U.S. Restaurant Menus for Kids Still Short on Nutrition

Updated: May 1, 2020

Several dozen U.S. restaurant chains that volunteered to improve nutrition in kids' meals have made little progress in reducing calories, saturated fat, and sodium, researchers reported.

Analysis of 45 chain restaurants throughout the country found that the 15 restaurants participating in Kids LiveWell, between 2012 and 2015, made no significant changes compared with non-participating restaurants, stated Alyssa Moran, MPH, RD, a doctoral candidate at Harvard T.H. Chan School of Public Health in Boston, and colleagues.

Kids LiveWell is a 2011 National Restaurant Association initiative to improve the nutritional quality of children's menus.

Also, compared with non-participating restaurants, those involved with Kids LiveWell did reduce entrée calories between 2012 and 2013 (-24, 95% CI -40.4, -7.2) and 2012 and 2014 (-40, 95% CI -68.1, -11.4), but increased side dish calories between 2012 and 2015 (49, 95% CI 44.6, 92.7), suggesting a lack of "evidence that these voluntary pledges have had an industry-wide impact," the authors wrote in the American Journal of Preventive Medicine.

In an interview with MedPage Today, Moran said "although the National Restaurant Association's program is a step in the right direction, restaurants are only required to offer one meal and one other item that meet certain nutritional thresholds to participate in Kids LiveWell. These healthy items may be lost in what is often a sea of less healthy options."

Skylar Griggs, RD, LDN, of Children's Hospital Boston, agreed that it is all too easy for healthy menu items to get overlooked.

"If you offer it, they will choose it," wrote Griggs, who was not involved in the study, in an email to MedPage Today. "Pairing a healthy option next to an unhealthy one, unhealthy will succeed, especially in children and adolescents."

Moran's group used data from MenuStat -- a nutrition census of the nation's largest restaurant chains according to U.S. sales -- to examine trends in the nutritional content of the nation's top 100 fast food, fast casual, and full-service restaurant chains.

Restaurant chains were considered "national" if they were located in all U.S. census regions. Chains were "full service" if they offered table service; "fast casual" if they offered at least two of the following: nondisposable utensils, onsite food preparation, no table service, or commitment to better quality or fresh ingredients or sustainability; or were otherwise considered "fast food." Children's items were designated as any item with the words "kid," "child," or "children" appearing in the menu item or its description.

The final data set included 4,016 menu items, including beverages, entrées, side dishes, and desserts, from 45 U.S. chain restaurants from 2012 to 2015.

Using bootstrapped, mixed, linear models, the researchers estimated changes in mean calories, saturated fat, and sodium in children's menu items between 2012 and 2013, 2014, and 2015. Changes in nutrient content of these items, as well as children's beverages, were compared among restaurants participating in the Kids LiveWell initiative and non-participating restaurants.

Moran and colleagues found that between 2012 and 2015, beverages, entrées, side dishes, and desserts contained an average of 139 kcal (SE=5.6), 362 kcal (SE=8.8), 157 kcal (SE=10.4), and 360 kcal (SE=22.0), respectively. Entrées, side dishes, and desserts contained 794 mg (SE=21.0), 231 mg (SE=23.5), and 159 mg (SE=13.1) of sodium, and 6.1 g (SE=0.3), 1.7 g (SE=0.2), and 10.5 g (SE=0.9) of saturated fat, respectively.

They observed a significant increase in mean beverage calories from 2012 to 2013 (6, 95% CI 0.8, 10.6) and from 2012 to 2014 (11, 95% CI 43.7, 18.3), but no change between 2012 and 2015.

Although the amount of soda on kids' menus declined, the team found that sugary drinks -- including flavored milks, sports drinks, and sweetened teas -- still comprised 80% of children's beverage offerings. They specifically noted the increased incidence of flavored milks which nearly doubled from 7% of sugar-sweetened beverages in 2012 to 12% in 2015 (P=0.014).

"This implies that restaurant commitments to remove soda from kids' menus may not yet be having the public health effect we'd hoped for," they wrote.

Moran told Medpage Today that she would like to see public health practitioners and restaurants work together to implement evidence-based guidelines, including guidelines for healthy beverages, across a broader range of kids' menu items.

"As public health practitioners, we need to do a better job of engaging restaurants in offering and promoting healthy meals to kids," she stated.

She also suggested tracking restaurant commitments to determine whether restaurants in the Kids LiveWell program actually improve the nutritional quality of their offerings over time.

"Kids deserve to have delicious and nutritious options, and restaurants can play a role in making these meals available," she said.

Griggs agreed, nothing that "healthy doesn't attract kids the way that it might an adult trying to improve their own or their family's nutrition. Children might not have the capacity to understand how making an unhealthy choice affects their health."

"Healthy tastes different, and when people get accustomed to certain flavors and they change, they might not return," she added.

Study limitations included the short study period, as well as limited data available for just 15 of more than 150 restaurants participating in Kids LiveWell.

Another limitation was that the researchers were only able to assess items available on kids' menus, which meant they couldn't account for what children actually purchased or consumed, Moran explained to MedPage Today.

"Some children, especially adolescents, may be ordering off of the adult menu. And we know that changes to how menu items are bundled or promoted can impact purchases," she said.


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