1. 1 The Health Check Program in Restaurants: Consumer Awareness, Use of Nutrition Information and Consumption Patterns Christine White, Heather Lillico & David Hammond CPHA - Public Health 2014 May 29, 2014

2. 2 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.html 4. Canadian Council of Food and Nutrition. Tracking Nutrition Trends VII. August 2008.

3. 3 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/

4. 4 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/

5. 5 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

6. 6 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-dining 2.Heart and Stroke Foundation. (2014). Health Check Can Help – Eating Out. http://www.healthcheck.org/page/health-check-can-help-eating-out

7. 7 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

8. 8 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-out 2.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

9. 9 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

10. 10 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)

11. 11 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

12. 12 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

13. 13 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

14. 14 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

15. 15 Characteristic Health Check (n=589) Comparison (n=537) Mean age* 43 yrs40 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% Not stated 25%24% Sample Characteristics (n=1,126) *p<0.05

16. 16 Did you notice any nutrition information anywhere in the restaurant today? (N=1,126) (OR=0.72, p=0.019) Health CheckComparison Noticing Nutrition Information 34.2% 28.1%

17. 17 Where did you notice nutrition information? (N=1,126) Health Check (n=589) Comparison (n=537) Menu/menu board* 21.6%9.3% Poster5.1%6.5% Wall/window/door5.6%5.0% Pamphlet* 1.9%5.0% Napkin3.9%- Next to food item* 1.5%3.5% Wrapper0.7%0.4% Tray liner0.7% *p<0.05 Noticing Nutrition Information

18. 18 What type of information did you notice? (N=1,126) Health Check (n=589) Comparison (n=537) Calories23.8%15.3% Fat9.2%7.1% Health Check logo5.3%1.3% Sodium / Salt3.9%1.3% Sugar / Carbohydrates2.2%1.3% “Other” health symbol0.5%2.6% Other8.6%5.2% Noticing Nutrition Information

19. 19 Use of Nutrition Information Did the nutrition information influence what you ordered? (N=1,126) Health CheckComparison (OR=0.34, p<0.001) 10.9% 4.5%

20. 20 Health Check Symbol Yes: 91.0% Do you recognize this symbol? (n=589)

21. 21 Did any of the items you ordered today have this symbol? (N=1,126) Health Check Symbol

22. 22 p<0.01 Did any of the items you ordered today have this symbol? (N=1,126)  Health Check restaurants = 7.5%

23. Health Check Symbol 23 p<0.01 Among those who reported ordering a Health Check approved item: (among those at Health Check restaurants)  22% “symbol influenced their choice”

24. 24 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)

25. 25 * * p<0.05 Mean nutrients consumed in meal (includes beverage) Nutrient Consumption

26. 26 *** * p<0.05 Mean nutrients consumed in meal (includes beverage) Nutrient Consumption

27. 27 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

28. 28  Naturalistic environment  Assumptions required when calculating food & nutrient consumption  Self-reported data Strengths & Limitations

29. 29  Natural policy experiments  “No policy” vs. Voluntary vs. Mandatory policies Future Research Photo Credit: https://www.healthyfamiliesbc.ca/about-us/informed-dining-national : /

30. 30 Funding support National Institutes of Health Grant # 1 P01 CA138-389-01 - Hammond CCSRI Junior Investigator Award Hammond CIHR New Investigator Award Hammond

31. Contact Christine White, MSc School of Public Health & Health Systems University of Waterloo Tel. 519 888 4567 ext.36525 Emailc5white@uwaterloo.cac5white@uwaterloo.ca 31