The rationale for menu labelling
Prevention of obesity is a public health priority both globally and in Ireland. While the causes of obesity are complex and multifaceted, poor diet is a leading risk factor. Foods prepared outside the home (e.g., fast food outlets, restaurants, worksite canteens) represent increasing proportions of diets worldwide. Frequent consumption of these foods is associated with poorer dietary quality, increased risk of chronic diseases such as obesity and type 2 diabetes, and all-cause mortality. One commonly proposed strategy to improve the nutritional quality of foods served by the food service industry and selected by consumers in the out-of-home food environment is menu labelling. While evidence suggests menu labelling may only have a modest effect on consumer and industry behaviour [1, 2], this may result in a meaningful impact for frequent users of out-of-home prepared foods. The impact of menu labelling policies on industry behaviours, such as reformulation, may also be greater when these policies are mandatory, and thoroughly monitored and evaluated . Researchers have also noted that changes in industry behaviour (such as reformulation to reduce energy content) in response to menu labelling may benefit all groups and particularly, lower SES groups where fast food consumption may be higher . Finally, international obesity experts highlight that menu labelling is necessary though not sufficient for obesity prevention and should form part of a wide-ranging portfolio of policies and interventions to contribute to global obesity prevention efforts .
Menu labelling adoption and implementation challenges
To date, a growing number of countries and regions around the world have adopted menu labelling policies on a voluntary or mandatory basis. In Ireland, a voluntary approach to calorie menu labelling has been in place since 2012. There is growing evidence of implementation issues (e.g. delays in legislation implementation, poor uptake by food service businesses, lack of adherence to best practices and inaccurate calorie menu labels). These implementation challenges are not unique to menu labelling, with research showing the implementation of evidence-based obesity prevention policies being slow and inconsistent . International obesity experts now call for a greater application of implementation science to understand the contexts and drivers of successful policy implementation . It is recognised that the potential public health benefits of evidence-based obesity prevention policies, including menu labelling, may not be realised without adequate implementation.
My PhD research on menu labelling implementation
The core focus of my PhD research was on the implementation of menu labelling interventions, including determinants and fidelity of implementation. The research explored the implementation process through the lens of the Consolidated Framework for Implementation Research, which brings together constructs from an array of implementation theories to understand the complexity of implementing policies and interventions. The research included the first systematic review to synthesise the evidence on the determinants of menu labelling implementation. Findings showed implementation was influenced by multiple interdependent factors, particularly related to the external (e.g. consumers, legislation) and internal (e.g. compatibility, available information and resources) context of food businesses, and features of the menu labelling intervention (e.g. perceived benefits, cost) . The research also included a mixed methods study to assess fidelity to a calorie posting policy in Irish public hospitals. Findings showed partial adherence across hospitals, where influencing factors were multiple, and operated independently and in combination. Factors were related to the external (e.g., national policy, monitoring) and internal (e.g., perceived importance of calorie posting implementation) hospital environments, features of the policy (e.g., availability of supporting materials) and the implementation process (e.g., engaging relevant stakeholders) .
The overall research findings point to the need for menu labelling legislation with adequate monitoring and enforcement as well as increased consumer demand. These research implications are briefly discussed in turn below.
A prominent determinant of implementation across my PhD studies included menu labelling legislation. The research findings echo concerns of international public health experts [10,11,7], that a voluntary approach may be insufficient to encourage the uptake of menu labelling by foodservice operators. In response to inadequate uptake of obesity prevention policies, such as menu labelling, governments need to be prepared to implement the regulation. Despite research showing poor uptake of a voluntary calorie menu labelling scheme in Ireland , legislation has been under consideration for 10 years now. Research shows that government development and implementation of nutrition legislation can be hindered by several factors, such as industry resistance and lobbying, and government capacity and will. To help overcome these barriers, action and advocacy by many stakeholders, including consumers, are required.
- Monitoring and accountability
Lack of monitoring and enforcement was a common barrier to menu labelling implementation across my PhD studies. Monitoring the degree of implementation of public health policies, such as menu labelling, is an important part of ensuring progress towards achieving its intended outcomes . In the absence of monitoring and enforcement, there is a risk of superficial implementation in response to menu labelling policy/legislation. This may present issues around the accuracy of calorie information on menus, as identified in the current research. To date, most countries and regions with menu labelling legislation do not specify the mechanisms of verifying the accuracy of calorie menu labels. If monitoring is in place, the focus is on the provision of calorie information on menus and not the accuracy of this information. Public health experts highlight the need for stronger accountability systems to ensure mechanisms are in place to hold the food industry to account for their actions [7, 13].
- Mobilising consumer demand
Consumer demand for menu labelling was another important determinant across both studies. This is in line with previous research which shows implementation of obesity prevention policies can be facilitated or hindered by public opinion. While research shows high levels of public support for food/obesity policies that provide information such as calorie labelling on menus, international obesity experts argue that this support has not translated into sufficient public demand for action to overcome the industry opposition and government reluctance . Public demand for interventions is important for policy makers, and can help overcome political inertia and enable policy action to improve population health. Swinburn and colleagues  highlight the need to mobilise demand for change, as public pressure drives both public-sector and private-sector policy actions to address obesity.
- Crockett R, King S, Marteau T, Prevost A, Bignardi G, Roberts N, et al. Nutritional labelling for healthier food or non-alcoholic drink purchasing and consumption. Cochrane Database Syst Rev. 2018; 2: CD009315.
- Shangguan S, Afshin A, Shulkin M, Ma W, Marsden D, Smith J, et al. A meta-analysis of food labeling effects on consumer diet behaviors and industry practices. Am J Prev Med. 2019; 56: 300–14.
- Vandevijvere S & Vanderlee L. Effect of Formulation, Labelling, and Taxation Policies on the Nutritional Quality of the Food Supply. Curr Nutr Rep. 2019; 8(3): 240-249.
- Ananthapavan J, Sacks G, Brown V, Moodie M, Nguyen TMP, Barendreg J, et al. Assessing Cost
Effectiveness of Obesity Prevention Policies in Australia 2018 (ACE Obesity Policy). Melbourne: Deakin University; 2018
- Robinson E, Marty L, Jones A, White M, Smith R, & Adams J. Will calorie labels for food and drink served outside the home improve public health? BMJ. 2021; 372: n40.
- Vandevijvere S, Barquera S, Caceres G, Corvalan C, Karupaiah T, Kroker‐Lobos MF, et al. An 11‐country study to benchmark the implementation of recommended nutrition policies by national governments using the Healthy Food Environment Policy Index, 2015‐2018. Obes Rev. 2019; 20(S2): 57-66.
- Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, et al. The global syndemic of obesity, undernutrition, and climate change: the Lancet Commission report. Lancet. 2019; 393(10173): 791-846.
- Kerins C, McHugh S, McSharry J, Reardon CM, Hayes C, Perry IJ, et al. Barriers and facilitators to implementation of menu labelling interventions from a food service industry perspective: a mixed methods systematic review. Int J Behav Nutr Phys Act. 2020; 17: 48.
- Kerins C, Kelly C, Reardon CM, Houghton C, Toomey E, Hayes CB, et al. Factors influencing fidelity to a calorie posting policy in public hospitals: a mixed methods study. Front Public Health. 2021; 9.
- Mozaffarian D, Angell SY, Lang T, & Rivera JA. Role of government policy in nutrition— barriers to and opportunities for healthier eating. BMJ. 2018; 361: k2426.
- Ngqangashe Y, Goldman S, Schram A, & Friel S. A narrative review of regulatory governance factors that shape food and nutrition policies. Nutr Rev. 2022; 80(2): 200-214.
- Fitzgerald S, Gilgan L, McCarthy M, Perry IJ, Geaney F. An evaluation and exploration of Irish food-service businesses’ uptake of and attitudes towards a voluntary government-led menu energy (calorie) labelling initiative. Public Health Nutr. 2018;21:3178–91.
- World Health Organization [WHO]. European Regional Obesity Report 2022. Copenhagen: WHO Regional Office for Europe; 2022.
|Dr. Claire Kerins is a Postdoctoral Researcher with the Health Promotion Research Centre at University of Galway. She is also a registered dietitian and recently completed her PhD through the HRB SPHeRE Programme. Prior to commencing her doctoral studies, she was the Lead Specialist Dietitian for the National Institute for Preventive Cardiology (NIPC) based in the Croí Heart and Stroke Centre, Galway. She received her undergraduate degree in Human Nutrition & Dietetics from Trinity College Dublin, followed by a MA in Health Promotion from the University of Galway. Her research interests include the application of implementation science to understand the contexts and drivers of successful evidence-based obesity prevention policy implementation.|