Using Healthy Defaults in Walt Disney World Restaurants to Improve Nutritional Choices

Food parenting at-home vs. in restaurants among African American parents of 3-to-8-year-old children

Feeding style refers to the approach that parents use to feed their child and the emotional climate during eating. Indulgent styles, characterized by low structure and high responsiveness, have been linked to childhood weight gain. Few studies have examined feeding styles within out-of-home contexts (e.g., restaurants), which are common eating environments for many families. This study sought to examine feeding styles at-home and in restaurants among African American parents. 52 African American parents with a 3-to-8-year-old child (M = 35.6 years, 86% mothers, 57% annual household income <$50,000, 57% Associate's degree or higher) who regularly dined at restaurants completed an online survey in winter 2022-2023. Parents reported on demographics, anthropometrics, and their feeding styles at home and in restaurants via The Caregiver's Feeding Style Questionnaire. Findings indicated that the indulgent style was the most common overall. Indulgent styles were more prevalent in restaurants (χ2 = 7.4, p = 0.007) than home, and authoritarian styles more prevalent at home (χ2 = 4.5, p = 0.03). Child weight status differed by feeding style in both contexts (p ≤ 0.04); indulgent styles in restaurants were linked to higher BMI z-scores, while authoritarian styles at home were linked to lower BMI z-scores. Higher parent BMI was linked to increased likelihood of having an indulgent style at home (OR = 1.13, p = 0.03), while lower parent BMI was linked to increased likelihood of the uninvolved style at home (OR = 0.76, p = 0.049). Overall, indulgent styles were common and more prevalent in restaurants, where they were linked to higher child weight status. Findings may inform future health promotion efforts in out-of-home eating contexts.

How do defaults and framing influence food choice? An intervention aimed at promoting plant-based choice in online menus

Nudging consumers towards plant-based foods by making these choices the default option is a promising strategy for effecting sustainable dietary change. In the hypothetical context of online food ordering in a Northern European country, we examined the underlying mechanisms and effectiveness of swapping the default in menus from meat to a plant-based meat alternative. Results showed that pre-selecting a plant-based option in the online setting was not enough to increase choice of plant-based meals alone. Rather, additionally framing the plant-based default as the more sustainable or tasty option was needed to significantly increase choice. While ease was unimportant and held constant in this online setting, endowment and implied endorsement were found to mediate default success such that the positive influence of endowment outweighed the (surprising) negative effect via endorsement. In contrast to general theoretical expectations of default nudges, an endorsement by an online food provider is unlikely to encourage plant-based choices.

Breaking down silos: the multifaceted nature of obesity and the future of weight management

The continued global increase in the prevalence of obesity prompted a meeting at the Royal Society of London investigating causal mechanisms of the disease, 'Causes of obesity: theories, conjectures, and evidence' in October 2022. Evidence presented indicates areas of obesity science where there have been advancements, including an increased understanding of biological and physiological processes of weight gain and maintenance, yet it is clear there is still debate on the relative contribution of plausible causes of the modern obesity epidemic. Consensus was reached that obesity is not a reflection of diminished willpower, but rather the confluence of multiple, complex factors. As such, addressing obesity requires multifactorial prevention and treatment strategies. The accumulated evidence suggests that a continued focus primarily on individual-level contributors will be suboptimal in promoting weight management at the population level. Here, we consider individual biological and physiological processes within the broader context of sociodemographic and sociocultural exposures as well as environmental changes to optimize research priorities and public health efforts. This requires a consideration of a systems-level approach that efficiently addresses both systemic and group-specific environmental determinants, including psychosocial factors, that often serve as a barrier to otherwise efficacious prevention and treatment options. This article is part of a discussion meeting issue 'Causes of obesity: theories, conjectures and evidence (Part I)'.

Differences in food parenting at home versus restaurants among parents of 3-to-8-year-old children

Indulgent parent feeding styles have been linked to less healthful eating behaviors and higher BMI among children. Restaurants are becoming a frequent eating environment for children. Frequent intake of food from restaurants has been associated with increased weight status, making restaurants a target for childhood obesity prevention efforts. Currently, little research has considered parent feeding styles in restaurants and how they might differ from the home setting. Given the increased frequency of children's restaurant consumption, examining parent feeding styles in restaurants may contribute to future research in this area. Therefore, the objective of this study was to examine parent feeding styles at home and in restaurants. Parents whose 3-to-8-year-old children dined out regularly completed a one-time, online survey in February/March 2022. The Caregiver's Feeding Style Questionnaire assessed parent feeding styles at home and in restaurants. Differences in feeding styles were examined across settings. Indulgent feeding styles were most common overall. Parents (n = 117; 92% mothers; 85% white; 61% reported household income > $75,000/year) reported higher demandingness at home (M = 2.6 ± 0.5) compared to restaurants (M = 2.4 ± 0.5; t(116) = 6.7, P < 0.001). Parents were more likely to use indulgent feeding styles (X² = 11.6, P < 0.001) and less likely to use authoritarian feeding styles (X² = 4.6, P < 0.05) in restaurants compared to the home, suggesting parent feeding styles are less structured in restaurants. Results may have implications for future healthy eating interventions in away-from-home contexts.

Addictive behavior as molar behavioral allocation: Distinguishing efficient and final causes in translational research and practice

OBJECTIVE

Translational research on addictive behaviors viewed as molar behavioral allocation is critically reviewed. This work relates rates of behavior to rates of reinforcement over time and has been fruitfully applied to addictive behaviors, which involve excessive allocation to short-term rewards with longer term costs.

METHOD

Narrative critical review.

RESULTS

This approach distinguishes between final and efficient causes of discrete behaviors. The former refers to temporally extended behavior patterns into which the act fits. The latter refers to environmental stimuli or internal psychological mechanisms immediately preceding the act. Final causes are most clear when addictive behaviors are studied over time as a function of changing environmental circumstances. Discrete acts of addictive behavior are part of an extended/molar behavior pattern when immediate constraints on engagement are low and few rewarding alternatives are available. Research framed by efficient causes often use behavioral economic simulation tasks as individual difference variables that precede discrete acts. Such measures show higher demand for addictive commodities and steeper discounting in various risk groups, but whether they predict molar addictive behavior patterning is understudied.

CONCLUSIONS

Although efficient cause analysis has dominated translational research, research supports viewing addictive behavior as molar behavioral allocation. Increasing concern with rate variables underpinning final cause analysis and considering how study methods and temporal units of analysis inform an efficient or final cause analysis may advance understanding of addictive behaviors that occur over time in dynamic environmental contexts. This approach provides linkages between behavioral science and disciplines that study social determinants of health. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Nudging low-medium income mothers towards healthy child options in an online restaurant scenario

Helping mothers make the healthiest choices for their children when eating out can contribute to preventing the prevalence of childhood overweight and obesity, particularly in economically disadvantaged classes. Herein, we tested whether two different nudges (a default option and a social norm prompt) could guide low- and middle-income mothers towards healthier children's menu choices in a fictive restaurant setting and investigated the drivers of healthy child menu selection. A cross-sectional online survey was performed among 809 Italian mothers with children aged between 3 and 12 years, and a between-subjects design (control, nudge 1, and nudge 2) was applied. The findings revealed that both nudges had no significant effect on the number of healthy menu selections compared with the healthy choices made in the control condition. Furthermore, considering the entire sample, the results show that certain characteristics of a mother (e.g., authoritative parenting style) and child (younger age) duo increase the likelihood of the former selecting a healthy children's menu. Similarly, a positive correlation between the likelihood of choosing a healthy children's menu and the mother's involvement in the child's nutrition (meal preparation and weekly diet) was observed.

Matching, behavioral economics, and teleological behaviorism: Final cause analysis of substance use and health behavior

Howard Rachlin and his contemporaries pioneered basic behavioral science innovations that have been usefully applied to advance understanding of human substance use disorder and related health behaviors. We briefly summarize the innovations of molar behaviorism (the matching law), behavioral economics, and teleological behaviorism. Behavioral economics and teleological behaviorism's focus on final causes are especially illuminating for these applied fields. Translational and applied research are summarized for laboratory studies of temporal discounting and economic demand, cohort studies of alcohol and other drug use in the natural environment, and experimental behavioral economic modeling of health behavior-related public health policies. We argue that the teleological behavioral perspective on health behavior is conducive to and merges seamlessly with the contemporary socioecological model of health behavior, which broadens the contextual influences (e.g., community, economic, infrastructure, health care access and policy) of individuals' substance use and other health risk behaviors. Basic-to-applied translations to date have been successful and bode well for continued applications of basic science areas pioneered by Howard Rachlin and his contemporaries.

Effects of a grocery shopping intervention designed to improve diet adherence in diabetes: a randomized trial

OBJECTIVE

The goal of this study was to examine the potential of an optimal-defaults intervention to promote grocery purchases corresponding to a diet for diabetes.

METHODS

In total, 65 adults diagnosed with or at increased risk for type 2 diabetes who grocery shopped at one of two study stores were randomized to one of three groups: Defaults, Online, or Control. All groups received diabetes-friendly recipes. In addition, the Online group was asked to grocery shop online during a 3-week intervention, and the Defaults group was asked to shop online, with their online grocery carts prefilled with food items needed to prepare provided recipes. Participants provided weekly grocery receipt data at baseline, at each week of the 3-week intervention, and at post-intervention.

RESULTS

Overall, the Defaults group had grocery purchases of a significantly greater nutritional quality versus other groups (F = 16.3, p < 0.001). Between-group comparisons of least-squares means showed consistent effects of the Defaults intervention while intervention components were in place, with a similar pattern for energy and carbohydrate content of grocery purchases.

CONCLUSIONS

These results build upon emerging evidence that optimal defaults can promote healthier grocery purchases. Continued examination of this approach could promote healthy food acquisition in accordance with individual dietary preferences and needs.

Restaurant kids' meal beverage offerings before and after implementation of healthy default beverage policy statewide in California compared with citywide in Wilmington, Delaware

OBJECTIVE

In 2019, California and Wilmington, Delaware' implemented policies requiring healthier default beverages with restaurant kids' meals. The current study assessed restaurant beverage offerings and manager perceptions.

DESIGN

Pre-post menu observations were conducted in California and Wilmington. Observations of cashiers/servers during orders were conducted pre-post implementation in California and post-implementation in Wilmington. Changes in California were compared using multilevel logistic regression and paired t tests. Post-implementation, managers were interviewed.

SETTING

Inside and drive-through ordering venues in a sample of quick-service restaurants in low-income California communities and all restaurants in Wilmington subject to the policy, the month before and 7-12 months after policy implementation.

PARTICIPANTS

Restaurant observations (California n 110; Wilmington n 14); managers (California n 75; Wilmington n 15).

RESULTS

Pre-implementation, the most common kids' meal beverages on California menus were unflavoured milk and water (78·8 %, 52·0 %); in Wilmington, juice, milk and sugar-sweetened beverages were most common (81·8 %, 66·7 % and 46·2 %). Post-implementation, menus including only policy-consistent beverages significantly increased in California (9·7 % to 66·1 %, P < 0·0001), but remained constant in Wilmington (30·8 %). During orders, cashiers/servers offering only policy-consistent beverages significantly decreased post-implementation in California (5·0 % to 1·0 %, P = 0·002). Few managers (California 29·3 %; Wilmington 0 %) reported policy knowledge, although most expressed support. Most managers wanted additional information for customers and staff.

CONCLUSIONS

While the proportion of menus offering only policy-consistent kids' meal default beverages increased in California, offerings did not change in Wilmington. In both jurisdictions, managers lacked policy knowledge, and few cashiers/servers offered only policy-consistent beverages. Additional efforts are needed to strengthen implementation of kids' meal beverage policies.

Switching up sides: Using choice architecture to alter children's menus in restaurants

U.S. children's frequent consumption of restaurant foods has been associated with low vegetable consumption. Use of choice architecture in restaurants has been shown to increase children's orders of healthy sides, but what children consume when healthy sides are included is unknown. The purpose of the present study was to investigate whether altering the choice architecture of children's meals by restructuring the menu, using optimal defaults and vice-virtue bundles, would impact ordering of side dishes and consumption of a vegetable side dish during a restaurant meal. Families with a child between 4-8y attended three dinners at a university-based restaurant. Children's meals included choice of entree (macaroni-and-cheese or chicken tenders) and default side: all carrots (150 g; Menu-1), small fries (50 g)/large carrots (100 g; Menu-2), and small carrots (50 g)/large fries (100 g; Menu-3). Participants could opt-out of the default side for: only fries (Menu-1) or only fries or carrots (Menus-2/3). All foods were pre- and post-weighed to determine consumption. Descriptive statistics examined children's ordering behavior. Repeated measures ANOVA examined differences in consumption of study foods. A paired samples t-test examined differences in french fry consumption (Menus-2/3). Forty-eight children (6.2 ± 1.3 years; 25 male) participated. Most children remained with the default side (Meal-1: 90%; Meal-2: 88%; Meal-3: 85%). Significant differences were seen in children's consumption of french fries (t = -2.57, p = .014) where children ate more during meal 3 compared to meal 2. There were no significant differences in carrot consumption. Use of optimal defaults led to increased orders of healthy sides and steady consumption across the meal conditions. However, use of an optimal, vice-virtue bundle led to a decrease in consumption of french fries. Further investigation of optimal default use on children's menus is warranted.

Plant-Based Meat Alternatives: Motivational Adoption Barriers and Solutions

Meat consumption is increasingly being seen as unsustainable. However, plant-based meat alternatives (PBMA) are not widely accepted yet. PBMA aim to imitate the experience of eating meat by mimicking animal meat in its sensory characteristics such as taste, texture, or aesthetic appearance. This narrative review explores the motivational barriers to adopting PBMA while focusing on food neophobia, social norms and rituals, as well as conflicting eating goals that prevent consumers from switching to a plant-based diet. Based on the key characteristics of these motivational barriers, which are informed by research findings in consumer psychology and marketing, solutions are discussed that can help counter the barriers.

Voluntary healthier kids' meals policies: Are caregivers choosing kids' meals and healthier items for their child?

BACKGROUND

Children's fast-food consumption increases risks for obesity and other diet-related diseases. To address concerns, from 2010 to 2016 U.S. fast-food restaurants implemented voluntary policies to offer healthier drinks and/or sides with kids' meals.

OBJECTIVES

Examine the effectiveness of voluntary kids' meal policies.

METHODS

Online repeated cross-sectional survey (2010, 2013, 2016) of U.S. caregivers (N = 2093) who purchased fast-food for their child (2-11 years) in the past week. Logistic regression examined associations between healthier kids' meal policy implementation and caregivers' purchases of kids' meals and selection of healthier sides and drinks. Separate models investigated caregivers' attitudes about McDonald's kids' meal items.

RESULTS

Overall, 55% of caregivers reported choosing a kids' meal for their child, and approximately one-half of those caregivers selected a healthier drink and/or side. Healthier kids' meal policy implementation was associated with increased selection of healthier sides, but not healthier drinks or choice of kids' meals over higher-calorie menu items. Child's age, caregiver gender and visit frequency were significant in most models. Caregivers' perceptions that their child(ren) like healthier drinks and sides were positively associated with selection of those items.

CONCLUSIONS

Existing healthier kids' meal policies may not improve children's fast-food consumption. Public health initiatives should examine more effective alternatives.

Behavioral Economic Approaches to Childhood Obesity Prevention Nutrition Policies: A Social Ecological Perspective

Childhood obesity is a significant public health concern associated with the development of the leading causes of death. Dietary factors largely contribute to childhood obesity, but prevention interventions targeting these factors have reported relatively small effect sizes. One potential explanation for the ineffectiveness of prevention efforts is lack of theoretical grounding. Behavioral economic (BE) theory describes how people choose to allocate their resources and posits that some children place higher value on palatable foods (relative reinforcing value of food) and have difficulty delaying food rewards (delay discounting). These seemingly individual-level decision making processes are influenced by higher-level variables (e.g., environment/policy) as described by the social ecological model. The purpose of this manuscript is to provide a theoretical review of policy-level childhood obesity prevention nutrition initiatives informed by BE. We reviewed two policy-level approaches: (1) incentives-/price manipulation-based policies (e.g., sugary drink tax, SNAP pilot) and (2) healthful choices as defaults (Healthy Hunger Free Kids Act/National School Lunch Program, advertising regulations, default items). We review current literature as well as its limitations and future directions. Exploration of BE theory applications for nutrition policies may help to inform future theoretically grounded policy-level public health interventions.

A Default Option to Improve Nutrition for Adults With Low Income Using a Prefilled Online Grocery Shopping Cart

OBJECTIVE

To determine whether a prefilled online grocery shopping (default) cart improves the nutritional quality of groceries purchased compared with receiving nutrition education (NE).

DESIGN

Longitudinal study.

SETTING

Three food pantries in the US.

PARTICIPANTS

Thirty-eight adults with low income.

INTERVENTION

Groceries were purchased online for 5 consecutive weeks. After a baseline shopping trip, participants were randomized to receive NE or a nutritionally balanced prefilled online grocery shopping cart (ie, default cart) before shopping (from week 1 [T1] to week 4 [T4]).

MAIN OUTCOME MEASURES

Diet quality (Healthy Eating Index [HEI-2015] scores), energy, and energy density of each online cart (ie, grocery purchases).

ANALYSIS

Piecewise linear mixed-effects models.

RESULTS

From baseline to T1, HEI-2015 scores in the default condition significantly increased (95% confidence interval [CI], 9.79-23.39), whereas total calories (95% CI, -10,942 to -1,663) and energy density (95% CI, -0.70 to -0.45) significantly decreased compared with NE. Improved HEI-2015 scores were maintained through T4. Calories and energy density increased from T1 to T4 in the default condition, but values remained lower (ie, more healthful) than the NE condition. In the NE condition, outcomes did not significantly change during the intervention.

CONCLUSIONS AND IMPLICATIONS

Providing an online default cart may improve the nutritional quality of grocery purchases. However, future research is warranted to assess whether adding a second nudge later in the intervention or combining the NE and default cart further promotes healthy purchasing behavior.

An online randomized controlled trial and survey of behavioural factors influencing patients' willingness to attend a video consultation

OBJECTIVES

To examine whether the phrasing of a hospital appointment invitation influences patient preference to attend in person or by video. The study also explores patient capabilities, opportunities, and motivations to attend video consultations.

DESIGN

A randomized controlled trial followed by a cross-sectional survey.

METHODS

Participants (1,481 total, 780 females) were residents of the United Kingdom who self-identified as being diagnosed with a chronic disease. Participants considered one of three hypothetical invitations. In one group, participants were invited to attend in person. Those in another group were invited to attend by video. These participants could either accept the invitation or request the other option. In the final 'active choice' group, participants were asked to choose to attend either in-person or by video appointment. Then, all participants responded to open- and closed-ended items about attending video consultations.

RESULTS

When the default option was in person, 25% of participants chose video consultation, compared with 41% in the active choice group (RR = 1.65, 95% CI: 1.37-1.99, p < .001) and 65% in the default video group (RR = 2.60, 95% CI: 2.20-2.96, p < .001). Closed-ended responses suggested that younger patients and those with previous experience were more likely to prefer video consultations. Most open-ended responses contained themes about opportunities, followed by motivations and then capabilities.

CONCLUSIONS

Patients are more likely to express a preference to attend by video when video is the default option. The real-world effectiveness of this intervention is more likely to be realized where hospitals also support patient capabilities, opportunities, and motivations.

Baseline Assessment of Children's Meals and Healthy Beverage Options Prior to a State-Level Healthy Default Beverage (HDB) Law

In January 2020, Hawai'i became the second state with a healthy default beverage (HDB) law, requiring restaurants to offer HDBs with their children's meals. This observational study presents baseline characteristics of restaurants with a children's menu and meal. The study describes pre-law beverage options to inform future HDB policy language, implementation, and evaluation. Between November and December 2019, data were collected from a statewide sample of unique restaurants (N = 383) with health inspection permits. Restaurants were assessed separately for a children's menu and meal using website reviews, telephone calls, and in-person visits. Meals were evaluated for pre-law beverage type and compliance. Logistic regression was used to estimate the likelihood of having a children's menu and meal. Most of the restaurants were full-service (70.2%) and non-chains (67.9%). While 49.3% of restaurants had a children's menu, only 16.7% had a children's meal. Significant predictors of having a children's menu were being full-service, national/international or local chains, neighbor island (non-Honolulu) locations, and hotel locations. Only being a national/international chain significantly predicted having a children's meal. Although 35.9% of children's meals offered a non-sugar-sweetened beverage (SSB) option, only 3.1% offered law-compliant beverages. Inclusion of an SSB default option (60.9%) and not specifying the type of default beverage were the predominant factors for pre-law non-compliance. Results support the need for HDB regulations, especially for national/international chains, which were most likely to have children's meals, and provide data to inform policies in other jurisdictions.

Taste Ratings of Healthier Main and Side Dishes among 4-to-8-Year-Old Children in a Quick-Service Restaurant Chain

Restaurants are regular eating environments for many families. Children's consumption of restaurant foods has been linked with poorer diet quality, prompting emerging research examining strategies to encourage healthier eating among children in restaurants. Although taste is a primary determinant of restaurant meal choices, there is a lack of research considering children's perspectives on the taste of different healthier kids' meal options. The current study sought to examine, via objective taste testing, children's liking of and preference for healthier kids' meal options at a quick-service restaurant (QSR) and to describe bundled kids' meals with evidence of both taste acceptability and consistency with nutrition guidelines. Thirty-seven 4-to-8-year-old children completed taste tests of ten healthier main and side dish options. Liking and preference were assessed using standard methods after children tasted each food. Children also reported their ideal kids' meal. Results show the majority of children liked and preferred three main (turkey sandwich, chicken strips, peanut butter/banana sandwich) and side dishes (yogurt, applesauce, broccoli), with rank order differing slightly by age group. Accepted foods were combined into 11 bundles meeting nutritional criteria. Results highlight healthier kids' meals with evidence of appeal among children in a QSR. Findings can inform future research and may increase the success of healthy eating interventions in these settings.

Contributions of Food Environments to Dietary Quality and Cardiovascular Disease Risk

PURPOSE OF REVIEW

To evaluate the multidimensional influence of food environments on food choice, dietary quality, and diet-related health and identify critical gaps necessary to develop effective population interventions that influence food choice.

RECENT FINDINGS

Multicomponent interventions that interact with multiple layers of the food environment show limited but consistent effects on dietary behaviors and may have wider and substantive population-level reach with greater incorporation of validated, holistic measurement tools. Opportunities to use smartphone technology to measure multiple components of the food environment will facilitate future interventions, particularly as food environments expand into online settings and interact with consumers in novel ways to shape food choice. While studies suggest that all dimensions of the food environment influence diet and health outcomes, robust and consistent measurements of food environments that integrate objective and subjective components are essential for developing stronger evidence needed to shift public policies.

Reinventing health promotion for healthy default beverage laws in the face of COVID-19

Shortly after a healthy default beverage (HDB) law took effect in Hawai'i, requiring restaurants that serve children's meals to offer healthy beverages with the meals, the COVID-19 pandemic struck. Efforts to contain the virus resulted in changes to restaurants' operations and disrupted HDB implementation efforts. Economic repercussions from containment efforts have exacerbated food insecurity, limited access to healthy foods, and created obstacles to chronic disease management. Promoting healthy default options is critical at a time when engaging in healthy behaviors is difficult, but important, to both prevent and manage chronic disease and decrease COVID-19 risk. This commentary discusses COVID-19's impact on restaurant operations and healthy eating, and the resulting challenges and opportunities for this promising health promotion intervention.

An online randomized trial of healthy default beverages and unhealthy beverage restrictions on children's menus

Several U.S. jurisdictions have adopted policies requiring healthy beverage defaults on children's menus, but it is unknown whether such policies or restrictions leads to fewer calories ordered. We recruited 479 caregivers of children for an online choice experiment and instructed participants to order dinner for their youngest child (2-6 years) from two restaurant menus. Participants were randomly assigned to one type of menu: 1) standard beverages on children's menus (Control; n = 155); 2) healthy beverages on children's menus (water, milk, or 100% juice), with unhealthy beverages available as substitutions (Default; n = 162); or 3) healthy beverages on children's menus, with no unhealthy beverage substitutions (Restriction; n = 162). We used linear regression with bootstrapping to examine differences between conditions in calories ordered from beverages. Secondary outcomes included percent of participants ordering unhealthy beverages (full-calorie soda, diet soda, and/or sugar-sweetened fruit drinks) and calories from unhealthy beverages. Calories ordered from beverages did not differ across conditions at Chili's [Default: 97.6 (SD = 69.8); p = 0.82; Restriction: 102.7 (SD = 71.5); p = 0.99; Control: 99.4 (SD = 72.7)] or McDonald's [Default: 90.2 (SD = 89.1); p = 0.55; Restriction: 89.0 (SD = 81.0); p = 0.94; Control: 96.5 (SD = 95.2)]. There were no differences in the percent of orders or calories ordered from unhealthy beverages. Though Restriction participants ordered fewer calories from full-calorie soda [(3.0 (SD = 21.6)] relative to Control participants [13.4 (SD = 52.1); p = 0.04)] at Chili's, we observed no such difference between Default and Control participants, or across McDonald's conditions. Overall, there was no effect of healthy default beverages or restrictions in reducing total calories ordered from unhealthy beverages for children in our experiment.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.

Orders of Healthier Adult Menu Items in a Full-Service Restaurant Chain with a Healthier Children's Menu

This study evaluated orders of adult menu items designated as healthier at the Silver Diner, a regional full-service restaurant chain serving over 4 million customers annually. This restaurant implemented a healthier children’s menu in April 2012. Orders of adult menu items were abstracted from before (September 2011–March 2012; PRE; n = 1,801,647) and after (September 2012–March 2013; POST; n = 1,793,582) the healthier children’s menu was introduced. Entrées, appetizers, and sides listed as healthier options on the menu were coded as healthier. PRE to POST changes in the percentage of orders of healthier items, soda, and dessert were evaluated using McNemar tests of paired proportions. Orders of healthier entrées, appetizers, and sides on the adult menu increased PRE to POST (8.9% to 10.4%, 25.5% to 27.5%, and 7.3% to 9.3%, respectively), and soda and dessert orders decreased (23.2% to 21.7% and 29.0% to 28.3%, respectively). All shifts were statistically significant (p < 0.0001). Our findings demonstrate improvements in orders of healthier adult menu options during the same time frame as a healthy children’s menu change. Future research can help elucidate mechanisms to inform future health promotion efforts in restaurants in ways that have the potential to impact both adults and children.

Environmental Interventions to Reduce the Consumption of Sugar-Sweetened Beverages: Abridged Cochrane Systematic Review

BACKGROUND

Regular consumption of sugar-sweetened beverages (SSB) can increase the risk for obesity, type 2 diabetes, cardiovascular disease, and dental caries. Interventions that alter the physical or social environment in which individuals make beverage choices have been proposed to reduce the consumption of SSB.

METHODS

We included randomised controlled, non-randomised controlled, and interrupted time series studies on environmental interventions, with or without behavioural co-interventions, implemented in real-world settings, lasting at least 12 weeks, and including at least 40 individuals. Studies on the taxation of SSB were not included, as these are subject of a separate Cochrane review. We used standard Cochrane methods for data extraction, risk of bias assessment, and evidence grading and synthesis. Searches were updated to January 24, 2018.

RESULTS

We identified 14,488 unique records and assessed 1,030 full texts for eligibility. We included 58 studies comprising a total of 1,180,096 participants and a median length of follow-up of 10 months. We found moderate-certainty evidence for consistent associations with decreases in SSB consumption or sales for the following interventions: traffic light labelling, price increases on SSB, in-store promotion of healthier beverages in supermarkets, government food benefit programs with incentives for purchasing fruits and vegetables and restrictions on SSB purchases, multi-component community campaigns focused on SSB, and interventions improving the availability of low-calorie beverages in the home environment. For the remaining interventions we found low- to very-low-certainty evidence for associations showing varying degrees of consistency.

CONCLUSIONS

With observed benefits outweighing observed harms, we suggest that environmental interventions to reduce the consumption of SSB be considered as part of a wider set of measures to improve population-level nutrition. Implementation should be accompanied by evaluations using appropriate methods. Future studies should examine population-level effects of interventions suitable for large-scale implementation, and interventions and settings not yet studied thoroughly.

Voluntary Kids' Meal Beverage Standards: Are They Sufficient to Ensure Healthier Restaurant Practices and Consumer Choices?

Many quick-service restaurants (QSRs) instituted voluntary kids’ meal default beverage standards (standards) between 2013 to 2017. Little is known about impacts of standards on QSR drive-through practices and on customer choices. This study assessed differences in restaurant practices including kids’ meal beverages shown on menu boards, offered by cashiers, and selected by customers in QSRs with and without voluntary standards. Observations (n = 111) and customer surveys (n = 84) were conducted in 2018 at QSRs with standards (n = 70) and without (n = 41) in low-income California, U.S. neighborhoods. Kids’ meal beverages on menu boards (n = 149) and offered by cashiers (n = 185) at QSRs with and without standards were analyzed using multilevel logistic regression. Significantly more menu boards at QSRs with standards (n = 103) vs. without (n = 46) featured only milk, water or unsweetened juice (65.1% vs. 4.4%; p < 0.001). Most cashiers at QSRs with standards and QSRs without (53.1%, 62.5%) asked what drink the data collector wanted rather than first offering default beverages. A small sample of customer interviews found that customers at QSRs with standards most commonly ordered juice (37.0%); at QSRs without standards, soda (45.5%). Although menu boards showed healthier kids’ meal beverages at QSRs with standards than without, cashier behavior was inconsistent. Results suggest additional measures (legislation, implementation support, enforcement) may be needed to ensure optimal implementation.

Nudging while online grocery shopping: A randomized feasibility trial to enhance nutrition in individuals with food insecurity

Food insecurity, the inability to acquire adequate food due to insufficient resources for food, is associated with an increased risk for obesity and associated health problems. This study assessed the feasibility and initial efficacy of a prefilled online grocery shopping cart (i.e., default option) in promoting healthier grocery purchases in individuals with food insecurity. Fifty participants recruited from food pantries in New York in 2018 were randomized to review nutrition information before purchasing groceries online (n = 23) or modify a prefilled, nutritionally balanced online shopping cart (n = 27) based on a budget corresponding to Supplemental Nutrition Assistance Program benefits. Compared to nutrition education, the default shopping cart resulted in the purchase of significantly more ounces of whole grains (Mean Difference [M_diff] = -4.05; 95% Confidence Interval [CI] = -6.14, -1.96; p < .001), cups of fruits (M_diff = -1.51; 95% CI = -2.51, -0.59; p = .002) and vegetables (M_diff = -2.21; 95% CI = -4.01, -0.41; p = .02), foods higher in fiber (mg; M_diff = -15.65; 95% CI = -27.43, -3.87; p = .01), and lower in sodium (mg; M_diff = 1642.66; 95% CI = 660.85, 2624.48; p = .002), cholesterol (mg; M_diff = 463.86; 95% CI = 198.76, 728.96; p = .001), and grams of fat (M_diff = 75.42; 95% CI = 42.81, 108.03; p < .001) and saturated fat (M_diff = 26.20; 95% CI = 14.07, 38.34; p < .001). The use of a default online shopping cart appears to improve nutritional quality of food purchases in individuals facing financial constraints.

Optimal defaults as a strategy to improve selections from children's menus in full-service theme park dining

An "optimal default" refers to a pre-selected default option that promotes an outcome intended to be favorable to the individual and/or society at large. Optimal defaults preserve the decision-maker's ability to opt-out of the default and choose an alternative option. This behavioral economics strategy has been shown to nudge both child and adult consumers toward healthier food selections. Full-service restaurants with children's menus are key settings for implementing this approach. The current field study manipulated children's menus at two theme park restaurants, testing the effects of three different item presentations (i.e., lower-energy-dense default, standard fare default, and free array menus). Each menu was presented to consumers for 1 week at a time, in random order. Full choice was preserved with all menu options appearing across conditions, with non-default items listed as available upon request. The restaurants tracked food orders during each of the three weeks. Results showed that positioning lower-energy-dense foods as default menu choices increased the likelihood of lower-energy-dense menu selections and decreased the likelihood that customers would "opt-out" for standard fare. There were also significant differences in total caloric value of food ordered across conditions, with the optimal default menu condition promoting the lowest potential energy intake. This study further supports the effectiveness of optimal defaults to increase healthy food choices for children.

Trends in Calories and Nutrients of Beverages in U.S. Chain Restaurants, 2012-2017

INTRODUCTION

Although beverages comprise one third of all menu items at large chain restaurants, no prior research has examined trends in their calorie and nutrient content.

METHODS

Beverages (n=13,879) on the menus of 63 U.S. chain restaurants were the final analytic sample obtained from a restaurant nutrition database (MenuStat, 2012-2017). For each beverage type, cluster-bootstrapped mixed-effects regressions estimated changes in mean calories, sugar, and saturated fat for beverages available on menus in all years and for newly introduced beverages. Data were analyzed in 2018.

RESULTS

Traditional sugar-sweetened beverages, sweetened teas, and blended milk-based beverages (e.g., milkshakes) were significantly higher in calories from 2012 to 2017 for newly introduced beverages (p-value for trend <0.004). For all newly introduced sweetened beverages, sugar increased significantly (2015, +7.9 g; 2016, +8.2 g; p<0.004) whereas saturated fat declined (2016, -2.3 g; 2017, -1.6 g; p<0.004). For beverages on menus in all years, saturated fat declined significantly (p<0.001), whereas mean calories and sugar remained relatively constant. Significant declines were observed for sweetened coffees (-10 kcal, -0.5 g saturated fat, p<0.001), teas (-2.6 g sugar, p=0.001), and blended milk-based beverages (-28 kcal, -4.2 g sugar, -0.8 g saturated fat, p<0.001). From 2012 to 2017, the total number of beverage offerings increased by 155%, with 82% of this change driven by sweetened beverages.

CONCLUSIONS

Sweetened beverages available in large chain restaurants were consistently high in calories, sugar, and saturated fat and substantially increased in quantity and variety from 2012 to 2017.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

Recent progress in children's meals law in restaurants in Baltimore City and California State: Making a healthy beverage option the default choice

In July 2018, Baltimore became the largest US city to prohibit restaurants from including sugar-sweetened beverages on kids' menus. In September 2018, California made history by becoming the first US state to require either water or milk as the default beverage with children's meals at all restaurants. Supporters of children's meals laws view them as helping to change the culture of health on beverage preferences and subtly influencing the choices of patrons. Using subtle methods of influencing children's beverage choices at restaurants, or nudges, will not on its own eradicate childhood obesity. However, the law aims to make healthier choices easier options and to influence people's choices in predictable ways without restricting their options. Evidence from a wide range of fields shows that people tend to stick with defaults and that setting beneficial defaults has high rates of acceptability. The laws in Baltimore and California, along with the other jurisdictions that have passed similar legislation, reflect a growing understanding - among restaurant owners, community members and policymakers alike - of the importance of feeding children healthy meals. They also signal that making healthier beverages the default option on children's menus is gaining strength in the US. Cities and states across the country should consider enacting similar laws as part of a greater public health initiative to combat the childhood obesity epidemic.

Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents

Excess consumption of added sugars, especially from sugary drinks, poses a grave health threat to children and adolescents, disproportionately affecting children of minority and low-income communities. Public policies, such as those detailed in this statement, are needed to decrease child and adolescent consumption of added sugars and improve health.

Behavioral Correlates of Empirically-Derived Dietary Patterns among University Students

Given the importance of young adulthood in establishing lifelong dietary habits, it is imperative to better understand potential underlying drivers of dietary behavior in the university-age population. Dietary patterns have been associated with disease risk, but behavioral predictors of dietary pattern adherence are poorly understood, especially among emerging adults. This study aims to evaluate health-related behaviors associated with dietary pattern scores among freshmen participating in the Tufts Longitudinal Health Study (TLHS; n = 630). We previously derived dietary patterns using principal components analysis and orthogonal rotation from dietary intake data. Health-related behavior data were collected via survey. All data were collected during the Spring semesters of 1998⁻2007. Unadjusted linear models were used to determine associations between dietary pattern scores and health-related behaviors. Significant correlates were retained in multivariable regression models, which were adjusted for demographic characteristics. We found that never eating meals away from home was associated with higher adherence to the Prudent and lower adherence to the Western and Alcohol patterns. Intention to lose weight was negatively associated with the Western pattern, while intention to gain weight was positively associated with all dietary patterns. These findings suggest that intervention efforts aimed at improving eating out behaviors and engaging in healthy weight management strategies may promote healthier dietary patterns among university students.

The Application of Optimal Defaults to Improve Elementary School Lunch Selections: Proof of Concept

BACKGROUND

In this study, we applied behavioral economics to optimize elementary school lunch choices via parent-driven decisions. Specifically, this experiment tested an optimal defaults paradigm, examining whether strategically manipulating the health value of a default menu could be co-opted to improve school-based lunch selections.

METHODS

The design was a randomized comparison of optimal versus suboptimal (standard) default lunch menus for all first-graders in a school district for a period of 1 week. We hypothesized that making the default lunch option healthier, while providing parents the opportunity to access and choose from the standard school menu for their child, would yield more frequent selection of healthier items than when the default option was suboptimal.

RESULTS

Overall, 127 (93%) first-grade children's families participated. Among those families randomized to receive the nutritionally optimized default menu, all but one remained with these options; of those parents randomized to the standard menu (suboptimal default), all parents remained with these options (Χ² = 123.06, df = 1, p < .001).

CONCLUSIONS

The mere positioning of choices, without restricting options, significantly affected which menu items the children received during the test period. Results are proof of concept for a strategy to increase health-promoting school lunch content, procedures, and policies.

Effect of default menus on food selection and consumption in a college dining hall simulation study

OBJECTIVE

To test an obesity prevention strategy derived from behavioural economics (optimal defaults plus delay), focused on changing the college dining hall service method.

DESIGN

After a uniform pre-load, participants attended an experimental lunch in groups randomized to one of three conditions: a nutrient-dense, lower-fat/energy lunch as an optimal default (OD); a less-nutrient-dense, higher-fat/energy lunch as a suboptimal default (SD); or a free array (FA) lunch. In the OD condition, students were presented a menu depicting healthier vegetarian and omnivore foods as default, with opt-out alternatives (SD menu) available on request with a 15 min wait. In the SD condition, the same menu format was used with the positioning of food items switched. In the FA condition, all choices were presented in uniform fonts and were available immediately.

SETTING

Private rooms designed to provide a small version of a college dining hall, on two campuses of a Northeastern US university.

SUBJECTS

First-year college students (n 129).

RESULTS

There was a significant main effect for condition on percentage of optimal choices selected, with 94 % of food choices in the OD condition optimal, 47 % in the FA condition optimal and none in the SD condition optimal. Similarly, energy intake for those in the SD condition significantly exceeded that in the FA condition, which exceeded that in the OD condition.

CONCLUSIONS

Presenting menu items as optimal defaults with a delay had a significant impact on choice and consumption, suggesting that further research into its long-term applicability is warranted.

Promoting healthier children's meals at quick-service and full-service restaurants: Results from a pilot and feasibility study

High-calorie restaurant foods contribute to childhood overweight. Increased consumer demand for healthier kids' meals may motivate the restaurant industry to provide additional healthy options. This study pilot-tested a combination of four strategies (toy incentive, placemats, server prompts, signage) designed to increase demand for healthier kids' meals, which were defined as those eligible for the National Restaurant Association's Kids LiveWell program. Relative sales of healthier kids' meals were examined before (n = 3473 total kids' meal orders) and during Month 1 (n = 3546 total kids' meal orders) and Month 2 of implementation (n = 3645 total kids' meal orders) of an 8-week intervention in two locations each of a quick-service (QSR) and full-service (FSR) restaurant chain. Convenience samples of children (n = 27) and their parents (n = 28) were surveyed regarding parent and child perceptions of intervention components. Findings regarding the effectiveness and feasibility of the intervention were mixed. At the FSRs, the relative percentage of monthly sales from healthier kids' meals increased from 5.0% of kids' meal orders at baseline to 8.3% during Month 1, ending at 6.4% during Month 2. At the QSRs, the relative percentage of monthly sales from healthier kids' entrees decreased from 27.5% at baseline to 25.2% during Month 1, ending at 25.9% during Month 2. Implementation quality tracking showed that consistent implementation of intervention components was a challenge; parent- and child-reported awareness of intervention components supported this finding. Future directions are discussed, aiming to build upon these findings and maximize the feasibility, effectiveness, and sustainability of efforts to promote healthier eating in restaurants.

Integrating Behavioral Economics into Nutrition Education Research and Practice

Nutrition education has a long history of being informed by economic thinking, with the earliest nutrition education guides incorporating household food budgeting into nutrition advice. Behavioral economics research goes beyond that traditional role to provide new insights into how consumers make choices. These insights have numerous potential applications for nutrition interventions to promote healthy food choices consistent with the US Dietary Guidelines for Americans. Research to test the value of such applications can contribute to the development of evidence-based nutrition education practice called for in federal nutrition education programs.

Child and parent perspectives on healthier side dishes and beverages in restaurant kids' meals: results from a national survey in the United States

BACKGROUND

Children frequently consume foods from restaurants; considering the quick-service sector alone, 1/3 of children eat food from these restaurants on a given day, and among these consumers, 1/3 of their daily calories come from fast food. Restaurant foods and beverages are second only to grocery store foods and beverages in their contribution to total energy intake of U.S. 4- to 11-year-olds. Shifting their restaurant consumption in healthier directions could have a positive impact on child health. In 2014 this study examined self-reported child receptivity and parent awareness of child receptivity to ordering a fruit or vegetable side dish instead of French fries; and milk, water, or flavored water instead of soda/pop with a kids' meal when eating out. Child receptivity to side dishes was compared between 2010 and 2014.

METHODS

An online survey was administered by Nielsen via their Harris Poll Online to a national panel of 711 parents and their 8- to 12-year-old child, as part of a larger study. Frequencies, logistic regressions, t-tests, chi-square tests, and percent agreement were used to evaluate child likelihood of ordering certain side dishes; receptivity to healthier side dish and beverage alternatives; changes in receptivity to healthier sides across years; and parent awareness.

RESULTS

A majority of children said they were likely to order a meal with a vegetable (60%), fruit (78%), or French fry (93%) side dish. They were receptive to receiving a fruit or vegetable (FV) side dish instead of French fries (68%); or milk, water, or flavored water instead of soda (81%) with their restaurant kids' meal. Liking/taste was the most common reason for children's feelings. Child receptivity to a FV side dish instead of French fries was high in both years and significantly higher in 2014 (t = -2.12, p = 0.034). The majority of parent and child reports of child receptivity were concordant (85%).

CONCLUSIONS

These national survey results indicate that children are receptive to FV side dishes and healthier beverage options with their restaurant meals. Their receptivity has remained high in the recent past, and parents are aware of child receptivity. An opportunity exists for restaurants to leverage child receptivity to healthier sides and beverages by providing and promoting healthy options.

Progress Evaluation for the Restaurant Industry Assessed by a Voluntary Marketing-Mix and Choice-Architecture Framework That Offers Strategies to Nudge American Customers toward Healthy Food Environments, 2006-2017

Consumption of restaurant food and beverage products high in fat, sugar and sodium contribute to obesity and non-communicable diseases. We evaluated restaurant-sector progress to promote healthy food environments for Americans. We conducted a desk review of seven electronic databases (January 2006-January 2017) to examine restaurant strategies used to promote healthful options in the United States (U.S.). Evidence selection (n = 84) was guided by the LEAD principles (i.e., locate, evaluate, and assemble evidence to inform decisions) and verified by data and investigator triangulation. A marketing-mix and choice-architecture framework was used to examine eight voluntary strategies (i.e., place, profile, portion, pricing, promotion, healthy default picks, priming or prompting and proximity) to evaluate progress (i.e., no, limited, some or extensive) toward 12 performance metrics based on available published evidence. The U.S. restaurant sector has made limited progress to use pricing, profile (reformulation), healthy default picks (choices), promotion (responsible marketing) and priming and prompting (information and labeling); and some progress to reduce portions. No evidence was available to assess progress for place (ambience) and proximity (positioning) to promote healthy choices during the 10-year review period. Chain and non-chain restaurants can apply comprehensive marketing-mix and nudge strategies to promote healthy food environments for customers.

Association of a Community Campaign for Better Beverage Choices With Beverage Purchases From Supermarkets

IMPORTANCE

Data are needed to evaluate community interventions to reduce consumption of sugary drinks. Supermarket sales data can be used for this purpose.

OBJECTIVE

To compare beverage sales in Howard County, Maryland (HC), with sales in comparison stores in a contiguous state before and during a 3-year campaign to reduce consumption of sugary beverages.

DESIGN, SETTING, AND PARTIPICANTS

This observational experiment with a control group included 15 HC supermarkets and 17 comparison supermarkets. Weekly beverage sales data at baseline (January 1 to December 31, 2012) and from campaign years 1 to 3 (January 1, 2013, through December 31, 2015) were analyzed. A difference-in-differences (DID) regression compared the volume sales per product per week in the HC and comparison stores, controlling for mean product price, competitor's product price, product size, weekly local temperature, and manufacturer.

EXPOSURES

The campaign message was to reduce consumption of all sugary drinks. Television advertising, digital marketing, direct mail, outdoor advertising, social media, and earned media during the 3-year period created 17 million impressions. Community partners successfully advocated for public policies to encourage healthy beverage consumption in schools, child care, health care, and government settings.

MAIN OUTCOMES AND MEASURES

Sales were tracked of sugary drinks highlighted in the campaign, including regular soda, sports drinks, and fruit drinks. Sales of diet soda and 100% juice were also tracked. Sales data are expressed as mean fluid ounces sold per product, per store, per week.

RESULTS

Regular soda sales in the 15 HC supermarkets decreased (-19.7%) from 2012 through 2015, whereas sales remained stable (0.8%) in the 17 comparison supermarkets (DID adjusted mean, -369 fl oz; 95% CI, -469 to -269 fl oz; P < .01). Fruit drink sales decreased (-15.3%) in HC stores and remained stable (-0.6%) in comparison stores (DID adjusted mean, -342 fl oz; 95% CI, -466 to -220 fl oz; P < .001). Sales of 100% juice decreased more in HC (-15.0%) than comparison (-2.1%) stores (DID mean, -576 fl oz; 95% CI, -776 to -375 fl oz; P < .001). Sales of sports drinks (-86.3 fl oz; 95% CI, -343.6 to 170.9 fl oz) and diet soda (-17.8 in HC stores vs -11.3 in comparison stores; DID adjusted mean, -78.9 fl oz; 95% CI, -182.1 to 24.4 fl oz) decreased in both communities, but the decreases were not significantly different between groups.

CONCLUSIONS AND RELEVANCE

A locally designed, multicomponent campaign to reduce consumption of sugary drinks was associated with an accelerated decrease in sales of regular soda, fruit drinks, and 100% juice. This policy-focused campaign provides a road map for other communities to reduce consumption of sugary drinks.

Healthier Children's Meals in Restaurants: An Exploratory Study to Inform Approaches That Are Acceptable Across Stakeholders

OBJECTIVE

Assess parents', children's, and restaurant executives' perspectives on children's meals in restaurants.

DESIGN

Cross-sectional.

SETTING

Parents and children completed predominantly quantitative surveys at 4 quick- and full-service restaurant locations. Telephone interviews were conducted with executives representing additional restaurants.

PARTICIPANTS

Parents (n = 59) and their first- through fourth-grade children (n = 58); executives (n = 4).

VARIABLES MEASURED

Parent/child perspectives on child meal selection and toy incentives in restaurants; executives' views on kids' meals and barriers to supplying healthier kids' meals.

ANALYSIS

Frequencies, thematic analysis.

RESULTS

A total of 63% of children ordered from children's menus, 8% of whom ordered healthier kids' meals. Half of parents reported that children determined their own orders. Taste was the most common reason for children's meal choices. Most (76%) children reported visiting the restaurant previously; 64% of them placed their usual order. Parents' views on toy incentives were mixed. Themes from executive interviews highlighted factors driving children's menu offerings, including children's habits and preferences and the need to use preexisting pantry items. Executives described menu changes as driven by profitability, consumer demand, regulation, and corporate social responsibility.

CONCLUSIONS AND IMPLICATIONS

Findings can inform the development of restaurant interventions that are effective in promoting healthier eating and are acceptable to parents, children, and restaurant personnel.