Next Article in Journal
Diet and Environmental Sustainability: A Review of Australian Evidence
Previous Article in Journal
Healthy and Active Lifestyles Are Not Always Environmentally Sustainable: A Dietary Water Footprint Analysis in Mexico
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Dietetics
Volume 4
Issue 1
10.3390/dietetics4010004
dietetics-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Review

The Impact of Restaurant Menu Calorie Information on People with Eating Disorders: A Scoping Review

by
Hardip Malhi
1,*,
Jane Fletcher
1,2 and
Dorothy Balhatchet
3
1
Nutrition Nurses, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Edgbaston, Birmingham B15 2TH, UK
2
School of Nursing, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
3
School of Biosciences, University of Nottingham, Sutton Bonington, Loughborough LE12 5RD, UK
*
Author to whom correspondence should be addressed.
Dietetics 2025, 4(1), 4; https://doi.org/10.3390/dietetics4010004
Submission received: 7 October 2024 / Revised: 12 November 2024 / Accepted: 27 December 2024 / Published: 14 January 2025
Browse Figures
Review Reports Versions Notes

Abstract

Calorie information is often provided on food packaging and is a legal requirement in many countries. There is some evidence to suggest that attention to calorie counting can have a detrimental effect on those with eating disorders (EDs). The aim of this review is to summarise current research relating to the impact of restaurant menu calorie labelling on people with EDs. A search was carried out using the CINAHL Complete and Medline databases. Ten papers were included in the final review. Recent statistics show that the incidence of EDs is increasing. These studies assessed the impact of calorie information on people with EDs. Policies, such as calorie labelling on restaurant menus, could be a contributing factor. Studies exploring the effect the policy has had on obesity levels have not demonstrated a significant positive impact on reducing calorie intake. Qualitative studies conducted in England show the extent to which people with EDs are affected. Much of the data from the transcripts highlighted the negative thoughts that this policy has evoked. A review of the literature has demonstrated that this policy has had a negative impact on people with EDs and little benefit for those with obesity, who may also experience EDs.

1. Introduction

The balance of calorie consumption and expenditure is important in maintaining weight balance [1]. Calorie information is often provided on food packaging and is a legal requirement in many countries [2]. This information can enable individuals to determine how specific foods fit into their daily diet in the context of their individual weight goals. While this information may be helpful for some, there is some evidence to suggest that attention to calorie counting can have a detrimental effect on those with EDs [3] leading to concern that calorie labelling may also increase risk of eating disorder behaviour [4].
EDs are defined by NICE [5] as a persistent disturbance of eating or eating-related behaviour which causes significant impairment to health and psychosocial functioning. There are different types of EDs, each characterized by specific symptoms and behaviours. Anorexia nervosa (AN) is associated with starvation, emaciation, and may include excessive physical activity. Individuals with AN are characterized by an underweight BMI and are usually fixated on body image and weight [6]. Bulimia nervosa (BN) is characterized by episodes of eating abnormally large quantities of food, known as binge-eating, and engaging in compensatory behaviours, such as excessive exercise, vomiting, or misusing medications, such as laxatives [7]. Binge eating disorder (BED) is a condition that demonstrates intense periods of overeating, where those experiencing the condition will feel a lack of control over the binge-eating episodes. It often leads to other health conditions, such as obesity, diabetes, and hypertension [8]. “Eating disorder not otherwise specified (EDNOS)” is a term used in people who have clinically significant eating disorder symptoms but do not meet the diagnostic criteria for the categories above [5].
The global burden of disease study [9] stated 41.9 million cases of EDs globally. NICE [10] identifies that over 700,000 people in the UK have been diagnosed with an eating disorder, and that 94% of these are women. Prevalence is also increasing, with Solmi et al. [11] documenting a doubling of urgent and routine referrals for child and adolescent eating disorder services in the past year. EDNOS is the most common type, and AN is the least common type [10], suggesting that weight status may not be a strong indicator of the presence of eating disorder behaviour. This exacerbates concern that initiatives aimed at reducing obesity may inadvertently increase eating disorder behaviours.
The UK government introduced calorie information on restaurant menus in England in 2022 as an intervention to support a reduction in population obesity through empowering individuals to make lower calorie choices when eating out and incentivising restaurants to provide lower calorie choices [2]. The legislation requires restaurant organisations employing more than 250 people to publish calorie information on their menus [12]. A statement showing the average recommended adult calorie allowance is also required. The suggested statement is “adults need around 2000 kcals a day” [13]. However, this has raised concerns in eating disorder groups where people with EDs may become fixated on calories, thereby exacerbating their condition [14]. While the reasoning is clear, obesity researchers suggest that the evidence does not support a direct link between weight management intervention and eating disorder risk [15]; however, this study focused on participants engaging with obesity treatment services, a small subset of those suggested to be at risk and a context in which risk can perhaps be more carefully controlled than in wider, population health initiatives. It would, therefore, be useful to systematically explore research relating more specifically to any identified negative impact of calorie labelling.

2. Aim

The aim of this review is to summarise current research relating to any identified negative impact of restaurant menu calorie labelling on people with ED.

3. Methods

This scoping review has been conducted using the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [16]. A meta-analysis was not completed as the included studies demonstrated heterogeneity.

3.1. Search Strategy

A search was carried out on two healthcare databases, namely CINAHL Complete and Medline. MeSH terms of “product labelling”, “food labelling”, and “calorie labelling” were entered using the Boolean operator “OR”. Truncated terms are demonstrated with *. Further MeSH terms, namely “eating disorders +”, “eating disorder management”, “binge eating”, “bulimia nervosa”, “avoidant restrictive food intake disorder”, and “eating disord*” were also combined using the Boolean operator “OR”. These two strings of search terms were then combined using the Boolean operator “AND”. Publication dates from 2008 onwards were selected, as this was the year that restaurant calorie labelling first commenced in the USA.

3.2. Inclusion Criteria

The inclusion criteria were developed using the PICO method.

3.3. Inclusion Criteria Were

  • Articles published from 2008 onwards.
  • Available in the English language.
  • Full text available.
  • Population: adults and adolescents > 16 years of age.
  • Intervention: calories information provided on restaurant menus.
  • Comparison: absence of calories on restaurant menus or no intervention.
  • Outcome: any outcome relating to impact on people with ED or risk of ED.

3.4. Exclusion Criteria Were

  • Articles pre-2008.
  • Articles not in the English language.
  • Abstracts only, conference posters.
  • Paediatrics.
  • Calorie information on food packaging.

3.5. Identification of Relevant Papers

Title and abstract screen were completed to remove any papers that were not relevant to the aim. The studies included in the review were selected based on the inclusion criteria. References lists and suggested papers from the database search were hand searched to find any other papers.

3.6. Data Extraction

Data were extracted into a predesigned table. Authors, year of publication, study type, participants, study aims and objectives, methodology, and significant findings were recorded from each of the papers included for the full text review.
The key feelings and emotions described by participants with lived experience of EDs in qualitative studies were recorded and illustrated in a word cloud to enable visualisation.

3.7. Critical Analysis

Critical analysis was conducted on all included studies. A combination of the Critical Appraisal Skills Programme checklists [17,18,19], The Joanna Briggs Institute tools [20], Hong et al. [21] and Baker et al. [22] were utilised based on the study design.

4. Results

The total database search returned five results. There were no duplicates. Following title and abstract screening, all five papers were included for final review. The hand search returned an additional six papers, of which one was excluded as it did not meet the inclusion criteria, as this was a letter to the editor of a journal rather than a study. A total of ten papers were included in the final review. Figure 1 shows the PRISMA flow diagram outlining the screening process.
Table 1 shows the summary of study characteristics, and the outcomes from the critical analysis are shown in Table 2. The study designs included two qualitative studies, one randomised controlled trial, two cohort studies, two mixed methods studies, two cross-sectional studies, and one quasi-experimental study The participants of all the studies were aged 16 years or above.

Impact of Calorie Information

Several studies assessed the impact calorie information had on participants. A qualitative study by Haynos & Roberto [23] aimed to examine the impact of menu calorie labelling on the hypothetical food choices of women with disordered eating. The results of this study demonstrated that menu labelling did not differentially affect food selections in those with elevated disordered eating compared to those without (p = 0.45); however, some differences were seen when broken down by type of eating disorder. Those with a diagnosis of AN or BN ordered food with significantly fewer calories (p < 0.0001) and those with BED ordered food with significantly more calories (p = 0.0001) when presented with calorie information. A later study [24] demonstrated that females were more likely to use calorie information to order lower calorie foods compared to males. Raffoul et al. [31] had similar findings; those with disordered eating ordered fewer calories, and this was associated with a positive mindset.
Salvia et al. [29] assessed the impact that this information had on the ordering choices of sexual minority men. Sexual minority is defined as those whose sexual identity, orientation, or practice differs from the majority of the surrounding society [32]. This study found that those with reported disordered eating behaviours, such as fasting, self-induced vomiting, and laxative and diet pill use, were significantly more likely to notice the calorie information on menus (p = 0.038). These participants were also significantly less likely to maintain an isocaloric intake (p = 0.0147). Lillico et al. [30] did not find any adverse outcomes from calorie labelling on menus when assessing female students at high risk of eating pathologies. Calorie consumption from baseline to follow up did not really change in this study, and neither were any changes found in emotional state. Roberto et al. [14] demonstrated a positive attitude towards calorie information on menus regardless of ED diagnosis.
Two qualitative studies conducted in the UK five months and eight months, respectively, after the implementation of calorie labelling on restaurant menus [25,26] explored the impact on people with lived experience of EDs. Duffy et al. [26] used interpretative phenomenological analysis. Six key themes emerged from the data; (1) calories on menus as an attack; (2) calories in the spotlight; (3) normalising calorie counting; (4) active management; (5) impact on behaviour; and (6) strategies for managing. The participants felt that EDs were dismissed by policy makers and they were being targeted at the expense of an obesity strategy which was perceived by participants to be ineffectual. Frances et al. [25] also identified six key themes which were (1) impact on relationships; (2) exclusion and increased isolation; (3) restricted freedom; (4) dis/embodiment; (5) anger and frustration at the perpetuation of diet culture; and (6) we are all responsible for ourselves. Amongst the key themes identified were negative feelings that have been collated and depicted in Figure 2. Whilst most participants felt the legislation was harmful, a small number did see the benefit.
Liddiard and Hamshaw [27] explore the role that body dissatisfaction plays within our experience of calorie labels on menus. They found that the group with no access to calorie labels ordered more calories than those with access. They also found that participants who were not concerned with body dissatisfaction ordered more calories than those that did regardless of whether the menu they saw had calorie information provided. There was no statistical association found between menu format (calorie information vs. no calorie information) and body dissatisfaction (p = 0.716). The authors also asked participants to rate how hungry they were when making their menu choice, and this was found to have a significant impact on the calorie content of choices (p = 0.014), with hungrier people choosing higher calorie meals.
Putra et al. [28] compared various interventions for tackling obesity, with calorie information on menus being one of them. The results of this study demonstrated that those with an ED had a lower level of agreement on the implementation of this policy than those without an ED. Concerns, such as worsening of symptoms, feeling anxious, and feeling guilty for the choices they make, were all reasons given for why they opposed this policy. Four key themes were identified. The negative effect themes were hyper-fixation and gateway to relapse, as well as negative effects on mood. Two themes of positive effects identified were calorie counting and control (helping them track calories when eating out), and feeling informed and reassured.
Figure 2 shows the word cloud representing feelings expressed by participants in qualitative studies.

5. Discussion

Recent statistics show that the incidence of EDs is increasing in the UK. This is reflected in the number of admissions to hospital, with the Royal College of Psychiatrists quoting an increase of 84% for those struggling to manage their ED [33]. Policies introduced by the government, such as calorie labelling on restaurant menus, could be a contributing factor. Often, these patients are admitted to either a general medical ward or a gastroenterology ward for management. Nursing, medical staff, and allied health professionals in acute hospitals may not have the training or expertise to manage these patients appropriately [34]. Patients with EDs are admitted to acute care when their BMI is too low for safe community management, such as when they are at risk of serious complications, e.g., cardiac problems. People with a very low BMI are also at risk of refeeding syndrome, and reintroduction of nutrition must be closely monitored to reduce complications [35].
The increase in EDs is likely multifactorial and heavily impacted by the recent COVID-19 pandemic, both in terms of overall negative impact on ED behaviour [36,37] and on worsening mental health in those with pre-existing EDs [38]. However, the introduction of calorie labelling on menus could also be a contributing factor. Studies focusing on people with current or previous EDs, such as the ones included in this review, illustrate the impact of this approach. Haynos and Roberto [22] demonstrated that participants with EDs used calorie information to support their ED behaviours, as did Salvia et al. [29]. The study by Larson et al. [24] also found a similar result—those with EDs used the calorie information to their detriment. Furthermore, Putra et al. [28] found that those with EDs were less supportive of this policy compared to those without EDs. The participants of this study also felt the policy would enable ED behaviours, leading to significant negative health impacts. Participants in one study [31] found that calorie information had a negative impact on their food choices, as they often avoided higher calorie items. An example of this behaviour in this paper is where one participant discussed not having a dessert despite wanting something sweet. Declining dessert based on the number of calories had a negative impact on the participants attitude towards food and their subsequent behaviour. The authors stated that had the calorie content not been visible, the participant would most likely have eaten the dessert. This demonstrates how calorie information might have a negative impact on choices of food items that as part of a balanced diet would not be an issue.
Calorie information on menus was introduced to tackle rising obesity levels. Studies exploring the effect the policy has had on obesity levels have not demonstrated a significant positive impact in reducing calorie intake [39]. Petimar et al. [39] evaluated the effect of the policy a year after its implementation in the US and found that although there was an initial decrease in the number of calories purchased, this slowly increased again over the first year of the policy being in place. A systematic review conducted in 2014 that included 31 papers [40] also found that whilst patrons were aware of calorie information, this alone did not influence them in purchasing healthier options when eating out. This supports arguments raised about the potential damage that this approach can cause to those with EDs, despite the prevalence being lower for this population, as there appears to be little gain for those living with obesity, some of whom may also experience EDs. Later systematic reviews [41,42] found an overall small, but statistically significant, reduction in the number of calories purchased, which demonstrates the effective use of this intervention. However, the reviews state there is minimal evidence to support this strategy as an effective method in tackling obesity, as the number of “real world” studies conducted is limited. Most of the studies were conducted in laboratory or simulation settings; therefore, the choices available were limited and, therefore, the food choices made were not reflective of real-life decisions.
Qualitative studies conducted in England [25,26] show the extent to which people with EDs are affected. Much of the data included from the transcripts in these studies highlighted the negative thoughts that this policy has evoked. Figure 2 demonstrates some of the phrases that recurred in both studies. The participants raised concerns about calorie counting being normalised. Some participants with EDs specified calorie counting as the starting point of their condition. There seemed to be a consensus that this policy reinforces eating disorder behaviours. Another key theme was the feeling of social isolation and experiencing barriers to being able to eat out at restaurants, which is a key part of the eating disorder recovery process. Therefore, this intervention has been described in these studies as a personal attack on people with lived experience of EDs for little proven benefit, aligning with the outcomes from quantitative studies included in this review.
Whilst most studies found a negative impact on EDs, Liddiard and Hamshaw [27] showed some positive results towards the policy as well as negative ones. Participants in this study found calorie labels empowering as it helped them make a choice of food that would not negatively impact their psychological state. However, feelings of anxiety, guilt and shame were also linked to seeing calorie labels.
Lillico et al. [30] demonstrated indifference to the introduction of calorie information on menus. However, the response rate to the survey in this study was only 60.5% and the authors stated they chose all female participants as they are considered to be at a higher risk of EDs. Therefore, the results of the study cannot be used in a generalisation as they focus on a very specific group (female undergraduates).
ED activists had a very negative view on the policy. Beat (the UK’s eating disorders charity) have been working closely with people with lived experience of EDs to help support them through the challenges that the implementation of this policy will produce. Multiple petitions have been created to try to stop this policy being implemented or to at least make it more inclusive to support those with EDs (www.change.org) [accessed on 20 August 2023]. Beat also addressed these concerns through a letter to the Secondary Legislation Scrutiny Committee [43]. The charity highlights how they support the government’s concerns regarding obesity and the need to address this, but that the methods employed to do this should be evidence based. The letter highlights how there is a low evidence base for the effectiveness of this strategy, as documented in a Cochrane review by Crockett et al. [44]. Currently, the policy has not yet been evaluated in England—there are plans to do this within 5 years of implementation of the policy [21].
Whilst there is a clear need to address obesity levels, there is no clear evidence to support calorie labelling as an effective intervention to achieve this. The studies in this review demonstrate that a mixed response to the calorie information is required. Some people noticed the information was there but did not use it in any context. Others used this information to restrict their food intake, exacerbating ED behaviour. However, some participants found the information empowering and helpful.

5.1. Recommendations for Future Research

There is a clear need for more research in this field, particularly in the England where it is a relatively new policy. It would also be beneficial to see more qualitative studies in this area to evaluate the feelings behind the policy alongside the statistics. The authors of the studies included in the review have also highlighted a need for further research in this area to help evaluate the effectiveness of this policy.

5.2. Recommendations for Practice

Although there is limited evidence overall, there appears to be a good rationale for a link between calorie information on menus and negative impact on ED behaviours, risk, and barriers to recovery. Health professionals working with people with EDs should, therefore, consider the new calorie information regulations when making recommendations, for example advising about how to request a menu without the information or carefully selecting the restaurants based on whether this information will be present on the menus.

6. Conclusions

The introduction of calorie information on menus was implemented in England in April 2022 as a public health strategy to address obesity and calorie-controlled eating. The rising rates of obesity, including in children, are causing concern for the future health of multiple generations and the subsequent impact on the health service. There has also been an increase in the rate of EDs diagnosed, exacerbated by the COVID-19 pandemic. The impact of this policy on this vulnerable population has been raised as a concern. A review of the literature has demonstrated that this policy has had a negative impact on people with EDs and little benefit for those with obesity, who may also experience EDs. It is recommended that professionals working with people with EDs consider this new guidance within any treatment they are providing. There are overall limited data on this population in relation to this policy. It would be beneficial to see more studies focusing on the impact on these people as well as studies to see whether these policies reduce levels of obesity. It would be useful to incorporate the impact on those with EDs into the government’s evaluation of the programme.

Author Contributions

Conceptualisation, H.M.; methodology H.M. and D.B.; formal analysis, H.M.; writing—original draft preparation, H.M., J.F. and D.B; writing—review and editing, H.M., J.F. and D.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Data sharing not applicable–no new data generated.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Hill, J.; Wyatt, H.R.; Peters, J.C. The importance of energy balance. Eur. Endocrinol. 2013, 9, 111–115. [Google Scholar] [CrossRef] [PubMed]
  2. Kanter, R.; Vanderlee, L.; Vandevijvere, S. Front-of-packaging nutrition labelling policy: Global progress + future directions. Public Health Nutr. 2018, 21, 1399–1408. [Google Scholar] [CrossRef] [PubMed]
  3. Kaur, A.; Briggs, A.; Adams, J.; Rayner, M. New calorie labelling regulations in England. Br. Med. J. 2022, 377, o1079. [Google Scholar] [CrossRef]
  4. Whiteside, A. Collateral damage in a reductionist strategy: The effect of calorie labelling on those with eating disorders. Br. Med. J. 2022, 377, o1402. [Google Scholar] [CrossRef]
  5. National Institute for Health and Care Excellence. Eating Disorders: What Is It? 2019. Available online: https://cks.nice.org.uk/topics/eating-disorders/background-information/definition/ (accessed on 21 July 2023).
  6. Bulik, C.M.; Reba, L.; Siega-Riz, A.; Reichborn-Kjennerud, T. Anorexia Nervosa: Definition, Epidemiology, and Cycle of Risk. Int. J. Eat. Disord. 2005, 37, S2–S9. [Google Scholar] [CrossRef] [PubMed]
  7. Williams, S.E.; Watts, T.K.O.; Wade, T.D. A review of the definitions of outcome used in the treatment of bulimia nervosa. Clin. Psychol. Rev. 2012, 32, 292–300. [Google Scholar] [CrossRef] [PubMed]
  8. Keski-Rahkonen, A. Epidemiology of binge eating disorder: Prevalence, course, comorbidity, and risk factors. Curr. Opin. Psychiatry 2021, 34, 525–531. [Google Scholar] [CrossRef]
  9. Vos, T.; Lim, S.S.; Abbafati, C.; Abbas, K.M.; Abbasi, M.; Abbasifard, M.; Abbasi-Kangevari, M.; Abbastabar, H.; Abd-Allah, F.; Abdelalim, A.; et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: A systematic analysis for the Global burden of disease study 2019. Lancet 2020, 369, 1204–1222. [Google Scholar] [CrossRef] [PubMed]
  10. National Institute for Health and Care Excellence. Eating Disorders: How Common Is It? 2019. Available online: https://cks.nice.org.uk/topics/eating-disorders/background-information/prevalence/ (accessed on 22 July 2023).
  11. Solmi, F.; Downs, J.L.; Nicholls, D.E. COVID-19 and eating disorders in young people. Lancet Child Adolesc. Health 2021, 5, 316–318. [Google Scholar] [CrossRef]
  12. Department of Health and Social Care. Consultation on Mandating Calorie Labelling in the Out-Of-Home Sector. 2018. Available online: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/751529/consultation-on-calorie-labelling-outside-of-the-home.pdf (accessed on 11 August 2023).
  13. Department of Health and Social Care. Calorie Labelling in the Out of Home Sector: Implementation Guidance. 2021. Available online: https://www.gov.uk/government/publications/calorie-labelling-in-the-out-of-home-sector/calorie-labelling-in-the-out-of-home-sector-implementation-guidance (accessed on 25 July 2023).
  14. Roberto, C.A.; Haynos, A.F.; Schwartz, M.B.; Brownell, K.D.; White, M.A. Calorie estimation accuracy and menu labeling perceptions among individuals with and without binge eating and/ or purging disorders. Eat. Weight. Disord. 2013, 18, 255–261. [Google Scholar] [CrossRef] [PubMed]
  15. Jebeile, H.; Libesman, S.; Melville, H.; Low-wah, T.; Dammery, G.; Seidler, A.L.; Jones, R.A.; McMaster, C.M.; Paxton, S.J.; Hill, A.J.; et al. Eating disorder risk during behavioural weight management in adults with overweight or obesity: A systematic review and meta-analysis. Obes. Rev. 2023, 24, e13561. [Google Scholar] [CrossRef] [PubMed]
  16. Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D.G.; Group, P. Preferred reporting items for systematic reviews and meta-analyses. The PRISMA statement. Ann. Intern. Med. 2009, 151, 264–269. [Google Scholar] [CrossRef]
  17. Critical Appraisal Skills Programme. Qualitative Studies Checklist. 2018. Available online: https://casp-uk.net/images/checklist/documents/CASP-Qualitative-Studies-Checklist/CASP-Qualitative-Checklist-2018/pdf (accessed on 25 July 2023).
  18. Critical Appraisal Skills Programme. Cohort Study Checklist. 2018. Available online: https://casp-uk.net/checklists/casp-cohort-studies-checklist-fillable.pdf (accessed on 25 July 2023).
  19. Critical Appraisal Skills Programme. Randomised Controlled Trial Standard Checklist. 2020. Available online: https://casp-uk.net/images/checklist/documents/CASP-Randomised-Controlled-Trial-Checklist/CASP-RCT-Checklist-PDF-Fillable-Form.pdf (accessed on 25 July 2023).
  20. Moola, S.; Munn, Z.; Tufanaru, C.; Aromataris, E.; Sear, K.; Sfetcu, R.; Currie, M.; Quershi, R.; Mattis, P.; Lisy, K.; et al. Checklist for Analytical Cross-Sectional Studies. 2020. Available online: http://joannabriggs.org/research/critical-appraisal-tools.html (accessed on 25 July 2023).
  21. Hong, Q.N.; Pluye, P.; Fabregues, S.; Bartlett, G.; Boardman, F.; Cargo, M.; Dagenais, P.; Gagnon, M.P.; Griffiths, F.; Nicolau, B.; et al. Mixed Methods Appraisal Tool (MMAT) Version 2018. 2019. Available online: https://www.mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/12796259/MMAT_2018_criteria-manual_2018-08-01_ENG.pdf (accessed on 8 August 2023).
  22. Barker, T.H.; Habibi, N.; Aromataris, E.; Stone, J.C.; Leonardi-Bee, J.; Sears, K.; Hasanoff, S.; Klugar, M.; Tufanaru, C.; Moola, S.; et al. The revised JBI critical appraisal tool for the assessment of risk and bias quasi-experimental studies. JBI Evid. Synth. 2023, 22, 378–388. [Google Scholar] [CrossRef] [PubMed]
  23. Haynos, A.F.; Roberto, C.A. The effects of restaurant menu calorie labeling on hypothetical meal choices of females with disordered eating. Int. J. Eat. Disord. 2017, 50, 275–283. [Google Scholar] [CrossRef]
  24. Larson, A.F.; Roberto, C.A.; Loth, K.A.; Neumark-Sztainer, D. Calorie labels on the restaurant menu: Is the use of weight-control behaviours related to ordering decisions? J. Acad. Nutr. Diet. 2018, 118, 399–408. [Google Scholar] [CrossRef] [PubMed]
  25. Frances, T.; O’Neill, K.; Newman, K. ‘An extra fight I didn’t ask for’: A qualitative survey exploring the impact of calories on menus for people with experience of eating disorders. Br. J. Health Psychol. 2023, 29, 20–36. [Google Scholar] [CrossRef] [PubMed]
  26. Duffy, F.; Peebles, I.; Maloney, E.; Robertson, M.D.A.; Sharpe, H. Individuals with restrictive eating disorders’ experience of the introduction of calories on menus in England: An interpretative phenomenological analysis study. Eur. Eat. Disord. Rev. 2023, 31, 802–812. [Google Scholar] [CrossRef]
  27. Liddiard, E.; Hamshaw, R.J.T. Body dissatisfaction and beyond: Investigating attitudes towards calorie labels on UK food menus. Appetite 2024, 199, 107418. [Google Scholar] [CrossRef]
  28. Putra, I.G.N.E.; Polden, M.; Wareing, L.; Robinson, E. Acceptability and perceived harm of calorie labelling and other obesity polices: A cross-sectional survery study of UK adults with eating disorders and other mental health conditions. Int. J. Eat. Disord. 2024, 56, 2049–2061. [Google Scholar] [CrossRef]
  29. Salvia, M.G.; Mattie, H.; Tran, A. Noticing and Responding to Calorie Labels on Restaurant Menus: Patterns in Sexual-Minority Men. Am. J. Prev. Med. 2024, 66, 269–278. [Google Scholar] [CrossRef]
  30. Lillico, H.G.; Hanning, R.; Findlay, S.; Hammond, D. The effects of calorie labels on those at high-risk of eating pathologies: A pre-post intervention study in a University cafeteria. Public Health 2015, 129, 732–739. [Google Scholar] [CrossRef]
  31. Raffoul, A.; Gibbons, B.; Boluk, K.; Neiterman, E.; Hammond, D.; Kirkpatrick, S.I. “Maybe a little bit of guilt isn’t so bad for the overall health of an individual”: A mixed-methods exploration of young adults’ experiences with calorie labelling. BMC Public Health 2022, 22, 938. [Google Scholar] [CrossRef] [PubMed]
  32. Math, S.B.; Seshadri, S.P. The invisible ones: Sexual minorities. Indian J. Med. Res. 2013, 137, 4–6. [Google Scholar]
  33. Royal College of Psychiatrists. Hospital Admissions for Eating Disorders Increased by 84% in the Last Five Years. Press Release. 2022. Available online: https://www.rpsych.ac.uk/news-and-features/latest-news/detail/2022/05/18/hospital-admissions-for-eating-disorders-increased-by-84-in-the-last-five-year (accessed on 29 July 2024).
  34. Davidson, A.R.; Braham, S.; Dasey, L.; Reidlinger, D.P. Physicians’ perspectives on the treatment of patients with eating disorders in the acute setting. J. Eat. Disord. 2019, 7, 1. [Google Scholar] [CrossRef]
  35. Cioffi, I.; Ponzo, V.; Pellegrini, M.; Evangelista, A.; Bioletto, F.; Ciccone, G.; Pasanisi, F.; Ghigo, E.; Bo, S. The Incidence of the refeeding syndrome. A systematic review and meta-analyses of literature. Clin. Nutr. 2021, 40, 3688–3701. [Google Scholar] [CrossRef] [PubMed]
  36. Ioannidis, K.; Hook, R.W.; Wiedemann, A.; Bhatti, J.; Czabanowska, K.; Roman-Urrestarazu, A.; Grant, J.E.; Goodyer, I.M.; Fonagy, P.; Bullmore, E.T.; et al. Associations between Covid-19 pandemic impact, dimensions of behaviour and eating disorders: A longitudinal UK-based study. Compr. Psychiatry 2022, 115, 152304. [Google Scholar] [CrossRef] [PubMed]
  37. Branley-Bell, D.; Talbot, C.V. Exploring the impact of the Covid19 Pandemic and UK lockdown on individuals with experience of eating disorders. J. Eat. Disord. 2020, 8, s40337. [Google Scholar] [CrossRef] [PubMed]
  38. Warne, N.; Heron, J.; Mars, B.; Kwong, A.S.F.; Solmi, F.; Pearson, R.; Moran, P. Disordered eating and self-harm as risk factors for poorer mental health during the COVID-19 pandemic: A UK-based birth cohort study. J. Eat. Disord. 2021, 9, s40337. [Google Scholar] [CrossRef]
  39. Petimar, J.; Zhang, F.; Cleveland, L.P.; Simon, D.; Gortmaker, S.L.; Polacsek, M.; Bleich, S.N.; Rimm, E.B.; A Roberto, C.; Block, J.P. Estimating the effect of calorie menu labelling on calories purchased in a large restaurant franchise in the southern United States: Quasi-experimental study. Br. Med. J. 2019, 367, 15837. [Google Scholar]
  40. Kiszko, K.M.; Martinez, O.D.; Abrams, C.; Elbel, B. The Influence of Calorie Labeling on Food Orders and Consumption: A review of the literature. J. Community Health 2014, 39, 1248–1269. [Google Scholar] [CrossRef] [PubMed]
  41. Long, M.W.; Tobias, D.K.; Cradock, A.L.; Batchelder, H.; Gortmaker, S.L. Systematic review and Meta-analysis of the impact of restaurant menu calorie labeling. Am. J. Public Health 2015, 105, e11–e24. [Google Scholar] [CrossRef]
  42. Bleich, S.N.; Economos, C.D.; Spiker, M.L.; Vercammen, K.A.; VanEpps, E.M.; Block, J.P.; Elbel, B.; Story, M.; Roberto, C.A. A systematic review of calorie labeling and modified calorie labeling interventions: Impact on consumer and restaurant behaviour. Obesity 2017, 25, 2018–2044. [Google Scholar] [CrossRef] [PubMed]
  43. Clarke, S. Why the Government Must Drop Its Plan to Make Calorie Labels Mandatory. Available online: https://commitees.parliament.uk/publications/6182/documents/68918/default/ (accessed on 11 August 2023).
  44. Crockett, R.A.; E King, S.; Marteau, T.; Prevost, A.; Bignardi, G.; Roberts, N.W.; Stubbs, B.; Hollands, G.; Jebb, S.A. Nutritional labelling for healthier food or non-alcoholic drink purchasing and consumption. Cochrane Database Syst. Rev. 2019, 2, 2. [Google Scholar]
Dietetics 04 00004 g001
Figure 1. PRISMA flow diagram of the search strategy.
Figure 1. PRISMA flow diagram of the search strategy.
Dietetics 04 00004 g001
Dietetics 04 00004 g002
Figure 2. Word cloud representing the feelings of people with lived/living experience of EDs. Created using Worditout.com (accessed on 15 August 2023).
Figure 2. Word cloud representing the feelings of people with lived/living experience of EDs. Created using Worditout.com (accessed on 15 August 2023).
Dietetics 04 00004 g002
Table 1. Summary of the study characteristics.
Table 1. Summary of the study characteristics.
Author(s)Study TypeParticipantsAim/ObjectivesMethodsSignificant Findings
1Haynos & Roberto [23]Randomised controlled trial716 females ≥ 18 yearsTo examine the impact of a popular obesity public policy, menu calorie labelling, on hypothetical food choices of women with disordered eating.Completion of an online survey in which they were then randomly assigned to receive a restaurant menu with or without calorie information listed. Participants selected a meal as they would in a restaurant and answered questions about menu labelling. Menu labelling did not differentially affect the food selections of those with elevated disordered eating (p = 0.45). However, when examined by eating disorder, participants with anorexia nervosa or bulimia nervosa ordered significantly fewer (p < 0.001) and participants with binge eating disorder ordered significantly more (p = 0.001) calories in the menu label versus no label condition.
2Larson et al. [24]Cross-sectional study788 men and 1042 women, mean age 31.0 ± 1.6 yearsTo describe demographic patterns in the use of calorie information on restaurant menus and investigate the relationships between using this information to limit calorie intake and measures of restaurant visit frequency and weight-related concerns and behaviour.Completion of the EAT-IV survey either online, by mail or over the phone. The survey collected data on calorie information on restaurant menus, restaurant use, weight-related concerns, intuitive eating, weight-control behaviours, binge eating, weight status, and demographic characteristics.52.7% noticed calorie information on menus. 38.2% reported they did not use the information in deciding what to order. Using menu labels to limit calories was related to binge eating among women and was associated with more weight-related concerns, dieting, and unhealthy weight control behaviours among both men and women.
3Roberto et al. [14]Cohort study371 adults, males and femalesTo compare individuals with self-reported binge eating disorder, bulimia nervosa, and purging disorder and those without EDs on restaurant calorie information knowledge and perceptions of menu labelling legislation. Completion of an online survey. Two questionnaires: the eating disorder examination questionnaire (EDE-Q) and a restaurant calorie information quiz developed specifically for this study.The findings did not differ based on eating disorder, dieting, weight status, or race/ethnicity. The results indicated that people have difficulty estimating the calories in restaurant meals, and that individuals with and without EDs are largely in favour of menu labelling laws.
4Frances et al. [25]Qualitative study399 participants, males, females, non-binary, non-conforming, sex not disclosed, aged 16–65+ yearsTo explore the impact of calorie labelling on menus on adults with experience of EDs in England.Qualitative online survey using Qualtrics. Six themes were developed: (1) impacts on relationships; (2) exclusion and increased isolation; (3) restricted freedom; (4) dis/embodiment, (5) anger and frustration at the perpetuation of diet culture; and (6) we are all responsible for ourselves. Most participants found calorie labels on menus to be detrimental to their eating disorder and/ or recovery.
5Duffy et al. [26]Qualitative study11 participants, male and females, 18+ years of ageTo explore the impact of the introduction of calories on menus via the out of home legislation in England on individuals with lived/living experience of EDs. Online interviews hosted on Microsoft Teams. Interpretative phenomenological analysis (IPA) was used to explore their experience and establish themes.Six themes were identified: (1) calories on menus as an attack; (2) calories in the spotlight; (3) normalising calorie counting; (4) active management; (5) impact on behaviour; and (6) strategies for managing. EDs were dismissed by policy makers at the expense of an obesity strategy which was perceived to be ineffectual.
6Liddiard & Hamshaw [27]Mixed methods study562 participants included in final analysis (227 men, 335 women)To investigate both the role that body dissatisfaction plays within our experience of calorie labels on menus, as well as attitudes towards calorie labels on menus more broadly.Randomised parallel group design (allocation ratio 1:1). An online survey platform, Qualtrics, randomly allocated participants to one of two menus. Gender identity, body mass index, activity level, and hunger levels were treated as covariates. The survey featured open-ended questions to qualitatively explore attitudes towards calorie labels on menus. Quantitative results did not demonstrate participants with higher levels of body dissatisfaction were at significantly greater odds of using calorie labels to order fewer calories. Qualitative analysis revealed that experiences of calorie labels could be shaped by body image concerns. Themes drew on how calorie labels were empowering, but there were also concerns about their oversimplicity.
7Putra et al. [28]Cohort study1273 participants (n = 583 with an ED)To investigate the acceptability and perceived harm of mandatory calorie labelling on menus in UK adults with an ED and mental health conditions. Participants recruited online. Collected data on socio-demographic characteristics. Participants completed a 7-item Eating Disorder Examination Questionnaire (EDE-Q7). They also completed a four-item Patient Health Questionnaire to assess general mental health (PHQ-4). Five-point Likert scale questions were used to assess perceptions of obesity policies. Participants with an ED had a lower level of support for the implementation of the calorie labelling policy compared to those without an ED (43% vs. 58%, respectively). Half of the respondents with an ED reported that labelling may worsen their ED symptoms. Qualitative data indicated perceived potential harm and perceived benefits of calorie labelling in participants with an ED.
8Salvia et al. [29]Cross-sectional study504 participantsTo quantify the proportion of gay and bisexual men in this sample who reported noticing calorie information on restaurant menus. To describe associations in reported ordering-behaviour changes in response to calorie information with muscle-enhancing and disordered eating behaviours.Online survey using Qualtrics survey panels.Those who reported disordered eating behaviours, such as fasting, self-induced vomiting, and use of laxatives and diet pills, were significantly more likely to notice calories.
9Lillico et al. [30]Quasi-experimental’ study299 female, undergraduate students, 18+ years of age To examine the effect of a public policy on those at high risk for eating pathologies. Specifically looking for any adverse effects related to eating disturbance level. Students at the university completed a 10 min exit survey one month before and one week after the introduction of calorie information on cafeteria menus. Calorie consumption did not significantly decrease from the baseline. There were no changes in emotional states, such as body image satisfaction, anxiety, positive affect, negative affect, and unhealthy weight-related behaviours, such as binging, exercising excessively, or restricting calories.
10Raffoul et al. [31]Mixed methods study10 females, 3 males, 18+ years of ageTo explore young adults’ experiences with labelling, with a focus on its implications for their relationships with food.Qualitative data collected through semi-structured one-on-one interviews. Quantitative data collected through survey consisting of socio-demographic and food and body-related measures.Participants’ perceptions of and experiences with calorie labels were shaped by gender, body esteem, and disordered eating risk.
Table 2. Critical review of studies by authors.
Table 2. Critical review of studies by authors.
AuthorCritical Appraisal ToolAnalysis
Haynos, & Roberto [23]Critical Appraisal Skills Programme—randomised controlled trial checklist [19]Research question follows PICO but no comparator. Randomisation took place through survey website maintaining blinding for the investigator. The intervention of this study was completed before the original study was conducted. Losses to follow up/exclusions after randomisation not discussed. All participants had an eating disorder. Statistical analysis of results. Power calculations and confidence intervals reported. Results can be used for populations with ED but not generalisable to the wider public.
Larson et al. [24]Joanna Briggs Institute—checklist for analytical cross-sectional studies [20]No inclusion/ exclusion criteria defined. Return of completed survey implied consent. The survey used a self-reporting method. This exposes the study to bias. Likert scales were used to answer questions. All participants received the same questionnaire, so they were all reporting in the same way.
Roberto et al. [14]Critical Appraisal Skills Programme—cohort study checklist [18]Clear and focused issue addressed in introduction. Online recruitment of participants through an advertisement. Self-reported ED and measures were all self-reported data. No clarity on how bias was minimized. Confidence intervals not reported. Population was 86% female and 80% Caucasian, so results not generalizable outside this cohort. Maybe helpful in the context of ED population but not for the general public.
Frances et al. [25]Critical Appraisal Skills Programme—qualitative study checklist [17]Clear statement of aims incorporating PICO. Methodology promotes anonymity which will have helped with recruitment and retention. Questionnaire relied on self-reporting. Skip logic resulted in missing demographic data. The participants remained anonymous throughout the study. Data analysis conducted manually and used a thematic approach. Very valuable study as provides insight into the impact of the intervention on a vulnerable population.
Duffy et al. [26] Critical Appraisal Skills Programme—qualitative study checklist [17]Clear aims of the study. Online interviews and survey for demographic data. Purposive sampling via social media used for recruitment to obtain the target population. Ethical considerations have not been documented. Thematic analysis used with raw data to support the themes.
Liddiard, & Hamshaw [27]Mixed methods appraisal tool (MMAT) [21]Clear research question. Data collected allow the question to be answered. Good rationale for mixed methods design. Outputs of qualitative and quantitative components adequately interpreted. Different components of the study adhere to the quality criteria of each tradition of the methods involved.
Putra et al. [28]Critical Appraisal Skills Programme—cohort study checklist [18]Clear and focussed issue addressed in the introduction. Participants recruited online using prolific academic and social media. Multiple methods used to collect data, all of which were self-reported. Descriptive statistics used to analyse the results. p-value and confidence intervals reported. Participants were mostly Caucasian women which reflects the other literature in the prevalence of ED.
Salvia et al. [29]Joanna Briggs Institute—Checklist for Analytical Cross-Sectional Studies [20]Clear inclusion criteria. Participants were paid for completing the survey. Demographics of participants given in table. The survey was self-reported, which exposes the study to bias. An attention check question was used to reduce low quality responses. All participants received the same questionnaire. Statistical analysis was used to interpret the results.
Lillico et al. [30]Joanna Briggs Institute—checklist for quasi-experimental studies [22]The cause and the effect are clearly discussed in the introduction. No comparisons other than the intervention were made. All participants were exposed to the same intervention in the same manner. There was not a control group. Participants completed two surveys (pre and post). A total of 325 participants started the study; however, due to incomplete data only 299 were included in the final results. Outcomes were measured using the same validated tools. However, participants that completed one of the two surveys were included as well as those that completed both. Statistical analysis was completed using SPSS.
Raffoul et al. [31]Mixed methods appraisal tool (MMAT) [21]The research question highlights the population, intervention, and outcome. There is no comparator in this study. The data collected answer the research question. The study has an adequate rationale for mixed methods. Quantitative data captures demographics and body-related measures whereas are qualitative data used to assess the impact on participants. Participants were recruited from a larger study—those indicating they would be happy to participate in similar studies were invited. The two components are integrated to assess body esteem and eating attitudes with thoughts and feelings on calorie information on menus. Statistical analysis as performed on quantitative data. Common themes identified and discussed from qualitative data.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Malhi, H.; Fletcher, J.; Balhatchet, D. The Impact of Restaurant Menu Calorie Information on People with Eating Disorders: A Scoping Review. Dietetics 2025, 4, 4. https://doi.org/10.3390/dietetics4010004

AMA Style

Malhi H, Fletcher J, Balhatchet D. The Impact of Restaurant Menu Calorie Information on People with Eating Disorders: A Scoping Review. Dietetics. 2025; 4(1):4. https://doi.org/10.3390/dietetics4010004

Chicago/Turabian Style

Malhi, Hardip, Jane Fletcher, and Dorothy Balhatchet. 2025. "The Impact of Restaurant Menu Calorie Information on People with Eating Disorders: A Scoping Review" Dietetics 4, no. 1: 4. https://doi.org/10.3390/dietetics4010004

APA Style

Malhi, H., Fletcher, J., & Balhatchet, D. (2025). The Impact of Restaurant Menu Calorie Information on People with Eating Disorders: A Scoping Review. Dietetics, 4(1), 4. https://doi.org/10.3390/dietetics4010004

Article Metrics

Back to TopTop