- Email: [email protected]
Nutritional Value of Meals at Full-service Restaurant Chains
Research Brief
Podcast available online at www.jneb.org
Nutritional Value of Meals at Full-service Restaurant Chains
Amy H. Auchincloss, PhD, MPH1; Beth L. Leonberg, MS, RD, CSP, FADA, LDN2; Karen Glanz, PhD, MPH3; Samantha Bellitz, MS, MPH1; Andrew Ricchezza, MS1; Allison Jervis, MS1 ABSTRACT
Objective: To assess the nutritional value of meals at full-service national restaurant chains with outlets in the Philadelphia region in 2011. Methods: Chains were eligible if nutritional information for all menu items was on company Web pages or printed menus at Philadelphia outlets. Nutrient profiles were analyzed for 2,615 items from 21 eligible chains (out of 29) and compared with United States Department of Agriculture guidelines. Results: Adult meals (entree, side dish, and one-half appetizer) approximated 1,495 kcal, 28 g saturated fat, 3,512 mg sodium, and 11 g fiber; and rose to 2,020 kcal after including a beverage and one-half dessert. Better calorie and fat profiles were observed for entrees tagged ‘‘healthy choice’’ or aimed at seniors or children; however, sodium far exceeded recommended limits. Conclusions and Implications: Foods served at full-service restaurant chains are high in calories, saturated fat, and sodium. Standard definitions are needed for ‘‘healthy choice’’ tags and for entrees targeted to vulnerable age groups. Key Words: nutrition policy, nutrition labeling, energy intake, nutrients, dietary sodium, restaurants (J Nutr Educ Behav. 2014;46:75-81.)
INTRODUCTION Rising trends in obesity have been attributed largely to increased caloric intake1 and have coincided with an exponential increase in the amount of money households in developed nations spend on food away from home, currently representing over one third of calories purchased in the US.2 Food prepared away from home is typically higher in calories and lower in nutrient density than foods prepared at home. Recent work characterizing the nutritional quality of foods sold at quick-service restaurants has documented high energy, fat, and sodium in those foods.3-5 Available data suggest that full-
service restaurants serve oversized portions and foods of low nutritional quality.5-8 Yet, very little work has been done that systematically characterizes the nutritional quality of foods sold at full-service restaurants and restaurants' ‘‘healthy choice’’ items, and that describes differences by restaurant price point. An increasing number of fullservice chain restaurants have chosen to tag a few menu items with ‘‘healthy choice,’’ yet they provide limited nutrition information about those items. Thus, it is not known whether tagged items conform to dietary guidelines.9 Within the full-service restaurant category, the type and range of menu offerings can vary by
1
Department of Epidemiology and Biostatistics, School of Public Health, Drexel University, Philadelphia, PA 2 Department of Nutrition Sciences, College of Nursing and Health Professions, Drexel University, Philadelphia, PA 3 Perelman School of Medicine and School of Nursing, University of Pennsylvania, Philadelphia, PA Address for correspondence: Amy H. Auchincloss, PhD, MPH, Department of Epidemiology and Biostatistics, School of Public Health, Drexel University, 3215 Market Street, Philadelphia, PA 19104; Phone: (215) 762-2056; Fax: (215) 762-1174; E-mail: aha27@ drexel.edu Ó2014 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR http://dx.doi.org/10.1016/j.jneb.2013.10.008
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014
restaurant price point, but how much nutritional quality varies by price point is unknown. Characterizing restaurant menu profiles by price point is relevant to the ongoing discussion about how much the price of healthier foods relative to unhealthy foods contributes to income disparities in obesity, diet quality, and related chronic diseases.10 When fully implemented, a section of the US Patient Protection and Affordable Health Care Act mandates that fast-food and full-service chains with $ 20 locations provide nutrition information at point of purchase.11 This legislation was motivated by low consumer knowledge and awareness of the nutritional values of restaurant foods.12,13 In addition, labeling may spur improvements in restaurant menus as restaurant owners, managers, and chefs become more cognizant of excessive calories, fat, and sodium in their food, and/or because they anticipate negative reactions from the media and their customers.14,15 Information about nutrition at fullservice restaurants has lagged behind fast-food restaurants, in part because many full-service chains have not disclosed nutritional information on their Web sites and Affordable Health
75
76 Auchincloss et al Care Act menu labeling requirements have not yet taken effect. In 2010, Philadelphia passed a point of purchase menu labeling ordinance that required calorie disclosure for all items on menu boards; it also required that chain restaurants ($ 15 locations anywhere in the US) display information about calories, saturated fat, trans fat, sodium, and carbohydrates adjacent to all standard menu items on printed menus.16 The Philadelphia labeling ordinance provided a unique opportunity to analyze the menus of these restaurants. The current study compiled and analyzed full-service chain restaurant menus for select menu categories. In addition, it examined the prevalence of healthy choice tags and whether tagged items correspond to federal dietary guidelines. Chain restaurants were stratified by price point to assess whether nutritional quality varied by restaurant price point.
METHODS Full-service restaurant chains in the Philadelphia region were eligible for inclusion if they displayed calories and sodium for all menu items on either their Web site or their printed menus at Philadelphia outlets between March, 2011 and May, 2011, and the majority of main dishes were singleserving entrees. Of 29 chains, 21 restaurants were eligible for inclusion (see Supplement Figure 1). Three higherpriced restaurants did not meet the criteria for displaying nutrient content, and 3 mid-priced and 2 high-priced restaurants did not meet the criteria for serving single serving entrees. Entree prices were classified based on prices displayed on printed menus at the Philadelphia outlets: lower-priced (most entrees were $6–$9; 23%; n ¼ 5); mid-priced (most entrees were $10–$16; 67%; n ¼ 14); and higherpriced (most entrees were $ $25; 10%; n ¼ 2). (No restaurants had entrees priced mostly in the range of $17–$24.) Nutrition data were downloaded or transcribed from restaurant Web sites and print menus. Analyses focused on the following menu sections because they were consistently reported and had the largest number of items across chains: appetizers, a la carte entrees (a single portion and single plate that typically included a
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014 protein source and was the primary focus of the main course of a meal), and side dishes. Other categories were less consistently labeled but are reported here to describe added calories from these menu sections: desserts, nonalcoholic drinks, alcoholic drinks, and dessert-like drinks (milkshakes, floats, malts, and smoothies). Details on menu categories and classification are in the online Supplement. The final analysis sample of menu items was 2,615. The Institutional Review Board of the Philadelphia Department of Public Health deemed this study exempt because human subjects were not recruited for this research.
Analyses The researchers selected nutrients for analysis based on their inclusion in the US Dietary Guidelines17 and because they were consistently listed on menus: calories (all 21 menus), sodium (all 21 menus), saturated fat (20 menus), total fat (16 menus), and fiber (15 menus). To assess the prevalence of healthier menu items, offerings were designated as ‘‘healthier’’ using criteria based on general nutrition advice in the US Dietary Guidelines (see Supplement Table 1).17 Dietary reference values (DRV) were used for a 2,000-calorie diet for adults and 1,400 calories for children.18 This calorie level for children represents typical calorie needs for sedentary to moderately active 8-year-olds, depending on gender and body size, and has been used by others.17,19 No guidelines exist for appropriate nutrient levels for full-service restaurant menu items. Thus, this study had to define its own criteria using thresholds that resembled those used by others8,19 and were based on US dietary patterns for dinner meals. In the US, full-service restaurants are frequented mostly for dinner, and dinner meals typically account for a larger share of a day's intake than other meal times.20,21 The authors selected # 40% of the DRV to indicate maximum appropriate nutrient levels for a la carte entrees (excluding sides/add-ons and excluding a beverage) and # 10% of the DRV for adult side dishes (Supplement Table 1 provides details). Data were normally distributed (evaluated via plots, qualitative comparison of means and medians, and
skewness statistic). Means and standard deviations were used to characterize the distribution of nutrient content by menu category and menu price. To avoid overweighting restaurants that listed a disproportionate number of menu items per category, summary nutrient values were first calculated for each restaurant by category and then values were averaged across restaurants. To provide information about sodium that can be compared across menu sections and between this study and other studies, the authors calculated the absolute value of sodium and a standardized measure, sodium density (for each menu item, density was defined as milligrams of sodium per 1,000 calories4,22). Generalized linear regression was used with a random intercept for each restaurant chain to account for correlated values with chains (random intercept models).23,24 These models were used assess (1) how much the nutrient content of entrees varied within each restaurant (indicating a high variety of options on the menu) vs between restaurants (indicating a high variety across restaurant establishments); and (2) whether there were differences in calories and nutrients for lower-, mid-, and higher-priced restaurants. For these models, a random intercept was used for each restaurant chain; calories and nutrients were outcome variables; and independent variables were number of items offered per restaurant, price point (high, medium, and low), and calories (when the outcome was not calories). All analyses were done using SAS 9.2 (SAS Institute, Cary, NC, 2009; proc mixed used for regression analyses).
RESULTS Nutrients and Prevalence of Healthier Menu Items Mean calorie content of both a la carte entrees and appetizers was approximately 800 kcal (Table 1, Supplement Figure 1) and did not meet the healthier criteria for calories about 50% of the time (Table 2; see criteria in Supplement Table 1). Approximately 30% of a la carte entrees and appetizers exceeded the DRV for saturated fat and sodium; only 20% of
Calories
A la carte entreesc Burgers and sandwiches Other entrees (not burger or sandwich) Entrees targeted at seniorsd Healthy choice entreesd
Items, n 1,342 180 1,162 48 74
Calories From Fat
Mean Items, (SD) na 804 (180) 1,051 879 (210) 144 797 (187) 907 528 (135) 48 517 (132) 71
Percentage Mean (SD) 46 (7) 47 (6) 46 (8) 46 (6) 34 (15)
Saturated Fat
Sodium Densityb
Fiber
Milligrams, Mean (SD) 1,792 (553) 1,971 (887) 1,769 (507) 1,173 (242) 1,567 (432)
Milligrams, Mean (SD) 2,380 (547) 2,334 (711) 2,383 (564) 2,209 (55) 3,154 (1110)
Items, Grams, na Mean (SD) 1,028 5 (2) 149 5 (2) 879 5 (2) 48 3 (2) 71 6 (2)
Sodium
Items, Grams, Items, na Mean (SD) na 1,247 15 (4) 1,334 160 15 (6) 180 1,087 15 (5) 1,154 48 9 (3) 48 51 7 (8) 74
Appetizers
297 804 (323)
224
49 (5)
277
14 (8)
295
1,896 (682)
2,605 (523)
207
5 (2)
Adult side dishes
563 289 (71)
489
45 (12)
522
6 (2)
545
772 (154)
3,101 (918)
438
3 (1)
166 464 (154)
141
39 (7)
146
8 (4)
159
993 (358)
2,294 (712)
144
3 (1)
171 724 (310)
136
43 (9)
158
20 (10)
170
365 (161)
530 (190)
138
2 (1)
e
247 244 (48)
129
1 (2)
–
–
225
125 (71)
523 (349)
15
1 (0)
Beverages, nonalcoholic (not milkshakes)e
369 161 (72)
299
6 (5)
342
1 (2)
356
66 (48)
631 (527)
–
–
21
41 (8)
22
21 (9)
22
230 (101)
322 (104)
–
–
Children’s a la carte entrees
e
Dessertse Beverages, alcoholic
Dessert-like beverages (milkshakes, floats, malts, and smoothies)e
22 696 (195)
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014
Table 1. Number of Items and Means (SD), by Menu Category, Full-service Restaurant Chains, 2011
a Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%; bSodium density is milligrams of sodium per 1,000 calories; cAll entrees shown are a la carte, which signifies that the entree is without side dishes or accompaniments; d Entrees targeted at seniors and ‘‘healthy choice’’ entrees are not unique to this row. The items are included in entree categories above. Nineteen percent of chains listed entrees targeted to seniors (n ¼ 4) and 52% of chains tagged entrees as ‘‘healthy choice’’ (n ¼ 11) (see Supplement Table 2); eNot all chains had nutritional values for these categories. The proportion (and number) of chains are as follows: children’s a la carte entrees, 25% (n ¼ 5); desserts, 86% (n ¼ 18); alcoholic beverages, 38% (n ¼ 8); nonalcoholic beverages, 71% (n ¼ 15); and dessert-like beverages (milkshakes, floats, malts, and smoothies), 24% (n ¼ 5).
Auchincloss et al 77
78 Auchincloss et al
Table 2. Proportion of Items That Exceeded Healthier Criteria, by Menu Category, Full-service Restaurant Chains, 2011 Proportion of Calories Proportion of Fat Proportion of Saturated (%) Exceeding Calories (%) Exceeding Fat (%) Exceeding
Proportion of Sodium (%) Exceeding
Maximum Criteria for Maximum Criteria for Maximum Criteria for Maximum Criteria for Daily Limit, Healthier Daily Healthier Daily Healthier Daily Healthier Based on Limitb Itemsb Limitb Itemsb Limitb Itemsb $ 1,500 mg Items, na Itemsb
Proportion of Fiber Under Minimum Criteria for Healthier Itemsb
50%
0%
60%
7%
72%
21%
79%
61%
19%
80%
1,342 180
49% 59%
0% 0%
60% 72%
8% 12%
72% 73%
27% 34%
78% 88%
52% 61%
25% 30%
86% 97%
1,162
47%
0%
58%
7%
72%
26%
77%
51%
24%
85%
48
6%
0%
31%
0%
44%
2%
58%
29%
4%
100%
74
3%
0%
6%
0%
12%
2%
80%
43%
8%
89%
Appetizers
297
47%
3%
68%
20%
68%
27%
84%
63%
32%
83%
Adult side dishes
563
62%
0%
65%
0%
76%
3%
81%
87%
1%
60%
Children’s a la carte entrees
166
31%
0%
38%
2%
55%
14%
70%
38%
13%
96%
A la carte entreesc Burgers and sandwiches Other entrees (not burger or sandwich) Entrees targeted at seniorsd Healthy choice entreesd
a
Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%; bCriteria for ‘‘healthier items’’ and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and ‘‘healthier’’ limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for ‘‘healthier items,’’ used recommendations to not exceed 2,300 mg sodium/d; cAll entrees shown are a la carte, which signifies that the entree is without side dishes or accompaniments; dEntrees targeted at seniors and healthy choice entrees are not unique to this row; the items are included in entree categories above.
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014
Average across categories
Maximum Daily Limit, Based on $ 2,300 mg
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014 items met recommended fiber minimums. Meals that were composed of an adult entree, side dish, and a shared appetizer totaled approximately 1,495 kcal, 28 g saturated fat, 3,312 mg sodium, and 11 g fiber; adding a beverage (nonalcoholic) and shared dessert totaled approximately 2,020 kcal, 39 g saturated fat, 3,760 mg sodium, and 12 g fiber. Calorie values were highly correlated with most other nutrients. For the a la carte entree category, Pearson correlations with calories were r ¼ 0.76 for saturated fat, r ¼ 0.60 for sodium, r ¼ 0.67 for carbohydrates, and r ¼ 0.49 for fiber (all P < .001, not shown in tables).
had healthier nutrient content profiles than other entrees, with the exception of sodium density (approximately 3,100 mg/1,000 kcal) (see details in Table 1).
Variation Within and Between Restaurants
Twenty percent of menus had sections that targeted seniors (ie, ‘‘Senior Fare,’’ ‘‘55 Plus Specialty Entrees,’’ ‘‘Guests 60 plus’’). A la carte entrees in this section had lower calories than other entree categories but still exceeded the DRV for saturated fat and sodium, and approximately 33% contained sodium in excess of the maximum recommended intake for an entire day. A total of 75% of menus had sections that targeted children. Children's a la carte entrees had a mean of 464 kcal, with 31% and 70% exceeding healthier calorie and sodium DRVs, respectively. If one half of an adult side dish and one half of an adult-sized nonalcoholic beverage were added to the children's entree, mean calories would be approximately 690 kcal.
Regression model variance decomposition analyses found that about 20% of a la carte entree variability in calories and nutrients resulted from between-restaurant variability, with the rest of the variation found within restaurants (Supplement Table 3). Overall, restaurants differed most on entree calories and percentage of fat calories (about 24% of total variation) and were more similar on sodium, fiber, and saturated fat (16%, 18%, and 7%, respectively). Relative to the higher priced restaurants, lower-price restaurants had 772 mg higher sodium values (95% confidence interval [CI], 208–1,336) and mid-priced restaurants had entrees with 942 mg higher sodium values (95% CI, 441–1,472). However, relative to the higher-priced restaurants, entrees in lower and mid-priced restaurants were lower in saturated fat by 5.5 g (95% CI, 9.2 to 1.8) and 6.1 g (95% CI, 9.6 to 2.5), respectively. Restaurant entree calories, fiber, and percent calories from fat did not statistically significantly differ by restaurant price point (P $ .06). Because of the small numbers of restaurants in each price category, price-point regression results are exploratory and results have wide confidence intervals.
‘‘Healthy Choice’’ Tags
DISCUSSION
Overall, half of the restaurants (n ¼ 11) tagged menu items by name (eg, ‘‘Simple and Fit’’), or symbol (eg, a halo over a chili pepper) to indicate that the company considered it to be a healthy choice item. The proportion of adult a la carte entrees tagged as ‘‘healthy choice’’ ranged from 0% to 25% (mean, 10%) (Supplement Table 2). Among restaurants with ‘‘health choice’’ tags, most used calories alone as the basis for these tags (n ¼ 7; 64%); calorie criteria ranged from < 550 to < 750 calories. Entrees tagged as ‘‘healthy choice’’
This study of 21 full-service restaurant chain menus found that calories and nutrients were high. Values exceeded appropriate levels for a single meal, and under common meal scenarios, exceeded maximum recommended intakes for an entire day, particularly for sodium and saturated fat. Consumers tend to view full-service restaurants as superior in quality and healthfulness compared with quickservice restaurants.25,26 Because of sample and classification differences, it is difficult to make comparisons across studies. However, a few
Items Targeted to Seniors and Children
Auchincloss et al 79 studies contrasted nutritional values by restaurant types and found much higher calories and nutrients at full-service restaurants. For example, Breummer et al27 reported that median values for entrees (some of which included side dishes) at quick-service vs full-service chains had 620 vs 1,010 kcal, 1,480 vs 1,930 mg sodium, and 16.5 vs 10.0 g saturated fat. The regression analysis of Wu and Sturm5 found that relative to fast-food restaurants, entrees at full-service family style restaurants had 1,100 more kcal, 5 g more saturated fat, and 400 mg more sodium. Other studies have noted that relative to quick-service restaurants, full-service restaurants had less healthy profiles for children's entrees: larger portion sizes, more calories,7 and a lower proportion of healthier items.8 The current study found that the prevalence of ‘‘healthy choice’’ tags was low: only 50% of chains tagged items, and among those, only about 10% of a la carte entrees were tagged. Historically, the restaurant industry has reported that customer demand for healthier items is low.28 However, a recent study29 along with industry reports30,31 suggests that healthy choice items account for about 8% to 15% of sales, which is similar to the average proportion of healthy choice offerings found on menus in this study. Future research could examine whether offering a larger percentage of healthy options would proportionally increase sales of healthy choice items.32 In the US, average diets exceed 4,000 mg of sodium per day33; historically, average sodium consumption is even higher in many European countries.34 The US-based National Salt Reduction Initiative has set goals to reduce salt in processed and restaurant food by 25% by 2014. However, current sodium levels at full-service restaurants are so high that even after a reduction of 25%, mean sodium in a la carte entrees would still be about 1,300 mg. Chains dominate the full-service restaurant industry, capturing 70% of market share,35 and their ubiquity in the US points to their potential contribution to dietary intake.36 Although this study's sample of restaurants does not necessarily represent nutritional values in all full-service chains, the
80 Auchincloss et al companies in this sample owned or operated over 12,000 outlets and reported sales exceeding $30 billion in 2010.37 This study relied on nutrition information that may have had some inaccuracies; nevertheless, nutrition information provided by restaurants has been found to have good agreement with laboratory measurements,38 despite some variation by country.39 The present study found sodium to be high at all restaurants, but it was considerably lower at higher-priced full-service restaurants compared with other restaurants, although items at higher-priced restaurants were higher in saturated fat. However, the analysis only included 2 higher priced restaurants, and both featured steak; thus, the generalizability of these results is uncertain.
IMPLICATIONS FOR RESEARCH AND PRACTICE The need to educate customers about the nutritional content of restaurant foods is acute because consumers increasingly eat away from home,2,40 restaurants serve large portions of energy-dense and high-sodium foods, and the prevalence of obesity and other diet-related diseases are high.41 Nutrition educators and other health professionals can promote awareness of recommended intakes of calories, fat, saturated fat, and sodium and instruct consumers on how to use menu labeling to make healthier choices when dining at restaurants that display labels. Nutrition educators working in the hospitality industry could advocate for expanding healthy choice offerings and incorporating a range of nutritional criteria into ‘‘healthy choice’’ tags. Educators can use findings from this and similar studies5,27,28,42 to plan interventions and advocate for public policies that encourage restaurant chains to make healthier choices the standard through product reformulation and portion downsizing. Researchers can use findings reported here as baseline data to assess whether the healthfulness of menus improves over time in response to consumer demand, regulatory activity,43,44 or other factors.28
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014
ACKNOWLEDGMENTS The authors thank Jessica Clark for assistance with compiling data for this project. Funding was made possible, in part, by Cooperative Agreement 1U58DP002626-01 from the Centers for Disease Control and Prevention, US Department of Health and Human Services; and Get Healthy Philly, an initiative of the Philadelphia Department of Public Health. The views expressed in this report do not necessarily reflect the official policies of the Department of Health and Human Services or the Philadelphia Department of Public Health. Mention of trade names, commercial practices, or organizations does not imply endorsement by the authors, the institutions where the authors work, or the funding entities.
7.
8.
9.
10.
11.
SUPPLEMENTARY DATA Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/ j.jneb.2013.10.008. 12.
REFERENCES 1. Swinburn B, Sacks G, Ravussin E. Increased food energy supply is more than sufficient to explain the US epidemic of obesity. Am J Clin Nutr. 2009;90:1453-1456. 2. Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, Ludwig DS. Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. Pediatrics. 2004;113: 112-118. 3. Bassett MT, Dumanovsky T, Huang C, et al. Purchasing behavior and calorie information at fast-food chains in New York City, 2007. Am J Public Health. 2008;98:1457-1459. 4. Johnson CM, Angell SY, Lederer A, et al. Sodium content of lunchtime fast food purchases at major US chains. Arch Intern Med. 2010;170:732-734. 5. Wu HW, Sturm R. What’s on the menu? A review of the energy and nutritional content of US chain restaurant menus. Public Health Nutr. 2012;16:1-10. 6. Binkley JK. Calorie and gram differences between meals at fast food and table service restaurants. Applied Eco-
13.
14.
15.
16.
17.
nomic Perspectives and Policy. 2008;30: 750-763. Reeves S, Wake Y, Zick A. Nutrition labeling and portion size information on children’s menus in fast-food and table-service chain restaurants in London, UK. J Nutr Educ Behav. 2011; 43:543-547. Saelens BE, Glanz K, Sallis JF, Frank LD. Nutrition Environment Measures Study in restaurants (NEMS-R): development and evaluation. Am J Prev Med. 2007;32: 273-281. Jones JL, Krummel DA, Wheeler K, Forbes B, Fitch C. The prevalence of heart-healthy menu items in West Virginia restaurants. Am J Health Behav. 2004;28:328-334. Drewnowski A. Obesity, diets, and social inequalities. Nutr Rev. 2009; 67(suppl 1):S36-S39. US Food and Drug Administration, Division of Dockets Management, Food and Drug Administration. New menu and vending machines labeling requirements. FDA-2011-F0172 (menu). http://www.fda.gov/ food/ingredientspackaginglabeling/labe lingnutrition/ucm217762.htm. Accessed October 1, 2013. Burton S, Howlett E, Tangari AH. Food for thought: how will the nutrition labeling of quick service restaurant menu items influence consumers’ product evaluations, purchase intentions, and choices? Journal of Retailing. 2009; 85:258-273. Elbel B. Consumer estimation of recommended and actual calories at fast food restaurants. Obesity (Silver Spring). 2011;19:1971-1978. Condrasky MD, Obbagy JE, Ledikwe JH, Flood J, Rolls BJ. Chefs’ opinions about reducing the calorie content of menu items in restaurants. Obesity (Silver Spring). 2007;15: 2086-2094. Pulos E, Leng K. Evaluation of a voluntary menu-labeling program in fullservice restaurants. Am J Public Health. 2010;100:1035-1039. Philadelphia Department of Public Health. Philadelphia Menu Labeling Ordinance [Code §§ 6-102, 6-308]. http://www.phila.gov/health/pdfs/Menu LabelinguideFINAL2010-27.pdf. Accessed October 1, 2013. US Department of Agriculture, Dietary Guidelines for Americans Committee. Dietary Guidelines for Americans, 2010. Washington, DC: US Dept of Agriculture; 2011.
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014 18. Committee on Obesity Prevention Policies for Young Children, Institute of Medicine. Early childhood obesity prevention policies, goals, recommendations, and potential actions. http://www .iom.edu/Reports/2011/Early-Childhood -Obesity-Prevention-Policies/Recommendations.aspx. Accessed October 1, 2013. 19. Wellard L, Glasson C, Chapman K. Fries or a fruit bag? Investigating the nutritional composition of fast food children’s meals. Appetite. 2012;58: 105-110. 20. de Castro JM. The time of day of food intake influences overall intake in humans. J Nutr. 2004;134:104-111. 21. Mancino L, Todd J, Lin B-H. Separating what we eat from where: measuring the effect of food away from home on diet quality. Food Policy. 2009;34:557-562. 22. US Department of Agriculture, Hoy MK, Goldman JD, Murayi T, Rhodes DG, Moshfegh AJ. Sodium intake of the U.S. population what we eat in America, NHANES 2007-2008. http:// www.ars.usda.gov/Services/docs.htm? docid¼19476. Accessed October 1, 2013. 23. Merlo J, Chaix B, Yang M, Lynch J, Rastam L. A brief conceptual tutorial of multilevel analysis in social epidemiology: linking the statistical concept of clustering to the idea of contextual phenomenon. J Epidemiol Commun Health. 2005;59:443-449. 24. Snijders TAB, Bosker RJ. Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. 2nd ed. Thousand Oaks, CA: Sage; 2012. 25. Duarte Alonso A, O’Neill M, Liu Y, O’Shea M. Factors driving consumer restaurant choice: an exploratory study from the Southeastern United States. Journal of Hospitality Marketing and Management. 2012;22:547-567.
26. Kim D, Leigh JP. Are meals at full-service and fast-food restaurants ‘‘normal’’ or ‘‘inferior’’? Popul Health Manag. 2011; 14:307-315. 27. Bruemmer B, Krieger J, Saelens BE, Chan N. Energy, saturated fat, and sodium were lower in entrees at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in king county, washington. J Acad Nutr Diet. 2012;112:1169-1176. 28. Glanz K, Resnicow K, Seymour J, et al. How major restaurant chains plan their menus: the role of profit, demand, and health. Am J Prev Med. 2007;32:383-388. 29. Auchincloss AH, Mallya GG, Leonberg BL, Glanz K, Ricchezza A, Schwarz DF. Customer responses to mandatory menu labeling at full-service restaurants. Am J Prev Med. 2013;45:710–719. 30. Horovitz B. Restaurants say consumers are finally ordering healthier meals. USA Today. Published April 13, 2011. http://usatoday30.usatoday.com/money/ industries/food/2011-04-12-healthy-food -restaurants-applebees.htm. Accessed October 1, 2013. 31. Davidson/Freundlich Co. Inc. Restaurant Briefing. Carrollton, TX: Carlson Restaurants Worldwide: American Express Travel Related Services Company, Inc; 2008. 32. Glanz K, Bader MD, Iyer S. Retail grocery store marketing strategies and obesity: an integrative review. Am J Prev Med. 2012;42:503-512. 33. Hill JO. Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council. Am J Clin Nutr. 2009;89:477-484. 34. Public Health Agency of Canada, Penney S. Dropping the salt. http:// www.paho.org/english/ad/dpc/nc/salt-
Auchincloss et al 81 mtg-phac-paper.pdf. Accessed October 1, 2013. 35. The NPD Group. US Independent Restaurants Account for 87 Percent of Industry Traffic Losses Since 2008. Port Washington, NY: The NPD Group; 2012. 36. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100:590-595. 37. Technomic, Top 500 chain restaurant report, full-service chain share by menu category (Appendix E) and glossary of terms. Chicago, IL: Technomic, Inc; 2011. 38. Urban LE, McCrory MA, Dallal GE, et al. Accuracy of stated energy contents of restaurant foods. JAMA. 2011;306:287-293. 39. Stender S, Dyerberg J, Astrup A. Fast food: unfriendly and unhealthy. Int J Obes. 2007;31:887-890. 40. Guthrie JF, Lin BH, Frazao E. Role of food prepared away from home in the American diet, 1977-78 versus 199496: changes and consequences. J Nutr Educ Behav. 2002;34:140-150. 41. Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6-28. 42. Glanz K, Hoelscher D. Increasing fruit and vegetable intake by changing environments, policy and pricing: restaurant-based research, strategies, and recommendations. Prev Med. 2004;39(suppl 2):S88-S93. 43. Stein K. A national approach to restaurant menu labeling: the Patient Protection and Affordable Health Care Act, Section 4205. J Am Diet Assoc. 2010; 110:1280-1286. 1288-1289. 44. Pomeranz JL, Teret SP, Sugarman SD, Rutkow L, Brownell KD. Innovative legal approaches to address obesity. Milbank Q. 2009;87:185-213.
Podcast available online at www.jneb.org
Nutritional Value of Meals at Full-service Restaurant Chains
Amy H. Auchincloss, PhD, MPH1; Beth L. Leonberg, MS, RD, CSP, FADA, LDN2; Karen Glanz, PhD, MPH3; Samantha Bellitz, MS, MPH1; Andrew Ricchezza, MS1; Allison Jervis, MS1 ABSTRACT
Objective: To assess the nutritional value of meals at full-service national restaurant chains with outlets in the Philadelphia region in 2011. Methods: Chains were eligible if nutritional information for all menu items was on company Web pages or printed menus at Philadelphia outlets. Nutrient profiles were analyzed for 2,615 items from 21 eligible chains (out of 29) and compared with United States Department of Agriculture guidelines. Results: Adult meals (entree, side dish, and one-half appetizer) approximated 1,495 kcal, 28 g saturated fat, 3,512 mg sodium, and 11 g fiber; and rose to 2,020 kcal after including a beverage and one-half dessert. Better calorie and fat profiles were observed for entrees tagged ‘‘healthy choice’’ or aimed at seniors or children; however, sodium far exceeded recommended limits. Conclusions and Implications: Foods served at full-service restaurant chains are high in calories, saturated fat, and sodium. Standard definitions are needed for ‘‘healthy choice’’ tags and for entrees targeted to vulnerable age groups. Key Words: nutrition policy, nutrition labeling, energy intake, nutrients, dietary sodium, restaurants (J Nutr Educ Behav. 2014;46:75-81.)
INTRODUCTION Rising trends in obesity have been attributed largely to increased caloric intake1 and have coincided with an exponential increase in the amount of money households in developed nations spend on food away from home, currently representing over one third of calories purchased in the US.2 Food prepared away from home is typically higher in calories and lower in nutrient density than foods prepared at home. Recent work characterizing the nutritional quality of foods sold at quick-service restaurants has documented high energy, fat, and sodium in those foods.3-5 Available data suggest that full-
service restaurants serve oversized portions and foods of low nutritional quality.5-8 Yet, very little work has been done that systematically characterizes the nutritional quality of foods sold at full-service restaurants and restaurants' ‘‘healthy choice’’ items, and that describes differences by restaurant price point. An increasing number of fullservice chain restaurants have chosen to tag a few menu items with ‘‘healthy choice,’’ yet they provide limited nutrition information about those items. Thus, it is not known whether tagged items conform to dietary guidelines.9 Within the full-service restaurant category, the type and range of menu offerings can vary by
1
Department of Epidemiology and Biostatistics, School of Public Health, Drexel University, Philadelphia, PA 2 Department of Nutrition Sciences, College of Nursing and Health Professions, Drexel University, Philadelphia, PA 3 Perelman School of Medicine and School of Nursing, University of Pennsylvania, Philadelphia, PA Address for correspondence: Amy H. Auchincloss, PhD, MPH, Department of Epidemiology and Biostatistics, School of Public Health, Drexel University, 3215 Market Street, Philadelphia, PA 19104; Phone: (215) 762-2056; Fax: (215) 762-1174; E-mail: aha27@ drexel.edu Ó2014 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR http://dx.doi.org/10.1016/j.jneb.2013.10.008
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014
restaurant price point, but how much nutritional quality varies by price point is unknown. Characterizing restaurant menu profiles by price point is relevant to the ongoing discussion about how much the price of healthier foods relative to unhealthy foods contributes to income disparities in obesity, diet quality, and related chronic diseases.10 When fully implemented, a section of the US Patient Protection and Affordable Health Care Act mandates that fast-food and full-service chains with $ 20 locations provide nutrition information at point of purchase.11 This legislation was motivated by low consumer knowledge and awareness of the nutritional values of restaurant foods.12,13 In addition, labeling may spur improvements in restaurant menus as restaurant owners, managers, and chefs become more cognizant of excessive calories, fat, and sodium in their food, and/or because they anticipate negative reactions from the media and their customers.14,15 Information about nutrition at fullservice restaurants has lagged behind fast-food restaurants, in part because many full-service chains have not disclosed nutritional information on their Web sites and Affordable Health
75
76 Auchincloss et al Care Act menu labeling requirements have not yet taken effect. In 2010, Philadelphia passed a point of purchase menu labeling ordinance that required calorie disclosure for all items on menu boards; it also required that chain restaurants ($ 15 locations anywhere in the US) display information about calories, saturated fat, trans fat, sodium, and carbohydrates adjacent to all standard menu items on printed menus.16 The Philadelphia labeling ordinance provided a unique opportunity to analyze the menus of these restaurants. The current study compiled and analyzed full-service chain restaurant menus for select menu categories. In addition, it examined the prevalence of healthy choice tags and whether tagged items correspond to federal dietary guidelines. Chain restaurants were stratified by price point to assess whether nutritional quality varied by restaurant price point.
METHODS Full-service restaurant chains in the Philadelphia region were eligible for inclusion if they displayed calories and sodium for all menu items on either their Web site or their printed menus at Philadelphia outlets between March, 2011 and May, 2011, and the majority of main dishes were singleserving entrees. Of 29 chains, 21 restaurants were eligible for inclusion (see Supplement Figure 1). Three higherpriced restaurants did not meet the criteria for displaying nutrient content, and 3 mid-priced and 2 high-priced restaurants did not meet the criteria for serving single serving entrees. Entree prices were classified based on prices displayed on printed menus at the Philadelphia outlets: lower-priced (most entrees were $6–$9; 23%; n ¼ 5); mid-priced (most entrees were $10–$16; 67%; n ¼ 14); and higherpriced (most entrees were $ $25; 10%; n ¼ 2). (No restaurants had entrees priced mostly in the range of $17–$24.) Nutrition data were downloaded or transcribed from restaurant Web sites and print menus. Analyses focused on the following menu sections because they were consistently reported and had the largest number of items across chains: appetizers, a la carte entrees (a single portion and single plate that typically included a
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014 protein source and was the primary focus of the main course of a meal), and side dishes. Other categories were less consistently labeled but are reported here to describe added calories from these menu sections: desserts, nonalcoholic drinks, alcoholic drinks, and dessert-like drinks (milkshakes, floats, malts, and smoothies). Details on menu categories and classification are in the online Supplement. The final analysis sample of menu items was 2,615. The Institutional Review Board of the Philadelphia Department of Public Health deemed this study exempt because human subjects were not recruited for this research.
Analyses The researchers selected nutrients for analysis based on their inclusion in the US Dietary Guidelines17 and because they were consistently listed on menus: calories (all 21 menus), sodium (all 21 menus), saturated fat (20 menus), total fat (16 menus), and fiber (15 menus). To assess the prevalence of healthier menu items, offerings were designated as ‘‘healthier’’ using criteria based on general nutrition advice in the US Dietary Guidelines (see Supplement Table 1).17 Dietary reference values (DRV) were used for a 2,000-calorie diet for adults and 1,400 calories for children.18 This calorie level for children represents typical calorie needs for sedentary to moderately active 8-year-olds, depending on gender and body size, and has been used by others.17,19 No guidelines exist for appropriate nutrient levels for full-service restaurant menu items. Thus, this study had to define its own criteria using thresholds that resembled those used by others8,19 and were based on US dietary patterns for dinner meals. In the US, full-service restaurants are frequented mostly for dinner, and dinner meals typically account for a larger share of a day's intake than other meal times.20,21 The authors selected # 40% of the DRV to indicate maximum appropriate nutrient levels for a la carte entrees (excluding sides/add-ons and excluding a beverage) and # 10% of the DRV for adult side dishes (Supplement Table 1 provides details). Data were normally distributed (evaluated via plots, qualitative comparison of means and medians, and
skewness statistic). Means and standard deviations were used to characterize the distribution of nutrient content by menu category and menu price. To avoid overweighting restaurants that listed a disproportionate number of menu items per category, summary nutrient values were first calculated for each restaurant by category and then values were averaged across restaurants. To provide information about sodium that can be compared across menu sections and between this study and other studies, the authors calculated the absolute value of sodium and a standardized measure, sodium density (for each menu item, density was defined as milligrams of sodium per 1,000 calories4,22). Generalized linear regression was used with a random intercept for each restaurant chain to account for correlated values with chains (random intercept models).23,24 These models were used assess (1) how much the nutrient content of entrees varied within each restaurant (indicating a high variety of options on the menu) vs between restaurants (indicating a high variety across restaurant establishments); and (2) whether there were differences in calories and nutrients for lower-, mid-, and higher-priced restaurants. For these models, a random intercept was used for each restaurant chain; calories and nutrients were outcome variables; and independent variables were number of items offered per restaurant, price point (high, medium, and low), and calories (when the outcome was not calories). All analyses were done using SAS 9.2 (SAS Institute, Cary, NC, 2009; proc mixed used for regression analyses).
RESULTS Nutrients and Prevalence of Healthier Menu Items Mean calorie content of both a la carte entrees and appetizers was approximately 800 kcal (Table 1, Supplement Figure 1) and did not meet the healthier criteria for calories about 50% of the time (Table 2; see criteria in Supplement Table 1). Approximately 30% of a la carte entrees and appetizers exceeded the DRV for saturated fat and sodium; only 20% of
Calories
A la carte entreesc Burgers and sandwiches Other entrees (not burger or sandwich) Entrees targeted at seniorsd Healthy choice entreesd
Items, n 1,342 180 1,162 48 74
Calories From Fat
Mean Items, (SD) na 804 (180) 1,051 879 (210) 144 797 (187) 907 528 (135) 48 517 (132) 71
Percentage Mean (SD) 46 (7) 47 (6) 46 (8) 46 (6) 34 (15)
Saturated Fat
Sodium Densityb
Fiber
Milligrams, Mean (SD) 1,792 (553) 1,971 (887) 1,769 (507) 1,173 (242) 1,567 (432)
Milligrams, Mean (SD) 2,380 (547) 2,334 (711) 2,383 (564) 2,209 (55) 3,154 (1110)
Items, Grams, na Mean (SD) 1,028 5 (2) 149 5 (2) 879 5 (2) 48 3 (2) 71 6 (2)
Sodium
Items, Grams, Items, na Mean (SD) na 1,247 15 (4) 1,334 160 15 (6) 180 1,087 15 (5) 1,154 48 9 (3) 48 51 7 (8) 74
Appetizers
297 804 (323)
224
49 (5)
277
14 (8)
295
1,896 (682)
2,605 (523)
207
5 (2)
Adult side dishes
563 289 (71)
489
45 (12)
522
6 (2)
545
772 (154)
3,101 (918)
438
3 (1)
166 464 (154)
141
39 (7)
146
8 (4)
159
993 (358)
2,294 (712)
144
3 (1)
171 724 (310)
136
43 (9)
158
20 (10)
170
365 (161)
530 (190)
138
2 (1)
e
247 244 (48)
129
1 (2)
–
–
225
125 (71)
523 (349)
15
1 (0)
Beverages, nonalcoholic (not milkshakes)e
369 161 (72)
299
6 (5)
342
1 (2)
356
66 (48)
631 (527)
–
–
21
41 (8)
22
21 (9)
22
230 (101)
322 (104)
–
–
Children’s a la carte entrees
e
Dessertse Beverages, alcoholic
Dessert-like beverages (milkshakes, floats, malts, and smoothies)e
22 696 (195)
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014
Table 1. Number of Items and Means (SD), by Menu Category, Full-service Restaurant Chains, 2011
a Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%; bSodium density is milligrams of sodium per 1,000 calories; cAll entrees shown are a la carte, which signifies that the entree is without side dishes or accompaniments; d Entrees targeted at seniors and ‘‘healthy choice’’ entrees are not unique to this row. The items are included in entree categories above. Nineteen percent of chains listed entrees targeted to seniors (n ¼ 4) and 52% of chains tagged entrees as ‘‘healthy choice’’ (n ¼ 11) (see Supplement Table 2); eNot all chains had nutritional values for these categories. The proportion (and number) of chains are as follows: children’s a la carte entrees, 25% (n ¼ 5); desserts, 86% (n ¼ 18); alcoholic beverages, 38% (n ¼ 8); nonalcoholic beverages, 71% (n ¼ 15); and dessert-like beverages (milkshakes, floats, malts, and smoothies), 24% (n ¼ 5).
Auchincloss et al 77
78 Auchincloss et al
Table 2. Proportion of Items That Exceeded Healthier Criteria, by Menu Category, Full-service Restaurant Chains, 2011 Proportion of Calories Proportion of Fat Proportion of Saturated (%) Exceeding Calories (%) Exceeding Fat (%) Exceeding
Proportion of Sodium (%) Exceeding
Maximum Criteria for Maximum Criteria for Maximum Criteria for Maximum Criteria for Daily Limit, Healthier Daily Healthier Daily Healthier Daily Healthier Based on Limitb Itemsb Limitb Itemsb Limitb Itemsb $ 1,500 mg Items, na Itemsb
Proportion of Fiber Under Minimum Criteria for Healthier Itemsb
50%
0%
60%
7%
72%
21%
79%
61%
19%
80%
1,342 180
49% 59%
0% 0%
60% 72%
8% 12%
72% 73%
27% 34%
78% 88%
52% 61%
25% 30%
86% 97%
1,162
47%
0%
58%
7%
72%
26%
77%
51%
24%
85%
48
6%
0%
31%
0%
44%
2%
58%
29%
4%
100%
74
3%
0%
6%
0%
12%
2%
80%
43%
8%
89%
Appetizers
297
47%
3%
68%
20%
68%
27%
84%
63%
32%
83%
Adult side dishes
563
62%
0%
65%
0%
76%
3%
81%
87%
1%
60%
Children’s a la carte entrees
166
31%
0%
38%
2%
55%
14%
70%
38%
13%
96%
A la carte entreesc Burgers and sandwiches Other entrees (not burger or sandwich) Entrees targeted at seniorsd Healthy choice entreesd
a
Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%; bCriteria for ‘‘healthier items’’ and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and ‘‘healthier’’ limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for ‘‘healthier items,’’ used recommendations to not exceed 2,300 mg sodium/d; cAll entrees shown are a la carte, which signifies that the entree is without side dishes or accompaniments; dEntrees targeted at seniors and healthy choice entrees are not unique to this row; the items are included in entree categories above.
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014
Average across categories
Maximum Daily Limit, Based on $ 2,300 mg
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014 items met recommended fiber minimums. Meals that were composed of an adult entree, side dish, and a shared appetizer totaled approximately 1,495 kcal, 28 g saturated fat, 3,312 mg sodium, and 11 g fiber; adding a beverage (nonalcoholic) and shared dessert totaled approximately 2,020 kcal, 39 g saturated fat, 3,760 mg sodium, and 12 g fiber. Calorie values were highly correlated with most other nutrients. For the a la carte entree category, Pearson correlations with calories were r ¼ 0.76 for saturated fat, r ¼ 0.60 for sodium, r ¼ 0.67 for carbohydrates, and r ¼ 0.49 for fiber (all P < .001, not shown in tables).
had healthier nutrient content profiles than other entrees, with the exception of sodium density (approximately 3,100 mg/1,000 kcal) (see details in Table 1).
Variation Within and Between Restaurants
Twenty percent of menus had sections that targeted seniors (ie, ‘‘Senior Fare,’’ ‘‘55 Plus Specialty Entrees,’’ ‘‘Guests 60 plus’’). A la carte entrees in this section had lower calories than other entree categories but still exceeded the DRV for saturated fat and sodium, and approximately 33% contained sodium in excess of the maximum recommended intake for an entire day. A total of 75% of menus had sections that targeted children. Children's a la carte entrees had a mean of 464 kcal, with 31% and 70% exceeding healthier calorie and sodium DRVs, respectively. If one half of an adult side dish and one half of an adult-sized nonalcoholic beverage were added to the children's entree, mean calories would be approximately 690 kcal.
Regression model variance decomposition analyses found that about 20% of a la carte entree variability in calories and nutrients resulted from between-restaurant variability, with the rest of the variation found within restaurants (Supplement Table 3). Overall, restaurants differed most on entree calories and percentage of fat calories (about 24% of total variation) and were more similar on sodium, fiber, and saturated fat (16%, 18%, and 7%, respectively). Relative to the higher priced restaurants, lower-price restaurants had 772 mg higher sodium values (95% confidence interval [CI], 208–1,336) and mid-priced restaurants had entrees with 942 mg higher sodium values (95% CI, 441–1,472). However, relative to the higher-priced restaurants, entrees in lower and mid-priced restaurants were lower in saturated fat by 5.5 g (95% CI, 9.2 to 1.8) and 6.1 g (95% CI, 9.6 to 2.5), respectively. Restaurant entree calories, fiber, and percent calories from fat did not statistically significantly differ by restaurant price point (P $ .06). Because of the small numbers of restaurants in each price category, price-point regression results are exploratory and results have wide confidence intervals.
‘‘Healthy Choice’’ Tags
DISCUSSION
Overall, half of the restaurants (n ¼ 11) tagged menu items by name (eg, ‘‘Simple and Fit’’), or symbol (eg, a halo over a chili pepper) to indicate that the company considered it to be a healthy choice item. The proportion of adult a la carte entrees tagged as ‘‘healthy choice’’ ranged from 0% to 25% (mean, 10%) (Supplement Table 2). Among restaurants with ‘‘health choice’’ tags, most used calories alone as the basis for these tags (n ¼ 7; 64%); calorie criteria ranged from < 550 to < 750 calories. Entrees tagged as ‘‘healthy choice’’
This study of 21 full-service restaurant chain menus found that calories and nutrients were high. Values exceeded appropriate levels for a single meal, and under common meal scenarios, exceeded maximum recommended intakes for an entire day, particularly for sodium and saturated fat. Consumers tend to view full-service restaurants as superior in quality and healthfulness compared with quickservice restaurants.25,26 Because of sample and classification differences, it is difficult to make comparisons across studies. However, a few
Items Targeted to Seniors and Children
Auchincloss et al 79 studies contrasted nutritional values by restaurant types and found much higher calories and nutrients at full-service restaurants. For example, Breummer et al27 reported that median values for entrees (some of which included side dishes) at quick-service vs full-service chains had 620 vs 1,010 kcal, 1,480 vs 1,930 mg sodium, and 16.5 vs 10.0 g saturated fat. The regression analysis of Wu and Sturm5 found that relative to fast-food restaurants, entrees at full-service family style restaurants had 1,100 more kcal, 5 g more saturated fat, and 400 mg more sodium. Other studies have noted that relative to quick-service restaurants, full-service restaurants had less healthy profiles for children's entrees: larger portion sizes, more calories,7 and a lower proportion of healthier items.8 The current study found that the prevalence of ‘‘healthy choice’’ tags was low: only 50% of chains tagged items, and among those, only about 10% of a la carte entrees were tagged. Historically, the restaurant industry has reported that customer demand for healthier items is low.28 However, a recent study29 along with industry reports30,31 suggests that healthy choice items account for about 8% to 15% of sales, which is similar to the average proportion of healthy choice offerings found on menus in this study. Future research could examine whether offering a larger percentage of healthy options would proportionally increase sales of healthy choice items.32 In the US, average diets exceed 4,000 mg of sodium per day33; historically, average sodium consumption is even higher in many European countries.34 The US-based National Salt Reduction Initiative has set goals to reduce salt in processed and restaurant food by 25% by 2014. However, current sodium levels at full-service restaurants are so high that even after a reduction of 25%, mean sodium in a la carte entrees would still be about 1,300 mg. Chains dominate the full-service restaurant industry, capturing 70% of market share,35 and their ubiquity in the US points to their potential contribution to dietary intake.36 Although this study's sample of restaurants does not necessarily represent nutritional values in all full-service chains, the
80 Auchincloss et al companies in this sample owned or operated over 12,000 outlets and reported sales exceeding $30 billion in 2010.37 This study relied on nutrition information that may have had some inaccuracies; nevertheless, nutrition information provided by restaurants has been found to have good agreement with laboratory measurements,38 despite some variation by country.39 The present study found sodium to be high at all restaurants, but it was considerably lower at higher-priced full-service restaurants compared with other restaurants, although items at higher-priced restaurants were higher in saturated fat. However, the analysis only included 2 higher priced restaurants, and both featured steak; thus, the generalizability of these results is uncertain.
IMPLICATIONS FOR RESEARCH AND PRACTICE The need to educate customers about the nutritional content of restaurant foods is acute because consumers increasingly eat away from home,2,40 restaurants serve large portions of energy-dense and high-sodium foods, and the prevalence of obesity and other diet-related diseases are high.41 Nutrition educators and other health professionals can promote awareness of recommended intakes of calories, fat, saturated fat, and sodium and instruct consumers on how to use menu labeling to make healthier choices when dining at restaurants that display labels. Nutrition educators working in the hospitality industry could advocate for expanding healthy choice offerings and incorporating a range of nutritional criteria into ‘‘healthy choice’’ tags. Educators can use findings from this and similar studies5,27,28,42 to plan interventions and advocate for public policies that encourage restaurant chains to make healthier choices the standard through product reformulation and portion downsizing. Researchers can use findings reported here as baseline data to assess whether the healthfulness of menus improves over time in response to consumer demand, regulatory activity,43,44 or other factors.28
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014
ACKNOWLEDGMENTS The authors thank Jessica Clark for assistance with compiling data for this project. Funding was made possible, in part, by Cooperative Agreement 1U58DP002626-01 from the Centers for Disease Control and Prevention, US Department of Health and Human Services; and Get Healthy Philly, an initiative of the Philadelphia Department of Public Health. The views expressed in this report do not necessarily reflect the official policies of the Department of Health and Human Services or the Philadelphia Department of Public Health. Mention of trade names, commercial practices, or organizations does not imply endorsement by the authors, the institutions where the authors work, or the funding entities.
7.
8.
9.
10.
11.
SUPPLEMENTARY DATA Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/ j.jneb.2013.10.008. 12.
REFERENCES 1. Swinburn B, Sacks G, Ravussin E. Increased food energy supply is more than sufficient to explain the US epidemic of obesity. Am J Clin Nutr. 2009;90:1453-1456. 2. Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, Ludwig DS. Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. Pediatrics. 2004;113: 112-118. 3. Bassett MT, Dumanovsky T, Huang C, et al. Purchasing behavior and calorie information at fast-food chains in New York City, 2007. Am J Public Health. 2008;98:1457-1459. 4. Johnson CM, Angell SY, Lederer A, et al. Sodium content of lunchtime fast food purchases at major US chains. Arch Intern Med. 2010;170:732-734. 5. Wu HW, Sturm R. What’s on the menu? A review of the energy and nutritional content of US chain restaurant menus. Public Health Nutr. 2012;16:1-10. 6. Binkley JK. Calorie and gram differences between meals at fast food and table service restaurants. Applied Eco-
13.
14.
15.
16.
17.
nomic Perspectives and Policy. 2008;30: 750-763. Reeves S, Wake Y, Zick A. Nutrition labeling and portion size information on children’s menus in fast-food and table-service chain restaurants in London, UK. J Nutr Educ Behav. 2011; 43:543-547. Saelens BE, Glanz K, Sallis JF, Frank LD. Nutrition Environment Measures Study in restaurants (NEMS-R): development and evaluation. Am J Prev Med. 2007;32: 273-281. Jones JL, Krummel DA, Wheeler K, Forbes B, Fitch C. The prevalence of heart-healthy menu items in West Virginia restaurants. Am J Health Behav. 2004;28:328-334. Drewnowski A. Obesity, diets, and social inequalities. Nutr Rev. 2009; 67(suppl 1):S36-S39. US Food and Drug Administration, Division of Dockets Management, Food and Drug Administration. New menu and vending machines labeling requirements. FDA-2011-F0172 (menu). http://www.fda.gov/ food/ingredientspackaginglabeling/labe lingnutrition/ucm217762.htm. Accessed October 1, 2013. Burton S, Howlett E, Tangari AH. Food for thought: how will the nutrition labeling of quick service restaurant menu items influence consumers’ product evaluations, purchase intentions, and choices? Journal of Retailing. 2009; 85:258-273. Elbel B. Consumer estimation of recommended and actual calories at fast food restaurants. Obesity (Silver Spring). 2011;19:1971-1978. Condrasky MD, Obbagy JE, Ledikwe JH, Flood J, Rolls BJ. Chefs’ opinions about reducing the calorie content of menu items in restaurants. Obesity (Silver Spring). 2007;15: 2086-2094. Pulos E, Leng K. Evaluation of a voluntary menu-labeling program in fullservice restaurants. Am J Public Health. 2010;100:1035-1039. Philadelphia Department of Public Health. Philadelphia Menu Labeling Ordinance [Code §§ 6-102, 6-308]. http://www.phila.gov/health/pdfs/Menu LabelinguideFINAL2010-27.pdf. Accessed October 1, 2013. US Department of Agriculture, Dietary Guidelines for Americans Committee. Dietary Guidelines for Americans, 2010. Washington, DC: US Dept of Agriculture; 2011.
Journal of Nutrition Education and Behavior Volume 46, Number 1, 2014 18. Committee on Obesity Prevention Policies for Young Children, Institute of Medicine. Early childhood obesity prevention policies, goals, recommendations, and potential actions. http://www .iom.edu/Reports/2011/Early-Childhood -Obesity-Prevention-Policies/Recommendations.aspx. Accessed October 1, 2013. 19. Wellard L, Glasson C, Chapman K. Fries or a fruit bag? Investigating the nutritional composition of fast food children’s meals. Appetite. 2012;58: 105-110. 20. de Castro JM. The time of day of food intake influences overall intake in humans. J Nutr. 2004;134:104-111. 21. Mancino L, Todd J, Lin B-H. Separating what we eat from where: measuring the effect of food away from home on diet quality. Food Policy. 2009;34:557-562. 22. US Department of Agriculture, Hoy MK, Goldman JD, Murayi T, Rhodes DG, Moshfegh AJ. Sodium intake of the U.S. population what we eat in America, NHANES 2007-2008. http:// www.ars.usda.gov/Services/docs.htm? docid¼19476. Accessed October 1, 2013. 23. Merlo J, Chaix B, Yang M, Lynch J, Rastam L. A brief conceptual tutorial of multilevel analysis in social epidemiology: linking the statistical concept of clustering to the idea of contextual phenomenon. J Epidemiol Commun Health. 2005;59:443-449. 24. Snijders TAB, Bosker RJ. Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. 2nd ed. Thousand Oaks, CA: Sage; 2012. 25. Duarte Alonso A, O’Neill M, Liu Y, O’Shea M. Factors driving consumer restaurant choice: an exploratory study from the Southeastern United States. Journal of Hospitality Marketing and Management. 2012;22:547-567.
26. Kim D, Leigh JP. Are meals at full-service and fast-food restaurants ‘‘normal’’ or ‘‘inferior’’? Popul Health Manag. 2011; 14:307-315. 27. Bruemmer B, Krieger J, Saelens BE, Chan N. Energy, saturated fat, and sodium were lower in entrees at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in king county, washington. J Acad Nutr Diet. 2012;112:1169-1176. 28. Glanz K, Resnicow K, Seymour J, et al. How major restaurant chains plan their menus: the role of profit, demand, and health. Am J Prev Med. 2007;32:383-388. 29. Auchincloss AH, Mallya GG, Leonberg BL, Glanz K, Ricchezza A, Schwarz DF. Customer responses to mandatory menu labeling at full-service restaurants. Am J Prev Med. 2013;45:710–719. 30. Horovitz B. Restaurants say consumers are finally ordering healthier meals. USA Today. Published April 13, 2011. http://usatoday30.usatoday.com/money/ industries/food/2011-04-12-healthy-food -restaurants-applebees.htm. Accessed October 1, 2013. 31. Davidson/Freundlich Co. Inc. Restaurant Briefing. Carrollton, TX: Carlson Restaurants Worldwide: American Express Travel Related Services Company, Inc; 2008. 32. Glanz K, Bader MD, Iyer S. Retail grocery store marketing strategies and obesity: an integrative review. Am J Prev Med. 2012;42:503-512. 33. Hill JO. Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council. Am J Clin Nutr. 2009;89:477-484. 34. Public Health Agency of Canada, Penney S. Dropping the salt. http:// www.paho.org/english/ad/dpc/nc/salt-
Auchincloss et al 81 mtg-phac-paper.pdf. Accessed October 1, 2013. 35. The NPD Group. US Independent Restaurants Account for 87 Percent of Industry Traffic Losses Since 2008. Port Washington, NY: The NPD Group; 2012. 36. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100:590-595. 37. Technomic, Top 500 chain restaurant report, full-service chain share by menu category (Appendix E) and glossary of terms. Chicago, IL: Technomic, Inc; 2011. 38. Urban LE, McCrory MA, Dallal GE, et al. Accuracy of stated energy contents of restaurant foods. JAMA. 2011;306:287-293. 39. Stender S, Dyerberg J, Astrup A. Fast food: unfriendly and unhealthy. Int J Obes. 2007;31:887-890. 40. Guthrie JF, Lin BH, Frazao E. Role of food prepared away from home in the American diet, 1977-78 versus 199496: changes and consequences. J Nutr Educ Behav. 2002;34:140-150. 41. Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6-28. 42. Glanz K, Hoelscher D. Increasing fruit and vegetable intake by changing environments, policy and pricing: restaurant-based research, strategies, and recommendations. Prev Med. 2004;39(suppl 2):S88-S93. 43. Stein K. A national approach to restaurant menu labeling: the Patient Protection and Affordable Health Care Act, Section 4205. J Am Diet Assoc. 2010; 110:1280-1286. 1288-1289. 44. Pomeranz JL, Teret SP, Sugarman SD, Rutkow L, Brownell KD. Innovative legal approaches to address obesity. Milbank Q. 2009;87:185-213.