On today’s menu: Lana Vanderlee & David Hammond CPHA Annual Meeting May 28, Evaluation of a menu labelling initiative in hospital cafeterias in Ottawa, Canada.

2 1.Mancino et al. Separating what we eat from where: Measuring the effect of food away from home on diet quality. Food Policy 2009;34(6): Pereira MA et al. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. The Lancet 2005;365(9453): French SA, Harnack L, Jeffery RW. Fast food restaurant use among women in the Pound of Prevention study: dietary, behavioral and demographic correlates. International Journal of Obesity & Related Metabolic Disorders 2000;24(10). 4.Industry Canada Office of Consumer Affairs. Chapter 9 – Consumer Spending.  Food consumed away from home has poor nutritional value 1  Increased consumption of fast food associated with becoming overweight or obese. 2,3  One quarter of the Canadian food dollar is spent on food away from home. 4 Background

3  Menu labelling is currently mandatory in several US jurisdictions  United States will implement menu labelling federally in 2014 – via Patient Protection and Affordable Care Act  Canada has no mandatory menu labelling – Informed Dining voluntary program in BC – Government of Ontario announced Healthy Eating Decisions Made Easy Act Background

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5  Evidence for menu labelling is mixed  Reviews suggest little impact at a population level 5,6,7 Some impact upon population subgroups Impact varies upon settings  Little literature examining menu labeling in a Canadian context Background 5. Kiszko KM, Martinez OD, Abrams C, Elbel B. The influence of calorie labeling on food orders and consumption: a review of the literature. J Comm Health. DOI /s Swartz JJ, Braxton D, Viera AJ. Calorie menu labeling on quick-service restaurant menus: an updated systematic review of the literature. Int J Beh Nutr Phys Act. 2011, 8: Harnack LJ, French SA. Effect of point-of-purchase calorie labeling on restaurant and cafeteria food choices: a review of the literature. Int J Beh Nutr Phys Act. 2008, 5:51

The Ottawa Hospital Menu Labelling Program 6  Developed by Nutrition and Foodservices team with support from clinical nutrition team and external experts.  Identified an opportunity to implement a new menu labelling program with digital menu boards during renovations at the Civic hospital

Intervention components  5 digital menu boards with nutritional values for calories, sodium, saturated fat and total fat. 7  Information provided for most food items

Civic Cafeteria Jan

Intervention components  Health logo for items that meet the developed nutritional standards.  Educational campaign at the entrance to the seating area.  Removal of deep fryers and increase in healthier options. 9

CivicGeneralDifference Paninis Entrée Grill Salad Bar Sandwiches Soups120 0 Pizzas Breakfast Jan/2011– Food selection across sites (kcal)

11 General Cafeteria Jan 2011

12 General Cafeteria Sept 2012

Advertisements on menu boards Sept  20 seconds of ads, 20 seconds of nutrition information

Civic Displays January Study timeline 14 August/September Wave 1 General Displays September November/December Wave Wave 1Wave 2 Civicxx General0x

 2, 085 exit interviews – Wave 1 n=1,003 – Wave 2 n=1,082  10 minute intercept survey Food ordered in the cafeteria Noticing and use of menu labelling 15 Methods

 Nutritional analysis of food ordered and consumed  Nutrition information obtained from The Ottawa Hospital Nutrition Services (using C-Bord)  Several estimations made: Items from the salad bar Items lacking adequate description 16 Methods

Analysis  3 primary outcomes Noticing nutrition information Using nutrition information Nutrient consumption  Regression models used to test differences Wave Site 17

Analysis  Socio-demographics age, gender, ethnicity, income, education, BMI  Consumer and behavioural demographics consumer type, frequency of visiting the cafeteria, use of nutrition labels when shopping for food, frequency of eating out, self-reported general health, and dieting behaviour in the previous year 18

Results 19

Sample description 20 CivicGeneral Wave 1 n=497 Wave 2 n=511 Wave 1 n=506 Wave 2 n=571 Mean age (yrs) yrs 26%31%28%31% ‘White’ * 76%82%74%78% Female 59%61% 60% High income * 49%43%38%41% Staff * 58%55%53%51% Overweight/ obese 53%56%49%50%

General Civic Did you notice any nutrition information anywhere in the cafeteria? W1 W2W1W2 21  Significant change in noticing nutrition information between sites over time X 2 = 61.2, p<0.001 Wave 2 Noticing c c c

Did the nutrition information influence what you selected for your meal? Overall sample n=2,085 Among those who noticed n=1,210 GeneralCivic GeneralCivic W1 W2 W1W2 W1W2 W1W2 22  There was a significant change in use of nutrition information between sites over time X 2 =11.5, p=0.001 c Wave 2 Use c c

General Civic W1 W2 W1 W2 Calories consumed 23  There was a significant change in calorie consumption between sites over time X 2 = 5.7, p=0.017 Wave 2 Nutrient Consumption c

General Civic W1 W2 W1 W2 Saturated Fat consumed 24 Wave 2 Nutrient Consumption General Civic W1 W2W1 W2 Total fat consumed

General Civic W1 W2 W1 W2 Sodium consumed 25 Wave 2 Nutrient Consumption c Civic W1 W2

26  Calorie consumption lower among those who reported using nutritional labelling p= kcal 573 kcal Used labelling Didn’t use labelling Wave 1 & 2

Use of nutrition information more common among:  Those who are not of ‘White’ ethnicity p<0.001  Those who usually or always use nutrition information when shopping for food p<0.001  Those with improved general health p=0.027  Hospital staff compared to patients p=0.003 Socio-demographic correlates 27

Support for menu labelling 3% Maybe 2% No …in Ottawa Hospital cafeterias 95% Yes 28

4% Maybe 5% No 91% Yes 29 Support for menu labelling …in all fast-food and other chain restaurants

Preferred menu labels 71% want calories 55% want fat 48% want sodium 30

Conclusions  Indicates a positive impact of menu labelling  Importance of noticing information  Magnitude of impact  Nutrition content and product reformulation  Few socio-demographic differences 31

Additional support provided by: Acknowledgements Acknowledgements Funding for the project provided by: Stipend support to Lana Vanderlee funded by the CIHR Training Grant in Population Intervention for Chronic Disease Prevention: A Pan-Canadian Program (Grant #53893) 32

Questions? Lana Vanderlee PhD candidate School of Public Health and Health Systems University of Waterloo Tel: ext