A restaurant-based intervention to promote sales of healthy children's menu items: the Kids' Choice Restaurant Program cluster randomized trial

Barriers and Enablers for Equitable Healthy Food Access in Baltimore Carryout Restaurants: A Qualitative Study in Healthy Food Priority Areas

Black neighborhoods in the U.S., historically subjected to redlining, face inequitable access to resources necessary for health, including healthy food options. This study aims to identify the enablers and barriers to promoting equitable healthy food access in small, independently owned carryout restaurants in under-resourced neighborhoods to address health disparities. Thirteen in-depth interviews were conducted with restaurant owners in purposively sampled neighborhoods within Healthy Food Priority Areas (HFPAs) from March to August 2023. The qualitative data were analyzed using inductive coding and thematic analysis with Taguette software (Version 1.4.1). Four key thematic domains emerged: interpersonal, sociocultural, business, and policy drivers. Owners expressed mixed perspectives on customers' preferences for healthy food, with some perceiving a community desire for healthier options, while others did not. Owners' care for the community and their multicultural backgrounds were identified as potential enablers for tailoring culturally diverse menus to meet the dietary needs and preferences of their clientele. Conversely, profit motives and cost-related considerations were identified as barriers to purchasing and promoting healthy food. Additionally, owners voiced concerns about taxation, policy and regulation, information access challenges, and investment disparities affecting small business operations in HFPAs. Small restaurant businesses in under-resourced neighborhoods face both opportunities and challenges in enhancing community health and well-being. Interventions and policies should be culturally sensitive, provide funding, and offer clearer guidance to help these businesses overcome barriers and access resources needed for an equitable, healthy food environment.

The Nutritional Quality of Kids’ Menus from Cafés and Restaurants: An Australian Cross-Sectional Study

Australian families increasingly rely on eating foods from outside the home, which increases intake of energy-dense nutrient-poor foods. ‘Kids’ Menus’ are designed to appeal to families and typically lack healthy options. However, the nutritional quality of Kids’ Menus from cafes and full-service restaurants (as opposed to fast-food outlets) has not been investigated in Australia. The aim of this study was to evaluate the nutritional quality of Kids’ Menus in restaurants and cafés in metropolitan Perth, Western Australia. All 787 cafes and restaurants located within the East Metropolitan Health Service area were contacted and 33% had a separate Kids’ Menu. The validated Kids’ Menu Healthy Score (KIMEHS) was used to assess the nutritional quality of the Kids’ Menus. Almost all Kids’ Menus (99%) were rated ‘unhealthy’ using KIMEHS. The mean KIMEHS score for all restaurants and cafés was −8.5 (range −14.5 to +3.5) which was lower (i.e., more unhealthy) than the mean KIMEHS score for the top 10 most frequented chain fast-food outlets (mean −3.5, range −6.5 to +3). The findings highlight the need for additional supports to make improvements in the nutritional quality of Kids’ Menus. Local Government Public Health Plans provide an opportunity for policy interventions, using locally relevant tools to guide decision making.

Nudging and boosting children’s restaurant menus for healthier food choice: a blinded quasi-randomized controlled trial in a real life setting

Background

Restaurants are ideal settings for implementing food interventions targeted at children. Studies with adults suggest that changes to the physical menu can lead to healthier food choices; online studies with parents indicate that specific menu designs facilitate healthier choices. However, it is unknown whether applying well-established nudging and boosting methods to children’s menus also increases their choice of healthier meals in a real-world restaurant setting.

Methods

The effects of two versions of a restaurant menu on the frequency of choosing a healthy meal (newly created, healthy target dish) were tested in a blinded quasi-randomized controlled trial. The menu in the control condition contained all dishes (including the healthy target dish) in a standardized format. The intervention menu included nudging (e.g. comic character, fun attractive name for the dish) and boosting elements (e.g. information on low calorie density) next to the healthy target dish. Over five months, the control and intervention menus were switched every two weeks and records were made of how often the healthy target dish was ordered.

Results

In total, 607 orders were made from the children’s restaurant menu (57% from the intervention menu). During the intervention phase, 4.2% of all ordered dishes from the children’s menu were the healthy target dish, during the control phase, 4.4% of orders were for the target dish (p=.896).

Conclusions

Contrary to our hypothesis, a modified children’s menu did not lead to a significant increase in the number of orders for a healthy dish compared with a neutral control menu. Importantly, given that parents and children often choose the child’s dish together, particularly boosting methods that focus on social processes and joint decision making could be promising to increase children’s frequency of healthy food choices in restaurants.

Trial registration

DRKS00027039, registered on 11/22/2021, (Retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12365-5.

Feasibility of collaborating with independent Latino-owned restaurants to increase sales of a healthy combo meal

Americans spend the majority of their food dollars at restaurants and other prepared food sources, including quick-service and fast-food restaurants (PFS); independent small restaurants make up 66% of all PFS in the US. In this feasibility study, 5 independent and Latino-owned PFS in the Washington DC metro area worked with academic partners to start offering healthy combo meals with bottled water and promote these using on-site, community, and social media advertising. The number of healthy combos sold was collected weekly, showing that the new combos sold, and customers in all 5 sites were surveyed as they exited the PFS (n=50): >85% had noticed the combo meals; 100% thought it was a good idea to offer it, 68% had ordered the combo (of these, >94% of customers responded that they liked it). Results suggest that it is feasible to work with independent Latino-owned restaurants to promote healthy combos and collect data.

Using a Community-Based Participatory Mixed Methods Research Approach to Develop, Evaluate, and Refine a Nutrition Intervention to Replace Sugary Drinks with Filtered Tap Water among Predominantly Central-American Immigrant Families with Infants and Toddlers: The Water Up @Home Pilot Evaluation Study

Descriptions of the implementation of community-based participatory mixed-methods research (CBPMMR) in all phases of the engagement approach are limited. This manuscript describes the explicit integration of mixed-methods in four stages of CBPR: (1) connecting and diagnosing, (2) prescribing-implementing, (3) evaluating, and (4) disseminating and refining an intervention that aimed to motivate Latino parents (predominantly Central American in the US) of infants and toddlers to replace sugary drinks with filtered tap water. CBPMMR allowed for co-learning that led to the identification of preliminary behavioral outcomes, insights into potential mechanisms of behavior change, and revisions to the intervention design, implementation and evaluation.

KIMEHS-Proposal of an Index for Qualitative Evaluation of Children's Menus-A Pilot Study

Considering the importance of the food environments for health promotion, and the lack of simple, easy to use, low-cost measures of the quality of meals, the authors developed a qualitative menu index (KIMEHS—Kids’ Menu Healthy Score), tailored to children’s menu evaluation. Development of the tool was based on the Mediterranean food pattern. It includes 18 components, divided into seven main groups that reflect key aspects of menu quality, including protein source, side dishes, vegetables, dessert and beverages, and also allergens and nutritional information. The index was analysed for content and construct validity, as well as inter-rater reliability, and was applied to a sample of menus from restaurants in shopping centres in the Lisbon region. Possible index point ranges from −17 to 17, with a higher score indicating greater compliance with the recommendations. A value of 5.5 is obtained if all KIMEHS items are available, considering healthy and non-healthy options. The inter-rater reliability was assessed and values above 0.80 were obtained for Alpha Cronbach, as well as agreement % rate >75%. Agreement percentage is above 75% for all the components. Evaluated restaurants scored from −14 to 7, with an average KIMEHS of −6.15. Only four restaurants scored positive values, ranging from 0.25 to 7. KIMEHS was considered to be an adequate index to evaluate children’s menus, from the menu information displayed on restaurant websites and/or on restaurant displays or table menus. It is a simple, low-cost tool that may be used as a reference for health professionals as an objective measure to evaluate the food environment. Stakeholders could also be involved in their own assessment to help educate consumers about healthy food choices, strengthening the efforts to promote an adequate food pattern and health, contributing to the fight against obesity.

Desert on the menu? What children are served in German full-service restaurants

OBJECTIVES

Prevalence of obesity and overweight among children is rising worldwide. Thus, the importance of restaurants as food environments is also growing. Considering these developments, the present study describes and evaluates menus and meals offered to children in German full-service restaurants.

METHODS

Using quota sampling procedure, a representative sample of German full-service restaurants was identified. The individual meals were then assessed, using the Children's Menu Assessment tool (CMA). A total of 500 restaurants and 1,877 individual meals were analyzed.

RESULTS

On average, every menu included 3.76 ± 1.31 meals for children. The arithmetic mean of the CMA score was 0.73 ± 0.85. Around 80% of all offered meals were limited to eight typical dishes and over 50% included French fries or another form of fried potatoes. Not one of the meals included any nutritional information. Healthy entrees were never marked (e.g. by an optional qualitative information such as healthy food symbol or a healthier choice tag). Eighty-one percent of all the main components in the meals were rated as unhealthy and none of the meals used wholegrain products. The automatic inclusion of a drink and free refill options are both rather unusual in Germany, as well as the use of cartoon characters and product logos or giving away promotional toys. A positive correlation was found between the price of the food and its quality. The majority of dishes feature a high energy density while simultaneously having a low nutrient density.

CONCLUSIONS

Overall, the range of food on offer for children in German restaurants is unhealthy and lacking in variety. There is an urgent need for improvement of both the menus themselves as well as the offered meals. Our study is not only by far the most comprehensive study, but also the study with the worst CMA score values worldwide.

Engaging Ethnic Restaurants to Improve Community Nutrition Environments: A Qualitative Study with Hispanic Caribbean Restaurants in New York City

This study used interviews with New York City Hispanic Caribbean (HC) restaurant owners, managers, and cooks/chefs (n=19) to examine perceptions concerning the healthfulness of the HC diet and diet-related disparities in the HC community, and document factors potentially influencing their engagement in community nutrition interventions. The interviews revealed high awareness of diet-related issues. Respondents had mixed notions concerning their role in improving community food environments, noting important barriers for collaboration to consider in future interventions. The study underscores the important role of ethnic restaurants, providing information to facilitate engagement with this largely untapped sector in immigrant/ethnic communities in the US.

Obesity à la carte? Children’s meal options in German full-service restaurants

Objective:

In light of the increasing prevalence of juvenile obesity seen around the world, obesogenic environments in general and the food environment in particular are receiving increasing attention in current public health research. Restaurants play a significant role in the food environment. The present study aimed to quantitatively describe and qualitatively evaluate the range of children’s meals available in full-service restaurants in Germany.

Design:

Five hundred restaurants were identified using a systematic quota sampling technique. The individual meals were evaluated using quality standards stipulated by the German Nutrition Society (DGE).

Setting:

Nationwide sample of menus from full-service restaurants.

Participants:

Meals (n 1877) from 500 menus were analysed.

Results:

Menus included 3·76 (sd 1·31) meals for children. About 70 % of the meals were limited to six typical dishes of low nutritional quality. In total, 54 % of meals included French fries or another form of fried potatoes. Of all meals, 23 % did not fulfil any of the eleven quality criteria set by the DGE and 38 % satisfied only one criterion. The majority of dishes on offer featured high energy density while simultaneously having low nutrient density. Healthy dishes were not highlighted visually in any menu.

Conclusions:

The range of dishes on offer for children in German restaurants is severely lacking in variety and in need of improvement from a nutritional point of view. Considering the growing importance of restaurants as food environments, there is a need to improve the presentation of menus and the meals offered.

A cross-sectional description of mobile food vendors and the foods they serve: potential partners in delivering healthier food-away-from-home choices

Background

Food away from home (FAFH) in the US is associated with adverse health outcomes, and food dollars spent on FAFH continues to increase. FAFH studies have typically focused on restaurants and carryout establishments, but mobile food vendors – popularly known in the US as food trucks – have become more numerous and are an understudied segment of FAFH. The objective of this study was to assess mobile food vendors, their attitudes toward health and nutrition, and the foods they serve.

Methods

This was a cross-sectional study of 41 mobile food vendors in Michigan, US. The survey contained questions about food and nutrition attitudes, such as barriers to putting healthy items on menus and perceived agreement with healthy food preparation practices. Participants were classified into a healthy and a less healthy attitude group based on whether they believed healthy menu items could be successful or not. In addition, participant menus were collected and analyzed according to whether menu items were healthy, moderately healthy, or unhealthy. Descriptive, univariate, and bivariate analyses were conducted.

Results

Two-thirds of the participants felt that healthy menu items could be successful, and yet taste and value were the most important menu item success factors, each rated as important by 100% of the participants. Low consumer demand was the biggest barrier to putting healthy items on the menu (76%) whereas lack of chef interest (29%) and need for special training (24%) were the smallest. 72% of the vendors offered at least one healthy menu item, but only 20% of all reviewed menu items were healthy overall. There was no difference in the proportion of menu items that were healthy when comparing those with healthy attitudes (23% of menu items healthy) to those less healthy attitudes (17% of menu items healthy, p = 0.349).

Conclusions

Mobile food vendors had positive views about putting healthy items on menus. However, a low proportion of menu items were classified as healthy. This suggests that mobile food vendors are promising potential public health partners in improving the health profile of FAFH, but that education of vendors is needed to ensure the success of healthier items.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7075-8) contains supplementary material, which is available to authorized users.

A comparative analysis of the restaurant consumer food environment in Rochester (NY, USA) and London (ON, Canada): assessing children's menus by neighbourhood socio-economic characteristics

OBJECTIVE

To assess restaurant children's menus for content and nutritional quality; and to investigate the relationship between the restaurant consumer food environment for children and neighbourhood-level socio-economic characteristics within and between one Canadian city and one US city.

DESIGN

Cross-sectional observational study.

SETTING

London, ON, Canada and Rochester, NY, USA.ParticipantsRestaurant children's menus were assessed, scored and compared using the Children's Menu Assessment tool. We quantified neighbourhood accessibility to restaurants by calculating 800 m road-network buffers around the centroid of each city census block and created a new Neighbourhood Restaurant Quality Index for Children (NRQI-C) comprising the sum of restaurant menu scores divided by the total number of restaurants within each area. After weighting by population, we examined associations between NRQI-C and neighbourhood socio-economic characteristics using correlations and multiple regression analyses.

RESULTS

Nutritional quality of children's menus was greater, on average, in Rochester compared with London. Only one variable remained significant in the regression analyses for both cities: proportion of visible minorities had a positive effect on neighbourhood NRQI-C scores in London, whereas the reverse was true in Rochester.

CONCLUSIONS

Results suggest the presence of a socio-economic disparity within Rochester, where children in more disadvantaged areas have poorer access to better nutritional quality restaurant choices. In London, results suggest an inverse relationship across the city where children in more disadvantaged areas have better access to better nutritional quality restaurant choices. Given these disparate results, research on restaurant nutritional quality for children requires additional consideration.

You Can't Find Healthy Food in the Bush: Poor Accessibility, Availability and Adequacy of Food in Rural Australia

In high-income countries, obesity disproportionately affects those from disadvantaged and rural areas. Poor diet is a modifiable risk factor for obesity and the food environment a primary driver of poor diet. In rural and disadvantaged communities, it is harder to access affordable and nutritious food, affecting both food insecurity and the health of rural residents. This paper aims to describe the food environment in a rural Australian community (approx. 7000 km² in size) to inform the development of community-relevant food supply interventions. We conducted a census audit of the food environment (ground truthing) of a local government area (LGA). We used the Nutrition Environment Measurement tools (NEMS-S and NEMS-R) to identify availability of a range of food and non-alcoholic beverages, the relative price of a healthy compared to a less healthy option of a similar food type (e.g., bread), the quality of fresh produce and any in-store nutrition promotion. Thirty-eight food retail outlets operated at the time of our study and all were included, 11 food stores (NEMS-S) and 27 food service outlets (NEMS-R). The mean NEMS-S score for all food stores was 21/54 points (39%) and mean NEMS-R score for all food service outlets was 3/23 points (13%); indicative of limited healthier options at relatively higher prices. It is difficult to buy healthy food beyond the supermarkets and one (of seven) cafés across the LGA. Residents demonstrate strong loyalty to local food outlets, providing scope to work with this existing infrastructure to positively impact poor diet and improve food security.

Children’s meals at restaurants in Abu Dhabi, United Arab Emirates, have poor nutritional quality

BACKGROUND: Many people in the UAE eat out frequently, but there is limited knowledge about the nutritional quality of the consumed meals. OBJECTIVE: The aim of this study was to assess the nutritional quality of children’s meals in Abu Dhabi restaurants, considering deep-frying and food group content. METHODS: In this cross-sectional pilot study, popular food outlets were identified using an online customer rating application. Children menus were collected and the meal quality was assessed. A healthy meal should not be deep-fried and contain at least 2 of the following food groups: low-fat dairy/lean protein/whole grain/fruits/vegetables (criteria adapted from the “Kids Live Well Nutritional Criteria” by the National Restaurant Association, US). RESULTS: 58 restaurants were included, of which 29 had children menus, offering a total of 209 meals. 60% of the meals had beverages included in the price: 13% being water or milk. Overall, 78.9% of the assessed meals did not meet the cut-offs for healthy meals. CONCLUSIONS: In this pilot study, a majority of children’s meals in Abu Dhabi’s food outlets had poor nutritional quality. The findings suggest a need for more extensive studies around meal offerings at restaurants.

A Cluster Randomized Trial to Promote Healthy Menu Items for Children: The Kids' Choice Restaurant Program

Evidence indicates that restaurant-based interventions have the potential to promote healthier purchasing and improve the nutrients consumed. This study adds to this body of research by reporting the results of a trial focused on promoting the sale of healthy child menu items in independently owned restaurants. Eight pair-matched restaurants that met the eligibility criteria were randomized to a menu-only versus a menu-plus intervention condition. Both of the conditions implemented new healthy child menu items and received support for implementation for eight weeks. The menu-plus condition also conducted a marketing campaign involving employee trainings and promotional materials. Process evaluation data captured intervention implementation. Sales of new and existing child menu items were tracked for 16 weeks. Results indicated that the interventions were implemented with moderate to high fidelity depending on the component. Sales of new healthy child menu items occurred immediately, but decreased during the post-intervention period in both conditions. Sales of existing child menu items demonstrated a time by condition effect with restaurants in the menu-plus condition observing significant decreases and menu-only restaurants observing significant increases in sales of existing child menu items. Additional efforts are needed to inform sustainable methods for improving access to healthy foods and beverages in restaurants.

Factors Affecting Implementation of the California Childhood Obesity Research Demonstration (CA-CORD) Project, 2013

Introduction

Ecological approaches to health behavior change require effective engagement from and coordination of activities among diverse community stakeholders. We identified facilitators of and barriers to implementation experienced by project leaders and key stakeholders involved in the Imperial County, California, Childhood Obesity Research Demonstration project, a multilevel, multisector intervention to prevent and control childhood obesity.

Methods

A total of 74 semistructured interviews were conducted with project leaders (n = 6) and key stakeholders (n = 68) representing multiple levels of influence in the health care, early care and education, and school sectors. Interviews, informed by the Multilevel Implementation Framework, were conducted in 2013, approximately 12 months after year-one project implementation, and were transcribed, coded, and summarized.

Results

Respondents emphasized the importance of engaging parents and of ensuring support from senior leaders of participating organizations. In schools, obtaining teacher buy-in was described as particularly important, given lower perceived compatibility of the intervention with organizational priorities. From a program planning perspective, key facilitators of implementation in all 3 sectors included taking a participatory approach to the development of program materials, gradually introducing intervention activities, and minimizing staff burden. Barriers to implementation were staff turnover, limited local control over food provided by external vendors or school district policies, and limited availability of supportive resources within the broader community.

Conclusion

Project leaders and stakeholders in all sectors reported similar facilitators of and barriers to implementation, suggesting the possibility for synergy in intervention planning efforts.

Food ordering for children in restaurants: multiple sources of influence on decision making

OBJECTIVE

Restaurants are playing an increasingly important role in children's dietary intake. Interventions to promote healthy ordering in restaurants have primarily targeted adults. Much remains unknown about how to influence ordering for and by children. Using an ecological lens, the present study sought to identify sources of influence on ordering behaviour for and by children in restaurants.

DESIGN

A mixed-methods study was conducted using unobtrusive observations of dining parties with children and post-order interviews. Observational data included: child's gender, person ordering for the child and server interactions with the dining party. Interview data included: child's age, restaurant visit frequency, timing of child's decision making, and factors influencing decision making.

SETTING

Ten independent, table-service restaurants in San Diego, CA, USA participated.

SUBJECTS

Complete observational and interview data were obtained from 102 dining parties with 150 children (aged 3-14 years).

RESULTS

Taste preferences, family influences and menus impacted ordering. However, most children knew what they intended to order before arriving at the restaurant, especially if they dined there at least monthly. Furthermore, about one-third of children shared their meals with others and all shared meals were ordered from adult (v. children's) menus. Parents placed most orders, although parental involvement in ordering was less frequent with older children. Servers interacted frequently with children but generally did not recommend menu items or prompt use of the children's menu.

CONCLUSIONS

Interventions to promote healthy ordering should consider the multiple sources of influence that are operating when ordering for and by children in restaurants.