Journal of Nutrition Education and Behavior
Research ArticlePredictors of Total Calories Purchased at Fast-food Restaurants: Restaurant Characteristics, Calorie Awareness, and Use of Calorie Information
Introduction
The dramatic increase in the prevalence of obesity during the past 3 decades has moved it to the forefront of current public health priorities in the United States (US). Obesity contributes to diabetes and cardiovascular disease and is 1 of the leading preventable causes of death in the US.1 Health care to treat obesity-related conditions costs the US an estimated $75 billion each year in 2003 dollars2 and 32% of the adult population is currently obese.3 One factor contributing to the increase in obesity has been the shift in where people purchase and consume food. Consumption of out-of-home calories has increased significantly during the past few decades4 and Americans now spend about half of their food budget in restaurants.5 Purchases from fast-food venues have also increased6 and frequent fast-food consumption has been linked to high caloric intake and obesity.7, 8, 9, 10
Calorie labeling at the point of purchase has been identified as a way to inform consumers, improve dietary choices, and reduce the number of calories purchased and consumed at restaurants. This strategy is consistent with public health practice emphasizing environmental and policy change as a means for chronic disease prevention, and with nutrition practice and theory regarding the contribution of nutrition information to dietary behavior.11, 12 Numerous cities, counties, and states have already mandated that restaurants in their jurisdictions post calorie labels prominently for customers to use.13 Nationally, provisions included in the Patient Protection and Affordable Care Act of 2010 will require calorie labels in all large chain restaurants with ≥ 20 outlets in the US.14
Previous studies have demonstrated an association between calorie labeling at the point of purchase and increased customer awareness of calories15, 16, 17 and between self-reported use of posted calorie labels and purchasing fewer calories.18, 19 The evidence regarding the impact of calorie labels on customer behavior alone has been mixed.20 The strongest evidence of an association between calorie labels and purchasing behavior has been found in experimental studies with specific menus,21 for particular customers,22 and at specific restaurant chains.19
The current study was completed as part of a national chronic disease prevention initiative, Communities Putting Prevention to Work. It examined the purchase patterns at fast-food restaurants and their relation to restaurant characteristics, customer characteristics, and use of calorie information. The customer and restaurant characteristics measured were informed by both social cognitive23 and social ecological24 theories of behavior, which collectively emphasize the independent contributions of the individual, the environment, and the individual–environment interaction to behavior. It was expected that total calories purchased at fast-food restaurants would be independently associated with customer characteristics (individual) and restaurant characteristics (environment), and with use of calorie information during purchase decisions (individual–environment interaction). The current study also examined the extent to which purchase patterns could account for variations in total calories purchased. It was expected that the association between use of calorie information and the total amount of calories purchased could be partially accounted for by 3 purchase patterns that represent strategies for purchasing fewer calories: ordering low- or no calorie beverages, small or no fries, and < 3 items.
Section snippets
Design and Sampling
This study was completed with baseline data from a pre–post study designed to evaluate a media campaign promoting awareness and use of calorie labels posted at fast-food venues in New York State (NYS). Five counties were selected for inclusion. These included the 3 counties in NYS (exclusive of New York City) that required chain restaurants to label calories at the time of data collection (Albany, Schenectady, and Ulster), 1 county in NYS that had plans to require calorie labels right after the
Results
Table 1 presents data on the characteristics of the 31 fast-food restaurant sites surveyed and the caloric content of customer purchases at these sites. The median poverty level of the restaurant locations was 24% and the poverty levels at individual restaurant locations ranged from 8% to 80%. Calorie labels were displayed in just over half of all restaurants.
Table 2 presents data on participants' demographic characteristics, nutrition knowledge, awareness, and behavior, including the caloric
Discussion
The results of this study suggest that factors associated with the environment, individual, and individual–environment transaction contribute independently to the total calories adults purchase at fast-food restaurants. Results demonstrated that reported use of calorie information at fast-food restaurants during a purchase decision was associated with purchasing fewer calories independent of restaurant characteristics, customer demographics, calorie knowledge, and calorie awareness. Previous
Implications for Research and Practice
Findings from this study have direct implications for development of health education campaigns to support the mandatory calorie labeling provision included in the Affordable Care Act. Results suggest that calorie information provided to consumers should be associated with actionable strategies to assist consumers with reducing the caloric content of items they purchase. They also imply that calorie information provided to consumers should include a calorie reference to a single meal at the
Acknowledgments
This work was supported in part by a cooperative agreement from Centers for Disease Control's Communities Putting Prevention to Work program (grant 3U58DP001963-01S4). The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the US Department of Health and Human Services or the Centers for Disease Control and Prevention. From the Center for Human Services Research, the authors acknowledge Rose Greene for project guidance and the entire
References (34)
- et al.
Role of food prepared away from home in the American diet, 1977-78 versus 1994-96: changes and consequences
J Nutr Educ Behav
(2002) - et al.
Fast-food consumption among US adults and children: dietary and nutrient intake profile
J Am Diet Assoc
(2003) - et al.
Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis
Lancet
(2005) - et al.
The impact of menu labeling on fast-food purchases for children and parents
Am J Prev Med
(2011) - et al.
Nutrition label use partially mediates the relationship between attitude toward healthy eating and overall dietary quality among college students
J Am Diet Assoc
(2012) - et al.
Comparison of fast-food and non-fast-food children's menu items
J Nutr Educ Behav
(2009) - et al.
Nutrition labeling and portion size information on children's menus in fast-food and table-service chain restaurants in London, UK
J Nutr Educ Behav
(2011) - et al.
Mandatory menu labeling in one fast-food chain in King County, Washington
Am J Prev Med
(2011) - et al.
The continuing epidemics of obesity and diabetes in the United States
JAMA
(2001) - et al.
State-level estimates of annual medical expenditures attributable to obesity
Obes Res
(2004)
Prevalence of overweight and obesity in the United States, 1999-2004
JAMA
Trends in energy intake in U.S. between 1977 and 1996: similar shifts seen across age groups
Obes Res
Fast food consumption of U.S. adults: impact on energy and nutrient intakes and overweight status
J Am Coll Nutr
Fast food restaurant use among women in the Pound of Prevention study: dietary, behavioral and demographic correlates
Int J Obes
Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases
Annu Rev Public Health
The role of behavioral science theory in development and implementation of public health interventions
Annu Rev Public Health
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2020, Food Quality and PreferenceCitation Excerpt :Many preventive programmes for the education of children and adults about nutrition at healthcare facilities have not been successful, and consumers have not increased the consumption of fruits and vegetables despite recommendations (Kremer-Sadlik et al., 2015). Fast-food restaurants, which serve food with a relatively high fat content and low nutritional value, remain popular and people still consume these meals while away from home even though the information on the nutritional value of products is available at the fast food restaurants and on labels (Brissette, Lowenfels, Noble, & Spicer, 2013; Kirkpatrick et al., 2013). In the United States, 5.7 million people experience heart failure which is correlated with high consumption of red processed meat.
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2020, Food Research InternationalCitation Excerpt :These high knowledge scores, which exceed values reported in similar studies (e.g. McCrory, Vanderlee, White, Reid, & Hammond, 2016), may occur due to the larger proportion of highly educated people in the sample, as education is a recognized determinant for nutrition knowledge (Vasconcelos et al., 2019; Pillai, Liang, Thwaitesc, Sharmad, & Goldsmith, 2019; Mulders, Corneille, & Klein, 2018). Providing information enables consumers to make more informed choices and encourages the selection of healthier alternatives (Brissette, Lowenfels, Noble, & Spicer, 2013; Bialkova et al., 2014; Hieke et al., 2015; Dodds, 2014; Acton & Hammond, 2018; Arrúa, Curutchet et al., 2017; Khandpur et al., 2018; Machín, Aschemann-Witzel, Curutchet, Giménez, & Ares, 2018; Talati et al., 2017). However, it is necessary to present FoP nutrition labelling that is easy to understand.
A Meta-Analysis of Food Labeling Effects on Consumer Diet Behaviors and Industry Practices
2019, American Journal of Preventive MedicineCitation Excerpt :From 5,378 identified abstracts, 668 U.S. Department of Agriculture Economic Research Service websites, and 186 full-text articles identified from hand searching of reference lists and related articles in PubMed, 60 studies from 59 articles met inclusion criteria, comprising 2,078,043 unique observations (consumers, receipts, purchases) across 111 intervention arms (Figure 1). These included 16 randomized49–64 and 44 nonrandomized45,65–106 intervention studies conducted in 11 countries across four continents (Table 1, Appendix Tables 3–11, available online). The majority included both sexes, and most evaluated adults.