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
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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.
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Menu Labelling Regulations
3
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/
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/
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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 restaurants in Canada. Submitted, 2013.
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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
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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
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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
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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?
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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)
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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
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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
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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
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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
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Sample Characteristics (n=1,126)
Health Check
(n=589)
Comparison
(n=537)
43 yrs
40 yrs
50%
51%
High school or less
29%
27%
Some college/university
35%
39%
University degree or higher
36%
32%
< $50,000
16%
18%
$50,000 - $90,000
23%
21%
> $90,000
37%
37%
Not stated
25%
24%
Characteristic
Mean age*
% Male
Education
Income
*p<0.05
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Noticing Nutrition Information
Did you notice any nutrition information
anywhere in the restaurant today? (N=1,126)
34.2%
Health Check
28.1%
Comparison
(OR=0.72, p=0.019)
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Noticing Nutrition Information
Where did you notice nutrition information? (N=1,126)
Health Check
Comparison
(n=589)
(n=537)
21.6%
9.3%
Poster
5.1%
6.5%
Wall/window/door
5.6%
5.0%
Pamphlet*
1.9%
5.0%
Napkin
3.9%
-
Next to food item*
1.5%
3.5%
Wrapper
0.7%
0.4%
Tray liner
0.7%
0.7%
Menu/menu board*
*p<0.05
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Noticing Nutrition Information
What type of information did you notice? (N=1,126)
Health Check
Comparison
(n=589)
(n=537)
23.8%
15.3%
9.2%
7.1%
5.3%
1.3%
Sodium / Salt
3.9%
1.3%
Sugar / Carbohydrates
2.2%
1.3%
“Other” health symbol
0.5%
2.6%
Other
8.6%
5.2%
Calories
Fat
Health Check logo
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Use of Nutrition Information
Did the nutrition information influence
what you ordered? (N=1,126)
10.9%
Health Check
4.5%
Comparison
(OR=0.34, p<0.001)
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Health Check Symbol
Do you recognize this symbol? (n=589)
Yes:
91.0%
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Health Check Symbol
Did any of the items you ordered today
have this symbol? (N=1,126)
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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
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Health Check Symbol
Among those who reported ordering a
Health Check approved item:
(among those at Health Check restaurants)
 22% “symbol influenced their p<0.01
choice”
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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)
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Nutrient Consumption
Mean nutrients consumed in meal (includes beverage)
*
* p<0.05
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Nutrient Consumption
Mean nutrients consumed in meal (includes beverage)
*
*
*
* p<0.05
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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
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Strengths & Limitations
 Naturalistic environment
 Assumptions required when calculating food & nutrient
consumption
 Self-reported data
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Future Research
 Natural policy experiments
 “No policy” vs. Voluntary vs. Mandatory policies
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Photo Credit: https://www.healthyfamiliesbc.ca/about-us/informed-dining-national : /
Funding support
National Institutes of Health Grant # 1 P01 CA138-389-01 - Hammond
CCSRI Junior Investigator Award Hammond
CIHR New Investigator Award Hammond
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Contact
Christine White, MSc
School of Public Health & Health Systems
University of Waterloo
Tel.
519 888 4567 ext.36525
Email c5white@uwaterloo.ca
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