higher SEP (35%), but SEP did not moderate the impact of labels on drink selection. In conclusion, pictorial health warning labels may be less effective in reducing SSB selection in lab-based compared with online settings, or depending on label design and placement. Findings suggest that effects might be absent when choosing from real products with actual ‘on-pack’ labels, positioned in a ‘realistic’ manner. Field studies are needed to further assess the impact of ‘on-pack’ SSB warning labels in real-world settings to rule out the possible contribution of study design factors.

The effect of spatial location of calorie information on choice, consumption and eye movements

We manipulated the presence and spatial location of calorie labels on menus while tracking eye movements. A novel “lab-in-the-field” experimental design allowed eye movements to be recorded while participants chose lunch from a menu, unaware that their choice was part of a study. Participants exposed to calorie information ordered 93 fewer calories (11%) relative to a control group who saw no calorie labels. The difference in number of calories consumed was greater still. The impact was strongest when calorie information was displayed just to the right of the price, in an equivalent font. The effects were mediated by knowledge of the amount of calories in the meal, implying that calorie posting led to more informed decision-making. There was no impact on enjoyment of the meal. The eye-tracking data suggested that the spatial arrangement altered individuals’ search strategies while viewing the menu. This research suggests that the spatial location of calories on menus may be an important consideration when designing calorie posting legislation and policy.

A multi-country survey of public support for food policies to promote healthy diets: Findings from the International Food Policy Study

BackgroundPoor diet is a significant contributor to the burden of global disease. There are numerous policies available to address poor diets; however, these policies often require public support to encourage policy action. The current study aimed to understand the level of public support for a range of food policies and the factors associated with policy support.MethodsAn online survey measuring support for 13 food policies was completed by 19,857 adults in Australia, Canada, Mexico, the United Kingdom (UK) and the United States (US). The proportion of respondents that supported each policy was compared between countries, and the association between demographic characteristics and policy support was analysed using multivariate logistic regression.ResultsThe level of support varied between policies, with the highest support for policies that provided incentives (e.g., price subsidies) or information (e.g., calorie labelling on menus), and the lowest support for those that imposed restrictions (e.g., restrictions on sponsorship of sport events). This pattern of support was similar in all countries, but the level differed, with Mexico generally recording the highest support across policies, and the US the lowest. Several demographic characteristics were associated with policy support; however, these relationships varied between countries.ConclusionThe results suggest that support for food policies is influenced by several factors related to the policy design, country, and individual demographic characteristics. Policymakers and advocates should consider these factors when developing and promoting policy options.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health.

Working on healthy choices

Working on healthy choices

Cost-Effectiveness of the U.S. Federal Restaurant Menu Calorie Labeling Law for Improving Diet and Health: A Microsimulation Modeling Study (P22-014-19)

ObjectivesExcess caloric intake is linked to weight gain, obesity and related diseases including type 2 diabetes and cardiovascular disease (CVD). Obesity incidence has been on the rise, with almost 2 of 3 people being overweight or obese in the US. In 2018, the US federal government passed a law mandating the labeling of calories on all menu items across chain restaurants, as a strategy to support informed consumer choice and reduce caloric intake. Yet, potential health and economic impacts of this policy remain unclear. MethodsWe used a validated microsimulation model (CVD-PREDICT) to estimate reductions in CVD events, diabetes cases, gains in quality-adjusted life-years (QALYs), costs, and cost-effectiveness of two policy scenarios: (1) implementation of the federal menu calorie labelling (menu calorie label), and (2) further accounting for corresponding industry reformulation (menu calorie label + reformulation). The model utilized nationally representative demographic and dietary data from NHANES 2009–2016; policy effects on consumer intake and BMI-disease effects from published meta-analyses; and policy effects on industry reformulation, policy costs (policy administration, industry compliance and reformulation) and health-related costs (formal and informal healthcare costs, productivity costs) from established sources. We conservatively modeled change in calories to change in weight using an established dynamic weight-change model. Findings were evaluated over 10 years and lifetime from a healthcare and societal perspective. Costs were inflated to constant 2018 USD, and costs and QALYs were discounted at 3% annually. We performed probabilistic analyses and a range of one-way sensitivity and subgroup analyses to assess the robustness of our findings. ResultsSample statistics were shown (Table). American adults (35+) consume ∼21% calorie from restaurants (Figure) that would be reduced by 2% due to this law at the population level. Government administration costs were estimated at 11.6$M, industry compliance costs at 652$M, and industry reformulation costs at 9.2$B. Findings for all other analyses will be presented at the meeting. ConclusionsThese findings will provide much needed evidence on the health and economic impacts of the US menu calorie labeling law. Funding SourcesNIH, AHA. Supporting Tables, Images and/or Graphs▪▪

Cost-Effectiveness of the FDA Added Sugar Labeling to Reduce Cancer Burden in the United States (OR28-03-19)

ObjectivesMeta-analyses have identified obesity as an independent risk factor for 13 cancers and added sugars as a contributor to obesity. In 2016, the new Nutrition Facts label on US packaged foods mandated the inclusion of added sugar content. We assessed the health outcomes, costs, and cost-effectiveness of this policy on obesity-related cancer burdens among 250 million US adults over their lifetime. MethodsWe populated the Diet Cancer Outcome Model (DiCOM), a probabilistic cohort-state transitional model, to evaluate two effects of the policy on (a) consumer behavior alone; and (b) consumer behavior plus industry reformulation. Policy effect on consumer behavior was derived from a meta-analysis of calorie labeling; and on industry reformulation, from the FDA’s regulatory impact analysis and the UK sugar reformulation strategy. Effects of added sugar on obesity and obesity on cancer incidence were derived from meta-analyses and published literature. Cost-effectiveness was evaluated as net costs with 3% annual discounting, under both government affordability and societal perspectives. ResultsWe estimated that, based on consumer responses alone, the added sugar labeling would prevent 35,500 new cancer cases (95% uncertainty interval [UI]: 12,300 to 65,800) and 16,700 cancer deaths (95% UI: 5720 to 31,400) and gain 113,000 quality-adjusted life years (QALYs) (95% UI: 38,800 to 210,000) over a lifetime. Adding potential additional effects on industry reformulation, corresponding values were 79,700 new cancer cases (95% UI: 28,100 to 140,000), 37,500 cancer deaths (95% UI: 13,200 to 66,000), and 253,000 QALYs (95% UI: 89,600 to 444,000). Policy would result in estimated net cost savings of $8600 M (95% UI: $6900 M to $11,000 M) from governmental affordability and $7500 M ($5400 M to $9900 M) from societal perspectives based on consumer responses alone. With industry reformulation, net savings were $19,000 (95% UI: $15,000 M to $23,000 M) and $16,000 M (95% UI: $12,000 M to $20,000 M), respectively. ConclusionsOur modeling estimates that implementation of the FDA added sugar labeling will lead to significant numbers of averted cancer cases and deaths, with net cost-savings; and that potential industry responses may contribute to similar or larger benefits than consumer responses alone. Funding SourcesNIH/NIMHD. Supporting Tables, Images and/or Graphs▪▪

What is the impact of increasing the prominence of calorie labelling? A stepped wedge randomised controlled pilot trial in worksite cafeterias

BackgroundCalorie labelling may help to reduce energy consumption, but few well-controlled experimental studies have been conducted in real world settings. In a previous randomised controlled pilot trial we did not observe an effect of calorie labelling on energy purchased in worksite cafeterias. In the present study we sought to enhance the effect by making the labels more prominent, and to address the operational challenges reported previously by worksites. MethodsThree worksite cafeterias were randomised in a stepped wedge design to start the intervention at one of three fortnightly periods between March and July 2018. The intervention comprised introducing prominent calorie labelling for all cafeteria products for which calorie information was available (on average 87% of products offered across the three sites were labelled). Calorie content was displayed in bold capitalised Verdana typeface with a minimum font size of 14 e.g.120 CALORIES. Feasibility and acceptability were assessed using post-intervention surveys with cafeteria patrons and semi-structured interviews with managers. Effectiveness was assessed using total daily energy (kcal) purchased from intervention items across the three sites, analysed using semi-parametric GAMLSS models. ResultsRecruitment and retention of worksite cafeterias proved feasible: all three randomised sites successfully completed the study. Post-intervention feedback suggested high levels of intervention acceptability: 87% of responding patrons wanted calorie labelling to remain in place. No effect of the intervention on daily energy purchased was observed: −0.6% (95%CI -2.5 to 1.2, p = .487). By-site analyses showed similar null effects at each of the three sites, all ps > .110. ConclusionsThere was no evidence that prominent calorie labelling changed daily energy purchased across three English-based worksite cafeterias. The intervention was feasible to implement and acceptable to patrons and managers.

How much is a calorie worth? A study of willingness to pay for calorie labels in restaurant menus

AbstractWe asked individuals about their willingness to pay (WTP) either: (1) for a mandate requiring restaurants to post calorie information on their menus; or (2) to avoid such a mandate. On average, more people were in in favor of the mandate and were willing to pay four times more than those who were against it, thereby leading to a Kaldor–Hicks improvement from this policy. To ensure robustness, we tested the impact of providing three types of information during individuals’ WTP determinations: (1) visual examples of the proposed calorie labels; (2) data on their effectiveness at the individual level; and (3) data on their wider social and economic benefits. For those in favor, providing a simple visual of the label had no impact on WTP. Data on the individual effectiveness of the labels increased the WTP, while evidence on broader obesity reduction and economic benefits reduced it. For opponents, WTP did not change with provision of additional information except when provided with information on social and economic benefits. Under this condition, the opponents increased their WTP 12-fold to avoid a mandate of this policy. Finally, we measured individual well-being under this policy and found directionally similar results, confirming a net improvement in aggregate welfare. Our results suggest that messaging that focuses on private benefits (providing calorie information so that individuals can effectively choose to reduce excessive caloric consumption) rather than wider public benefits (reduction in overall health-related costs and obesity) is more likely to be effective.

Understanding the Calorie Labeling Paradox in Chain Restaurants: Why Menu Calorie Labeling Alone May Not Affect Average Calories Ordered

Menu calorie labeling is now required nationwide for chain restaurants in the United States; however, a number of studies have found that calorie labeling does not reduce average calories ordered. This research examines how different food value orientations are associated with divergent consumer responses to restaurants providing calorie information on menus and menu boards. Results from two pilot studies and two experiments, including a restaurant field experiment, indicate that calorie labeling is effective in decreasing the number of calories ordered by health value–oriented consumers. However, for quantity value and taste value–oriented consumers, menu calorie labeling may result in an increase in calories ordered. These influences counterbalance one another, leading to an overall nonsignificant effect of calorie labeling on calories ordered in restaurant settings. These findings offer a compelling explanation for the many studies showing nonsignificant effects of menu calorie labeling and inform ongoing policy debates regarding chain restaurants nationally implementing menu calorie labeling. The conceptual contributions and implications of these findings for public policy and consumer well-being are discussed.

The Influence of Health Motivation and Calorie Ending on Preferences for Indulgent Foods

Abstract Food and beverage manufacturers now regularly display “just below” calorie amounts (e.g., 99, 199, 299) in advertisements, presumably to appeal to health-motivated consumers. “Just below” values are those that fall one or more digits below a round number, most commonly seen as nine-ending numbers. However, although nine-ending prices are known to stimulate purchase intent, it is unclear whether or when nine-ending calorie labeling shapes food preferences. The present research shows that when consumers view indulgent foods with just-below (vs. round-ending) calorie amounts, they exhibit higher consumption intentions, purchase intent, and consumption behavior, yet only if they are high in health motivation. This is due to a tendency for health-motivated consumers to overweigh the leftmost digit in multidigit numbers—a cognitive bias known as the “level effect.” This bias results in the perception that just-below (vs. round) -ending indulgent foods have relatively fewer calories, decreasing anticipated guilt and increasing consumption intentions and behavior. The superiority of just-below calorie presentation under health motivation is attenuated with the addition of reference intake labeling (i.e., % daily calorie intake values), which equalizes the magnitude of nine- and round-ending calorie indulgent foods.

Impact of warning labels on sugar-sweetened beverages on parental selection: An online experimental study.

Sugar-sweetened beverages (SSBs) are one of the largest added sugar sources to diets in the UK and USA, particularly among young people. Warning labels, including calorie information labels, could reduce SSB consumption but uncertainty surrounds the labels that are most effective. This study assessed the impact of labels containing (a) each of two image-based warnings and (b) calorie information, singly and together, on SSB selection by parents of 11–16-year-olds living in the UK. Using a 3 (disease image, sugar content image, no image) × 2 (calorie information, no calorie information) between-subjects experimental design, 2002 participants were randomised to see beverages with one of six labels and selected one for their child to consume. The primary outcome was the proportion of participants selecting an SSB. Data were collected in December 2017. Logistic regressions showed SSB selection was lower when labels contained an image-based warning (35%), compared to not having any label (49%) or just calorie information (43.5%). The disease image lowered selection more than the sugar image (32% vs 40.5%). Providing calorie information with the disease image had no additional impact on selection (33%) but enhanced the impact of the sugar image (36%). Image-based warning labels discourage SSB selection by parents for their children. Images depicting health consequences of excess sugar consumption have larger effects than those depicting sugar content. Calorie information does not add to the effect of the former but does to that of the latter. Field studies are needed to assess the impact of SSB warning labels in real-life settings.

The effect of ingredient-specific calorie information on calories ordered

Providing calorie labeling is a widely used strategy to combat obesity. However, there is little evidence that the availability of calorie information at food-away-from-home establishments has an effect on food choices. Listing calorie information for each ingredient, though, may allow customers to avoid high-calorie items that add little to their enjoyment. Data from a natural experiment were used to compare total calories ordered before and after the provision of per-ingredient versus for build-your-own sandwiches, and per-sandwich for pre-defined sandwiches, at a supermarket sandwich counter.Sandwich order slips from a Lincoln, Neb. supermarket were collected from December 15, 2016 to February 4, 2018. In June 2017, calorie information was introduced. A total of 1134 build-your-own orders and 559 pre-defined orders were collected.Calories ordered before and after the provision of calorie information were examined for build-your-own and pre-defined sandwiches using two-sample t-tests. Orders post-calorie information were split into three periods to examine whether responses to information changed over time. Ingredients ordered were also examined before and after information was provided.Customers decrease calories ordered by 7.8% for build-your-own sandwiches when per-ingredient calorie information is introduced. There is no significant change in calories ordered for pre-defined sandwiches. Calorie reduction appears to result from substitution away from some higher calorie items, e.g., mayonnaise, towards lower calorie ingredients, like mustard. Despite low calorie content, customers did not increase the number of vegetables ordered. Finally, there is no attenuation of the effect of calorie information over time.

A quasi-experimental study of a mandatory calorie-labelling policy in restaurants: Impact on use of nutrition information among youth and young adults in Canada

In 2017, Ontario became the first Canadian province to require calorie amounts on menus/menu boards of chain restaurants. The province of British Columbia (BC) implemented a voluntary nutrition information initiative in which calorie and sodium information were available upon request. A quasi-experimental design was used to examine the use of nutrition information in Ontario (mandatory calorie labelling), compared to BC (voluntary policy) and three other provinces with no formal menu labelling policy (‘control’). Data were collected from youth and young adults (16–30 years) in all provinces pre- (fall 2016; n = 2929) and post- (fall 2017; n = 968) implementation of Ontario's calorie-labelling policy in January 2017. Generalized estimating equations tested differences between provinces over time in noticing and impact of nutrition information and support of mandatory calorie labelling. Noticing of nutrition information in restaurants increased in Ontario significantly more than in BC (+25.1% vs. +1.6%; AOR = 4.26, 95% CI = 2.39–7.61) and control provinces (+6.5%; AOR = 3.00, 95% CI = 1.91–4.73). Ontario respondents were significantly more likely to report that the nutrition information influenced their order than those in BC (+12.9% vs. +2.2%; AOR = 3.53, 95%CI = 1.61–7.76) and control provinces (+2.0%; AOR = 3.71, 95%CI = 1.87–7.36). Policy support increased in all groups at follow-up, with a significantly greater increase in Ontario than control provinces (+12.9% vs. +5.7%; AOR = 1.57, 95%CI = 1.06–2.34). Socio-demographic differences were also observed. Findings suggest that the mandatory menu labelling policy implemented in Ontario has increased noticing and use of nutrition information, with no evidence to support the effectiveness of voluntary policies that require consumers to request nutrition information.

Editorial and News

Editorial and News

Conceptual understanding and quantity inferences: a new framework for examining consumer understanding of food energy.

The study examined two components of consumer understanding of food energy information: understanding the concept of energy and its quantity. Using this new framework, we investigated whether activity-equivalent labels facilitated interpretations of food energy compared with calorie labels and whether an image format would strengthen this facilitative effect compared with text. We assessed the effect of energy representation and format in a 2 (activity v. calories)×2 (image v. text) between-subjects design. Conceptual understanding of energy was measured in terms of level of understanding and personal engagement. Quantitative understanding was measured in terms of participants' estimations of a food's contribution to their recommended daily intake and perceptions of energy values as precise or single-bound interval estimates. The experiment was conducted online through Qualtrics. Eight hundred and twelve participants (55 % female, age range 18-74 years) were recruited through a national survey panel in the UK. Participants were twice more likely to have a stronger conceptual understanding of energy and four times more likely to personally engage with activity labels v. calorie labels. Participants did not differ across labels in their estimations of energy quantities; however, they inferred quantities to mean exactly the stated number of calories, but at least the stated activity duration. There were no added benefits in presenting an image over the text format. Activity labels can facilitate conceptual understanding of energy, but may be subject to quantitative misinterpretations. Nutrition communication should consider what people infer from quantities represented on labels.

Promoting healthy choices from vending machines: Effectiveness and consumer evaluations of four types of interventions

Vending machines often provide relatively energy-dense snack foods and beverages at a wide variety of points-of-purchase. Vending-machine interventions that stimulate low-calorie choices can therefore play a role in improving the healthfulness of the food environment landscape. The aim of this study is to examine the effects of four vending-machine interventions, varying in level of intrusiveness, on consumers’ choices, consumers’ acceptance of such interventions, and consumers’ evaluations of the choice they made.In a between-subjects design experiment (N = 206), respondents were asked to purchase a snack and a beverage from a vending machine. In addition to a no-intervention condition, four types of incrementally intrusive interventions were implemented: calorie labelling, increasing accessibility of low-calorie choices, increasing prices of high-calorie choices, and restricting availability of high-calorie choices. A post-choice questionnaire included items concerning intervention acceptance, and assortment and choice evaluations.Compared to the no-intervention condition, the most intrusive intervention (i.e. restricting availability of high-calorie choices) led to more low-calorie choices (39% vs. 78%), while less intrusive interventions (i.e. calorie labelling, increasing accessibility of low-calorie choices, and increasing prices of high-calorie choices) did not. Intervention acceptance and choice evaluations were equally high across the four intervention types.Overall, the results suggest that restricting high-calorie options is a promising route to stimulate healthier choices from vending machines. As such, the present study provides intervention opportunities in the combat against obesity for governments and their potential allies, such as food manufacturers and the food service industry.

Compliance in 2017 With Federal Calorie Labeling in 90 Chain Restaurants and 10 Retail Food Outlets Prior to Required Implementation.

To examine early compliance with the delayed federal calorie labeling regulation that requires posting calories on menus and menu boards at retail food chains with 20 or more establishments nationally. We explored implementation of calorie labeling at 90 of the largest US chain restaurants and the 10 highest-grossing supermarket chains from May to December 2017. We contacted corporate offices and at least 2 locations for each chain, made site visits when possible, and supplemented these efforts with targeted Internet searches. Overall, 71 (79%) restaurant chains partially or fully implemented labeling, as did 9 (90%) supermarket chains. Fast-food and fast-casual restaurants fully implemented labeling at a modestly higher rate than did full-service restaurants. Most of the retail food chains we assessed implemented calorie labeling policies in advance of the May 2018 compliance date. Public Health Implications. Although implementation of federal calorie labeling has been delayed repeatedly in the 8 years since the passage of the legislation, retail food chains have demonstrated a high rate of compliance with calorie labeling in advance of the required May 2018 implementation date. Despite reports from some retail food industries that compliance will be difficult, current implementation shows the feasibility of complying.

The Effect of Graphic Warnings on Sugary-Drink Purchasing

Governments have proposed text warning labels to decrease consumption of sugary drinks—a contributor to chronic diseases such as diabetes. However, they may be less effective than more evocative, graphic warning labels. We field-tested the effectiveness of graphic warning labels (vs. text warning labels, calorie labels, and no labels), provided insight into psychological mechanisms driving effectiveness, and assessed consumer sentiment. Study 1 indicated that graphic warning labels reduced the share of sugary drinks purchased in a cafeteria from 21.4% at baseline to 18.2%—an effect driven by substitution of water for sugary drinks. Study 2 showed that graphic warning labels heighten negative affect and prompt consideration of health consequences. Study 3 indicated that public support for graphic warning labels can be increased by conveying effectiveness information. These findings could spur more effective labeling policies that facilitate healthier choices, do not decrease overall beverage purchases, and are publicly accepted.

Health Warning Labels Correct Parents’ Misperceptions About Sugary Drink Options

Noncarbonated sugar-sweetened beverages, such as fruit drinks, sports drinks, and sweetened teas are increasingly promoted to and consumed by youth. These beverages may be perceived as healthier options than soda. To educate consumers about beverages high in added sugar, several cities and states have proposed policies mandating health warning labels on sugar-sweetened beverages. In 2015, a total of 2,381 parents were randomized to a no label, calorie label, or warning label condition. An online survey asked about the healthfulness of different beverages, and asked parents to select a beverage for their child in a choice task. Regressions compared the warning and calorie label groups to the control group and measured mediating effects of health beliefs on beverage choice. Data were analyzed in 2016. Parents viewed fruit drinks, sports drinks, and sweetened teas as healthier and less likely to cause disease than soda. Compared with no label, warning labels significantly increased parents' risk perceptions for all beverages except soda. Warning labels significantly reduced the odds of selecting fruit drinks for the child (OR=0.42, 95% CI=0.32, 0.56), and this effect was mediated by changes in health beliefs and risk perceptions. Fruit drinks, sports drinks, and sweetened teas are increasingly promoted to youth. Parents believe these beverages are healthier and less likely to cause disease than soda, and warning labels may correct these misperceptions.