1. Elizabeth D. Mansfield, PhD, RD
RESEARCH
The Impact of Menu Labeling on Calories Selected or Consumed: A Systematic Review and Meta-Analysis
Susan E. Sinclair, MSc
Marcia Cooper, PhD, RD
Elizabeth D. Mansfield, PhD, RD
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).

2. Inclusion Criteria Exclusion Criteria
RESEARCH
Key criteria used to select studies for a systematic review and meta-analysis that measured the impact of menu labeling on calories selected or consumed
Inclusion Criteria
Exclusion Criteria
A controlled experimental or quasi-experimental design was used
A control or comparison group was not included (eg, before and after designs)
The effect of nutrition information on menus was tested
Outcomes measured included calories selected or consumed
Participants’ nutrition literacy or awareness of nutrition information was measured rather than actual behavior
Setting was Canada, or any other country with a similar nutrition labeling environment
Consumers’ intentions were measured rather than their actual food selection or consumption behavior
Participants were generally healthy adolescents or adults
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).

3. Data extraction and synthesis
RESEARCH
Key quality appraisal, data extraction, and data synthesis methods for a systematic review and meta-analysis that measured the impact of menu labeling on calories selected or consumed
Quality appraisal
The Scottish Intercollegiate Guidelines Network (SIGN) checklists for cohort studies and for controlled trials32 were used to assess the quality of the quasi-experimental and experimental studies, respectively.
Sensitivity analysis was used to take into account the influence of studies judged to be of lower quality.
Data extraction and synthesis
Authors were contacted by to obtain any information needed for data extraction.
To facilitate comparison between studies, proportional differences in calories consumed or selected were calculated.
Subgroup analyses were planned to test the influence of: gender, age, socio-economic status, setting, cost of food, type of label.
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).

4. RESEARCH
Table 3. Summary of characteristics and results of five quasi-experimental studies that measured the association between the introduction of menu labeling and average calories purchased per transaction
Lead author, year
Study location
(test vs. comparison)
Sample size (n)
Calories purchased per transaction at the test location before vs. after mandatory menu labeling was introduced (Calories)
Calories purchased per transaction at the comparison location at the same time points as the test location where mandatory menu labeling was introduced (Calories)
Test difference vs. comparison difference in calories purchased per transaction (Calories)
Elbel,
United States (New York City vs. Newark)
Males: 82
747 vs. 814
878 vs. 795
+67a vs. -83a
Females: 102
712 vs. 716
560 vs. 730
+4 vs. +170
Finkelstein,
United States (King County, Washington vs. adjacent counties)
>11,000
1211 vs. 1217
1391 vs. 1392
+5.7 vs. +0.9
Tandon,
United States (Seattle/King county, Washington vs. San Diego county)
128
823 vs. 720
895 vs. 789
-103a vs. -106a
Bollinger,
United States (New York City vs. Boston and Philadelphia)
118,480
247 vs a
NRb vs. NRb
-14.4 vs. NRb**
Elbel,
1156
825 vs. 846
823 vs. 826
+21a vs. +3a
a Value was imputed from other values provided in the study report (actual value was not reported).
b To protect the confidentiality of the data, the authors did not provide these data in the study report.
**The regression coefficient estimate of the effect of mandatory calorie posting was statistically significant (p<0.01)
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).

5. Test cafeteria vs. control cafeteria
RESEARCH
Table 4. Summary of characteristics and results of two quasi-experimental studies that measured the association between the introduction of menu labeling and the percent frequency with which targeted food items were purchased
Lead author, year
Comparison
Sample size (n)
Food items targeted with menu labeling
Frequency with which targeted items were purchased in the test cafeteria before vs. after menu labeling was introduced (%)
Frequency with which targeted items were purchased in the comparison cafeteria at the same time points as in the test cafeteria where menu labeling was introduced (%)
Test difference vs. control difference in frequency with which targeted items were purchased (%) (p-value)
Webb,
Test cafeteria vs. control cafeteria
600
Entrees
68.6 vs. 68.6a
79.2 vs. 79.3a vs
(p-value “not significant” – actual value not reported)
Sides
78.4 vs. 83.2a
69.2 vs. 64.4a
+4.8 vs. -4.8
(p=0.0007)
Snacks
40.3 vs. 41.6a
27.8 vs. 19.7a
+1.3 vs. -8.1
(p=0.006)
Levin,
406
4.3 vs. 11.9
(p<0.001)
5.4 vs. 5.1
(p=0.78)
+7.6a vs. -0.3a
(p-value not reported)
a Value was imputed from other values provided in the study report (actual value was not reported)
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).

6. RESEARCH
Table 8, Part 1. Sensitivity and subgroup analysis results for the effect of menu labeling on calories selected
Description of the sensitivity/subgroup analysis
Number of studies included in the sensitivity or subgroup analysis
Number of relevant menu labeling comparisons included in the studies
Number of participants in the menu label (test) group and in the no menu label (control) group conditions
Mean difference in calories between the menu label group and in no menu label group
(Calories) (95% confidence interval (CI); p-value)
Overall (all conditions) 7 18
test: 1267
control: 799
-42.54
(95% CI: , -3.19; p=0.03)
Conditions from studies rated as higher quality 3 6
test: 541
control: 409
-63.89
(95% CI: , 39.09; p=0.22)
Calorie content only menu label conditions 8
test: 776
control: 583
-30.84
(95% CI: , 34.18; p=0.35)
Calorie content and contextual or interpretive information menu label conditions 4
test: 351
control: 148
-67.39
(95% CI: , ; p=0.008)
Conditions from studies that took place in a natural setting 10
test: 580
control: 248
-52.57
(95% CI: , ; p=0.009)
Conditions from studies where participants believed they needed to pay for their meal 5 14
test: 1027
control: 683
-34.59
(95% CI: , 3.94; p=0.08)
Results reported for women separately 2
test: 128
control: 110
(95% CI: , ; p=0.002)
Results reported for men separately 1
test: 50
control: 61
+92.22
(95% CI: , ; p=0.13)
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).

7. RESEARCH
Table 8, Part 2. Sensitivity and subgroup analysis results for the effect of menu labeling on calories consumed
Description of the sensitivity/subgroup analysis
Number of studies included in the sensitivity or subgroup analysis
Number of relevant menu labeling comparisons included in the studies
Number of participants in the menu label (test) group and in the no menu label (control) group conditions
Mean difference in calories between the menu label group and in no menu label group
(Calories) (95% confidence interval (CI); p-value)
Overall (all conditions) 5 22
test: 855
control: 544
(95% CI: , -3.46; p=0.03)
Conditions from studies rated as higher quality 3 6
test: 541
control: 409
-45.18
(95% CI: , 38.86; p=0.29)
Calorie content only menu label conditions 4 8
test: 545
control: 383
-12.73
(95% CI: , 36.82; p=0.61)
Calorie content and contextual or interpretive information menu label conditions 10
test: 310
control: 161
-80.67
(95% CI: , ; p=0.007)
Results reported for women separately
test: 207
control: 97
-72.38
(95% CI: , ; p=0.01)
Results reported for men separately 2
test: 147
control: 60
-21.82
(95% CI: , 89.37; p=0.70)
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).

8. RESEARCH Sinclair SE , Cooper M, Mansfield ED.
Figure 8. Forest plot showing pooled weighted mean difference with 95% confidence interval (CI) for 8 informative conditions or subgroups and 16 contextual or interpretive conditions or subgroups for which the calories consumed effect was estimated
For each condition or subgroup, the shaded square represents the point estimate of the menu label effect. The horizontal lines join the lower and upper limits of the 95% CI of these effects. Arrows at the end of the line indicate that the CI extends beyond the scale shown at the bottom of the plot. The size of the shaded square reflects the relative weight of the study in the meta-analysis. The diamond at the bottom of each plot represents the pooled weighted mean difference with the 95% CI.
aStandard deviation; binverse variance; cconfidence interval; dcalorie content menu label; erestrained eating participants subgroup; ffemale participant subgroup; gmale participant subgroup; hunrestrained eating participants subgroup; icalorie content and value pricing label; j­calorie content and recommended daily caloric intake for an average adult label; kcalorie content and exercise equivalent label; lNutrition Facts table label; mlean participants subgroup; noverweight or obese participant subgroup; otraffic light label.
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).

9. RESEARCH Sinclair SE , Cooper M, Mansfield ED.
Figure 9 Forest plot showing pooled weighted mean difference with 95% confidence interval (CI) for 8 informative conditions or subgroups and 10 contextual or interpretive conditions or subgroups for which the calories selected effect was estimated
For each condition or subgroup, the shaded square represents the point estimate of the menu label effect. The horizontal lines join the lower and upper limits of the 95% CI of these effects. Arrows at the end of the line indicate that the CI extends beyond the scale shown at the bottom of the plot. The size of the shaded square reflects the relative weight of the study in the meta-analysis. The diamond at the bottom of each plot represents the pooled weighted mean difference with the 95% CI.
 aStandard deviation; binverse variance; cconfidence interval; dcalorie content menu label; efemale participant subgroup; fmale participant subgroup; gcalorie content and value pricing label; hcalorie content and traffic light symbol label; icalorie content and exercise equivalent label; j­calorie content and recommended daily caloric intake for an average adult label; klow-fat label on the beef item; llow-fat and preparation details label on the beef item; mlow-fat label on the haddock item; nlow-fat and preparation details label on the haddock item; olow-fat label on the pasta item; plow-fat and preparation details label on the pasta item.
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).

10. RESEARCH
Conclusions from a systematic review and meta-analysis that measured the impact of menu labeling on calories selected or consumed
The findings of this meta-analysis support menu labeling approaches that include contextual or interpretive nutrition information along with calories to help consumers select and consume fewer calories when eating in restaurants and other foodservice establishments.
The labeling of menus with calories alone does not have a significant impact upon consumers’ selection or consumption of calories.
The best approach for menu-based nutrition information, particularly, for those consumers who may be limited in their food and health literacy skills, merits further exploration.
Sinclair SE , Cooper M, Mansfield ED.
J Acad Nutr Diet. 2014;114(9).