Changes in the calorie and nutrient content of purchased fast food meals after calorie menu labeling: A natural experiment

Author summary Why was this study done? The 2010 Affordable Care Act required that all chain food establishments with >= 20 locations in the United States label their menus with calorie content of prepared foods to encourage healthier eating. There is little evidence on how the nutritional quality of purchased meals changed after nationwide implementation of this policy. What did the researchers do and find? We analyzed sales data from a franchise of 104 fast food restaurants (representing 3 large nationwide chains in the US) to determine how nutrient purchases changed after voluntary franchise labeling in April 2017 and nationwide implementation of labeling in May 2018. At the end of the study, nearly 1 year after nationwide implementation of calorie labeling, the average calorie content of meals was 4.7% lower than what would be expected had labeling not occurred. Other nutrients ranged from 1.8% lower (saturated fat) to 7.0% lower (sugar) at the end of the study, but the nutrient density of purchases still generally exceeded US dietary guidelines. What do these findings mean? Calorie menu labeling is a promising strategy for improving purchased meal quality in fast food restaurants, but the effect is small. Future food retail interventions may be necessary to make further improvements in meal quality in restaurants. Background Calorie menu labeling is a policy that requires food establishments to post the calories on menu offerings to encourage healthy food choice. Calorie labeling has been implemented in the United States since May 2018 per the Affordable Care Act, but to the best of our knowledge, no studies have evaluated the relationship between calorie labeling and meal purchases since nationwide implementation of this policy. Our objective was to investigate the relationship between calorie labeling and the calorie and nutrient content of purchased meals after a fast food franchise began labeling in April 2017, prior to the required nationwide implementation, and after nationwide implementation of labeling in May 2018, when all large US chain restaurants were required to label their menus. Methods and findings We obtained weekly aggregated sales data from 104 restaurants that are part of a fast food franchise for 3 national chains in 3 US states: Louisiana, Mississippi, and Texas. The franchise provided all sales data from April 2015 until April 2019. The franchise labeled menus in April 2017, 1 year prior to the required nationwide implementation date of May 2018 set by the US Food and Drug Administration. We obtained nutrition information for items sold (calories, fat, carbohydrates, protein, saturated fat, sugar, dietary fiber, and sodium) from Menustat, a publicly available database with nutrition information for items offered at the top revenue-generating US restaurant chains. We used an interrupted time series to find level and trend changes in mean weekly calorie and nutrient content per transaction after franchise and nationwide labeling. The analytic sample represented 331,776,445 items purchased across 67,112,342 transactions. Franchise labeling was associated with a level change of -54 calories/transaction (95% confidence interval [CI]: -67, -42, p < 0.0001) and a subsequent 3.3 calories/transaction increase per 4-week period (95% CI: 2.5, 4.1, p < 0.0001). Nationwide implementation was associated with a level decrease of -82 calories/transaction (95% CI: -88, -76, p < 0.0001) and a subsequent -2.1 calories/transaction decrease per 4-week period (95% CI: -2.9, -1.3, p < 0.0001). At the end of the study, the model-based predicted mean calories/transaction was 4.7% lower (change = -73 calories/transaction, 95% CI: -81, -65), and nutrients/transaction ranged from 1.8% lower (saturated fat) to 7.0% lower (sugar) than what we would expect had labeling not been implemented. The main limitations were potential residual time-varying confounding and lack of individual-level transaction data. Conclusions In this study, we observed that calorie labeling was associated with small decreases in mean calorie and nutrient content of fast food meals 2 years after franchise labeling and nearly 1 year after implementation of labeling nationwide. These changes imply that calorie labeling was associated with small improvements in purchased meal quality in US chain restaurants.