1. On today’s menu: Lana Vanderlee & David Hammond CPHA Annual Meeting May 28, 2014 1 Evaluation of a menu labelling initiative in hospital cafeterias in Ottawa, Canada.

2. 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):557-562. 2.Pereira MA et al. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. The Lancet 2005;365(9453):36-42. 3.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. https://www.ic.gc.ca/eic/site/oca-bc.nsf/eng/ca02117.html#a95.  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. 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

4. 4

5. 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 10.1007/s10900-014-9876-0 6. 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, 8:135 7. 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

6. 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

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

8. Civic Cafeteria Jan 2011 8

9. 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

10. CivicGeneralDifference Paninis408625 +217 Entrée435553 +118 Grill447536 +89 Salad Bar494568 +74 Sandwiches470519 +49 Soups120 0 Pizzas402400 -2 Breakfast332277 -55 10 Jan/2011– Food selection across sites (kcal)

11. 11 General Cafeteria Jan 2011

12. 12 General Cafeteria Sept 2012

13. Advertisements on menu boards Sept 2012 13  20 seconds of ads, 20 seconds of nutrition information

14. Civic Displays January Study timeline 14 August/September Wave 1 General Displays September November/December Wave 2 2011 2012 Wave 1Wave 2 Civicxx General0x

15.  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

16.  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

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

18. 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

19. Results 19

20. Sample description 20 CivicGeneral Wave 1 n=497 Wave 2 n=511 Wave 1 n=506 Wave 2 n=571 Mean age (yrs) 44.947.144.945.3 55+ 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%

21. 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

22. 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

23. 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

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

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

26. 26  Calorie consumption lower among those who reported using nutritional labelling p=0.009 500 kcal 573 kcal Used labelling Didn’t use labelling Wave 1 & 2

27. 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

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

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

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

31. 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

32. 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

33. Questions? Lana Vanderlee PhD candidate School of Public Health and Health Systems University of Waterloo Email: lana.vanderlee@uwaterloo.ca Tel: 519-888-4567 ext. 31066 33