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The Health Check Program in Restaurants:Consumer Awareness, Use of Nutrition Information and Consumption Patterns

Christine White, Heather Lillico & David HammondCPHA - Public Health 2014 May 29, 2014

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Obesity and Eating out

• 60% of Canadian adults obese or overweight.1

• Increased energy intake has been driven in part by greater caloric intake outside the home.2,3

• More than half of Canadians eat at least one meal prepared out of the home each day.4

Sources: 1. Tjepkema M. Measured Obesity Adult obesity in Canada: Measured height and weight. Nutrition: Findings from the Canadian Community Health Survey. Ottawa, ON; Statistics Canada, November, 2008. 2. French SA, Harnack L, Jeffery RW. Fast food restaurant use among women in the Pound of Prevention study: dietary, behavioral and demographic correlates. International Journal of Obesity 2000; 24:1353-1359.3. World Health Organization. Obesity and overweight: Facts. Available at: http://www.who.int/dietphysicalactivity/publications/facts/obesity/en/print.html4. Canadian Council of Food and Nutrition. Tracking Nutrition Trends VII. August 2008.

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Menu Labelling Regulations

Photo Credit: http://life.nationalpost.com/2014/02/24/calorie-counts-on-fast-food-menus-coming-to-ontario-as-liberal-government-promises-nutrition-labelling-bill/

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Menu Labelling Regulations - Canada

Source: 1. The Globe and Mail. Ontario to require chain restaurants to serve up calorie counts. Available at: http://www.theglobeandmail.com/news/national/ontario-to-move-ahead-with-calorie-counts-on-fast-food-chain-menus/article17063860/

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Availability of nutrition information Quick-service 2012

Source: Hobin E, Lebenbaum M, Rosella L, Hammond D. Availability, format, and type of on-premise nutrition information in the top 10 fast-food chain restaurants in Canada. Submitted, 2013.

• 26% had “any” nutrition information on menu

• 53% had nutrition information on back of tray liner

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Voluntary Policies

• Informed Dining program

• Heart & Stroke Foundation’s Health Check program

Sources: 1. The Province of British Columbia. Informed Dining. Available at: https://www.healthyfamiliesbc.ca/home/informed-dining2. Heart and Stroke Foundation. (2014). Health Check Can Help – Eating Out. http://www.healthcheck.org/page/health-check-can-help-eating-out

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The Health Check Program

Designed to help consumers identify healthy foods in grocery stores and restaurants

Items that meet nutrition criteria are identified with the Health Check symbol

Sources: 1. Heart and Stroke Foundation. (2014). Health Check Can Help – Eating Out. http://www.healthcheck.org/page/health-check-can-help-eating-out

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The Health Check Program

Nutrition criteria are based on Canada’s Food Guide and are developed by registered dietitians.

Menu items are evaluated on fat (quantity and type), fibre, sodium, protein, vitamin and mineral content.

Separate criteria for different menu categories (e.g., small entrées, large entrées, soups, salads, appetizers, pizza, children’s entrées)

Sources: 1. Heart and Stroke Foundation. (2014). Health Check Can Help – Eating Out. http://www.healthcheck.org/page/health-check-can-help-eating-out2. Heart and Stroke Foundation. (2014). Health Check Nutrient Criteria – Foodservice: October 2013. Available at:

http://www.healthcheck.org/sites/default/files/mmallet/HC13_NutrientCriteria_foodservice_%20october%202013_English.pdf

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Research Objectives

• Does consumer awareness of nutrition information differ by restaurant type?

• Does use of nutritional information (including the Health Check symbol) differ by restaurant type?

• Do nutrient consumption patterns differ by restaurant type?

Compare restaurants participating in the Health Check program vs. other restaurants

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Methods

Exit surveys with 1,126 patrons outside 4 Health Check restaurants and 4 comparison restaurants

Restaurants matched on menu (burger, pizza, pita, grill)

Data collection: May – June 2013

Eligibility criteria:• 18 years or older

• Purchased food/drink at restaurant

• Dine-in only (except at pita and pizza restaurants)

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Measures

Noticing Nutrition Information

Did you notice any nutrition information anywhere in the restaurant today? (yes/no)

Where was this information located?• e.g., on the menu, next to food item

What type of nutrition information did you notice?• e.g., calories, fat, Health Check logo

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Measures

Use of Nutrition Information

Did the nutrition information influence what you ordered? (yes/no)

How did the nutrition information influence what you ordered? • e.g., ordered a smaller size, ordered “healthier” items,

chose items with less calories

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Measures

Nutrient Consumption

Food order:

• Entrées, sides, drinks, appetizers/desserts, complimentary items, modifications (open-ended)

• Adjusted for whether they finished their meal

Nutritional content:

• Calories, fibre, protein, sodium, carbohydrate and fat

• Values for each item obtained from restaurant websites and Canadian Nutrient File

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Analysis

Chi-square tests and t-tests

• Test sample differences

Logistic and linear regression models:

• Health Check vs. Comparison Outcomes

• Odds ratios adjusted for age, sex, education, income, race, BMI, fruit and vegetable consumption, weight aspiration, and perceived overall diet quality

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Characteristic Health Check(n=589)

Comparison(n=537)

Mean age* 43 yrs 40 yrs

% Male 50% 51%

Education High school or less 29% 27% Some college/university 35% 39% University degree or higher 36% 32%

Income < $50,000 16% 18% $50,000 - $90,000 23% 21% > $90,000 37% 37% Not stated 25% 24%

Sample Characteristics (n=1,126)

*p<0.05

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Did you notice any nutrition information anywhere in the restaurant today? (N=1,126)

(OR=0.72, p=0.019)

Health Check Comparison

Noticing Nutrition Information

34.2% 28.1%

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Where did you notice nutrition information? (N=1,126)

Health Check(n=589)

Comparison(n=537)

Menu/menu board* 21.6% 9.3%Poster 5.1% 6.5%

Wall/window/door 5.6% 5.0%

Pamphlet* 1.9% 5.0%Napkin 3.9% -

Next to food item* 1.5% 3.5%Wrapper 0.7% 0.4%

Tray liner 0.7% 0.7%*p<0.05

Noticing Nutrition Information

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What type of information did you notice? (N=1,126)

Health Check(n=589)

Comparison(n=537)

Calories 23.8% 15.3%Fat 9.2% 7.1%

Health Check logo 5.3% 1.3%Sodium / Salt 3.9% 1.3%

Sugar / Carbohydrates 2.2% 1.3%

“Other” health symbol 0.5% 2.6%

Other 8.6% 5.2%

Noticing Nutrition Information

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Use of Nutrition Information

Did the nutrition information influence what you ordered? (N=1,126)

Health Check Comparison

(OR=0.34, p<0.001)

10.9% 4.5%

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Health Check Symbol

Yes: 91.0%

Do you recognize this symbol? (n=589)

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Did any of the items you ordered today have this symbol? (N=1,126)

Health Check Symbol

Health Check Symbol

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p<0.01

Did any of the items you ordered today have this symbol? (N=1,126)

Health Check restaurants = 7.5%

Health Check Symbol

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p<0.01

Among those who reported ordering a Health Check approved item: (among those at Health Check restaurants)

22% “symbol influenced their choice”

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Ordering Health Check Items

• 15% ordered at least 1 Health Check approved item (n=87)

• ~1% ordered a Health Check item and recalled seeing symbol (unprompted recall) (n=8)

• <4% ordered a Health Check item and were aware it was Health Check approved (when asked directly) (n=23)

• <2% ordered a Health Check item, were aware it was Health Check approved, and said the symbol influenced their order (n=13)

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*

* p<0.05

Mean nutrients consumed in meal (includes beverage)

Nutrient Consumption

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***

* p<0.05

Mean nutrients consumed in meal (includes beverage)

Nutrient Consumption

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Summary

Health Check program is associated with:• Greater levels of noticing and using nutrition

information when selecting meals• More favourable nutrient intake

Unclear if effects attributable to the program or reflect the type of restaurants that “self-select” into the program

Findings suggest modest impact of voluntary nutrition labelling in the restaurant

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Naturalistic environment

Assumptions required when calculating food & nutrient consumption

Self-reported data

Strengths & Limitations

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Natural policy experiments

“No policy” vs. Voluntary vs. Mandatory policies

Future Research

Photo Credit: https://www.healthyfamiliesbc.ca/about-us/informed-dining-national : /

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Funding support

National Institutes of Health Grant # 1 P01 CA138-389-01 - Hammond

CCSRI Junior Investigator Award Hammond

CIHR New Investigator Award Hammond

ContactChristine White, MScSchool of Public Health & Health SystemsUniversity of WaterlooTel. 519 888 4567 ext.36525Email c5white@uwaterloo.ca

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