Background
The global disease burden of obesity is substantial [
1] and increases in energy intake at the population level have likely played a key role in explaining the obesity crisis [
2,
3]. Consuming food served out of the home is now common. In the UK, between 25 and 39% of adults eat out in full-service or fast-food restaurants at least once a week and one in five eat takeaway meals at home on a weekly basis [
4,
5]. A number of studies indicate that more frequent consumption of restaurant or takeaway meals places a person at increased risk of increased body weight [
6,
7], most likely due to the lower nutritional quality and high energy density of food served outside of the home [
8]. A further problem with restaurant and takeaway food is that customers tend to underestimate the number of kilocalories (kcals) in large and calorie dense meals [
9,
10]. This is of particular relevance because recent research has shown that food served outside of the home is often energy dense [
11]. Because of these considerations, interventions designed to improve public health may benefit from targeting the out of home food sector.
One example of a public health intervention in the out of home food sector is kcal labelling of food and drink products. Because many consumers will underestimate the number of kcals in food and drink [
9,
10], legislation has now been passed in the US to ensure that kcal labelling of all food and drink products sold out of the home is provided by major catering companies [
12]. The best available evidence indicates that this may have a small public health benefit because provision of kcal labelling has been shown to reduce the number of kcals ordered in restaurants [
13], although this effect has not been consistently shown across all studies to date [
14]. In addition, a smaller number of studies suggest that when businesses are required to provide kcal information this results in a small reduction to the kcal content of products being sold via product reformulation or replacement [
15]. Therefore, although unlikely to bring about substantial improvements in population level nutrition and obesity if implemented in isolation, in combination with other policies kcal labelling has potential to improve public health.
Previous UK governments have encouraged catering chains to provide in store kcal information and in 2011, an industry and public health partnership (the Public Health Responsibility Deal) was launched that invited food industry companies to make voluntary pledges to improve public health [
16]. One pledge that food industry companies could sign up to was provision of kcal labelling at point of choice in retail outlets [
17]. Although the effectiveness of the Public Health Responsibility Deal has been examined more generally [
18], the result of the kcal labelling pledge scheme has not been examined in detail. Moreover, there has been no examination of kcal labelling practises in the UK eating out sector. These considerations are timely because the introduction of legislation to make kcal labelling mandatory among catering chains in the UK is currently being considered by government [
19]. As was the case in the US, the UK food industry may challenge any such legislation [
20], on the grounds of whether action is required, whether a mandatory policy is needed and/or the feasibility of implementing kcal labelling policies.
The main aims of the present study were to examine the proportion of major UK restaurant (fast-food and full-service) and take-away chains that provide kcal information to customers in store at point of choice and the extent to which current practises adhere to kcal labelling recommendations regarding the prominence, positioning and clarity of labelling. To develop a better understanding of kcal labelling practices in the eating out sector more generally, we also sampled chain coffee shops/cafes and in store cafes of major supermarkets. In addition, we examined the adequateness of kcal labelling practises among eligible chains in the present study that also signed the Public Health Responsibility Deal (2011) kcal labelling pledge. Finally, we also examined how common it was for chains to choose not to provide in store kcal labelling but have this information available (on their websites or on request), as we reasoned this would be indicative of how easily in store labelling could be adopted.
Discussion
We examined in store kcal labelling practises among restaurant and take-away chains with twenty or more outlets in the UK, as well as among major coffee shop/cafes and supermarket cafes. Overall, only a minority of the 104 chains sampled provided in store kcal labelling (18 chains, 17%). Of chains that did provide in store kcal labelling, quality of labelling was not consistently in line with public health recommendations. Although chains tended to provide kcal labelling at point of choice and close to product name or price on the menu, the majority of chains did not provide kcal labelling for all items sold and kcal information tended not to be presented in a prominent way. The majority of chains also did not provide contextual information that would allow customers to interpret and use kcal labelling easily (e.g. recommended daily amount of kcals).
Provision of kcal information at point of choice when eating out of the home allows consumers to make informed dietary decisions and there is some evidence that consumers use this information to make healthier choices [
13,
14]. It is therefore problematic that so few major eating out chains in the UK provide kcal labelling at point of choice. It is also likely that for kcal information to motivate healthier choices consumers need to understand the kcal information presented. For example, one US trial found that participants chose fewer kcals when kcal labels were paired with contextual information (e.g. proportion of recommended daily amount) that allowed participants to better understand the relative amount of kcals they were consuming, as opposed to no information [
26]. However, the present study indicates the UK kcal labelling that is being provided tends not to be displayed prominently and without contextual information (e.g. a statement on recommended daily kcal intake), which will likely minimise usage by consumers [
27]. We reasoned that chains which had previously committed to a voluntary public health pledge to provide kcal labelling may be providing kcal labelling in line with public health recommendations, but our analyses of these chains did not indicate this and we found that 4/16 (25%) chains were not using kcal labelling in the outlets of the chain that we visited. Collectively these findings suggest that voluntary policies in the UK to encourage the eating out sector to provide appropriate kcal information to customers at point of choice have not been successful [
16] and as is currently being considered by UK government, a mandated policy will now be necessary.
We also examined how common it was for chains not to provide point of choice kcal labelling in store but to have this information available (via their website or on request). We were able to identify that this was the case for 50% of these chains, although this number may be larger as not all chains responded to our requests. It therefore appears that kcal labelling could be relatively easily implemented by a large proportion of major UK chains currently choosing not to provide this information at point of choice. Data from the US indicates that the overwhelming majority of eating out chains that are eligible for mandated kcal labelling have been able to implement in store labelling [
21]. We did not sample smaller chains (e.g. less than 20 outlets) or independent outlets and we therefore do not know how common kcal labelling or collection of nutritional product information is among these types of businesses, but we would presume both would be less common among smaller businesses.
Strengths of the present research were that we pre-registered our study methods and analysis procedures and were able to sample a large number of eating out chains in the UK.
As noted, because of feasibility we did not examine smaller chains or independent restaurants. Because both chain and non-chain restaurants in the US have been shown to sell high kcal meals [
28] we reason that kcal labelling among all catering businesses in the UK would be preferable. We used a similar methodology as in [
21], using a combination of in store visits, chain website research and direct contact with chains to collect data. In addition to this it would have been ideal to visit outlets of every chain to confirm accuracy of data collection. However, we checked accuracy of instances in which we concluded a chain did not provide kcal labelling via direct contact with the chain and/or the chain’s website by visiting a subset of these chains (45%) and there were no discrepancies. Finally, although two independent researchers rated the quality of in store kcal labelling for each chain and inter-rater reliability was high, it would have been ideal to make these ratings for multiple outlets of each chain. However, menu information tends to be standardised across chain outlets, so we reason that it is unlikely that our results would differ substantially if we had adopted this approach.
Public health relevance
The findings of the present study suggest that in the UK voluntary ‘opt-in’ policies for kcal labelling of food and drink sold in the out of home food sector result in inadequate kcal labelling practises and a mandatory policy will therefore be required for widespread and adequate adoption of kcal labelling in the out of home food sector. It will however be important to assess how effective mandatory policies are in future research, because among businesses that were providing kcal labelling in the present study labelling was often provided in a way that would be unlikely to change consumer behaviour. Although eating out of the home is becoming more common and there is public support for kcal labelling [
29], given that kcal labelling will most likely have modest effects on consumer and business behaviour (e.g. reformulation), kcal labelling will need to be combined with a range of other policies to improve population level diet and nutrition.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.