Title: Implementation and assessment of mandatory calorie labeling in the out-of-home sector
Funder: Department of Health and Social Care

Abstract: Background In 2017-18, 22% of 4-5 year olds, 34% of 10-11 year olds and 64% of adults in England were overweight or obese. Eating food from out of home food outlets (OHFO) is common and associated with poorer dietary quality, weight gain and obesity. Calorie labelling in OHFO may act as an information intervention changing customer behaviour; and as an incentive to retailers to reduce the calorie content of menu items. The Government plans to introduce mandatory calorie labelling in OHFO, details are becoming clearer. We present an evaluation strategy which reflects currently available information on the nature of the intervention. Research questions and methods We propose an evaluative project with five work packages (WP). In WP1, we will conduct pre-post assessments in OHFO to determine whether implementation is associated with changes in: The extent and practice of OHFO calorie labelling, including compliance and fidelity. In WP2, we will conduct pre-post intercept surveys with OHFO customers to assess whether implementation was associated with changes in: Knowledge of calorie content of OHFO purchases. Use of OHFO calorie labelling when making purchasing choices in OHFO. Calorie content of OHFO purchases. In WP3, we will use pre-post data from an annual, international, survey to assess whether implementation was associated with a change in: Frequency, or type, of OHFO use. In WP4, we will expand our existing database of nutritional information of menu items sold by OHFO to assess whether implementation was associated with pre-post changes in: Calorie profile of OHFO menus, and calorie content of popular dishes. Proportion of menu items identified as healthier . Portion size, reformulation and menu items available. Menu diversity or item price. In WP5, we will conduct post-implementation interviews with those tasked with implementation and enforcement to document perceptions of: Barriers and enablers to the intervention achieving the intended changes. The process of intervention implementation. The administrative, business and investment impacts (including compensatory practices); and financial and opportunity costs of intervention implementation. Any exemptions. Enforcement activity and its success. Barriers and enablers to enforcement. The financial and opportunity costs of enforcement In WP2&3, we will explore differences by age, gender, socio-economic position and ethnicity of customers. In WP1,2&5, we will explore differences by business characteristics, including: business size (number of employees), business model (franchise vs owned), business type (Standard Industrial classification section), and deprivation profile of outlet locations (mean Index of Multiple Deprivation of all outlets within the business). Timelines for delivery Assuming implementation in April 2022, we propose a 33 month project starting in May 2021. Anticipated Impact and Dissemination The primary audience for our findings are DHSC and PHE colleagues. Our results will also be of interest to the wider public health policy and research communities, and the public. Anticipated impacts include on refinement of English calorie labelling policy, development of similar policies elsewhere, and development of public health theory and evidence. We will work with the Knowledge Exchange team in the MRC Epidemiology Unit to maximise the quality and reach of our dissemination and impact.

Lay abstract: Background In England, a quarter to a third of children and two-thirds of adults are overweight or obese. Out of home food outlets (OHFO) include cafes, restaurants, pubs, and takeaways. OHFO are becoming more common in the UK. Food from OHFO tends to have a lot of calories. People who eat more OHFO food have less healthy diets, and are more likely to be overweight or obese. Labels showing how many calories are in food served by OHFO may be one way to address these problems. Calorie labels might help customers make healthier choices. They might also prompt retailers to reduce the calories in their food. The Government plans to make calorie labelling in OHFO compulsory. Research questions and methods We will conduct a project with five parts. First, we will visit OHFO to find out how many provide calorie labels. We will do this before and after the new rules come in. Next, we will conduct surveys with customers in OHFO - before and after the rules come in. We will ask them what they bought, whether they noticed and used calorie labels, and how many calories they think they bought. We are partners in an annual internet survey. This includes questions on how often people use OHFO. We will use this to study whether the new rules on calorie labels change how often people visit OHFO. Some OHFO chains provide calorie information online. We will use this to study whether there is any reduction in how many calories are in OHFO meals after new rules come in. For OHFO that don't have online information, we'll buy meals and analyse them in a laboratory. Finally, we will interview people responsible for implementing and enforcing the rules. We will ask whether the rules did what they were supposed to, and if there were any problems with them. PPI At the start of the project, we will bring together three public involvement panels. One panel of adult OHFO users, one of young adult OHFO users, and one of people employed by OHFO. We will ask panels to help refine our methods and dissemination plans. A further involvement panel will help us run the research. This will include two young people, two adults, two people employed by OHFO, one person involved in implementation and one involved in enforcement. This panel will help us understand our findings and how we should tell others about them. Anticipated Impact and Dissemination We will share our results with people working in Government, other researchers and the public. Our results should help Government refine calorie labelling rules. Our results could also help governments in other countries develop similar rules.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: STROKE;METABOLIC AND ENDOCRINE;CANCER AND NEOPLASMS;ORAL AND GASTROINTESTINAL;CARDIOVASCULAR