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

Nutritional quality of children's menus in restaurants: does cuisine type matter?

OBJECTIVE

It is unknown whether the nutritional quality of children's menus varies depending on the cuisine type. This study aimed to investigate differences in the nutritional quality of children's menus by cuisine type in restaurants located in Perth, Western Australia (WA).

DESIGN

Cross-sectional study.

SETTING

Perth, WA.

PARTICIPANTS

Children's menus (n 139) from the five most prevalent restaurant cuisine types in Perth (i.e. Chinese, Modern Australian, Italian, Indian and Japanese) were assessed using the Children's Menu Assessment Tool (CMAT; range -5-21 with lower scores denoting lower nutritional quality) and the Food Traffic Light system, evaluated against Healthy Options WA Food and Nutrition Policy recommendations. Non-parametric ANOVA was used to test for a significant difference in total CMAT scores among cuisine types.

RESULTS

Total CMAT scores were low for all cuisine types (range -2-5), with a significant difference between cuisine types (Kruskal-Wallis H = 58·8, P < 0·001). The highest total CMAT score by cuisine type was Modern Australian (mean = 2·27, sd = 1·41) followed by Italian (mean = 2·02, sd = 1·02), Japanese (mean = 1·80, sd = 2·39), Indian (mean = 0·30, sd = 0·97) and Chinese (mean = 0·07, sd = 0·83). When using the Food Traffic Light for assessment, Japanese cuisine had the highest percentage of green food items (44 %), followed by Italian (42 %), Modern Australian (38 %), Indian (17 %) and Chinese (14 %).

CONCLUSIONS

Overall, the nutritional quality of children's menus was poor regardless of cuisine type. However, children's menus from Japanese, Italian and Modern Australian restaurants scored better in terms of nutritional quality than children's menus from Chinese and Indian restaurants.

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.

What Do Mom and Dad Think? Examining Parent Preferences for the Use of Behavioral Economic Strategies on Children's Menus in Restaurants

BACKGROUND

A majority of children's restaurant meals are nutritionally deficient; use of behavioral economics may improve healthful menu selections. Parents play a role in children's restaurant meal selection, thus understanding parent preferences for potential behavioral economic strategies is warranted.

OBJECTIVE

To examine parent-derived and -stated preferences for selected attributes of children's restaurant menus, which included behavioral economic strategies (eg, optimal defaults and vice-virtue bundles).

DESIGN

A descriptive, cross-sectional, within-subjects survey integrating a conjoint design was developed along with 8 children's menus. Menus were manipulated by varying levels of attributes (meal price, healthful side dishes, number of side dish items, healthful entrées, and cost for sugar-sweetened beverages [SSB]). Parents rated menus and attributes using Likert scales.

PARTICIPANTS/SETTING

A national sample of US parents with children 4 to 10 years (n = 463) were recruited in August of 2019 via Amazon's Mechanical Turk.

ANALYSIS

A conjoint (regression) analysis was conducted to derive parent preference for each attribute and overall menu preference. Descriptive statistics (means) described overall stated parent menu preferences and ratings. Cluster analysis segmented parents into groups with similar preferences.

RESULTS

Derived preferences showed parents had the strongest preference for choice of side dishes (β = .73) and low-priced menus (β = .51), and weak preferences for inclusion of healthful entrées (β = .04) and added cost for SSB (β = .18). Parents stated preference was for a menu that included healthful entrées, was low priced, and featured choices for side dishes. Cluster analysis revealed half of parents preferred the low-cost children's menu with the other half of parents split evenly across preferences related to health, choice, and traditional menus.

CONCLUSION

Parents stated preference was for a socially desirable menu featuring healthful entrée options and added cost for SSB, which was contrary to the conjoint derived menu preferences. Understanding parent preferences may help guide nutrition professionals working to build a more healthful food environment through the use of behavioral economic strategies.

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.

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.

Personal preferences for Personalised Trials among patients with chronic diseases: an empirical Bayesian analysis of a conjoint survey

OBJECTIVE

To describe individual patient preferences for Personalised Trials and to identify factors and conditions associated with patient preferences.

DESIGN

Each participant was presented with 18 conjoint questions via an online survey. Each question provided two choices of Personalised Trials that were defined by up to eight attributes, including treatment types, clinician involvement, study logistics and trial burden on a patient.

SETTING

Online survey of adults with at least two common chronic conditions in the USA.

PARTICIPANTS

A nationally representative sample of 501 individuals were recruited from the Chronic Illness Panel by Harris Poll Online. Participants were recruited from several sources, including emails, social media and telephone recruitment of the target population.

MAIN OUTCOME MEASURES

The choice of Personalised Trial design that the participant preferred with each conjoint question.

RESULTS

There was large variability in participants' preferences for the design of Personalised Trials. On average, they preferred certain attributes, such as a short time commitment and no cost. Notably, a population-level analysis correctly predicted 62% of the conjoint responses. An empirical Bayesian analysis of the conjoint data, which supported the estimation of individual-level preferences, improved the accuracy to 86%. Based on estimates of individual-level preferences, patients with chronic pain preferred a long study duration (p≤0.001). Asthma patients were less averse to participation burden in terms of data-collection frequency than patients with other conditions (p=0.002). Patients with hypertension were more cost-sensitive (p<0.001).

CONCLUSION

These analyses provide a framework for elucidating individual-level preferences when implementing novel patient-centred interventions. The data showed that patient preference in Personalised Trials is highly variable, suggesting that individual differences must be accounted for when marketing Personalised Trials. These results have implications for advancing precise interventions in Personalised Trials by indicating when rigorous scientific principles, such as frequent monitoring, is feasible in a substantial subset of patients.

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.

Patient preferences for personalized (N-of-1) trials: a conjoint analysis

OBJECTIVE

Despite their promise for increasing treatment precision, Personalized Trials (i.e., N-of-1 trials) have not been widely adopted. We aimed to ascertain patient preferences for Personalized Trials.

STUDY DESIGN AND SETTING

We recruited 501 adults with ≥2 common chronic conditions from Harris Poll Online. We used Sawtooth Software to generate 45 plausible Personalized Trial designs comprising combinations of eight key attributes (treatment selection, treatment type, clinician involvement, blinding, time commitment, self-monitoring frequency, duration, and cost) at different levels. Conditional logistic regression was used to assess relative importance of different attributes using a random utility maximization model.

RESULTS

Overall, participants preferred Personalized Trials with no costs vs. $100 cost (utility difference 1.52 [standard error 0.07], P < 0.001) and with less vs. more time commitment/day (0.16 [0.07], P < 0.015) but did not hold preferences for the other six attributes. In subgroup analyses, participants ≥65 years, white, and with income ≤$50,000 were more averse to costs than their counterparts (P all <0.05).

CONCLUSION

To optimize dissemination, Personalized Trial designers should seek to minimize out-of-pocket costs and time burden of self-monitoring. They should also consider adaptive designs that can accommodate subgroup differences in design preferences.