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Using student opinion and design inputs to develop an informed university foodservice menu
Appetite 69 (2013) 80–88
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Research report
Using student opinion and design inputs to develop an informed university foodservice menu Charles Feldman a,⇑, Heather Harwell b, Joseph Brusca a a b
Department of Nutrition and Food Sciences, Montclair State University, 1 Normal Ave., Montclair, NJ 07042, USA The Foodservice and Applied Nutrition Research Group, International Centre for Tourism and Hospitality Research, Bournemouth University, Poole, Dorset BH12 5BB, United Kingdom
a r t i c l e
i n f o
Article history: Received 17 January 2013 Received in revised form 22 March 2013 Accepted 11 May 2013 Available online 22 May 2013 Keywords: Students Nutrition information Menu design Focus groups Menu labeling
a b s t r a c t The potential for Universities and Colleges to be settings that promote health and wellbeing has become the subject for debate where the role of foodservice has been acknowledged as influential. The aim of this research was to evaluate an effective design to promote healthy selections from university foodservice menus. The research was designed around a grounded theory approach utilizing semiological prompts based on different existing nutrition labeling schemes. A total of 39 students (17 male, 22 female) participated in seven focus groups at Montclair State University, US. The participants of this study clearly called for nutrition labeling on college menus and a prototype design had been agreed. The students also itemized five nutrients they wanted listed in a Traffic Light system of colors and then quantified on the menu: calories, sodium, sugar, fat and carbohydrates, plus beneficial ingredients or nutrients for display in menu icons. The nutrients and display order varies somewhat from industry and government standards, though the student recommendations are suggestive of common understandings of published nutrient guidelines. Students have a stake in how menu information is presented on campus and their opinions could positively impact the general selection of healthy foods. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction Universities represent an important setting for promoting health where the foodscape can facilitate and support healthful behavior. However, there is cause for concern over the dietary and nutrition practices of university students. High percentages of this population have been found to be overweight and engaged in less than healthy dietary habits. This includes not meeting the recommended intake amounts for fruits, vegetables, fiber, whole grains, calories, saturated fats and sugars (American College Health Association, 2011; Byrd-Williams, Strother, Kelly, & Huang, 2009; Greaney et al., 2009; Rose, Hosig, Davy, Serrano, & Davis, 2007). University foodservices offer a significant opportunity for health promotion as eating patterns accrued may carry over into later life (Hoefkens, Lachat, Kolsteren, Van Camp, & Verbeke, 2011). The effect of menu labels and symbols for the promotion of healthy meal choices has been recently examined in the literature. However, the findings have been modest, ineffective or inconclusive. A number of attempts have been made to improve public health through nutrition labeling of food products where previous research has found a link between readers of nutrition labels on pre-packaged supermarket groceries and dietary health (Kozup, ⇑ Corresponding author. E-mail address: [email protected] (C. Feldman). 0195-6663/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.appet.2013.05.009
Creyer, & Burton, 2003). In 2012, the Institute of Medicine (IOM) released recommendations for front-of-pack (packaged food) rating systems and symbols that call for simple to understand food labels, with interpretive information for guidance that can be communicated by easily remembered names and symbols. The IOM further determined that the most critical nutrients to be listed on these labels are in respective order: calories, saturated and trans fats, sodium and added sugars (IOM, 2012). Mixed findings in the literature suggest that attractiveness, ease of use, and the clear presentation of information are the consumers’ most preferential attributes for nutrition labeling formats (Cranage, Conklin, & Lambert, 2004; Grunert & Wills, 2007). In addition, findings suggest the provision of nutrition information at the point-of-sale, over referrals to pamphlets or websites, is a more efficient way to facilitate individualism in the meal decision process (Cranage et al., 2004). Different classifications of nutrition labels have been presented in the literature generally based on their ease of use and understanding in balance with ostensive consumer needs to have detailed nutrient data (Hoefkens et al., 2011). A number of nutrition labeling formats for packaged food products are already in use, of which versions have been adapted for use in foodservice environs (Nordic Council of Ministers, 2011; Nutrition Australia, 2012; Pettigrew, Pescud, & Donovan, 2011). Some university foodservice operations (including the campus foodservice of the present study) provide nutrition information on their menus
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(Freeman & Conners, 2011). In 2010, the Grocery Manufacturers of America (GMA) and the US Food Marketing Institute (FMI) released the Facts-Up-Front labeling system for food products. These labels include four basic icons for nutrients to limit, in respective order: calories, saturated fat, sodium, sugars and up to 2 of a possible 8 ‘‘nutrients to encourage,’’ placed linearly in cylindrical shapes. The basic icons include quantitative numerical daily values as well as percentages (Roberto et al., 2010; Grocery Manufacturers Association, 2010). Health logos, or simple icons representing a healthy food choice, have also been advocated for being simple to read and, as such, more suited for making a quick product decision (Hodgkins et al., 2011). This includes the Nordic Keyhole, which is used jointly as a nutrition label with the provision of nutritional facts in Norway, Sweden and Denmark. The Keyhole is assigned to food products that are deemed to meet thresholds for less or healthier fats, less sugar, less salt and more fiber and wholegrain. A version of the Keyhole is currently available for use in restaurants, canteens and cafes (Nordic Council of Ministers, 2011). The Healthy Choice symbol is used in a variety of countries, including Belgium, Brazil, Germany, and Israel, to identify an overall healthy food item based on levels of fat, sugar, salt and fiber (Choices International Foundation, 2012). A number of international heart symbols are currently in use to identify food products that promote coronary health. For example, the American Heart Association’s (AHA) Heart-check mark is given to food products with ascribed healthy properties (AHA, 2011). Similar criteria are used for the heart of the British Heart Foundation (British Heart Foundation., n.d.), the Parempi Valinta of Finland (Sydänmerkki-tuotteet., 2012), and the Canadian Health Check (Heart & Stroke Health Check Program, n.d.). The US National Heart, Lung and Blood Institute categorizes some foods as ‘‘Whoa,’’ ‘‘Slow,’’ and ‘‘Go’’ based on caloric and nutrient density, and fat and sugar content, though no specific labeling system has been developed (Miller, Drewnowski, Heaney, King, & Kennedy, 2009; National Heart & Blood Institute, 2012). A Five-A-Day symbol, developed by the UK National Health Service, is used for the promotion of five servings of fruits and vegetables per day (National Health Service, 2012). The Traffic Light labeling system originally developed by the UK Food Standards Agency (and its various permutations including the Wheel of Health and Green Light, Eat Right – Feunekes, Gortemarker, Willems, Lion, & van den Kommer, 2008; Nutrition Australia, 2012), uses green, yellow and red colors to denote, in respective order, foods that are healthy to eat, okay to eat and foods that are not so healthy. The scheme typically only refers to levels of fat, sugar and sodium in foods (Roberto et al., 2010; Miller et al., 2009). There also is a variety of industry and foodservice symbols and adaptations available in the field for promoting individual nutrient properties. Research has shown that some of the aforementioned labeling systems can be confusing or ineffective, particularly for college students (Hoefkens et al., 2011). While it has been argued that a standard nutrition-labeling system could have an impact on health, this impact may be mitigated if consumers cannot interpret the information (Finkelstein, French, Variyanet, & Haines, 2004; Sharf et al., in press). Research findings have pointed to a disadvantage of quantitative data labeling systems (such as Facts-Up-Front): the consumer often feels time constraints and lacks the skills necessary for processing nutrient information (Hoefkens et al., 2011). In addition, scholarly opinion has been skeptical of food industry nutrition labeling initiatives and the reluctance of industry to embrace government supported recommendations and labeling designs. It has been suggested that the industry wants to stay away from negative labels that discourage consumers from buying particular food products (Nestle, 2012; Pettigrew & Donovan, 2011). Research conducted on general consumers and students demon-
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strate that provision of overall health claims on food products without supporting detail, often elicited feelings of mistrust, in particular by student consumers. Though it has been reported that a majority of college students desire to have nutrition information on dining hall menus, there may be an underlying distrust of the accuracy and truthfulness of nutrient labels (Chan, Patch, & Williams, 2005; Hodgkins et al., 2012; Kolodinsky, Green, Michahelles, & Harvey-Berino, 2008; Martinez, Roberto, Kim, Schwartz, & Brownell, 2012; Mirsa, 2007). The Traffic Light system has been reported to be more effective than percentage guidelines of nutrient amounts and overall health labeling systems (Balcombe, Fraser, & Di Falco, 2010; Feunekes et al., 2008; Kelly et al., 2009; Lobstein & Davies, 2008). The ostensive advantage of this labeling concept is its ability to overcome the difficulties consumers have in assessing an overall nutrition picture within the typically short time allocated for a consumption decision (Pohlmeier, Reed, Boylan, & Harp, 2012). Grunert and Wills (2007) suggest three attributes nutrient labels need to have in order for consumers to best utilize the information: The label must be easy to use, include informed nutrition information and it must not coerce the consumer into certain types of behavior. Federal US legislation has been enacted to encourage healthy menu selections through the Patient Protection and Affordable Care Act 2010, which requires restaurant chains with more than 20 outlets to postcalories counts on menus, drive through displays and vending machines for all the food items that they sell (Peregrin, 2010). Research findings and scholarly commentary on the effect of nutrient labeling schemes on healthy meal selection in college foodservice venues have been encouraging (Conklin, Lambert, & Cranage, 2005; Cranage et al., 2004). Recent menu strategies to promote healthy choices include nutrient labeling and the use of menu icons (Cranage et al., 2004; Downs, Loewenstein, & Wisdom, 2009; Harnack & French, 2008; Hwang & Lorenzen, 2008; Jones, 2009; Nutrition Australia, 2012). Interaction between health claims and quantified nutrition data on menus has been shown to be significant, demonstrating the potential of menus to help consumers make healthy food choices (Kozup et al., 2003). In a recent study, the majority of college students surveyed reported that nutrition information sometimes, often or always affects their food choices (Martinez et al., 2012). In college foodcourt settings data on calories and fat were the nutrients of greatest concern to students (Kolodinsky et al., 2008). While caloric information specifically on foodservice menus could positively impact healthy menu selections (Cranage et al., 2004), there appears to be a compound effect when calorie information is displayed together with respective recommended daily consumption percentages (Roberto, Larsen, Agnew, Biak, & Brownell, 2010). However, studies done in the UK suggest that making calorie counts more visible does not seem to have a significant impact on restaurant food purchases, where information is not seen by two-thirds and ignored by more than half of those who do observe the nutrition information (Denby & Loades, 2010). Findings from an investigation in catering facilities implemented on behalf of the UK Food Standards Agency, similarly suggests that calorie data was found most useful when it is clearly visible but use, and therefore, influence and impact on food choice was low (BMRB Social Research, 2009). The menu has been described as being one of the greatest merchandizing opportunities (Bowen & Morris, 1995; McCall & Lynn, 2008). It is a non-competitive advertisement that fundamentally informs the meal-selection decision, which follows almost immediately. It is, therefore, potentially a very powerful tool for the promotion of healthy eating. However, consumers are having difficulty understanding nutrient labels where they are currently marketed and particularly where foodservice products are sold (Hodgkins et al., 2012; Rothman et al., 2006; Hoefkens et al., 2011). While it has been reported that information contained in
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a nutrient label has a high amount of relevance to consumers, there has not been a consensus on the most effective way to market this information (Hodgkins et al., 2012). Notwithstanding, the style in which nutritional guidance is presented on college foodservice menus is open to debate and forms the focus of this study. The aim of this research, therefore, was to evaluate an effective design to promote healthy selections from university foodservice point-of-purchase (POP) menus. The research question was: What is the best design for college foodservice menus to inform and encourage students to make healthy meal selections? Rather than imposing a menu on students, and in doing so, possibly discrediting the provided nutritional data (Cranage et al., 2004), the researchers sought to involve these consumers in the menu design process. Methods Focus groups were used in this study to illicit in-depth attitudes towards how menus are merchandized in college foodservice environments. This method has been found to be particularly effective for uncovering hidden issues and solutions for quality of life, health, and nutrition investigations. Focus groups have also been useful in the industry for uncovering emergent consumer needs, while offsetting pre-conceived design notions and assumptions about product development (Hawthorne et al., 2006; Jones, 2010; Ruff, Alexander, & McKie, 2005). Seven focus groups (n = 3, 3, 5, 4, 4, 7, 13) totaling 39 students (17 male, 22 female) were assembled for data collection at Montclair State University during the spring of 2012. The students ranged from a required minimum of 18 years of age to 24 years of age. Other than age, the only exclusion criterion was that the students could not be enrolled in a food or nutrition program. Students were conveniently recruited, with signed consent, in or directly outside the universities’ main student cafeteria. The participants were on their way to lunch, thus the emulating the conditions students encounter, as they are about
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to make the meal consumption decision. In keeping with the nature of qualitative research, no attempt was made to enlist a specific number of participants. The investigators discontinued recruitment once the data was saturated. Data saturation was determined when the findings continued to be replicated across the groups and when the participants were no longer able to present new ideas or themes (Guest, Bunce, & Johnson, 2006). The research was designed around a grounded theory approach utilizing semiological prompts based on different existing nutrition labeling schemes. A grounded theory approach assumes that reality is uncovered from the data by carefully following a rigorous methodology. In keeping with this method, the researchers were simultaneously involved in data collection and analysis; the analytic codes were constructed from the data, not from pre-conceived hypothesis; the data was constantly compared between and across the focus groups; the theory was advanced during each step of data collection and analysis; relationships were elaborated and an independent analysis was constructed before a literature review was conducted. The transcripts were analyzed using deductive content analysis, which involved assigning codes to text passages (Charmaz, 2006). Three researchers analyzed the data separately to provide a multi-rater perspective (Jones, 2010; Webb & Kevern, 2001). To encourage an open dialogue, facilitators stressed the confidentiality of responses, and that there were no right or wrong answers. A two-part structured broad questioning process was used that is consistent with Spradley’s qualitative research approach (1979). The first part of each focus group consisted of open-ended ‘‘Grand Tour’’ questions to potentially enable the group to describe the dynamics behind campus meal decisions. For example, the participants were asked, ‘‘How does the campus menu affect your meal decision?’’ The participants were also asked key ‘‘Example’’ questions to keep them focused on the topic at hand. Such as, ‘‘What would you like to see on college foodservice menus?’’ Or, when the moderator presented a specific label or nutrient, ‘‘What does this symbol mean to you?’’
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( ) Fig. 1. An abbreviated listing of nutrition icons and labels used in the study. (See the above mentioned reference).
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To illicit responses, keep ideas flowing and to help participants rethink their conceptions, 27 nutrient labels and icons from international government and industry sources were presented to the participants in a PowerPoint display (Fig. 1A–H). The presentation included the Green Light, Eat Right icons from Nutrition Australia (2012); the international Five-A-Day symbol (B); the Nordic Keyhole (C); the international Healthy Choice (D) and Heart Healthy symbols (E); the Color-coded icons from the UK Traffic Light system and the Wheel of Health (F); the (US) Grocery Manufacturing Association and Food Marketing Institute Facts-Up-Front label (G); and 14 specific ‘‘nutrients to encourage’’ icon adaptations (e.g. source of iron, protein and calcium symbols – H) were also presented for discussion. The PowerPoint presentation of labels and icons was shuffled before the start of each focus group to reduce any ordering effects. A validity check of the instrument was concurrently done by one of the primary researchers with a group of 24 college students at Bournemouth University, UK. A process of iteration was used from the inception of the menu concept in the first focus group, through the theoretical saturation of ideas (Guest et al., 2006) during the final sessions. For each group, the impact of the college foodservice menu on food choice was discussed in-depth and recommendations from the students informed labeling and menu designs at every step. The focus group data was discursively refined across the groups to get a confirmatory model. At the beginning of each new session the facilitators first asked the participants for their responses to generalized questions about cafeteria food selection and health and then various menu labeling schemes and icons. Then to evolve the model, the researchers presented findings from the previous sessions for commentary (Birks, 2009). Data from early sessions was only presented to participants of a later group after the researchers felt that ideas from this group were completely put forth. As explained by the facilitators, at this point prior data was presented only to stimulate discussion and not to influence findings. At the end of each session, the investigators reiterated the conclusions of the focus group by summarizing the groups answer using the following rhetorical question: ‘‘In sum, what information would you like on the menu, and how would you like it presented?’’ Evolving visual displays (Fig. 2) were presented to participants to elicit comments, comparisons and suggestions. Potential labeling methods and menu layouts were continually refined in components, evolving into a cumulative menu-design. The menu was built subject to student approval for each step towards completion. No attempt was made by the researchers to artistically embellish the evolving menu instrument, which was designed to articulate, as closely as possible, how students want the food selections presented and described. All the sessions were audio taped, transcribed verbatim and re-read several times as soon as possible in order to preserve the full meaning of the participants’ words (Charmaz, 2006). The investigators hoped to generate knowledge grounded in the views of the participants, which can be used to deliver student-aided menu designs to enhance the dining experience, and ultimately lead to the improved health and wellbeing of campus populations. Results Two over-arching themes emerged from the analysis of the data: Theme 1 – The healthiness of the campus food in relation to weight gain Coded responses from 21 students (12 females, 9 males, or 54% of all participants) uncovered concerns over the healthiness of
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foods offered in college, which the student participants felt were becoming increasingly important with the incidence of college weight gain. Three students (1 female from group one, 2 males, one from group 3 and one from group 4) personally expressed concern over the relationship of potential weight gain to how the campus food is marketed. For example, in response to the question: ‘‘So then, should university menus have nutrition labels?’’, the female student stated, ‘‘I think so because then people will say this is not good for me. . . I’m [referring to herself] trying to lose weight, I shouldn’t eat this.’’ A male in the same group added, ‘‘adding calories in the student café [menu] did wonders for me.’’ Theme 2 – Trust of labels making health claims The trust value or the credibility of the symbols was generally agreed across all focus groups as very important. These icons should not be generated from a biased source, as many participants noted. A concordance of the students across all the groups (26 coded responses or 67% of the total participants), showed agreement that student-dining menus should only display nutrition labels if the information could be trusted to represent the intended healthy-eating standard. For example, one female students stated, ‘‘. . .cause if it says it’s good in one thing it might be bad in another.’’ The trouble with many symbols, as agreed, was that representations such as ‘‘low-fat’’ or ‘‘source of’’ do not provide corroborative quantitative information and thus, could not be trusted as representative of a nutrition attribute. A male participant from group 1 stated, ‘‘... it could say its fat free and still have a lot of sugar!’’ ‘‘I wouldn’t believe it,’’ said a male participant from group 5, ‘‘. . .a lot of times stuff will say it is one way and it really isn’t that way. . .[For example] a lot of times it will say organic, but how do you really know?’’ The relevancy of health claim symbols on a menu was also in doubt by a couple of students. Said one male participant from group 4, ‘‘I don’t think I’d be opposed to have something like this [a general health icon] on a menu, but I don’t chose anything more so because there is a symbol next to it.’’ One male student in the same group particularly did not like the health icons in general, as he explained, ‘‘The symbols, no!...If I know the exact [nutrient data] numbers, I would be more inclined to do something.’’ The students disagreed over their ability to decipher healthy diet information from existing food labeling schemes (Fig. 1). Whereas evidentiary labeling data was deemed important, there was concern over whether this information could be understood by the general student population (cf. Pohlmeier et al., 2012). Five female (only) students (1 from group 1, 2 from group 2 and 1 each from groups 4 and 5) were concerned that they would not be able to understand a percentage system. Said one female from group 2, ‘‘This doesn’t stand out to me because it doesn’t tell me if it’s a good amount or a bad amount.’’ Another female student from group 4 reported, ‘‘[It is a] little bit harder to comprehend, because you’re going to look at percentages, but its not going to mean anything if you’re unable to tell what they mean.’’ In a summary response to whether or not nutrient data should be put on university menus, a female student from the first focus group said, ‘‘No, because some people really don’t know how to work with all the numbers.’’ While participants generally liked the international healthychoice symbols (e.g. Five-A-Day, Healthy Choice and the international heart symbols), trust of these specific icons was an issue. One female participant from group 5 stated, ‘‘I feel like these specific symbols are made to make you look away from other things that can be bad.’’ Another female from group 6 said, ‘‘Personally no, I don’t [trust them]. I would have to see the ingredients, so symbols like this would not make a difference to me.’’ Out of all the study participants, only one student from group 2 was able
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Fig. 2. Draft label design schemes.
to express the meaning of Nordic Keyhole, which is not currently being used in the US. The heart symbols were very recognizable, though they also reportedly looked like advertisements as expressed by two students. In addition, heart-health was not an expressed issue for the overall student participants. One male student from group 2 expressed recognition for the Green Light, Eat Right angel (Fig. 1A). ‘‘It’s good for you’’, he stated,
‘‘for something, we don’t know what!’’ Two other female participants from group 4 were not in favor of having negative menu symbols (such as the Green Light, Eat Right devil). Said one, ‘‘I don’t think food should be deemed insanely bad. . .It’s like: Just point out the healthy options!’’ Fifteen students’ responses (a unanimous consensus from all students in the first four groups or 38% of the total participants) were coded for commenting silly or ‘‘weird,’’
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sinister or ‘‘insanely bad’’, or not clearly understood for Green Light, Eat Right angel and devil and the Nordic Keyhole. In regards to the Canadian Health Check, one male student from the third group expressed that this symbol would not be useful: ‘‘I see this [type of symbol] all the time and I don’t pay any attention to it.’’ A plurality of 30 students (18 females, 12 males, or 77% of all participants) enthusiastically liked the existing permutations of the UK Traffic Light system, including the Wheel of Health, though the cylindrical versions (over the wheel) were the favorites of all but one student (Figs. 1F and 2). Six female students (2 from group 2, 1 from group 3, 1 from group 4 and 2 from group 5) plus 1 male student (from group 2) verbally reported, with no disagreement from others, that these symbols provide ‘‘easily understandable’’ color-coding as well as quantitative nutrient information. For example, one female student from group 1 stated, ‘‘. . .the colors are attractive so I wanna read it and see what I’m putting in my body. I’d read it because it caught my attention.’’ Another female from group 2 expressed: ‘‘A person who hasn’t taken a nutrition course could understand this [type of label] more.’’ In response to the moderator’s query about possible negative components of the Traffic Light system, one female student from group 3 replied, ‘‘No [there is nothing bad about this system]. . .it’s color-coded, has grams, it tells you the calories too, so it’s good.’’ Still, three students from group 7 (1 female and 2 males or 23% of this group) were concerned that a symbol of this type, while good for processed food labeling, would ‘‘clutter’’ a foodservice menu. Said one: ‘‘. . .I like the colors and I want to know what I put in my body. . .so if it’s offered to me, yeah. . .as long as the instructions aren’t long.’’ Out of all the participants in the study, only one student (from group 4) suggested that specific meal ingredient information should be listed on college menus. However, 14 participants (7 males and 7 females or 36% of all participants) thought campus menus should provide an ingredient notation if the meal was made with whole grains and 6 participants (3 females and 3 males, across all groups) thought that labeling vegan meals was important. Many students (across the groups, as it was coded 43 times) expressed that foods with beneficial amounts of nutrients should receive an additional nutrient-specific menu icon, as this is important for students with particular needs. By the end of each of the first four focus group sessions, the participants tacitly concurred with the moderator’s overall summation that the design of college foodservice menus should include colors along with nutrients expressed in grams and percentage. Nearly all the participants from the fourth and remaining sessions agreed that informative color-coding, percentages of daily nutrient values and specific nutrient data are important to include on college foodservice menus. As stated by one female from group 4, ‘‘I think it’s kind of like the best of both worlds. . .you have the percentage. . .you know how people do food logs or whatever. . .and you know you can take a quick glance and say ‘oh it’s not bad at this and that.’’’ Based on this and recurring data and analysis thus far, the researchers began to design a number of draft labeling and design permutations for discussion with the subsequent focus groups as shown in Fig. 2A–G. However, there was a very small amount of dissenting student opinion across all the final three focus groups, regarding the direction of the design. For example, one female from the fifth focus group declared: ‘‘I think [the scheme of percent, data and colors suggested by the other students] makes [the menu] too complicated, like you have to look at it to really understand.’’ Another female in the same group remarked, ‘‘I don’t think the colors are appealing, but I think they are needed and good at telling people exactly what to look for.’’ No students in this group were able to suggest alternatives. A male participant from this group did not appreciate the overall value of menus in general: ‘‘I don’t spend
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much time looking at the menu. . .when students walk in they look at the food trays, not the menu.’’ A final draft menu was completed through discussion with the fifth and sixth focus groups. Further discussions included how many nutrients to include in the label (it was agreed that five primary nutrients are sufficient for labeling – more would clutter), where to place the general label (above, below, the side, etc. – centered below the menu item was agreed by all, with a specific icon to the left for important nutrients) and the colors and shape of the icons (round and cylindrical shapes) were chosen. By the sixth focus group, no new ideas or themes were generated. As such, the investigators determined that the data was saturated. The researchers then developed a final draft menu (Fig. 3) based on confirmatory confirmation of the summarized design ideas by participants of the fifth and sixth groups, and subsequent data analysis. Then one final focus group of 13 students was convened to assess the final product: a menu comprised of current university foodservice offerings, adapted to design inputs from the previous student focus groups. The facilitators presented these participants the final draft menu with adapted item names and nutrition data from the university’s existing foodservice menu database. The menu included a tentative labeling model of five nutrients (calories, sodium, sugar, fat and carbohydrates) and icons for beneficial nutrients based on data retrieved from the previous focus groups. Colored icons were also added to the menu categorize healthiness (green1 = healthiest choice, yellow = okay choice, red = less healthy choice). The researchers designation of healthiness was based on levels of calories, total fats, trans fat, sodium and sugars and the provision or lack of 10% of vitamin A, vitamin C, iron, calcium, protein, and fiber in accordance with current Institute of Medicine (2011) recommendations and US Food (2003) guidelines for ‘‘healthy labels’’ (US Department of Agriculture, 2010; US Government General Printing Office, 2011). All students in the final group approved the final menu design. After the final focus group, the investigators affirmed the participants’ selection for nutrition labeling attributes by assessing the overall coded frequency of student references to the importance of particular nutrients across the focus groups. The total list of nutrients affirmed as important to the students for labeling are, in respective order: Calories, sodium, sugar, fat, carbohydrates, cholesterol and trans fat. The students also identified the beneficial nutrients and food ingredients they would like to see displayed in a menu icon in respective order as follows: Whole grains, vegan, protein, iron, calcium and fiber. Table 1 compares the student preferences for labeled nutrients with IOM recommendations, the GMAFMI standard and the nutrients currently labeled in the university foodservices where the study was conducted. Discussion Coming to college results in changes for many students that may encourage unhealthy dietary practices. A number of nutrient labeling schemes have been presented in the literature that may be useful to help these students make healthy decisions in campus in foodservice environments. However, before the implementation of any health and nutrition policy, it is important to take into account the attitude of consumers themselves. Research has demonstrated that consumers who look at food labels can understand some of the terms but are confused by other types of information. Reaction to the health icons on menus has been found to be encouraging. However, it has been shown that icons do not have as strong an influence on participant choices as with the inclusion of nutritional information (Hodgkins et al., 2012; Jones, 2009). The 1 For interpretation of color in Figs. 1–3, the reader is referred to the web version of this article.
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Fig. 3. Final draft menu.
literature has also shown that consumers are able retrieve simple nutrition data, but their ability to process this information in short periods of time is questionable (Cowburn & Stockley, 2005). Therefore, the addition of interpretational aides has been recommended as it puts food products into a total diet context. In addition, while consumers may be wary of health claims, the provision of nutrition information has been shown to have a significant positive effect, in particular for reduced perceived disease risk, particularly in the context of a restaurant menu. It has been suggested that consumers may have more confidence in overall health claims if presented with evidentiary nutritional data (Kozup et al., 2003). The overall process of this study enabled the investigators to uncover a final set of data and design components that exemplified the process of the participants’ responses as they were more grounded in their own perspectives. The students who participated in this investigation indicated their preference for a university foodservice menu that includes components of a Traffic Light labeling system, quantitative nutrition data and threshold nutrient percentages. This finding is consistent with scholarly calls for a label that combines numerical information with visual aides such as color codes or stars and (high/medium/low) text, (Hoefkins et al.,
2011; Roberto et al., 2010; Pohlmeier et al., 2012). The students also itemized five nutrients they wanted labeled with colors and quantified on the menu (in respective order: calories, sodium, sugar, fat and carbohydrates), plus beneficial ingredients or nutrients for display as menu icons (Table 1). The final selected nutrients and display order varies somewhat from IOM recommendations, industry practice and literature findings (Roberto et al., 2010), though the present findings are suggestive of the students’ understanding of published guidelines of nutrients to limit (Table 1). In another recent study, students reported that calorie and ingredient information were the most needed information for nutrition labels followed by fat content, while the fewest number of these participants reported being interested in vitamins and minerals (Martinez et al., 2012). While it has been argued that a nutrition-labeling menu system could have an impact on students’ selection of healthier foods, the impact may be contingent on students’ motivation to make a change (Finkelstein et al., 2004; Sharf et al., in press; Yoon & George, 2012). Previous in vitro research has suggested consumers, and students in particular, believe nutrient labels will help them make healthier meal selections (Downs et al., 2009; Harnack &
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Table 1 A comparison of nutrients cited as important for campus foodservice menu labeling, with IOM recommendations, GMA-FMI Front-of Package labeling and the campus foodservice. IOM (Recommendations)
Nutrients to discourage 1. Calories 2. Saturated fat 3. Trans fat 4. Sodium 5. Added sugars 6. 7. Nutrients (or foods) to encourage Insufficient evidence to support inclusion of total fat, cholesterol, total carbohydrate or added sugars, protein, fiber, vitamins, and minerals other than sodium
GMA-FMI (Front-of-Package)
Campus foodservice
Students (n = frequency of coded responses on importance)
Calories Saturated fat Sodium Sugar
Calories Sodium Total fat Sugar Carbohydrates
Calories (n = 27) Sodium (n = 22) Sugar (n = 21) Fat (n = 27) Carbohydrates (n = 11) Cholesterol (n = 9) Trans fat (n = 4)
Optional two ‘‘nutrients to be encouraged’’: potassium, fiber, protein, vitamin A, vitamin C, vitamin D, calcium and Iron (must have more than 10% of the daily value per serving of the nutrient and meets the FDA requirements for a ‘‘good source nutrient claim.’’
No data provided on labels
Whole grains (n = 14)
French, 2008; Jones, 2009; Martinez et al., 2012). However, student behavior is highly complex with many external and internal influences on perception, attitude and action. Many students have a low intention to eat healthier at the baseline of entry into student dining facilities (Vyth et al., 2011). It has been suggested that multiple criterion need to be in place for a person to transition from an intention or plan into an actual behavior. The social and physical environment and available time must be favorable. The intended change must also be a high-priority for this person and likely fit into a peer-group norm (Atkins & Michie, 2013). In addition, a potential healthy menu decision may be mitigated by intervening factors before, or at the actual point of purchase, that include taste preferences, smells, dining atmosphere, anticipation of a pre-conceived desire or perceptions about a particular food, the consumer’s age, attitudes and predisposition to dietary change. Previous research has identified four key menu attributes that interact via various trade-offs affecting consumers’ decision-making process: taste, the most important attribute, followed respectively by price, nutrition and appearance. Moreover, predisposition to menu preferences may reach back to earlier years of adolescence (Bordi, Cranage, Borja, & Cole, 2003; Cranage & Lee, 2007; Lee & Cranage, 2007). In sum, students have to negotiate the tradeoffs between what appears healthy, what looks and tastes good, what is affordable (although these attributes need not be mutually exclusive) and a host of other menu selection influences. Therefore, nutrition only plays a part in an ingrained meal decision process. (Bordi et al., 2003; Cranage et al., 2007; Lee & Cranage, 2007). Menus designed with nutrient labels may not be enough to entirely overcome these dynamics. Implicit to the present research is the assumption that student’s food-related ideas and perceptions sometimes do not completely translate into behaviors. Still, initiatives by foodservice operators that inform and encourage better menu decision-making among college students could play a large role in the wellbeing of this population, at their present stage of life and beyond. Though, existing methods for improving college students’ present and future diets have yet to be proven successful. Nevertheless, there has been a scholarly call for foodservice operators to consider student opinion when designing menus (Martinez et al., 2012). In addition, foodservice management could foster trust, openness and overall positive perceptions of food quality by providing menus with informed food choices (Cranage et al., 2004). Still, better strategies
Vegan (n = 7) Protein (n = 7) Iron (n = 6) Calcium (n = 6) Fiber (n = 3)
need to be developed to influence menu choice before the student enters the college cafeteria setting. The student participants of this study clearly called for nutrition labeling on college menus. While the menu or variations may be student-inspired, the likelihood of other non-participating students actually making healthier selections from a student-inspired menu design is unknown. Further, it is not the intention of the authors to generalize the findings of this study. Rather, the researchers believe the data uncovered points to the importance of student involvement in campus foodservice menu design. Planned future research by this team may help determine whether the student-centered design approach actually encourages healthier meal selections from college foodservices.
Ethics The Internal Research Board of Montclair State University, US and the Ethics Committee of Bournemouth University, UK approved this research. References AHA. American Heart Association (2011). Heart-check mark nutritional guidelines.. American College Health Association (2011). American College Health AssociationNational College Health Assessment II. Reference Group Executive Summary Fall 2010. Linthicum, MD. American Heart Association (n.d.). Learn and live. . Bordi, P., Cranage, D., Borja, M., & Cole, C. (2003). What adolescents think they know about nutrition affects what they feel about nutrition and what they eat. Foodservice Research International, 14(1), 65–75. Bowen, J., & Morris, J. (1995). Menu design. Can menus sell? International Journal of Hospitality Management, 7, 4–9.
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British Heart Foundation (n.d.). British heart foundation.. Conklin, M., Lambert, C., & Cranage, D. (2005). Nutrition information at point of selection could benefit college students. Topics in Clinical Nutrition, 20(2), 90–96. Cowburn, G., & Stockley, L. (2005). Consumer understanding and use of nutrition labeling. A systematic review. Public Health Nutrition, 8(1), 21–28. Cranage, D., Conklin, M., & Lambert, C. (2004). Effect of nutrition information in perceptions of food quality, consumption behavior and purchase intentions. Journal of Foodservice Business Research, 7, 43–61. Cranage, D., & Lee, J. (2007). The relative importance of menu item attributes at point of selection for young adults in a campus setting. In Proceedings of the 2007 annual international CHRIE conference & exposition (pp. 58–66). Dallas, Texas. Denby, N., & Loades, C. (2010). Calories on the Menu, nannying or necessary? Complete Nutrition, 10, 51–52. Downs, J., Loewenstein, G., & Wisdom, J. (2009). Strategies for promoting healthier food choices. American Economic Review. Papers and Proceedings, 99(2), 159–164. Feunekes, G., Gortemarker, I., Willems, A., Lion, R., & van den Kommer, M. (2008). Front-of-pack nutrition labeling. Testing effectiveness of different nutrition labeling formats front-of-pack in four European countries. Appetite, 50, 57–70. Finkelstein, E., French, S., Variyanet, J., & Haines, P. (2004). Pros and cons of proposed interventions to promote healthy eating. Journal of Preventive Medicine, 27, 163–171. Freeman, M., & Conners, R. (2011). Point-of-purchase nutrition information influences food-purchasing behaviors of college students. A pilot study. Journal of the American Dietetic Association, 111, S42–S46. Grocery Manufacturers Association (2010). Facts up front.
Kozup, J., Creyer, E., & Burton, S. (2003). Making healthful food choices. The influence of health claims and nutrition information on consumers’ evaluations of packaged food products and restaurant menu items. Journal of Marketing, 67, 19–34. Lee, J., & Cranage, D. (2007). The relative importance of menu attributes at point of menu selection through conjoint analysis. Focused on adolescents. Journal of Foodservice Business Research, 10(2), 3–18. Lobstein, T., & Davies, S. (2008). Defining and labeling ‘healthy’ and ‘unhealthy’ food. Public Health Nutrition, 12, 331–340. Martinez, O., Roberto, C., Kim, J., Schwartz, M. & Brownell, K. (2012). A survey of undergraduate student perceptions and the use of nutrition labels in a university dining hall. Health Education Journal, Online version before print.. McCall, M., & Lynn, A. (2008). The effects of restaurant menu item descriptions on perceptions of quality, price, and purchase intention. Journal of Foodservice Business Research, 11, 439–445. Miller, G., Drewnowski, V., Heaney, R., King, J., & Kennedy, E. (2009). It is time for a positive approach to dietary guidance using nutrient density as a basic principal. Journal of Nutrition, 139(6), 1198–1202. Mirsa, R. (2007). Knowledge, attitudes, and label use among college students. Journal of the American Dietetic Association, 107, 2130–2134. National Health Service (2012). 5-A-day. . National Heart, Lung and Blood Institute (2012). Choosing foods for your family. . Nestle, M. (2012). FDA says facts-up-front is ok? . Nutrition Australia (2012). Green light. . Peregrin, T. (2010). Next on the menu. Labeling law could mean new career opportunities for RD’s. Journal of the American Dietetic Association, 110(8), 1144–1147. Pettigrew, S., Pescud, M., & Donovan, R. (2011). Traffic light food labeling in schools and beyond. Health Education Journal, 71(6), 746–753. Pohlmeier, A., Reed, D., Boylan, M., & Harp, S. (2012). Using focus groups to develop a nutrition labeling program within university food service. Family and Consumer Sciences Research Journal, 40(4), 431–443. Roberto, C., Larsen, P., Agnew, H., Biak, J., & Brownell, K. (2010). Evaluating the impact of menu labeling on food choices and intake. American Journal of Public Health, 100, 312–318. Rose, N., Hosig, K., Davy, B., Serrano, E., & Davis, L. (2007). Whole-grain intake is associated with body mass index in college students. Journal of Nutrition Education Behavior, 39, 90–94. Rothman, L., Housam, R., Weiss, H., Davis, D., Gregory, R., & Gebretsadik, T. (2006). Patient understanding of food labels. American Journal of Preventative Medicine, 31(5), 391–398. Ruff, C., Alexander, M., & McKie, C. (2005). The use of focus groups in health disparities research. Nursing Outlook, 53, 134–140. Sharf, M., Sela, R., Zentner, G., Shoob, H., Shai, I., & Stein-Zamir, C. (2012). Figuring out food labels: Young adults’ understanding of nutritional information presented on food labels is inadequate. Appetite, 58, 531–534. Spradley, J. (1979). Asking descriptive questions. The ethnographic interview. Belmont, CA: Wadsworth. Sydänmerkki-tuotteet. (2012). Sydänmerkki. . US Food and Drug Administration (2003). Claims that can be made for conventional foods and dietary supplements. . US Government General Printing Office. Health Claims General Requirements (2011). . Vyth, E., Steenhuis, I., Heymans, M., Roodenburg, A., Brug, J., & Seidell, J. (2011). Influence of placement of a nutrition logo on cafeteria menu items on lunchtime food choices at Dutch work sites. Journal of American Dietetic Association, 111(1), 131–136. Webb, C., & Kevern, J. (2001). Focus group as a research method. A critique of some aspects of their use in nursing research. Journal of Advanced Nursing, 33, 798–805. Yoon, H., & George, T. (2012). Nutritional information disclosure on the menu. Focusing on the roles of menu context, nutritional knowledge and motivation. International Journal of Hospitality and Management, 31(4), 1187–1194.
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Research report
Using student opinion and design inputs to develop an informed university foodservice menu Charles Feldman a,⇑, Heather Harwell b, Joseph Brusca a a b
Department of Nutrition and Food Sciences, Montclair State University, 1 Normal Ave., Montclair, NJ 07042, USA The Foodservice and Applied Nutrition Research Group, International Centre for Tourism and Hospitality Research, Bournemouth University, Poole, Dorset BH12 5BB, United Kingdom
a r t i c l e
i n f o
Article history: Received 17 January 2013 Received in revised form 22 March 2013 Accepted 11 May 2013 Available online 22 May 2013 Keywords: Students Nutrition information Menu design Focus groups Menu labeling
a b s t r a c t The potential for Universities and Colleges to be settings that promote health and wellbeing has become the subject for debate where the role of foodservice has been acknowledged as influential. The aim of this research was to evaluate an effective design to promote healthy selections from university foodservice menus. The research was designed around a grounded theory approach utilizing semiological prompts based on different existing nutrition labeling schemes. A total of 39 students (17 male, 22 female) participated in seven focus groups at Montclair State University, US. The participants of this study clearly called for nutrition labeling on college menus and a prototype design had been agreed. The students also itemized five nutrients they wanted listed in a Traffic Light system of colors and then quantified on the menu: calories, sodium, sugar, fat and carbohydrates, plus beneficial ingredients or nutrients for display in menu icons. The nutrients and display order varies somewhat from industry and government standards, though the student recommendations are suggestive of common understandings of published nutrient guidelines. Students have a stake in how menu information is presented on campus and their opinions could positively impact the general selection of healthy foods. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction Universities represent an important setting for promoting health where the foodscape can facilitate and support healthful behavior. However, there is cause for concern over the dietary and nutrition practices of university students. High percentages of this population have been found to be overweight and engaged in less than healthy dietary habits. This includes not meeting the recommended intake amounts for fruits, vegetables, fiber, whole grains, calories, saturated fats and sugars (American College Health Association, 2011; Byrd-Williams, Strother, Kelly, & Huang, 2009; Greaney et al., 2009; Rose, Hosig, Davy, Serrano, & Davis, 2007). University foodservices offer a significant opportunity for health promotion as eating patterns accrued may carry over into later life (Hoefkens, Lachat, Kolsteren, Van Camp, & Verbeke, 2011). The effect of menu labels and symbols for the promotion of healthy meal choices has been recently examined in the literature. However, the findings have been modest, ineffective or inconclusive. A number of attempts have been made to improve public health through nutrition labeling of food products where previous research has found a link between readers of nutrition labels on pre-packaged supermarket groceries and dietary health (Kozup, ⇑ Corresponding author. E-mail address: [email protected] (C. Feldman). 0195-6663/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.appet.2013.05.009
Creyer, & Burton, 2003). In 2012, the Institute of Medicine (IOM) released recommendations for front-of-pack (packaged food) rating systems and symbols that call for simple to understand food labels, with interpretive information for guidance that can be communicated by easily remembered names and symbols. The IOM further determined that the most critical nutrients to be listed on these labels are in respective order: calories, saturated and trans fats, sodium and added sugars (IOM, 2012). Mixed findings in the literature suggest that attractiveness, ease of use, and the clear presentation of information are the consumers’ most preferential attributes for nutrition labeling formats (Cranage, Conklin, & Lambert, 2004; Grunert & Wills, 2007). In addition, findings suggest the provision of nutrition information at the point-of-sale, over referrals to pamphlets or websites, is a more efficient way to facilitate individualism in the meal decision process (Cranage et al., 2004). Different classifications of nutrition labels have been presented in the literature generally based on their ease of use and understanding in balance with ostensive consumer needs to have detailed nutrient data (Hoefkens et al., 2011). A number of nutrition labeling formats for packaged food products are already in use, of which versions have been adapted for use in foodservice environs (Nordic Council of Ministers, 2011; Nutrition Australia, 2012; Pettigrew, Pescud, & Donovan, 2011). Some university foodservice operations (including the campus foodservice of the present study) provide nutrition information on their menus
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(Freeman & Conners, 2011). In 2010, the Grocery Manufacturers of America (GMA) and the US Food Marketing Institute (FMI) released the Facts-Up-Front labeling system for food products. These labels include four basic icons for nutrients to limit, in respective order: calories, saturated fat, sodium, sugars and up to 2 of a possible 8 ‘‘nutrients to encourage,’’ placed linearly in cylindrical shapes. The basic icons include quantitative numerical daily values as well as percentages (Roberto et al., 2010; Grocery Manufacturers Association, 2010). Health logos, or simple icons representing a healthy food choice, have also been advocated for being simple to read and, as such, more suited for making a quick product decision (Hodgkins et al., 2011). This includes the Nordic Keyhole, which is used jointly as a nutrition label with the provision of nutritional facts in Norway, Sweden and Denmark. The Keyhole is assigned to food products that are deemed to meet thresholds for less or healthier fats, less sugar, less salt and more fiber and wholegrain. A version of the Keyhole is currently available for use in restaurants, canteens and cafes (Nordic Council of Ministers, 2011). The Healthy Choice symbol is used in a variety of countries, including Belgium, Brazil, Germany, and Israel, to identify an overall healthy food item based on levels of fat, sugar, salt and fiber (Choices International Foundation, 2012). A number of international heart symbols are currently in use to identify food products that promote coronary health. For example, the American Heart Association’s (AHA) Heart-check mark is given to food products with ascribed healthy properties (AHA, 2011). Similar criteria are used for the heart of the British Heart Foundation (British Heart Foundation., n.d.), the Parempi Valinta of Finland (Sydänmerkki-tuotteet., 2012), and the Canadian Health Check (Heart & Stroke Health Check Program, n.d.). The US National Heart, Lung and Blood Institute categorizes some foods as ‘‘Whoa,’’ ‘‘Slow,’’ and ‘‘Go’’ based on caloric and nutrient density, and fat and sugar content, though no specific labeling system has been developed (Miller, Drewnowski, Heaney, King, & Kennedy, 2009; National Heart & Blood Institute, 2012). A Five-A-Day symbol, developed by the UK National Health Service, is used for the promotion of five servings of fruits and vegetables per day (National Health Service, 2012). The Traffic Light labeling system originally developed by the UK Food Standards Agency (and its various permutations including the Wheel of Health and Green Light, Eat Right – Feunekes, Gortemarker, Willems, Lion, & van den Kommer, 2008; Nutrition Australia, 2012), uses green, yellow and red colors to denote, in respective order, foods that are healthy to eat, okay to eat and foods that are not so healthy. The scheme typically only refers to levels of fat, sugar and sodium in foods (Roberto et al., 2010; Miller et al., 2009). There also is a variety of industry and foodservice symbols and adaptations available in the field for promoting individual nutrient properties. Research has shown that some of the aforementioned labeling systems can be confusing or ineffective, particularly for college students (Hoefkens et al., 2011). While it has been argued that a standard nutrition-labeling system could have an impact on health, this impact may be mitigated if consumers cannot interpret the information (Finkelstein, French, Variyanet, & Haines, 2004; Sharf et al., in press). Research findings have pointed to a disadvantage of quantitative data labeling systems (such as Facts-Up-Front): the consumer often feels time constraints and lacks the skills necessary for processing nutrient information (Hoefkens et al., 2011). In addition, scholarly opinion has been skeptical of food industry nutrition labeling initiatives and the reluctance of industry to embrace government supported recommendations and labeling designs. It has been suggested that the industry wants to stay away from negative labels that discourage consumers from buying particular food products (Nestle, 2012; Pettigrew & Donovan, 2011). Research conducted on general consumers and students demon-
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strate that provision of overall health claims on food products without supporting detail, often elicited feelings of mistrust, in particular by student consumers. Though it has been reported that a majority of college students desire to have nutrition information on dining hall menus, there may be an underlying distrust of the accuracy and truthfulness of nutrient labels (Chan, Patch, & Williams, 2005; Hodgkins et al., 2012; Kolodinsky, Green, Michahelles, & Harvey-Berino, 2008; Martinez, Roberto, Kim, Schwartz, & Brownell, 2012; Mirsa, 2007). The Traffic Light system has been reported to be more effective than percentage guidelines of nutrient amounts and overall health labeling systems (Balcombe, Fraser, & Di Falco, 2010; Feunekes et al., 2008; Kelly et al., 2009; Lobstein & Davies, 2008). The ostensive advantage of this labeling concept is its ability to overcome the difficulties consumers have in assessing an overall nutrition picture within the typically short time allocated for a consumption decision (Pohlmeier, Reed, Boylan, & Harp, 2012). Grunert and Wills (2007) suggest three attributes nutrient labels need to have in order for consumers to best utilize the information: The label must be easy to use, include informed nutrition information and it must not coerce the consumer into certain types of behavior. Federal US legislation has been enacted to encourage healthy menu selections through the Patient Protection and Affordable Care Act 2010, which requires restaurant chains with more than 20 outlets to postcalories counts on menus, drive through displays and vending machines for all the food items that they sell (Peregrin, 2010). Research findings and scholarly commentary on the effect of nutrient labeling schemes on healthy meal selection in college foodservice venues have been encouraging (Conklin, Lambert, & Cranage, 2005; Cranage et al., 2004). Recent menu strategies to promote healthy choices include nutrient labeling and the use of menu icons (Cranage et al., 2004; Downs, Loewenstein, & Wisdom, 2009; Harnack & French, 2008; Hwang & Lorenzen, 2008; Jones, 2009; Nutrition Australia, 2012). Interaction between health claims and quantified nutrition data on menus has been shown to be significant, demonstrating the potential of menus to help consumers make healthy food choices (Kozup et al., 2003). In a recent study, the majority of college students surveyed reported that nutrition information sometimes, often or always affects their food choices (Martinez et al., 2012). In college foodcourt settings data on calories and fat were the nutrients of greatest concern to students (Kolodinsky et al., 2008). While caloric information specifically on foodservice menus could positively impact healthy menu selections (Cranage et al., 2004), there appears to be a compound effect when calorie information is displayed together with respective recommended daily consumption percentages (Roberto, Larsen, Agnew, Biak, & Brownell, 2010). However, studies done in the UK suggest that making calorie counts more visible does not seem to have a significant impact on restaurant food purchases, where information is not seen by two-thirds and ignored by more than half of those who do observe the nutrition information (Denby & Loades, 2010). Findings from an investigation in catering facilities implemented on behalf of the UK Food Standards Agency, similarly suggests that calorie data was found most useful when it is clearly visible but use, and therefore, influence and impact on food choice was low (BMRB Social Research, 2009). The menu has been described as being one of the greatest merchandizing opportunities (Bowen & Morris, 1995; McCall & Lynn, 2008). It is a non-competitive advertisement that fundamentally informs the meal-selection decision, which follows almost immediately. It is, therefore, potentially a very powerful tool for the promotion of healthy eating. However, consumers are having difficulty understanding nutrient labels where they are currently marketed and particularly where foodservice products are sold (Hodgkins et al., 2012; Rothman et al., 2006; Hoefkens et al., 2011). While it has been reported that information contained in
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a nutrient label has a high amount of relevance to consumers, there has not been a consensus on the most effective way to market this information (Hodgkins et al., 2012). Notwithstanding, the style in which nutritional guidance is presented on college foodservice menus is open to debate and forms the focus of this study. The aim of this research, therefore, was to evaluate an effective design to promote healthy selections from university foodservice point-of-purchase (POP) menus. The research question was: What is the best design for college foodservice menus to inform and encourage students to make healthy meal selections? Rather than imposing a menu on students, and in doing so, possibly discrediting the provided nutritional data (Cranage et al., 2004), the researchers sought to involve these consumers in the menu design process. Methods Focus groups were used in this study to illicit in-depth attitudes towards how menus are merchandized in college foodservice environments. This method has been found to be particularly effective for uncovering hidden issues and solutions for quality of life, health, and nutrition investigations. Focus groups have also been useful in the industry for uncovering emergent consumer needs, while offsetting pre-conceived design notions and assumptions about product development (Hawthorne et al., 2006; Jones, 2010; Ruff, Alexander, & McKie, 2005). Seven focus groups (n = 3, 3, 5, 4, 4, 7, 13) totaling 39 students (17 male, 22 female) were assembled for data collection at Montclair State University during the spring of 2012. The students ranged from a required minimum of 18 years of age to 24 years of age. Other than age, the only exclusion criterion was that the students could not be enrolled in a food or nutrition program. Students were conveniently recruited, with signed consent, in or directly outside the universities’ main student cafeteria. The participants were on their way to lunch, thus the emulating the conditions students encounter, as they are about
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to make the meal consumption decision. In keeping with the nature of qualitative research, no attempt was made to enlist a specific number of participants. The investigators discontinued recruitment once the data was saturated. Data saturation was determined when the findings continued to be replicated across the groups and when the participants were no longer able to present new ideas or themes (Guest, Bunce, & Johnson, 2006). The research was designed around a grounded theory approach utilizing semiological prompts based on different existing nutrition labeling schemes. A grounded theory approach assumes that reality is uncovered from the data by carefully following a rigorous methodology. In keeping with this method, the researchers were simultaneously involved in data collection and analysis; the analytic codes were constructed from the data, not from pre-conceived hypothesis; the data was constantly compared between and across the focus groups; the theory was advanced during each step of data collection and analysis; relationships were elaborated and an independent analysis was constructed before a literature review was conducted. The transcripts were analyzed using deductive content analysis, which involved assigning codes to text passages (Charmaz, 2006). Three researchers analyzed the data separately to provide a multi-rater perspective (Jones, 2010; Webb & Kevern, 2001). To encourage an open dialogue, facilitators stressed the confidentiality of responses, and that there were no right or wrong answers. A two-part structured broad questioning process was used that is consistent with Spradley’s qualitative research approach (1979). The first part of each focus group consisted of open-ended ‘‘Grand Tour’’ questions to potentially enable the group to describe the dynamics behind campus meal decisions. For example, the participants were asked, ‘‘How does the campus menu affect your meal decision?’’ The participants were also asked key ‘‘Example’’ questions to keep them focused on the topic at hand. Such as, ‘‘What would you like to see on college foodservice menus?’’ Or, when the moderator presented a specific label or nutrient, ‘‘What does this symbol mean to you?’’
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( ) Fig. 1. An abbreviated listing of nutrition icons and labels used in the study. (See the above mentioned reference).
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To illicit responses, keep ideas flowing and to help participants rethink their conceptions, 27 nutrient labels and icons from international government and industry sources were presented to the participants in a PowerPoint display (Fig. 1A–H). The presentation included the Green Light, Eat Right icons from Nutrition Australia (2012); the international Five-A-Day symbol (B); the Nordic Keyhole (C); the international Healthy Choice (D) and Heart Healthy symbols (E); the Color-coded icons from the UK Traffic Light system and the Wheel of Health (F); the (US) Grocery Manufacturing Association and Food Marketing Institute Facts-Up-Front label (G); and 14 specific ‘‘nutrients to encourage’’ icon adaptations (e.g. source of iron, protein and calcium symbols – H) were also presented for discussion. The PowerPoint presentation of labels and icons was shuffled before the start of each focus group to reduce any ordering effects. A validity check of the instrument was concurrently done by one of the primary researchers with a group of 24 college students at Bournemouth University, UK. A process of iteration was used from the inception of the menu concept in the first focus group, through the theoretical saturation of ideas (Guest et al., 2006) during the final sessions. For each group, the impact of the college foodservice menu on food choice was discussed in-depth and recommendations from the students informed labeling and menu designs at every step. The focus group data was discursively refined across the groups to get a confirmatory model. At the beginning of each new session the facilitators first asked the participants for their responses to generalized questions about cafeteria food selection and health and then various menu labeling schemes and icons. Then to evolve the model, the researchers presented findings from the previous sessions for commentary (Birks, 2009). Data from early sessions was only presented to participants of a later group after the researchers felt that ideas from this group were completely put forth. As explained by the facilitators, at this point prior data was presented only to stimulate discussion and not to influence findings. At the end of each session, the investigators reiterated the conclusions of the focus group by summarizing the groups answer using the following rhetorical question: ‘‘In sum, what information would you like on the menu, and how would you like it presented?’’ Evolving visual displays (Fig. 2) were presented to participants to elicit comments, comparisons and suggestions. Potential labeling methods and menu layouts were continually refined in components, evolving into a cumulative menu-design. The menu was built subject to student approval for each step towards completion. No attempt was made by the researchers to artistically embellish the evolving menu instrument, which was designed to articulate, as closely as possible, how students want the food selections presented and described. All the sessions were audio taped, transcribed verbatim and re-read several times as soon as possible in order to preserve the full meaning of the participants’ words (Charmaz, 2006). The investigators hoped to generate knowledge grounded in the views of the participants, which can be used to deliver student-aided menu designs to enhance the dining experience, and ultimately lead to the improved health and wellbeing of campus populations. Results Two over-arching themes emerged from the analysis of the data: Theme 1 – The healthiness of the campus food in relation to weight gain Coded responses from 21 students (12 females, 9 males, or 54% of all participants) uncovered concerns over the healthiness of
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foods offered in college, which the student participants felt were becoming increasingly important with the incidence of college weight gain. Three students (1 female from group one, 2 males, one from group 3 and one from group 4) personally expressed concern over the relationship of potential weight gain to how the campus food is marketed. For example, in response to the question: ‘‘So then, should university menus have nutrition labels?’’, the female student stated, ‘‘I think so because then people will say this is not good for me. . . I’m [referring to herself] trying to lose weight, I shouldn’t eat this.’’ A male in the same group added, ‘‘adding calories in the student café [menu] did wonders for me.’’ Theme 2 – Trust of labels making health claims The trust value or the credibility of the symbols was generally agreed across all focus groups as very important. These icons should not be generated from a biased source, as many participants noted. A concordance of the students across all the groups (26 coded responses or 67% of the total participants), showed agreement that student-dining menus should only display nutrition labels if the information could be trusted to represent the intended healthy-eating standard. For example, one female students stated, ‘‘. . .cause if it says it’s good in one thing it might be bad in another.’’ The trouble with many symbols, as agreed, was that representations such as ‘‘low-fat’’ or ‘‘source of’’ do not provide corroborative quantitative information and thus, could not be trusted as representative of a nutrition attribute. A male participant from group 1 stated, ‘‘... it could say its fat free and still have a lot of sugar!’’ ‘‘I wouldn’t believe it,’’ said a male participant from group 5, ‘‘. . .a lot of times stuff will say it is one way and it really isn’t that way. . .[For example] a lot of times it will say organic, but how do you really know?’’ The relevancy of health claim symbols on a menu was also in doubt by a couple of students. Said one male participant from group 4, ‘‘I don’t think I’d be opposed to have something like this [a general health icon] on a menu, but I don’t chose anything more so because there is a symbol next to it.’’ One male student in the same group particularly did not like the health icons in general, as he explained, ‘‘The symbols, no!...If I know the exact [nutrient data] numbers, I would be more inclined to do something.’’ The students disagreed over their ability to decipher healthy diet information from existing food labeling schemes (Fig. 1). Whereas evidentiary labeling data was deemed important, there was concern over whether this information could be understood by the general student population (cf. Pohlmeier et al., 2012). Five female (only) students (1 from group 1, 2 from group 2 and 1 each from groups 4 and 5) were concerned that they would not be able to understand a percentage system. Said one female from group 2, ‘‘This doesn’t stand out to me because it doesn’t tell me if it’s a good amount or a bad amount.’’ Another female student from group 4 reported, ‘‘[It is a] little bit harder to comprehend, because you’re going to look at percentages, but its not going to mean anything if you’re unable to tell what they mean.’’ In a summary response to whether or not nutrient data should be put on university menus, a female student from the first focus group said, ‘‘No, because some people really don’t know how to work with all the numbers.’’ While participants generally liked the international healthychoice symbols (e.g. Five-A-Day, Healthy Choice and the international heart symbols), trust of these specific icons was an issue. One female participant from group 5 stated, ‘‘I feel like these specific symbols are made to make you look away from other things that can be bad.’’ Another female from group 6 said, ‘‘Personally no, I don’t [trust them]. I would have to see the ingredients, so symbols like this would not make a difference to me.’’ Out of all the study participants, only one student from group 2 was able
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Fig. 2. Draft label design schemes.
to express the meaning of Nordic Keyhole, which is not currently being used in the US. The heart symbols were very recognizable, though they also reportedly looked like advertisements as expressed by two students. In addition, heart-health was not an expressed issue for the overall student participants. One male student from group 2 expressed recognition for the Green Light, Eat Right angel (Fig. 1A). ‘‘It’s good for you’’, he stated,
‘‘for something, we don’t know what!’’ Two other female participants from group 4 were not in favor of having negative menu symbols (such as the Green Light, Eat Right devil). Said one, ‘‘I don’t think food should be deemed insanely bad. . .It’s like: Just point out the healthy options!’’ Fifteen students’ responses (a unanimous consensus from all students in the first four groups or 38% of the total participants) were coded for commenting silly or ‘‘weird,’’
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sinister or ‘‘insanely bad’’, or not clearly understood for Green Light, Eat Right angel and devil and the Nordic Keyhole. In regards to the Canadian Health Check, one male student from the third group expressed that this symbol would not be useful: ‘‘I see this [type of symbol] all the time and I don’t pay any attention to it.’’ A plurality of 30 students (18 females, 12 males, or 77% of all participants) enthusiastically liked the existing permutations of the UK Traffic Light system, including the Wheel of Health, though the cylindrical versions (over the wheel) were the favorites of all but one student (Figs. 1F and 2). Six female students (2 from group 2, 1 from group 3, 1 from group 4 and 2 from group 5) plus 1 male student (from group 2) verbally reported, with no disagreement from others, that these symbols provide ‘‘easily understandable’’ color-coding as well as quantitative nutrient information. For example, one female student from group 1 stated, ‘‘. . .the colors are attractive so I wanna read it and see what I’m putting in my body. I’d read it because it caught my attention.’’ Another female from group 2 expressed: ‘‘A person who hasn’t taken a nutrition course could understand this [type of label] more.’’ In response to the moderator’s query about possible negative components of the Traffic Light system, one female student from group 3 replied, ‘‘No [there is nothing bad about this system]. . .it’s color-coded, has grams, it tells you the calories too, so it’s good.’’ Still, three students from group 7 (1 female and 2 males or 23% of this group) were concerned that a symbol of this type, while good for processed food labeling, would ‘‘clutter’’ a foodservice menu. Said one: ‘‘. . .I like the colors and I want to know what I put in my body. . .so if it’s offered to me, yeah. . .as long as the instructions aren’t long.’’ Out of all the participants in the study, only one student (from group 4) suggested that specific meal ingredient information should be listed on college menus. However, 14 participants (7 males and 7 females or 36% of all participants) thought campus menus should provide an ingredient notation if the meal was made with whole grains and 6 participants (3 females and 3 males, across all groups) thought that labeling vegan meals was important. Many students (across the groups, as it was coded 43 times) expressed that foods with beneficial amounts of nutrients should receive an additional nutrient-specific menu icon, as this is important for students with particular needs. By the end of each of the first four focus group sessions, the participants tacitly concurred with the moderator’s overall summation that the design of college foodservice menus should include colors along with nutrients expressed in grams and percentage. Nearly all the participants from the fourth and remaining sessions agreed that informative color-coding, percentages of daily nutrient values and specific nutrient data are important to include on college foodservice menus. As stated by one female from group 4, ‘‘I think it’s kind of like the best of both worlds. . .you have the percentage. . .you know how people do food logs or whatever. . .and you know you can take a quick glance and say ‘oh it’s not bad at this and that.’’’ Based on this and recurring data and analysis thus far, the researchers began to design a number of draft labeling and design permutations for discussion with the subsequent focus groups as shown in Fig. 2A–G. However, there was a very small amount of dissenting student opinion across all the final three focus groups, regarding the direction of the design. For example, one female from the fifth focus group declared: ‘‘I think [the scheme of percent, data and colors suggested by the other students] makes [the menu] too complicated, like you have to look at it to really understand.’’ Another female in the same group remarked, ‘‘I don’t think the colors are appealing, but I think they are needed and good at telling people exactly what to look for.’’ No students in this group were able to suggest alternatives. A male participant from this group did not appreciate the overall value of menus in general: ‘‘I don’t spend
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much time looking at the menu. . .when students walk in they look at the food trays, not the menu.’’ A final draft menu was completed through discussion with the fifth and sixth focus groups. Further discussions included how many nutrients to include in the label (it was agreed that five primary nutrients are sufficient for labeling – more would clutter), where to place the general label (above, below, the side, etc. – centered below the menu item was agreed by all, with a specific icon to the left for important nutrients) and the colors and shape of the icons (round and cylindrical shapes) were chosen. By the sixth focus group, no new ideas or themes were generated. As such, the investigators determined that the data was saturated. The researchers then developed a final draft menu (Fig. 3) based on confirmatory confirmation of the summarized design ideas by participants of the fifth and sixth groups, and subsequent data analysis. Then one final focus group of 13 students was convened to assess the final product: a menu comprised of current university foodservice offerings, adapted to design inputs from the previous student focus groups. The facilitators presented these participants the final draft menu with adapted item names and nutrition data from the university’s existing foodservice menu database. The menu included a tentative labeling model of five nutrients (calories, sodium, sugar, fat and carbohydrates) and icons for beneficial nutrients based on data retrieved from the previous focus groups. Colored icons were also added to the menu categorize healthiness (green1 = healthiest choice, yellow = okay choice, red = less healthy choice). The researchers designation of healthiness was based on levels of calories, total fats, trans fat, sodium and sugars and the provision or lack of 10% of vitamin A, vitamin C, iron, calcium, protein, and fiber in accordance with current Institute of Medicine (2011) recommendations and US Food (2003) guidelines for ‘‘healthy labels’’ (US Department of Agriculture, 2010; US Government General Printing Office, 2011). All students in the final group approved the final menu design. After the final focus group, the investigators affirmed the participants’ selection for nutrition labeling attributes by assessing the overall coded frequency of student references to the importance of particular nutrients across the focus groups. The total list of nutrients affirmed as important to the students for labeling are, in respective order: Calories, sodium, sugar, fat, carbohydrates, cholesterol and trans fat. The students also identified the beneficial nutrients and food ingredients they would like to see displayed in a menu icon in respective order as follows: Whole grains, vegan, protein, iron, calcium and fiber. Table 1 compares the student preferences for labeled nutrients with IOM recommendations, the GMAFMI standard and the nutrients currently labeled in the university foodservices where the study was conducted. Discussion Coming to college results in changes for many students that may encourage unhealthy dietary practices. A number of nutrient labeling schemes have been presented in the literature that may be useful to help these students make healthy decisions in campus in foodservice environments. However, before the implementation of any health and nutrition policy, it is important to take into account the attitude of consumers themselves. Research has demonstrated that consumers who look at food labels can understand some of the terms but are confused by other types of information. Reaction to the health icons on menus has been found to be encouraging. However, it has been shown that icons do not have as strong an influence on participant choices as with the inclusion of nutritional information (Hodgkins et al., 2012; Jones, 2009). The 1 For interpretation of color in Figs. 1–3, the reader is referred to the web version of this article.
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Fig. 3. Final draft menu.
literature has also shown that consumers are able retrieve simple nutrition data, but their ability to process this information in short periods of time is questionable (Cowburn & Stockley, 2005). Therefore, the addition of interpretational aides has been recommended as it puts food products into a total diet context. In addition, while consumers may be wary of health claims, the provision of nutrition information has been shown to have a significant positive effect, in particular for reduced perceived disease risk, particularly in the context of a restaurant menu. It has been suggested that consumers may have more confidence in overall health claims if presented with evidentiary nutritional data (Kozup et al., 2003). The overall process of this study enabled the investigators to uncover a final set of data and design components that exemplified the process of the participants’ responses as they were more grounded in their own perspectives. The students who participated in this investigation indicated their preference for a university foodservice menu that includes components of a Traffic Light labeling system, quantitative nutrition data and threshold nutrient percentages. This finding is consistent with scholarly calls for a label that combines numerical information with visual aides such as color codes or stars and (high/medium/low) text, (Hoefkins et al.,
2011; Roberto et al., 2010; Pohlmeier et al., 2012). The students also itemized five nutrients they wanted labeled with colors and quantified on the menu (in respective order: calories, sodium, sugar, fat and carbohydrates), plus beneficial ingredients or nutrients for display as menu icons (Table 1). The final selected nutrients and display order varies somewhat from IOM recommendations, industry practice and literature findings (Roberto et al., 2010), though the present findings are suggestive of the students’ understanding of published guidelines of nutrients to limit (Table 1). In another recent study, students reported that calorie and ingredient information were the most needed information for nutrition labels followed by fat content, while the fewest number of these participants reported being interested in vitamins and minerals (Martinez et al., 2012). While it has been argued that a nutrition-labeling menu system could have an impact on students’ selection of healthier foods, the impact may be contingent on students’ motivation to make a change (Finkelstein et al., 2004; Sharf et al., in press; Yoon & George, 2012). Previous in vitro research has suggested consumers, and students in particular, believe nutrient labels will help them make healthier meal selections (Downs et al., 2009; Harnack &
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Table 1 A comparison of nutrients cited as important for campus foodservice menu labeling, with IOM recommendations, GMA-FMI Front-of Package labeling and the campus foodservice. IOM (Recommendations)
Nutrients to discourage 1. Calories 2. Saturated fat 3. Trans fat 4. Sodium 5. Added sugars 6. 7. Nutrients (or foods) to encourage Insufficient evidence to support inclusion of total fat, cholesterol, total carbohydrate or added sugars, protein, fiber, vitamins, and minerals other than sodium
GMA-FMI (Front-of-Package)
Campus foodservice
Students (n = frequency of coded responses on importance)
Calories Saturated fat Sodium Sugar
Calories Sodium Total fat Sugar Carbohydrates
Calories (n = 27) Sodium (n = 22) Sugar (n = 21) Fat (n = 27) Carbohydrates (n = 11) Cholesterol (n = 9) Trans fat (n = 4)
Optional two ‘‘nutrients to be encouraged’’: potassium, fiber, protein, vitamin A, vitamin C, vitamin D, calcium and Iron (must have more than 10% of the daily value per serving of the nutrient and meets the FDA requirements for a ‘‘good source nutrient claim.’’
No data provided on labels
Whole grains (n = 14)
French, 2008; Jones, 2009; Martinez et al., 2012). However, student behavior is highly complex with many external and internal influences on perception, attitude and action. Many students have a low intention to eat healthier at the baseline of entry into student dining facilities (Vyth et al., 2011). It has been suggested that multiple criterion need to be in place for a person to transition from an intention or plan into an actual behavior. The social and physical environment and available time must be favorable. The intended change must also be a high-priority for this person and likely fit into a peer-group norm (Atkins & Michie, 2013). In addition, a potential healthy menu decision may be mitigated by intervening factors before, or at the actual point of purchase, that include taste preferences, smells, dining atmosphere, anticipation of a pre-conceived desire or perceptions about a particular food, the consumer’s age, attitudes and predisposition to dietary change. Previous research has identified four key menu attributes that interact via various trade-offs affecting consumers’ decision-making process: taste, the most important attribute, followed respectively by price, nutrition and appearance. Moreover, predisposition to menu preferences may reach back to earlier years of adolescence (Bordi, Cranage, Borja, & Cole, 2003; Cranage & Lee, 2007; Lee & Cranage, 2007). In sum, students have to negotiate the tradeoffs between what appears healthy, what looks and tastes good, what is affordable (although these attributes need not be mutually exclusive) and a host of other menu selection influences. Therefore, nutrition only plays a part in an ingrained meal decision process. (Bordi et al., 2003; Cranage et al., 2007; Lee & Cranage, 2007). Menus designed with nutrient labels may not be enough to entirely overcome these dynamics. Implicit to the present research is the assumption that student’s food-related ideas and perceptions sometimes do not completely translate into behaviors. Still, initiatives by foodservice operators that inform and encourage better menu decision-making among college students could play a large role in the wellbeing of this population, at their present stage of life and beyond. Though, existing methods for improving college students’ present and future diets have yet to be proven successful. Nevertheless, there has been a scholarly call for foodservice operators to consider student opinion when designing menus (Martinez et al., 2012). In addition, foodservice management could foster trust, openness and overall positive perceptions of food quality by providing menus with informed food choices (Cranage et al., 2004). Still, better strategies
Vegan (n = 7) Protein (n = 7) Iron (n = 6) Calcium (n = 6) Fiber (n = 3)
need to be developed to influence menu choice before the student enters the college cafeteria setting. The student participants of this study clearly called for nutrition labeling on college menus. While the menu or variations may be student-inspired, the likelihood of other non-participating students actually making healthier selections from a student-inspired menu design is unknown. Further, it is not the intention of the authors to generalize the findings of this study. Rather, the researchers believe the data uncovered points to the importance of student involvement in campus foodservice menu design. Planned future research by this team may help determine whether the student-centered design approach actually encourages healthier meal selections from college foodservices.
Ethics The Internal Research Board of Montclair State University, US and the Ethics Committee of Bournemouth University, UK approved this research. References AHA. American Heart Association (2011). Heart-check mark nutritional guidelines.
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British Heart Foundation (n.d.). British heart foundation.
Kozup, J., Creyer, E., & Burton, S. (2003). Making healthful food choices. The influence of health claims and nutrition information on consumers’ evaluations of packaged food products and restaurant menu items. Journal of Marketing, 67, 19–34. Lee, J., & Cranage, D. (2007). The relative importance of menu attributes at point of menu selection through conjoint analysis. Focused on adolescents. Journal of Foodservice Business Research, 10(2), 3–18. Lobstein, T., & Davies, S. (2008). Defining and labeling ‘healthy’ and ‘unhealthy’ food. Public Health Nutrition, 12, 331–340. Martinez, O., Roberto, C., Kim, J., Schwartz, M. & Brownell, K. (2012). A survey of undergraduate student perceptions and the use of nutrition labels in a university dining hall. Health Education Journal, Online version before print.