Healthy menu choices in midwest restaurants

REPORT Healthy Menu Choices in Midwest Restaurants RITA R. WEISBROD,l PHYLLIS

2

L.

PIRIE,! REBECCA M. MULLIS,2 AND PATRICIA SNYDER 4

I Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55455; Current affiliation: Division of Nutrition, Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia 30333; and 3 Division of Human Development and Nutrition, School of Public Health,. University of Minnesota, Minneapolis, Minnesota 55455.

INTRODUCTION

healthy menu choices when eating out. Little descriptive information exists on the availability of healthy menu choices typically facing a person when dining out in American communities. How healthy is the array of choices hel she faces? Are certain kinds of dining sites or certain communities more likely to present healthy menu choices? The study reported here provides some preliminary answers to these questions.

Two recent reports make very similar recommendations regarding desirable changes in the American diet in order to prevent chronic disease: the second joint U.S. Departments of Agriculture and Health and Human Services' Dietary Guidelines for Americans (1) and the National Research Council (NRC) Committee's report Diet and Health (2). Their prescription for the American public emphasizes reducing dietary fat (particularly saturated fat and cholesterol) and sodium, and increasing carbohydrates and dietary fiber by consuming more fruits, vegetables, legumes and whole grain cereals. In fact, dietary intake among American women examined from 1977 to 1985 indicates that these changes are in progress, with low-fat milk and whole grain product consumption rising markedly, and fat and cholesterol consumption falling during this period (3). At the same time, Americans are eating a greater proportion of their meals away from home. In a survey conducted by the Gallup organization in 1987, 39% of Americans reported they had eaten out within the past 48 hours and that they were now spending 40% of their food dollar away from home, compared with the 25% of their food dollar that was spent away from home in 1955 (4). This trend towards more eating out is expected to continue, but there is some evidence that dining out mitigates against dietary improvement. A 1986 Gallup survey (5) indicated that only 39% of those surveyed said they had improved their eating habits away from home. This figure contrasts with the 61 % of those surveyed who reported that they had improved their eating habits at home. A National Restaurant Association survey indicates substantial growth in the popularity of healthy menu items such as fruits, main dish salads and juices (6), but there still may be limited aVailability of

METHODS A comparable sample of food service managers in six Midwestern communities ranging in size from 25,000 to 100,000 were surveyed. The communities were regional service centers for a surrounding area, and provided retail and wholesale trade, professional services, education and government services, as well as jobs in manufacturing and other industries. The communities, in order of size, were Winona, Mankato and St. Cloud, Minnesota; Eau Claire, Wisconsin; Sioux Falls, South Dakota; and Fargo-Moorhead on the Minnesota/North Dakota border. This survey of healthy menu choices was part of a broader community study of health promotion in these communities, which included a worksite telephone survey and personal and telephone interviews with other health promotion providers (7,8). A purposive sampling method was adopted in order to encompass the main categories of dining facilities and to equalize their representation in the sample. That is, each community's dining sites were sampled in the same way, so that whole communities might be characterized for comparative purposes. Within each community, the following restaurants were selected: the six largest restaurants as nominated by local nutrition informants; the largest caterer; all cafeterias from a worksite survey of large employers (over 100 employees); senior dining programs; school and college food services; and a one-in-four random sample of the remaining restaurants listed in the yellow pages of the telephone directory. The random sample of dining

Address for correspondence: Rita R. Weisbrod, Ph.D, 14866 Old Marine Trail, Marine at St. Croix, MN 55074. 0022-3182191/2306-0303$03.00/0 © 1991 SOCIETY FOR NUTRITION EDUCATION

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Table 1. Fifteen pairs of menu items queried in community surveys of dining sites sampled.' Healthier

Less Healthy

Baked chicken Broiled fish Regular (under 4 oz.) hamburger Spaghetti

Fried chicken Fried fish Large (over 4 oz.) hamburger Dinner sausage, hot dog or bratwurst Hot beef and gravy sandwich Chef's salad (with meat and cheese) French fries with entree Regular salad dressing

Roast beef sandwich (no sauce) Tossed salad entree Vegetables with entree Reduced calorie salad dressing Whole grain breads SherbeVice milk or frozen yogurt Fruit Cereal Breakfast ham Low fat milk Milk with coffee

White breads Ice cream Pastry (cookies, pies, cakes) Sweet rolls/donuts Bacon Regular milk Dairy cream with coffee

, The questions were asked in the following format: "Which of these items do you offer-fried chicken or baked chicken?" Response alternatives were: "both," "one (which one?)," "none." A probe where both items were offered was: "Which one do you sell the most of?"

sites was limited to "full menu" sites, eliminating limited menu sites such as fast food outlets, delicatessens and exclusively ethnic (e.g., Chinese) sites, because the questions asked did not apply to these operations for many of the menu choices. However, such sites were included in the random sample frame if they specifically advertised an expanded menu in the telephone yellow pages. Substitutions for out-of-business restaurants were made in the random sample only. The distribution of types of food service sites did not differ Significantly across communities. Managers of dining sites were interviewed by telephone in the spring of 1987 for Winona, Mankato and St. Cloud, and in the spring of 1988 for Eau Claire, Sioux Falls and Fargo-Moorhead. Interviews averaged ten minutes in duration. Out of 215 dining sites contacted, 14 were closed and there were five refusals to partiCipate in the survey. The overall response rate among the eligible institutions was 97.6%. The size of the dining service was obtained by asking each dining service for the average number of persons served at lunch on a typical weekday. The research instrument consisted of three sections:

SECTION 1: Fifteen pairs of menu items (Table 1) were constructed to measure aVailability and demand for healthy menu choices. One item in each pair was judged by a staff of registered dieticians to be more consistent with healthy diet recommendations than was the other food item. The menu items were selected to cover a diversity of menu categories and included the most common healthy

menu choices encountered in pilot interviews. There appears to be no reason to expect price differentials between healthy and less healthy items. Managers were asked whether they offered either or both of the items in the pair; if both the healthy and the less healthy item were offered, managers were asked to give their best judgment of which one sold better.

SECTION 2: Changes in food preparation methods were measured by asking whether the dining service was now deep fat frying or broiling meat and/or using salt more/the same/less than twelve months previously. SECTION 3: Menu changes were measured by asking whether in the last twelve months items had been modified to be lower in calories or if low-calorie items had been added to the menu, if low-fat or low-salt items had been added or if entrees had been modified to be lower in fat or salt. To summarize the data on availability of menu items, four dependent variables were constructed: 1. Both items offered: the number of times each restaurant offered the customer both the healthy and the less healthy item. 2. Only healthier items offered: the number of times each restaurant offered the healthy food item only. 3. Only less healthy items offered: the number of times each restaurant offered the customer the less healthy food item only. 4. Neither item offered: the number of times each restaurant gave the customer neither of the 15 pairs of food items. In all four of these variables the possible range in scores is from 0 to 15; the four variables together must sum to 15.

To summarize the data on consumer demand for healthy items, calculations were made for: 1. The percentage of times that the healthier item sold better when both were offered. 2. The percentage of times the less healthy item sold better when both were offered. These percentages sum to less than 100% because some respondents reported that the healthierlless healthy items sold equally well. Dining sites also were asked to estimate the number of persons they served at an average weekday lunch, so that the effect of dining site size on availability could be examined. Subsequently, data analysis did show a significant effect of size on the dependent variables, and the results shown have been adjusted for this size effect, using quartiles that divided dining sites into sets with equal frequenCies. (Quartiles were: less than 100, 101-175, 176-350, 350 or more diners served. ) While cafeterias accounted for most of the largest quartile (37 out of the 50 sites), the type of dining site did not correlate Significantly with restaurant size. Data were analyzed using analysis of variance techniques for the four healthy menu variables with communities and

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Table 2. Availability of healthy and less healthy menu choices in restaurants and cafeterias in six communities in 1986-87 (N = 201).1 (Adjusted for number of persons served lunch on a weekday.)

Among 15 pairs of healthy and less healthy menu items, numbers of pairs where: Both options Only the healthier Only the less healthy item was offered were offered item was offered

X

7.22 0.22

(sem)

Neither item was offered

3.33 0.13

2.36 0.12

2.00 0.15

Percent of time that healthier items sold better when both items were offered Percent of time that less healthy item sold better when both items were offered Communities were Winona, St. Cloud, Mankato, Minnesota; Eau Claire, Wisconsin; Sioux Falls, South Dakota; Fargo-Moorhead (N. Dakota/Minn.). 2 Percents do not total 100% because some dining sites reported healthy and less healthy items sold equally. 1

Table 3. Percentage of restaurants and cafeterias making healthy changes in food preparation and menu selections in six communities in 1986-87 (N = 201). FOOD PREPARATION Compared with 12 months prior to the survey, restaurants reported: Deep-fat frying less often

38.3%

Broiling meat more often

19.4%

Using salt less often

43.3%

MENU CHANGES Compared with 12 months prior to the survey, restaurants had: Changed items so they are lower in calories or added low-calorie items

48.3%

Changed items so they are lower in fat or added low-fat items

33.8%

Added low-salt items

14.9%

restaurant size as the grouping factors (9), and comparisons of frequencies were made using Chi-Square analysis. The BMDP package of statistical programs running on a VAX 8600 was utilized for this analysis.

RESULTS Table 2 reports the averages and standard errors for the four availability variables. As noted, the community samples did not vary significantly, so their results are combined here. For all dining sites surveyed, both the healthy and unhealthy choices were available for 7.22 out of 15 food pairs; only the healthy choice was offered for 2.36 of the pairs; and only the unhealthy choice was offered for 3.33 of the pairs. When both options were offered, the less healthy item was reported to sell significantly better-56% of the time, compared with 33% of the time that the healthier item was reported to sell better. For all communities (Table 3), the most common food preparation change was using salt less often than a year ago, reported by 43.3% of all dining sites, and deep fat

frying less often, reported by 38.3%. The most common

menu change was adding low calorie items (48.3%). Also, 33.8% reported modifYing menu items so they were lower in fat or adding low-fat items to the menu. Only 14.9% reported adding low-salt items to the menu. An important finding in these surveys is a Significant trend favoring the larger dining sites (Table 4), which are more likely to offer both the healthy and less healthy options, and are Significantly less likely to limit menu options to the less healthy choice. While not statistically significant, there is also a trend faVOring the largest dining site in higher sales of the healthy item when both items were offered. Analysis of food preparation changes by dining site size shows that the most common change, using less salt, varied significantly and was most common at the largest sites, which, as has been noted, are primarily cafeterias. Analysis of menu changes by dining site size did not show an effect for the most common change (lowering calories); however, lowering fat varied by dining site size, again faVOring the larger sites. Looking at specific menu items, it might be asked what the chances were of finding a speCific healthy choice in 1987-88. Looking at the sample of201 dining sites in all six Midwestern communities and calculating the percentage offering that menu choice, the follOwing rank order for 15 healthy menu items can be derived: Rank:

1 Low-fat milk (any type) 2 Whole grain bread 3 Tossed salad 4 Vegetable with entree 5 Reduced calorie salad dreSSing 6 Roast beef sandwich (no sauce) 7 Spaghetti 8 Baked chicken 9 Fruit 10 Broiled fish

96.5% offered this healthy menu choice 91.1% 78.8% 74.9% tie

68.5% 64.0% 63.5% 62.5% 61.1%

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Table 4. Restaurant/dining service size and menu choice, selection, menu changes and food preparation changes at dining sites in six Midwestern communities (N = 201). Average number of people served at a weekday lunch

176 -350 = 47)

> 350 (N = 45)

6.86 2.46 3.92

7.77 2.47 3.06

8.09 2.76 2.04

2.64

1.76

1.70

2.11

33%

28%

33%

39%

58%

65%

56%

53%

Percent of Dining sites reporting Menu Changes in last 12 months2 Added low calorie items Added lower fat items (p = .05)3 Added low salt items

50.8% 32.2% 8.5%

48.0% 20.0% 16.0%

38.3% 40.4% 14.9%

55.6% 44.4% 22.2%

Percent of Dining sites reporting Preparation Changes in last 12 months: 2 Deep-fat frying less often Broiling meat more often Using less salt (p = .02)3

37.3% 20.3% 37.3%

28.0% 14.0% 30.0%

51.1% 27.7% 48.9%

37.8% 15.6% 60.0%

~

Among 15 item pairs,

Quartiles:

Number of pairs where: Both items were offered (p = .03)1 Only healthy option was offered Only less healthy option was offered (p < .0001) 1 Neither option was offered Percent of times that healthier item sold better when both items were offered Percent of times less healthy item sold better when both items were offered 2

1

2 3

(N

100

101 -175 (N = 50)

6.44 1.93 3.98

= 59)

(N

Differences significant by ANOVA at the levels shown. Percents do not total 100% because some dining sites reported healthy and less healthy items sold equally. Differences significant by Chi Square test at the levels shown.

52.7% 11 Low fat frozen dessert 12 Cereal for breakfast 51.2% 13 Breakfast ham 45.3% 14 Regular hamburger 42.8% 15 Milk with coffee 30.5% It might also be asked what the chances were of being faced with only the less healthy menu choice in these communities in 1987-88. Calculating the percentage of the 201 dining sites where only the unhealthy item was available, consumers were most likely to be limited to the less healthy choice in: Rank: 1 Large hamburger 49.8% made only this less healthy choice available 45.3% 2 Dairy cream with coffee 3 Ice cream 36.5% 4 Pastries for dessert 31.0% 5 Fried fish 27.1 % 6 Fried chicken 24.1% tie 7 Regular salad dressing 21.2% 8 Fench fries with entree 9 Chefs salad 13.8%

10 Dinner sausage 13.3% 11 Hot beef and gravy 12.3% tie sandwich 12 Sweet rolls/donuts 13 Bacon 14 White bread 6.9% 15 Regular milk 2.5%

DISCUSSION Healthy menu choices were more available in cafeterias and larger restaurants than in smaller ones. This finding is clear, and encompasses the menu choice, food preparation change and menu change variables. Dining site size was determined by using the manager's estimate of the average number of people served at a weekday lunch, and this definition may be flawed. However, a separate analysis by dining site type (cafeteria, large restaurant, random sample restaurant) showed no Significant effects, indicating that size of the dining site (number of people served) is the more discriminating variable. It does not seem likely that cafeterias and larger restaurants offer more healthy menu choices only in the years covered by this study, but this observation requires testing. In examining the effect of dining site size, there is some

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tendency towards a curvilinear effect (on food preparation change and on menu change items), indicating that the smallest dining sites may be more likely to introduce changes than midsize sites. It was surprising that in the cities studied, there appeared to be no real community differences in the availability of healthy menu items or in consumer demand for them. Based on the index of fifteen pairs of items, the conclusion was drawn that healthy menu choices were generally available when dining out in all the communities. While the list of 15 pairs of items was necessarily limited, a full range of menu segments from entrees to beverages, breakfast to dinner, was included. Across the full range of 15 menu choices specified, the healthy choice was available 9.59 times, and one was likely to be limited to an unhealthy choice only 3.32 times. For particular menu pairs, the aVailability of the healthy choice ranged from 30% to about 96%, but most items fell between 50% and 75%. Although data on the past is lacking, the data on availability in 1987 and 1988 indicates that progress in making healthy items available has been particularly apparent in low-fat milk and whole grain bread, which are now almost ubiquitous. The present estimates are limited to the arena of full service dining sites sampled and may be overly optimistic, because fast food sites were excluded. The level of reported change in menu items and preparation methods was substantial, but may be confounded by recall bias. On the other hand, less healthy items generally sold better than healthy items when both were offered (56% to 33%). Thus, it appears that food service institutions were not restricting choice but rather that diners may be resistant to making healthy choices when dining out. This study focuses on institutional variables and changes rather than on individual variables and food choices, so no conclusions can be drawn regarding nutrition education

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efforts targeting individual diners. However, the findings do suggest that it may be wise to begin nutrition interventions by targeting larger restaurants of all types, since they are likely to already have had some success with including healthy menu items. Small restaurants may be the next most likely targets for such intervention. ACKNOWLEDGMENTS Research reported here was supported by grant HL 25523 from the National Heart, Lung, and Blood Institute, National Institute of Health. All authors were on the staff of the Minnesota Heart Health Program at the time of the study.

NOTES AND REFERENCES 1 U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and your health: Dietary guidelines for Americans (2nd Edition). Washington, DC: Government Printing Office. 1985. 2 Committee on Diet and Health, National Research Council, National Academy of Sciences. Diet and health. Implications for reducing chronic risk. Washington, DC: National Academy Press, 1989. 3 Peterkin, B.B. Women's diets: 1977 and 1985. Journal of Nutrition Education 18(6}:251-257, 1986. 4 Sinclair, V. (ed). The Gallup annual report on eating out. Princeton, NJ: Gallup Organization, 1988. 5 Regan, C. Promoting nutrition in commercial food service establishments. JOllrnal of the American Dietetic Association 87 ( 4 ): 48~88. 1987. 6 National Restaurant Association and the Gallup Organization. Changes in consllmer eating habits. Washington. DC: National Restaurant Association, 1986. 7 Weisbrod, R., P. Pirie, N. Bracht, and P. Elstun. Worksite health promotion in four Midwest cities. Journal of Commllnity Health , 1990, III press. 8 Weisbrod, R., N. Bracht. P. Pirie, and S. Mortenson. Health promotion in Midwest cities. Public Health Reports, 1990, in press 9 Dixon, W. J. BMDP statistical softlL'Ore. Berkeley: University of California Press, 1985, pp. 359-387.