Recruitment

To recruit implementers, we used purposive sampling to achieve variation in business types that have been used in prior research on the out-of-home food sector in England including fast food, cafes, restaurants, and pubs [20]. The inclusion criteria for implementers were [1] being employed by a food business subject to the calorie labelling regulations implemented in England in April 2022 [21], and [2] being involved in the delivery of the menu labelling. Being involved included either or both at the strategic level (how to respond to the new regulations), and the operational level (how labels should appear on and be added to menus, and how calorie values should be calculated). We also included representatives of trade organisations because these organisations often represented food business interests to the Government. Initial contacts were sent to employees at 22 food businesses or organizations, from which 12 agreed to interview. One person dropped out before the interview citing their manager no longer wanted them to conduct the interview. No more than one participant was recruited from each organisation. Contact details for interviewees were sourced via business websites and LinkedIn, a professional networking platform [22]. Before recruitment began, we aimed to recruit up to a maximum of 25 implementers. Recruitment was stopped after reaching thematic saturation, which was operationalized as no new themes related to implementation or enforcement provided in 5 consecutive interviews [23]. Field notes assisted with reflections during interviews and helping to identify repeating themes.

To recruit enforcers, we used purposive sampling of LAs to represent four geographical areas (North, Midlands, South and London) and all five quintiles of income deprivation according to the Office for National Statistics [24]. To cover the different types of enforcement activities, we included LAs with and without Primary Authority relationships with large food businesses. The Primary Authority is an LA relationship with business wherein businesses “receive assured and tailored advice on meeting environmental health [or] trading standards” [25]. The inclusion criteria for enforcers were working for an LA and active involvement in enforcing the regulations or providing guidance to businesses as part of a Primary Authority agreement. Thirty-six LAs were initially contacted, from which 10 agreed to interview. One interviewee dropped out before the interview, citing that they had nothing relevant to policy enforcement to report. No more than one participant was recruited from each organisation. Contact details for interviewees were sourced via local government websites and LinkedIn. Before recruitment began, we aimed to recruit up to a maximum of 15 enforcers. Recruitment was stopped after reaching thematic saturation, which was operationalized as no new themes related to implementation or enforcement provided in 5 consecutive interviews [23].

An initial introductory template email was sent to potential interviewees, followed by an approximately 15-minute telephone call to explain the study purpose and check eligibility. All contacts were also sent a Participant Information Sheet (S2 File) explaining the study and its purpose. After the introductory call, if the potential participants met the inclusion criteria and were willing to proceed, then they signed a written electronic consent form prior to the recorded interview.

Data collection: interviews

Semi-structured interviews directed by topic guides were conducted by ME using video conferencing software, and participants were told the interview could last up to 60 minutes. Interviews were conducted from 28 June 2022 to 15 December 2022. Topic guides for implementers and enforcers were similar in the broad topics covered, such as the feasibility of implementation/enforcement, potential barriers and challenges, and the expected impacts of the policy on businesses/local authorities and customers. However, they were specifically adapted to address the unique perspectives and experiences of each group. The guide for implementers focused on their internal processes, including how they implemented the labelling requirements, challenges faced, and changes in business practices. The guide for enforcers was designed to explore regulatory aspects, such as enforcement challenges, compliance monitoring, and interactions with businesses. This tailored approach ensured that we captured a range of experiences related to both implementing and enforcing the calorie labelling policy.

The interview topic guides were developed collaboratively by the research team to address the aims of the work. They were piloted in two instances: first, with a colleague who has led numerous policy-relevant qualitative interview research, and second, in a presentation to the departmental qualitative methods group. The full interview topic guides are provided as supporting files S3 & S4 File Interviews were digitally audio recorded and transcribed verbatim by a trusted external transcription company. Transcripts were checked for accuracy and anonymised for analysis.

Data coding and analysis

Given the pragmatic and descriptive aims of this study, which sought to evaluate and inform policy rather than develop or test theoretical constructs, we used the Framework Method for data analysis [26]. Employing a broadly deductive approach, pre-specified topic guides were used to answer questions related to the experiences and processes of implementing calorie labelling in addition to a more inductive approach to generate open, unrestricted codes from the interview data (S3 & S4 File). Three researchers (ME, JA, MW) independently coded three transcripts to ensure important aspects of the data were not missed, and ME coded all remaining transcripts. The Constant Comparative Method and Deviant Case Analysis were used to ensure reliability of themes. We attempted to reduce our influence on participants’ responses by following a standardised topic guide, asking for clarification where necessary, with the goal of capturing interviewees’ perspectives and experiences as independent from our own expectations. The independent coding by three researchers with mixed methods experience was another procedure to reduce bias. Data were compared within and across participant interviews to identify key themes as well as contradictions or points of tension. During the data analysis phase, researchers most directly involved in analysis (ME, JA, MA) met with other members of the research team to share emerging insights from the data and seek alternative interpretations.

After codes were developed iteratively from the topic guides and transcripts, we proceeded with data analysis. Digital tools, including Microsoft Excel [27] and NVivo, version 12 [28], were used to develop analytical themes, and whiteboard diagramming was used to generate insights regarding the structural relationships between interviewees and themes encoded from the data. To ensure the research included insights from our entire study sample, data were charted into a matrix to compare cases and codes. Memos were developed for all themes and provided a substantive basis for reporting in the Results section. Anonymized verbatim quotations were used to illustrate findings [26].

Reflexivity statement

This work was conducted by an inter-disciplinary team of academic researchers with expertise in dietary public health, evaluation of public health interventions, behavioural science, health geography, data science, health economics and mixed-methods research. ME, who is a male research associate with a PhD in nutrition with a minor in epidemiology and an MSc in Medical Anthropology, conducted the interviews. He completed training from the Social Research Association for planning and designing a qualitative study, and had meetings with the project lead, MW, who has extensive experience publishing qualitative research. We have conducted research on current UK implementation of calorie labelling, OHFO and the food they serve, and have experience of policy evaluations including of school food standards, television food advertising restrictions, the Soft Drinks Industry Levy and other soda taxes, and supermarket checkout food policies.

Economic context

Participants reported that when the calorie labelling regulations were implemented, businesses were already struggling because of global financial challenges. Supply chain issues (shortages or higher costs) resulting from forced business closures due to COVID-19 and the economic fallout from the war in Ukraine were particularly mentioned. These conditions created additional challenges to implementing the calorie labelling regulations including frequent changes in ingredient supply.

Participants also felt that this economic background impacted customers. Businesses perceived that customers’ concerns about long-term health and diet-related diseases had become subordinate to more immediate economic concerns, with the ‘cost-of-living crisis’ leading to a focus on ‘value for money’ when eating out of home. Paradoxically, therefore, calorie labelling may have facilitated making selections based on cost per calorie (Table 2).

Business context of the out-of-home food sector

The out-of-home food business context included implementers’ perceptions about why customers use the out-of-home sector and their expectations of the food served; implementers’ claims about central government’s understanding of their sector; and how calorie labelling fit into pre-existing business plans.

Out-of-home food is a treat

According to many implementers, customers believe out-of-home eating is spontaneous and indulgent. One business that conducted detailed customer research summarized their findings, “healthy is more planned, indulgence is spontaneous…” (Implementer 09). This led some implementers to suggest a policy encouraging healthier out-of-home eating misunderstands how customers interact with the sector. Implementers suggested that even if customers are trying to restrict calories, they may not do so when eating out-of-home (Table 2). Some implementers suggested that even very large meals were not important in the context of longer time scales.

From a long-term health perspective... if you think about 2,000 calories a day, 14,000 calories a week, one restaurant meal per week is not a disproportionate amount. There’s so many other inputs to that calorie build during the period of the week that dining out once a week makes virtually zero difference to your overall calorie consumption in a week or a month (Implementer 06).

In many cases, implementers perceived that their food is not identified by customers as health promoting, but that is part of the attraction.

They know what they’re buying…we’re a fun brand, people come for us for a treat, and as a treat it’s going to be calorific on the whole, so generally we want to support the government strategies, but we also want to ensure that we’re not alienating our loyal customer base (Implementer 07).

Diversity of the sector

The common claim that the out-of-home sector is an indulgent treat for customers contrasted with claims that the diversity of the out-of-home sector was not reflected in the design of the regulations. Implementers claimed central government could have understood the business context better, and in doing so could have delivered a better policy.

Government doesn’t understand the out-of-home sector and how it works, how store layout is, how consumers work in those environments, they don’t understand that at all, which doesn’t help. On top of that, you have an industry that is very, very different... So the same tactic can’t necessarily be applied to all of those (Implementer 04).

The diversity of the out-of-home sector also contrasted with a perceived homogeneity of the grocery retail sector. Business participants suggested any lessons by Central Government from regulating supermarkets did not apply to the out-of-home sector.

You have a number of different supermarkets but essentially it’s the same model and way of getting food into your business… whereas the hospitality sector is much more diverse. Just taking, well, this works in a supermarket, let’s stick it wholesale onto out-of-home, be it, on allergens, be it on calories or whatever... it doesn’t work as simply as that (Implementer 02).

Businesses emphasize customer choice and want a level playing field with other businesses

Despite indicating that the OOH food sector may not represent a supportive context for calorie labelling, participants also reported that their businesses wanted to be seen as responsive to customers’ needs and expectations.

We always want to be seen as a company that listens, reacts and hopefully makes our offers open and viable to all parties without losing that reason that they’re coming to us for a great occasion… there will be some dishes over 2,000 calories but there’ll be a balance across the menus that give us that ability to be able to service everyone’s needs” (Implementer 09).

Although implementers agreed they could support healthier eating, several businesses expressed concerns about a level playing field, both from their own perspective and from the perspective of customers. Issues included larger businesses facing a competitive disadvantage compared to smaller businesses serving similar food that were not in scope of the regulations.

If you look at a company like [online food delivery company], they would tell you that 50–60% of business they have in their books are actually very small business that don’t need to provide that information. (Implementer 11)

Some implementers suggested smaller out-of-home food establishments were the real public health problem if people ate there on a regular basis.

So, the chip shop that is serving a little village you know three times a week doesn’t have to do any of this, but actually they’ve got a far greater impact on their local population than a [chain restaurant] or a pub. (Implementer 06)

Regulatory context – central government and local authorities

Business impacts

Impact on customers

Both implementers and enforcers reported receiving few complaints from the public in relation to calorie labelling and expressed uncertainty and scepticism that the regulations impacted consumer purchases. This scepticism related to a number of issues: customers were perceived to be uninterested in calorie information; the wider food environment was considered too unhealthy for a single policy to make a difference; eating habits were considered too ingrained to be responsive to calorie labelling; focusing on calories alone was felt to be a simplistic response to unhealthy eating and the policy was not considered well targeted to those people who most need to change.

Both implementers and enforcers felt a key barrier to policy success was the lack of messaging to the customer about how to use calorie labels. In some cases, the existing contextual messaging that ‘adults need around 2000 kcal a day’ was considered insufficient (Table 2).

Both implementers and enforcers expressed that the ultimate success or failure of the policy depends on whether people pay attention to the policy and use the information.

Has it been successful or not, I think time will tell and I think it goes back to my point around the number of people that are actually looking at it (Implementer 08)

Some implementers suggested a focus on calories as the only nutritional information provided in labels was overly simplistic and may not necessarily direct customers to healthier choices.

I think if the Government wanted people to know that information, putting calories on something doesn’t really tell the customer much about it... those calories could be mostly sugar, those could be mostly fat. (Implementer 03)

Summary of main findings

This is the first qualitative investigation of the process of mandatory calorie labelling implementation in England’s out-of-home sector. In-depth interviews with individuals responsible for implementing and enforcing the calorie labelling regulations revealed that the potential impact of the policy is influenced by five themes: three contexts, including economic, regulatory and business contexts, and two areas of impact: businesses and customers. Implementers faced extra demands during a financially difficult time. Delivery and enforcement were decentralized, with varied assistance from LAs due to resource constraints. Enforcement activity was low due to resource constraints, few complaints from the public about missing or incorrect labels, and calorie labelling being deemed low priority by LAs that were more concerned about acute threats like allergens. Primary authority relationships played a key role in resolving businesses’ queries about the regulations, creating a sense of “presumed compliance”. Businesses complied with regulations to protect their reputation and maintain customers’ trust. Both sets of participants were supportive of calorie labelling but believed it would have little impact on customer behaviour. There was some indication that calorie labelling may have triggered or accelerated reformulation of menu items.

Strengths and limitations

A key strength of this study was the diverse sample of interview participants working in either implementation or enforcement, which provided a broad understanding of the various perspectives on the calorie labelling regulations. Methodological rigor was maintained through several approaches. Credibility was ensured via triangulation, with two researchers (MW and JA) independently coding 15% of transcripts and reviewing the findings with the primary researcher (ME) to confirm consistency. Transferability was enhanced by sampling participants from different regions for enforcers and across various business types for implementers, ensuring a range of experiences was captured. Recruitment saturation was considered as a balance between pragmatism and methodological rigor throughout the recruitment process, and by the study’s conclusion there was substantial repetition in topics covered by participants. Dependability was supported by a structured data analysis process using the Framework Method, with consistent coding practices and the use of coding memos to track emerging patterns and reflections. Confirmability was achieved through detailed notes from monthly meetings with the core project team (ME, JA, MW), facilitating regular discussions on coding interpretations and methodological adjustments, and maintaining an audit trail of key analytical decisions to reduce potential bias.

While our study provides insights into the impact of calorie labelling, there are limitations that affect our ability to fully understand its effects on implementation and enforcement, as well as its implications for future policy. We did not conduct interviews with central government policymakers or customers, who would likely have provided useful additional insights. Our specific focus on the regulatory and enforcement structure related to calorie labelling in England may not be generalizable to other country contexts with different economic and social conditions and enforcement structures. Interviews concluded approximately seven months after the policy was implemented, which prevents us from drawing conclusions about longer-term impacts or perceptions of the policy.

Interpretation and implications of findings

Insights from these interviews have the potential to refine current policies for enhanced impact and contribute to the development of future policies. Although our findings are grouped differently, they encompass key components of process evaluation frameworks such as the Consolidated Framework for Implementation Research (CFIR; [29]). Specifically, they identify how elements—such as intervention characteristics, outer setting pressures, inner setting constraints, characteristics of individuals, and the process of implementation—collectively influenced the adoption, compliance, and perceived effectiveness of calorie labeling in England’s out-of-home food sector. We outline each set of implications below according to the analytical themes.

Economic context

Our findings on the economic context suggest that the cost-of-living crisis may lead some customers to seek value for money instead of using calorie labels to select lower-calorie options. These claims align with other evidence that people with the lowest income quintile in the UK would need to spend half their disposable income to meet Government dietary guidelines, and that healthier foods are more expensive per calorie [30]. To address the impact of economic factors on food choices, policymakers should prioritize interventions that enhance the affordability of healthier options, and public health campaigns could incorporate messaging that addresses both the health and economic aspects of choosinglower-calorie options. To enhance compliance and optimize the effectiveness of policies, businesses facing financial constraints may benefit from receiving targeted financial or logistical support, thereby increasing the potential benefits to the public.

Implications for regulation and enforcement

Our findings from the regulatory context suggest additional central guidance could increase efficiencies, particularly in a context of stretched LA resources. Although businesses expressed confidence in their own adherence to protect their reputations, enforcement may still be required to verify these claims. Verifying adherence may also become more challenging if regulations are extended to smaller businesses.

Our study identified two layers of trust in enforcement: LAs trusted businesses to comply with the regulations, while businesses trusted LAs to correctly implement them after receiving guidance. However, other research on the compliance practices of OHFOs in England found 80% of the sampled businesses displayed any calorie information, 67% of business had legible calorie information, and 15% followed all compliance criteria [15]. Those findings suggest that the presumed compliance described in this study may not reflect actual practice. Governments play a key role in holding business entities to account, a role that is diminished if governments lack the resources to enforce their own policies [31]. Although few complaints or enforcement actions were reported, our interviews were completed at seven months post-implementation, and there may be more enforcement contacts in the future once COVID-related inspection backlogs clear. An over-reliance on complaints as an indicator of poor compliance may also lead LAs to underestimate compliance, and additional monitoring may be necessary.

Business impacts

Areas for policy improvement from a business perspective centred on more guidance from Central Government, for example publishing frequently asked questions. Businesses also criticized the policy for having too short a timeline given the large amount of work required to calculate and accurately display calorie information on menus. However, plans for a calorie labelling policy were announced in a 2018 policy document, years before the April 2022 implementation [32]. Other studies on financial impacts of the calorie labelling policy on businesses would be required to assess the accuracy of cost-related claims.

Business claims about customers

Although our data reported business claims about customers’ beliefs, rather than customers’ stated or revealed beliefs, implementers made a consistent set of claims regarding their views of their customers. A commercial determinants of health perspective shows how poor diets are heavily influenced by commercial interests [33], and our interviews surfaced tactics employed by the out-of-home food sector that echo strategies found in a broader industry playbook resisting regulation [34].

One common industry tactic is “to turn a health challenge into a fundamental debate about individual freedom and choice” [35]. Implementers asserted business commitments to providing choices based on customer preferences, even if they were unhealthy. For example, offering some menu items with 2,000 calories “to service everyone’s needs” because “different people need different calorie intake” (2,000 calories is the recommended maximum daily intake for an adult). Some implementers agreed their food was not healthy, but that was part of the attraction. This orientation toward customer choice suggests that businesses exist to satisfy customer demand, and that demand is for a treat experience. However, customer preferences are also shaped by industry marketing, which has been shown to promote eating energy-dense, nutritionally poor foods and encourage customer indulgence [36,37]. Implementers also suggested that OOH eating is not the norm, which could be a strategy to reduce the perceived impact of the out-of-home food sector on population obesity. This evidence suggests that regulating industry marketing practices that promote energy-dense, nutritionally poor foods could complement other regulations of the out-of-home food sector.

There were also several claims from businesses about why they should not be regulated or why calorie labels would not affect customers. Implementers claimed that focusing on calories alone was overly simplistic, may not lead to healthier consumer choices, and the out-of-home sector is exceptional because it is too diverse to regulate as a whole. These claims echo common “complexity arguments” that there is “no one-size fits all” solution used by food, beverage, alcohol and gambling industries to limit the scope of public health interventions and in this case to suggest simple solutions like calorie information are ineffective [34]. Some implementers suggested other small out-of-home food establishments were the real public health problem and insisted on the need for a level playing field so all out-of-home eating was subject to the same regulations. This reflects previous claims of ‘exceptionalism.’

If implementer claims about the difficulty to effectively regulate are taken at face value, then a potential solution is co-production of the policy among key stakeholders, which could enhance anticipation and mitigation of barriers [38]. However, previous work on public-private partnerships like the Public Health Responsibility Deal found minimal health impact [39], and improving the efficacy of public-private partnerships may require greater monitoring and enforcement resources [40].

Although the doubts expressed by implementers are common industry arguments against regulation, public health policymakers should also pursue policies with a clear evidence-based theory of change [41]. In addition to product reformulation, the other potential mode of action of calorie labelling is via informed consumer decision making. This depends on consumer attention to and utilization of the information provided. Customer noticing and use of calorie labelling policies are generally low across countries. A multi-country study found within jurisdictions with mandatory calorie labeling in restaurants, only 21% of participants noticed and 11% used calorie information [42]. In England, pre-post surveys of approximately 3,000 out-of-home customers found 32% of participants noticed calorie labels post-implementation, and only 22% of those who noticed also used calorie labelling to make their purchasing decision [16]. This study also found no evidence of change in the energy content of purchases [16]. This reflects both implementers’ and enforcers’ uncertainty that the regulations were likely to impact on consumer behaviour. To address these barriers, messaging strategies could be developed that emphasise social awareness and support for government-led food environment policies [43]. Future menu labelling policies should consider effective label types and designs, such as supportive messaging or alternative labelling (e.g., warning labels), that may have a greater impact on lowering consumer demands compared to information-based policies like calorie labels. Contextual or interpretive labels may help customers select fewer calories [44]. An online randomized controlled trial found added-sugar warning labels on restaurant menus have also led to small reductions in high-sugar menu orders [45]. Although we identified several gaps in compliance and enforcement, policies that make high demands on consumers may not address the key barriers to healthy eating, regardless of the fidelity of implementation.

Finally, the most common proposed solution given by interviewees to improve diets was the suggestion for more customer education. Shifting responsibility to information, education, and individual choice is a common food industry response to regulation [34]. This was also seen in the context of the Public Health Responsibility deal, where despite a claimed commitment to public health, proposed solutions focused on individual behavior changes such as providing information and were ineffective [39].

Unanswered questions or future research

Future research could examine the long-term impact of mandatory calorie labelling regulations on food business menus and customer behaviours. Businesses may prefer to make gradual changes to menus, and future work should explore long-term menu changes. However, it is possible these changes would have eventually occurred anyway according to general business strategies of slow reduction in nutrients of concern. We also identified a general perception of low enforcement activity. Whilst this reflects our own empirical findings on enforcement [15], to our knowledge, there have been no studies testing the accuracy of calorie labelling values. Future work could examine accuracy of calorie labels and whether greater resources for enforcement increases compliance and accuracy. More research on consumer attitudes related to the calorie labelling law in England is also needed, particularly in relation to potentially competing economic concerns. A better understanding of the barriers to consumer change, as well as perspectives from central government officials, could lead to improved future policies or complementary policies that reduce barriers to change.