The Health Check Program in Restaurants:

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

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. TjepkemaM. 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. 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. 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. Availability of nutrition information Quick-service 2012 26% had “any” nutrition information on menu 53% had nutrition information on back of tray liner 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 restaurantsin Canada. Submitted, 2013.

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

7. The Health Check Program • Designed to help consumers identify healthy foods in grocery stores and restaurants • Items that meetnutrition criteria are identified with the Health Check symbol Sources: Heart and Stroke Foundation. (2014). Health Check Can Help – Eating Out. http://www.healthcheck.org/page/health-check-can-help-eating-out

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 andmineral content. • Separate criteria for different menu categories (e.g., small entrées, large entrées, soups, salads, appetizers, pizza, children’s entrées) Sources: Heart and Stroke Foundation. (2014). Health Check Can Help – Eating Out. http://www.healthcheck.org/page/health-check-can-help-eating-out 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. Research Objectives • Compare restaurants participating in the Health Check program vs. other restaurants • 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?

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. 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. 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. 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. 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. Sample Characteristics (n=1,126) *p<0.05

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

17. Noticing Nutrition Information Where did you notice nutrition information? (N=1,126) *p<0.05

18. Noticing Nutrition Information What type of information did you notice? (N=1,126)

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

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

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

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

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

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

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

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

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

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 Email c5white@uwaterloo.ca