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Consumer responses to nutrition guidelines labeling in a university restaurant
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Consumer responses to nutrition guidelines labeling inauniversity restaurant BARBARA A. ALMANZA, PhD, RD; APRIL C. MASON, PhD; RICHARD WIDDOWS, PhD;FREDRICKJ. GIRARD
n spite of the growing consumer interest in nutrition, the use of nutrition information to make food choices is thought to be difficult, even for well-informed, motivated consumers (1). The situation has been made more difficult by the lack of uniformity in presenting nutrition information (2). Reports by The American Dietetic Association (3), the National Academy of Sciences (4), and the Surgeon General (5) have suggested that energy and the following nutrients are of greatest concern to most Americans: protein, fat, cholesterol, complex carbohydrates, fiber, sodium, and calcium. Recent research suggests that although consumers may associate an individual nutrient with certain diseases, they are not knowledgeable about the specifics of that nutrient, such as recommended intakes, sources, functions, or classifications (6). The best format for providing nutrition information is not clear. Forexample, some suggest that alternative labeling formats, such as a bar graph, are more useful to consumers than is the traditional label format (7). The US food labeling system is presently under revision, but the regulations will primarily affect retail products, not foods sold in foodservice operations. In the November 27, 1991, Federal Register, however, the Food and Drug Administration proposed that restaurants choosing to make nutrient content claims should adhere to the proposed guidelines (8). B. A. Almanza (corresponding author) is an assistantprofessorand F J Girardis a graduate student in the Restaurant, Hotel, Institutional and Tourism Management Department;A. C. Mason is an associateprofessor in the Foods and Nutrition Department; and R. Widdows is a professor in the Consumer Sciences and Retailing Department, Purdue University, West Lafayette, IN 4 7907-1266. 580 / MAY 1993 VOLUME 93 NUMBER 5
METHODOLOGY Menu Format The aim of our study was to evaluate consumer preferences for presentation of information about nutrition guidelines on a university restaurant menu. Information used to define guidelines for this study was from the American Heart Association (9,10) and the National Restaurant Association (11). Recipes were evaluated for nutrient contentbymeans ofthe Computrition computer program (1991, Computrition, Chatsworth, Calif). In the first format for providing nutrition information, a symbol (apple) indicated that an entree met the established nutrition guidelines. In the second format, colored dots designated which of the guidelines an entree met. For example, an entree was given a blue dot if it met the lowsodium guideline, a red dot if it met the low-calorie guideline, and so on. The third format listed numeric values for energy and nutrient content (fat, cholesterol, sodium, fiber) in a separate pamphlet for each of the menu selections. In addition, an asterisk was placed next to values that met the established nutrition guidelines. Study Design The study was conducted in a sit-down restaurant called the John Purdue Room, which is open to the public but primarily serves faculty, staff, and students at Purdue University. The study included all lunch customers during 4 weeks in the month of April 1991. The first week was called the control week and no nutrition information was presented to customers. Customers were asked by the waitstaff to complete an anonymous, self-administered questionnaire after making menu selections. Customers could refer to the menu in answering the questionnaire. Two types of learning effect were a concern for the month-long study period. One type was the amount of learning that might occur from one week of the study to the next. To minimize this problem, the for-
mats were presented in the order of the least amount of information to the greatest amount. There was also concern about the learning effect that might occur if a customer ate in the restaurant more than once per week. To minimize this effect, customers were asked to complete the questionnaire only one time per week. A study awareness effect (when participants act differently simply because a study is being done) was also a concern for the study period but could not be avoided. Data analysis was carried out using the Statistical Analysis System software package (version 6.03, 1988, SAS Institute, Cary, NC) (12). Means and frequencies were determined and X2 was done. RESULTS AND DISCUSSION
Demographics The 456 respondents made the overall response rate 46%. This is considered low but comparable to that reported in other studies (13). The sample was 53% men and 47% women. Age ranged widely in the study group (19 to 79 years); the median age was 41 years. The educational level of respondents was skewed compared with the general population, but expected for a university foodservice. Nutrition Knowledge Five nutrition knowledge questions tested the respondents' use of the nutrition information presented. Questions asked the respondents to pick which of three entrees was lowest in fat, cholesterol, sodium, or energy or highest in fiber. Overall, the greatest improvements in nutrition knowledge clearly occurred in week 4 when the pamphlet format was used (Table). Entree Choice More than two thirds of the respondents read the nutrition information. The percentage of respondents who read the nutrition information was greatest when the colored dots were used (85.5%) compared with the apple (67.1%) or the pamphlet (67.3%) formats. This result may have been due to the striking appearance of the menu when colored dots were used. The percentage of respondents who reported selecting a different entree because of the nutrition information that was presented was greatest with the pamphlet format (Table). When nutrition information was presented, more entrees that met the nutrition guidelines were selected. The percentage of entrees chosen that met the guidelines almost doubled when the apple format was used (25.3% to 49.3%), but the increase was not statistically significant (Pr > F = .094). When colored dots were
RESEA................................................... RCH AND AND PROFESSIONAL BRIEFS ..................................................... RESEARCH
Table Changes in nutrition knowledge and entree choice %of questions answered correctly
Week Fat
Energy
Fiber
Cholesterol
28.0 44.6 42.5 59.4
29.8 23.7 40.3 58.9
51.0 50.0 68.9 61.5
(
1-control 2-apples 3-dots 4-pamphlets
8.5 8.5 6.3 44.9
Sodium
Average
27.5 42.1 31.0 50.0
29.0 33.8 37.8 54.9
%
used, the percentage of entrees chosen that met three guidelines increased 33.8%, but once again the increase was not significant. When the pamphlet was used, however, the percentage of entrees chosen that met three guidelines almost doubled (49.5%, Pr > F = .000), and the increase was very significant.
%of all respondents who changed their choice of entree
%of those who read the information who changed their choice of entree
. 18.1 13.7 29.4
27.0 16.0 43.7
)
most useful for consumer purchase decisions using adaptive conjoint analysis. J Am Diet Assoc. 1991; 91:800-807. 8. Federal Register. 1991; 56(229):6042660427. 9. Grocery Guide: Tips on Wise Food Selec tion. Dallas, Tex: American Heart Association, Minnesota Affiliate; 1982. 10. The American Heart Association Diet: An EatingPlanforHealthyAmericans. Dal-
las, Tex: American Heart Association; 1985. 11. ANutrition Guideforthe Restauranteur. Washington, DC: National Restaurant Association; 1986. 12. SAS Institute. SAS User's Guide:Basics. 5th ed. Cary, NC: SAS Institute; 1988. 13. Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York, NY: John Wiley &Sons; 1978.
APPLICATIONS Our study did not use a random population, and the response rate was somewhat low. Given these limitations, we conclude that consumers appear to be interested in nutrition, but they need more information about the nutrient content of food to make informed choices. When three common labeling formats were compared (apples, colored dots, and a pamphlet), the use of the pamphlet resulted in the greatest increase in nutrition knowledge and the greatest selection of entrees that met nutrition guidelines. The colored dots, however, were the most visible and widely read format. Further research about the most appropriate method to provide nutrition information is needed.
References 1. Nutrition information on food labels (ADA timely statement). J Am Diet Assoc. 1989; 89:266-268. 2. Position of The American Dietetic Association: nutrition and health information on food labels. JAm Diet Assoc. 1990; 90:583-585. 3. ADA testifies on Nutrition Labeling and Education Act of 1989. JAm DietAssoc. 1990; 90:12-16. 4. Committee on Diet and Health, Food and Nutrition Board. Diet and Health, Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press; 1989. 5. The Surgeon General'sReport on Nutrition and Health. Washington, DC: US Dept of Healthand Human Services; 1988. DHHS (PHS) publication 88-50210. 6. Fullmer S, Geiger CJ, Parent CRM. Consumers' knowledge, understanding, and attitudes toward health claims on food labels. J Am Diet Assoc. 1991; 91:166-171. 7. Geiger CJ, Wyse BW, Parent CRM, Hansen RG. Nutrition labels in bargraph format deemed
Does keeping adietary history increase self-reports of alcohol use during pregnancy? CATHERINE STEVENS-SIMON, MD; ELIZABETH R. McANARNEY, MD
M
ost patients do not report substance
use reliably during pregnancy (13). In one study, reliance on patient self-reports resulted in the misclassification of more than 25% of pregnant cocaine users as nonusers (2). Similarly, because the metabolites of most commonly abused substances are cleared rapidly from the body, sole reliance on chemical analyses to detect substance abuse results in the misclassification of many infrequent substance users as nonusers (3). Informing patients that they will be tested for substance use improves reporting accuracy (1,2), but many substanceabusing patients are still misclassified as C. Stevens-Simon (corresponding author) is with the Department of Pediatrics, University of Colorado HealthScience Center, The Children's Hospital, Denver, CO 80218. E. R. McAnarney is with the Division of Adolescent Medicine, University of RochesterMedical Center, Rochester, NY
nonusers. The purpose of this study was to determine whether embedding a list of alcoholic beverages and tobacco products in a questionnaire designed to elicit the frequency with which subjects consumed various foods enhances the accuracy of self-reported alcohol and tobacco use during pregnancy.
METHODS Subjects The data were collected as part of the Rochester Study of Adolescent Pregnancy, which was a 3-year prospective study of the relationships among maternal age, maternal weight gain, and infant outcome in 195 consecutively enrolled, poor, black, prenatal patients aged 12 through 30 years old. Details of the study design and study population have been published (4-6). The study protocol was approved by the Committee on Investigations Involving Human Subjects at the University of Rochester Medical Center.
JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 581
..........
ND RO
.RESEARCH.. ...
ON
BR
..
............................................
RESEARCH AND PROFESSIONAL BRIEFS
Consumer responses to nutrition guidelines labeling inauniversity restaurant BARBARA A. ALMANZA, PhD, RD; APRIL C. MASON, PhD; RICHARD WIDDOWS, PhD;FREDRICKJ. GIRARD
n spite of the growing consumer interest in nutrition, the use of nutrition information to make food choices is thought to be difficult, even for well-informed, motivated consumers (1). The situation has been made more difficult by the lack of uniformity in presenting nutrition information (2). Reports by The American Dietetic Association (3), the National Academy of Sciences (4), and the Surgeon General (5) have suggested that energy and the following nutrients are of greatest concern to most Americans: protein, fat, cholesterol, complex carbohydrates, fiber, sodium, and calcium. Recent research suggests that although consumers may associate an individual nutrient with certain diseases, they are not knowledgeable about the specifics of that nutrient, such as recommended intakes, sources, functions, or classifications (6). The best format for providing nutrition information is not clear. Forexample, some suggest that alternative labeling formats, such as a bar graph, are more useful to consumers than is the traditional label format (7). The US food labeling system is presently under revision, but the regulations will primarily affect retail products, not foods sold in foodservice operations. In the November 27, 1991, Federal Register, however, the Food and Drug Administration proposed that restaurants choosing to make nutrient content claims should adhere to the proposed guidelines (8). B. A. Almanza (corresponding author) is an assistantprofessorand F J Girardis a graduate student in the Restaurant, Hotel, Institutional and Tourism Management Department;A. C. Mason is an associateprofessor in the Foods and Nutrition Department; and R. Widdows is a professor in the Consumer Sciences and Retailing Department, Purdue University, West Lafayette, IN 4 7907-1266. 580 / MAY 1993 VOLUME 93 NUMBER 5
METHODOLOGY Menu Format The aim of our study was to evaluate consumer preferences for presentation of information about nutrition guidelines on a university restaurant menu. Information used to define guidelines for this study was from the American Heart Association (9,10) and the National Restaurant Association (11). Recipes were evaluated for nutrient contentbymeans ofthe Computrition computer program (1991, Computrition, Chatsworth, Calif). In the first format for providing nutrition information, a symbol (apple) indicated that an entree met the established nutrition guidelines. In the second format, colored dots designated which of the guidelines an entree met. For example, an entree was given a blue dot if it met the lowsodium guideline, a red dot if it met the low-calorie guideline, and so on. The third format listed numeric values for energy and nutrient content (fat, cholesterol, sodium, fiber) in a separate pamphlet for each of the menu selections. In addition, an asterisk was placed next to values that met the established nutrition guidelines. Study Design The study was conducted in a sit-down restaurant called the John Purdue Room, which is open to the public but primarily serves faculty, staff, and students at Purdue University. The study included all lunch customers during 4 weeks in the month of April 1991. The first week was called the control week and no nutrition information was presented to customers. Customers were asked by the waitstaff to complete an anonymous, self-administered questionnaire after making menu selections. Customers could refer to the menu in answering the questionnaire. Two types of learning effect were a concern for the month-long study period. One type was the amount of learning that might occur from one week of the study to the next. To minimize this problem, the for-
mats were presented in the order of the least amount of information to the greatest amount. There was also concern about the learning effect that might occur if a customer ate in the restaurant more than once per week. To minimize this effect, customers were asked to complete the questionnaire only one time per week. A study awareness effect (when participants act differently simply because a study is being done) was also a concern for the study period but could not be avoided. Data analysis was carried out using the Statistical Analysis System software package (version 6.03, 1988, SAS Institute, Cary, NC) (12). Means and frequencies were determined and X2 was done. RESULTS AND DISCUSSION
Demographics The 456 respondents made the overall response rate 46%. This is considered low but comparable to that reported in other studies (13). The sample was 53% men and 47% women. Age ranged widely in the study group (19 to 79 years); the median age was 41 years. The educational level of respondents was skewed compared with the general population, but expected for a university foodservice. Nutrition Knowledge Five nutrition knowledge questions tested the respondents' use of the nutrition information presented. Questions asked the respondents to pick which of three entrees was lowest in fat, cholesterol, sodium, or energy or highest in fiber. Overall, the greatest improvements in nutrition knowledge clearly occurred in week 4 when the pamphlet format was used (Table). Entree Choice More than two thirds of the respondents read the nutrition information. The percentage of respondents who read the nutrition information was greatest when the colored dots were used (85.5%) compared with the apple (67.1%) or the pamphlet (67.3%) formats. This result may have been due to the striking appearance of the menu when colored dots were used. The percentage of respondents who reported selecting a different entree because of the nutrition information that was presented was greatest with the pamphlet format (Table). When nutrition information was presented, more entrees that met the nutrition guidelines were selected. The percentage of entrees chosen that met the guidelines almost doubled when the apple format was used (25.3% to 49.3%), but the increase was not statistically significant (Pr > F = .094). When colored dots were
RESEA................................................... RCH AND AND PROFESSIONAL BRIEFS ..................................................... RESEARCH
Table Changes in nutrition knowledge and entree choice %of questions answered correctly
Week Fat
Energy
Fiber
Cholesterol
28.0 44.6 42.5 59.4
29.8 23.7 40.3 58.9
51.0 50.0 68.9 61.5
(
1-control 2-apples 3-dots 4-pamphlets
8.5 8.5 6.3 44.9
Sodium
Average
27.5 42.1 31.0 50.0
29.0 33.8 37.8 54.9
%
used, the percentage of entrees chosen that met three guidelines increased 33.8%, but once again the increase was not significant. When the pamphlet was used, however, the percentage of entrees chosen that met three guidelines almost doubled (49.5%, Pr > F = .000), and the increase was very significant.
%of all respondents who changed their choice of entree
%of those who read the information who changed their choice of entree
. 18.1 13.7 29.4
27.0 16.0 43.7
)
most useful for consumer purchase decisions using adaptive conjoint analysis. J Am Diet Assoc. 1991; 91:800-807. 8. Federal Register. 1991; 56(229):6042660427. 9. Grocery Guide: Tips on Wise Food Selec tion. Dallas, Tex: American Heart Association, Minnesota Affiliate; 1982. 10. The American Heart Association Diet: An EatingPlanforHealthyAmericans. Dal-
las, Tex: American Heart Association; 1985. 11. ANutrition Guideforthe Restauranteur. Washington, DC: National Restaurant Association; 1986. 12. SAS Institute. SAS User's Guide:Basics. 5th ed. Cary, NC: SAS Institute; 1988. 13. Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York, NY: John Wiley &Sons; 1978.
APPLICATIONS Our study did not use a random population, and the response rate was somewhat low. Given these limitations, we conclude that consumers appear to be interested in nutrition, but they need more information about the nutrient content of food to make informed choices. When three common labeling formats were compared (apples, colored dots, and a pamphlet), the use of the pamphlet resulted in the greatest increase in nutrition knowledge and the greatest selection of entrees that met nutrition guidelines. The colored dots, however, were the most visible and widely read format. Further research about the most appropriate method to provide nutrition information is needed.
References 1. Nutrition information on food labels (ADA timely statement). J Am Diet Assoc. 1989; 89:266-268. 2. Position of The American Dietetic Association: nutrition and health information on food labels. JAm Diet Assoc. 1990; 90:583-585. 3. ADA testifies on Nutrition Labeling and Education Act of 1989. JAm DietAssoc. 1990; 90:12-16. 4. Committee on Diet and Health, Food and Nutrition Board. Diet and Health, Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press; 1989. 5. The Surgeon General'sReport on Nutrition and Health. Washington, DC: US Dept of Healthand Human Services; 1988. DHHS (PHS) publication 88-50210. 6. Fullmer S, Geiger CJ, Parent CRM. Consumers' knowledge, understanding, and attitudes toward health claims on food labels. J Am Diet Assoc. 1991; 91:166-171. 7. Geiger CJ, Wyse BW, Parent CRM, Hansen RG. Nutrition labels in bargraph format deemed
Does keeping adietary history increase self-reports of alcohol use during pregnancy? CATHERINE STEVENS-SIMON, MD; ELIZABETH R. McANARNEY, MD
M
ost patients do not report substance
use reliably during pregnancy (13). In one study, reliance on patient self-reports resulted in the misclassification of more than 25% of pregnant cocaine users as nonusers (2). Similarly, because the metabolites of most commonly abused substances are cleared rapidly from the body, sole reliance on chemical analyses to detect substance abuse results in the misclassification of many infrequent substance users as nonusers (3). Informing patients that they will be tested for substance use improves reporting accuracy (1,2), but many substanceabusing patients are still misclassified as C. Stevens-Simon (corresponding author) is with the Department of Pediatrics, University of Colorado HealthScience Center, The Children's Hospital, Denver, CO 80218. E. R. McAnarney is with the Division of Adolescent Medicine, University of RochesterMedical Center, Rochester, NY
nonusers. The purpose of this study was to determine whether embedding a list of alcoholic beverages and tobacco products in a questionnaire designed to elicit the frequency with which subjects consumed various foods enhances the accuracy of self-reported alcohol and tobacco use during pregnancy.
METHODS Subjects The data were collected as part of the Rochester Study of Adolescent Pregnancy, which was a 3-year prospective study of the relationships among maternal age, maternal weight gain, and infant outcome in 195 consecutively enrolled, poor, black, prenatal patients aged 12 through 30 years old. Details of the study design and study population have been published (4-6). The study protocol was approved by the Committee on Investigations Involving Human Subjects at the University of Rochester Medical Center.
JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 581