Eating-Out: A Study Of The Nutritional Quality Of Canadian Chain .

Eating-Out: A Study of the Nutritional Quality of CanadianChain Restaurant Foods and Interventions to PromoteHealthy EatingbyMary J. ScourboutakosA thesis submitted in conformity with the requirementsfor the degree of Doctor of PhilosophyDepartment of Nutritional SciencesUniversity of Toronto Copyright by Mary J. Scourboutakos 2016

Eating-Out: A Study of the Nutritional Quality of Canadian ChainRestaurant Foods and Interventions to Promote Healthy EatingMary J. ScourboutakosDoctor of PhilosophyDepartment of Nutritional SciencesUniversity of Toronto2016AbstractCanadians are increasingly eating outside-the-home. At the outset of this thesis therewere no data on the nutritional quality of Canadian chain restaurant foods, the Sodium WorkingGroup’s plan to monitor sodium reductions in the food supply was abandoned, and despiteinterest and numerous bills, there was no existing menu-labelling legislation in Canada.The specific objectives of this thesis were to 1) investigate the nutritional quality of theCanadian chain restaurant food supply; 2) explore consumers’ use of menu-labelling; and 3) testthe potential of alternative forms of labelling in non-chain restaurant settings.Objective 1 was investigated by developing and analyzing a national database of over9000 menu-items from Canadian fast-food and sit-down chain restaurants which was created in2010. There was wide variation in calorie levels within each restaurant and food category;furthermore, portion size, as opposed to calorie density, was the most important driver of thisvariation. Sodium levels in menu items often exceed daily recommendations and despite reportedefforts by the restaurant sector to improve, as of 2013, reductions were minimal.Objective 2 used an online, national consumer survey to test three menu-labellingtreatments (calories; calories and sodium; and calories, sodium and serving size labelling). Theeffect of labelling on consumer choice varied depending on the restaurant setting, however,overall, labelling sodium in addition to calories led consumers to choose meals with significantlyless sodium. There was no additional benefit from adding serving size information.ii

Objective 3 was examined in a quasi-experimental, population-level nutritionlabelling/education intervention study in a campus cafeteria. Results showed that thisintervention could modestly increase fruit and vegetable consumption, and decrease sugarsweetened beverage consumption among University students.Overall, this thesis provides food supply and consumer data to inform public healthpolicy debates around issues concerning food consumed outside-the-home.iii

DedicationThis thesis is dedicated to my Mom,who told me what a PhD was when I was twelve,and then encouraged me to do one.iv

AcknowledgmentsIn the summer following my second year of undergrad, I wrote down an idea for a researchproject ―test healthy take-out food‖ little did I know that two years later, Dr. Mary L’Abbé would propose a somewhat similaridea, that set me on a journey that ended up being more than I ever dreamed it would be.Throughout the journey, the famous quotation attributed to Sir Isaac Newton ―If I have seen further than others it is because I have stood on the shoulders of giants‖ has crossed my mind on numerous occasions, because there have been so many giants in mylife, without whom, none of this would have been possible. Here I will attempt to acknowledgeall of the special people on whose shoulders I stand First and foremost, thank you to Dr. Mary L’Abbé. I can’t imagine what my life would be likeif I hadn’t met you. Words cannot express how fortunate I feel for having had the privilege ofbeing your student. Thank you for teaching and mentoring me, for being patient with me(especially in the early days), for encouraging and inspiring me, for supporting me and for givingme opportunities that exceeded my wildest dreams. So much of what I have achieved, I owe toyou.Second, one of the greatest gifts I gained as part of this experience was my lab sisters, aka, theL’Abbé Lab girls, who journeyed with me. Each of you has brought so much to my life. I trulycherish the friendships we’ve formed and I feel so privileged to have shared this experience withyou.Specifically, I must recognize my ―big sisters‖ JoAnne Arcand, Teri Emrich, Christina Wongand Alyssa Schermel. Thank you for nurturing me when I was a naive undergraduate who wasway too excited and probably asked you far too many questions. Words cannot express howlucky I feel to have benefited from all of your wisdom, insight, advice and guidance. You havetruly been the best role models I could have asked for. You pushed me and inspired me toachieve more than I ever could have without you.Additionally, thank you to the second generation of L’Abbé lab girls: Chelsea Murray, MahsaJessri, Mavra Ahmed, Jodi Bernstein, Sheida Noorhosseini, Marie-Eve Labonté, andBeatriz Franco Arellano. Thank you for listening to my never ending stories, my research rants,and for making Fitz 87 a very special place to be.An immense thanks is owed to my thesis committee members. First, thank you to Dr. ThomasWolever for bringing scientific rigor to my committee meetings and for pushing my thinking andv

my research to new levels. You have been an inspiration and I immensely appreciate the multiyear commitment you made to my academic development. Thank you to Dr. Catherine Mah forbeing a fantastic mentor right from the beginning. I truly appreciate the time you devoted tofostering my intellectual development. Thank you for challenging and encouraging me. I willnever forget that you were a key agent in connecting me with the real policy world and so muchmore.Thank you to my examiners, Dr. Loren Vanderlinen and Dr. Alison Duncan who generouslyagreed to play this role, challenged me with their insight and helped me produce an even betterfinished product.Numerous professors have greatly shaped and contributed to this intellectual endeavour. Thankyou to Dr. Paul Corey, for taking such a genuine interest in my work, for contributing yourexpertise so generously and for all the stimulating discussions about nutrition science. Dr.Gillian Einstein for pushing my thinking into new realms, for cheering me on, and forintroducing me to the world of women’s health. Thank you to the late Dr. Sharon Parker whobelieved in me way back in my undergrad and who wrote countless reference letters on mybehalf. Taking your fourth year course in my second year was an immense joy and the first tastethat got me hooked on public health nutrition.The administrators in the Department of Nutritional Sciences are like angels that take care of allthe DNS students. A special thanks is owed to Louisa Kung, Emelia D’Souza, Patrice Lee andLucile Lo.I am indebted to numerous volunteers who have contributed to my research, notably, ZhilaSemnani-Azad and Sahar Qassem who motivated me by enthusiastically entering data that ledto some of the papers I am most proud of. As well, thank you to Sarah Murphy, Frank Mazza,and Andriana Chomka, who diligently spent many evenings with me, watching people makefood selections.A special thanks is owed to the Victoria College community, especially Chef Nathan Barrettand Bill McFadden, for letting me into your cafeteria, for being so generous with your time, andfor supporting my research. A huge thanks is owed to former Vic President Paul Gooch whohas been my guardian angel since undergrad. Thank you for reading my column and seeingpotential in me way back. You have opened so many doors for me and I am eternally grateful foryour kindness and constant support.Throughout this journey, Massey College has been my home away from home. A huge thankyou is owed to Former Master John Fraser for your wisdom, support, constant encouragementand ego pumping. But most of all, thank you for your dedication to creating such an inspiringand loving environment for graduate students. A special thanks to my Quadrangler mentorsElizabeth Wilson and David Scott, to Senior Fellows Dr. Aubie Angel for running theintellectually enriching Massey Grand Rounds which I learned so much from, and especially,vi

Michael Valpy for being a constant source of encouragement and nutritional experimentation.Most importantly, thank you to my Junior Fellow friends who have inspired me and with whom Ihave shared so much of this journey.A special thanks is owed to the team at Toronto Public Health especially, Loren Vanderlindenand Dia Mamatis, also to MPP France Gelinas, who gave me the opportunity to use myresearch to inform policy.Thank you to all of the journalists who reported on our work and helped our message reach somany people.Thank you to all of the teachers I’ve had since Kindergarten who fostered my love of learning, tosay the least. Especially Dr. Gabriel Ayyavoo, my high school science teacher, whose love forthe science fair inspired me to pursue my first nutrition research project.I owe a huge thank you to the staff, students and professors in the department of NutritionalSciences. A special thanks goes to Beatrice Boucher for being my mentor, Julie Mason, whohas helped and inspired me throughout the years, and to Katie Hopperton who co-founded theDNS journal club with me, and whose insight I learned from at each of our meetings.Thank you to the friends that have supported me. Especially Jemy Joseph who has been afriend, mentor and constant source of inspiration for the past 13 years. I owe so much to you.Also, thank you to Nan Zheng for support and encouragement and to my PhD piano teacherswho gave me a break from research, especially, Midori Koga, Megumi Okamoto, MelodyChan, Matthew Li, and Selena Shen.Thank you to my extended family, especially my Grandma who read all of my papers and evencame to one of my lectures!I owe everything to my Mom, Dad and brother Pete. Thank you for listening to me talk aboutmy research 24/7. Thank you to my Mom for reading every proposal, paper, manuscript, blogpost, etc. over the years. Thank you for encouraging my ideas, cooking for me, listening to meand every other little thing that would take innumerable pages to document. Words cannotexpress how grateful I am for everything you had done for me. I owe my entire success to you.And finally, thank you to God for the life I’ve been gifted with.Funding AcknowledgementI have been extremely fortunate to have received numerous scholarships throughout the course ofmy PhD. The Canadian Institutes of Health Research provided funding through the generousVanier Canada Graduate Scholarship that allowed me to spend more time digging deeper andlearning more about nutrition. I was also the recipient of two Ontario Graduate Scholarships. Mysincerest thanks goes out to Barb Riley (and all of the founders of PICDP) as well as Robvii

Schwartz, whose training programs in Population Intervention for Chronic Disease Preventionand Public Health Policy, respectively, not only provided financial support, but were also keyelements of my training and academic development. I would like to thank you to the AmericanSociety for Nutrition for various travel awards and honorariums.viii