Advertisement

Nutritional Value of Meals at Full-service Restaurant Chains

      Abstract

      Objective

      To assess the nutritional value of meals at full-service national restaurant chains with outlets in the Philadelphia region in 2011.

      Methods

      Chains were eligible if nutritional information for all menu items was on company Web pages or printed menus at Philadelphia outlets. Nutrient profiles were analyzed for 2,615 items from 21 eligible chains (out of 29) and compared with United States Department of Agriculture guidelines.

      Results

      Adult meals (entree, side dish, and one-half appetizer) approximated 1,495 kcal, 28 g saturated fat, 3,512 mg sodium, and 11 g fiber; and rose to 2,020 kcal after including a beverage and one-half dessert. Better calorie and fat profiles were observed for entrees tagged “healthy choice” or aimed at seniors or children; however, sodium far exceeded recommended limits.

      Conclusions and Implications

      Foods served at full-service restaurant chains are high in calories, saturated fat, and sodium. Standard definitions are needed for “healthy choice” tags and for entrees targeted to vulnerable age groups.

      Key Words

      Introduction

      Rising trends in obesity have been attributed largely to increased caloric intake
      • Swinburn B.
      • Sacks G.
      • Ravussin E.
      Increased food energy supply is more than sufficient to explain the US epidemic of obesity.
      and have coincided with an exponential increase in the amount of money households in developed nations spend on food away from home, currently representing over one third of calories purchased in the US.
      • Bowman S.A.
      • Gortmaker S.L.
      • Ebbeling C.B.
      • Pereira M.A.
      • Ludwig D.S.
      Effects of fast-food consumption on energy intake and diet quality among children in a national household survey.
      Food prepared away from home is typically higher in calories and lower in nutrient density than foods prepared at home. Recent work characterizing the nutritional quality of foods sold at quick-service restaurants has documented high energy, fat, and sodium in those foods.
      • Bassett M.T.
      • Dumanovsky T.
      • Huang C.
      • et al.
      Purchasing behavior and calorie information at fast-food chains in New York City, 2007.
      • Johnson C.M.
      • Angell S.Y.
      • Lederer A.
      • et al.
      Sodium content of lunchtime fast food purchases at major US chains.
      • Wu H.W.
      • Sturm R.
      What's on the menu? A review of the energy and nutritional content of US chain restaurant menus.
      Available data suggest that full-service restaurants serve oversized portions and foods of low nutritional quality.
      • Wu H.W.
      • Sturm R.
      What's on the menu? A review of the energy and nutritional content of US chain restaurant menus.
      • Binkley J.K.
      Calorie and gram differences between meals at fast food and table service restaurants.
      • Reeves S.
      • Wake Y.
      • Zick A.
      Nutrition labeling and portion size information on children's menus in fast-food and table-service chain restaurants in London, UK.
      • Saelens B.E.
      • Glanz K.
      • Sallis J.F.
      • Frank L.D.
      Nutrition Environment Measures Study in restaurants (NEMS-R): development and evaluation.
      Yet, very little work has been done that systematically characterizes the nutritional quality of foods sold at full-service restaurants and restaurants' “healthy choice” items, and that describes differences by restaurant price point.
      An increasing number of full-service chain restaurants have chosen to tag a few menu items with “healthy choice,” yet they provide limited nutrition information about those items. Thus, it is not known whether tagged items conform to dietary guidelines.
      • Jones J.L.
      • Krummel D.A.
      • Wheeler K.
      • Forbes B.
      • Fitch C.
      The prevalence of heart-healthy menu items in West Virginia restaurants.
      Within the full-service restaurant category, the type and range of menu offerings can vary by restaurant price point, but how much nutritional quality varies by price point is unknown. Characterizing restaurant menu profiles by price point is relevant to the ongoing discussion about how much the price of healthier foods relative to unhealthy foods contributes to income disparities in obesity, diet quality, and related chronic diseases.
      • Drewnowski A.
      Obesity, diets, and social inequalities.
      When fully implemented, a section of the US Patient Protection and Affordable Health Care Act mandates that fast-food and full-service chains with ≥ 20 locations provide nutrition information at point of purchase.

      US Food and Drug Administration, Division of Dockets Management, Food and Drug Administration. New menu and vending machines labeling requirements. FDA-2011-F-0172 (menu). http://www.fda.gov/food/ingredientspackaginglabeling/labelingnutrition/ucm217762.htm. Accessed October 1, 2013.

      This legislation was motivated by low consumer knowledge and awareness of the nutritional values of restaurant foods.
      • Burton S.
      • Howlett E.
      • Tangari A.H.
      Food for thought: how will the nutrition labeling of quick service restaurant menu items influence consumers' product evaluations, purchase intentions, and choices?.
      • Elbel B.
      Consumer estimation of recommended and actual calories at fast food restaurants.
      In addition, labeling may spur improvements in restaurant menus as restaurant owners, managers, and chefs become more cognizant of excessive calories, fat, and sodium in their food, and/or because they anticipate negative reactions from the media and their customers.
      • Condrasky M.D.
      • Obbagy J.E.
      • Ledikwe J.H.
      • Flood J.
      • Rolls B.J.
      Chefs' opinions about reducing the calorie content of menu items in restaurants.
      • Pulos E.
      • Leng K.
      Evaluation of a voluntary menu-labeling program in full-service restaurants.
      Information about nutrition at full-service restaurants has lagged behind fast-food restaurants, in part because many full-service chains have not disclosed nutritional information on their Web sites and Affordable Health Care Act menu labeling requirements have not yet taken effect. In 2010, Philadelphia passed a point of purchase menu labeling ordinance that required calorie disclosure for all items on menu boards; it also required that chain restaurants (≥ 15 locations anywhere in the US) display information about calories, saturated fat, trans fat, sodium, and carbohydrates adjacent to all standard menu items on printed menus.

      Philadelphia Department of Public Health. Philadelphia Menu Labeling Ordinance [Code §§ 6-102, 6-308]. http://www.phila.gov/health/pdfs/MenuLabelinguideFINAL2010-27.pdf. Accessed October 1, 2013.

      The Philadelphia labeling ordinance provided a unique opportunity to analyze the menus of these restaurants. The current study compiled and analyzed full-service chain restaurant menus for select menu categories. In addition, it examined the prevalence of healthy choice tags and whether tagged items correspond to federal dietary guidelines. Chain restaurants were stratified by price point to assess whether nutritional quality varied by restaurant price point.

      Methods

      Full-service restaurant chains in the Philadelphia region were eligible for inclusion if they displayed calories and sodium for all menu items on either their Web site or their printed menus at Philadelphia outlets between March, 2011 and May, 2011, and the majority of main dishes were single-serving entrees. Of 29 chains, 21 restaurants were eligible for inclusion (see Supplement Figure 1). Three higher-priced restaurants did not meet the criteria for displaying nutrient content, and 3 mid-priced and 2 high-priced restaurants did not meet the criteria for serving single serving entrees. Entree prices were classified based on prices displayed on printed menus at the Philadelphia outlets: lower-priced (most entrees were $6–$9; 23%; n = 5); mid-priced (most entrees were $10–$16; 67%; n = 14); and higher-priced (most entrees were ≥ $25; 10%; n = 2). (No restaurants had entrees priced mostly in the range of $17–$24.)
      Nutrition data were downloaded or transcribed from restaurant Web sites and print menus. Analyses focused on the following menu sections because they were consistently reported and had the largest number of items across chains: appetizers, a la carte entrees (a single portion and single plate that typically included a protein source and was the primary focus of the main course of a meal), and side dishes. Other categories were less consistently labeled but are reported here to describe added calories from these menu sections: desserts, nonalcoholic drinks, alcoholic drinks, and dessert-like drinks (milkshakes, floats, malts, and smoothies). Details on menu categories and classification are in the online Supplement. The final analysis sample of menu items was 2,615. The Institutional Review Board of the Philadelphia Department of Public Health deemed this study exempt because human subjects were not recruited for this research.

      Analyses

      The researchers selected nutrients for analysis based on their inclusion in the US Dietary Guidelines

      US Department of Agriculture, Dietary Guidelines for Americans Committee. Dietary Guidelines for Americans, 2010. Washington, DC: US Dept of Agriculture; 2011.

      and because they were consistently listed on menus: calories (all 21 menus), sodium (all 21 menus), saturated fat (20 menus), total fat (16 menus), and fiber (15 menus). To assess the prevalence of healthier menu items, offerings were designated as “healthier” using criteria based on general nutrition advice in the US Dietary Guidelines (see Supplement Table 1).

      US Department of Agriculture, Dietary Guidelines for Americans Committee. Dietary Guidelines for Americans, 2010. Washington, DC: US Dept of Agriculture; 2011.

      Dietary reference values (DRV) were used for a 2,000-calorie diet for adults and 1,400 calories for children.

      Committee on Obesity Prevention Policies for Young Children, Institute of Medicine. Early childhood obesity prevention policies, goals, recommendations, and potential actions. http://www.iom.edu/Reports/2011/Early-Childhood-Obesity-Prevention-Policies/Recommendations.aspx. Accessed October 1, 2013.

      This calorie level for children represents typical calorie needs for sedentary to moderately active 8-year-olds, depending on gender and body size, and has been used by others.

      US Department of Agriculture, Dietary Guidelines for Americans Committee. Dietary Guidelines for Americans, 2010. Washington, DC: US Dept of Agriculture; 2011.

      • Wellard L.
      • Glasson C.
      • Chapman K.
      Fries or a fruit bag? Investigating the nutritional composition of fast food children's meals.
      No guidelines exist for appropriate nutrient levels for full-service restaurant menu items. Thus, this study had to define its own criteria using thresholds that resembled those used by others
      • Saelens B.E.
      • Glanz K.
      • Sallis J.F.
      • Frank L.D.
      Nutrition Environment Measures Study in restaurants (NEMS-R): development and evaluation.
      • Wellard L.
      • Glasson C.
      • Chapman K.
      Fries or a fruit bag? Investigating the nutritional composition of fast food children's meals.
      and were based on US dietary patterns for dinner meals. In the US, full-service restaurants are frequented mostly for dinner, and dinner meals typically account for a larger share of a day's intake than other meal times.
      • de Castro J.M.
      The time of day of food intake influences overall intake in humans.
      • Mancino L.
      • Todd J.
      • Lin B.-H.
      Separating what we eat from where: measuring the effect of food away from home on diet quality.
      The authors selected ≤ 40% of the DRV to indicate maximum appropriate nutrient levels for a la carte entrees (excluding sides/add-ons and excluding a beverage) and ≤ 10% of the DRV for adult side dishes (Supplement Table 1 provides details).
      Data were normally distributed (evaluated via plots, qualitative comparison of means and medians, and skewness statistic). Means and standard deviations were used to characterize the distribution of nutrient content by menu category and menu price. To avoid overweighting restaurants that listed a disproportionate number of menu items per category, summary nutrient values were first calculated for each restaurant by category and then values were averaged across restaurants. To provide information about sodium that can be compared across menu sections and between this study and other studies, the authors calculated the absolute value of sodium and a standardized measure, sodium density (for each menu item, density was defined as milligrams of sodium per 1,000 calories
      • Johnson C.M.
      • Angell S.Y.
      • Lederer A.
      • et al.
      Sodium content of lunchtime fast food purchases at major US chains.

      US Department of Agriculture, Hoy MK, Goldman JD, Murayi T, Rhodes DG, Moshfegh AJ. Sodium intake of the U.S. population what we eat in America, NHANES 2007-2008. http://www.ars.usda.gov/Services/docs.htm?docid=19476. Accessed October 1, 2013.

      ).
      Generalized linear regression was used with a random intercept for each restaurant chain to account for correlated values with chains (random intercept models).
      • Merlo J.
      • Chaix B.
      • Yang M.
      • Lynch J.
      • Rastam L.
      A brief conceptual tutorial of multilevel analysis in social epidemiology: linking the statistical concept of clustering to the idea of contextual phenomenon.
      • Snijders T.A.B.
      • Bosker R.J.
      Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling.
      These models were used assess (1) how much the nutrient content of entrees varied within each restaurant (indicating a high variety of options on the menu) vs between restaurants (indicating a high variety across restaurant establishments); and (2) whether there were differences in calories and nutrients for lower-, mid-, and higher-priced restaurants. For these models, a random intercept was used for each restaurant chain; calories and nutrients were outcome variables; and independent variables were number of items offered per restaurant, price point (high, medium, and low), and calories (when the outcome was not calories). All analyses were done using SAS 9.2 (SAS Institute, Cary, NC, 2009; proc mixed used for regression analyses).

      Results

      Nutrients and Prevalence of Healthier Menu Items

      Mean calorie content of both a la carte entrees and appetizers was approximately 800 kcal (Table 1, Supplement Figure 1) and did not meet the healthier criteria for calories about 50% of the time (Table 2; see criteria in Supplement Table 1). Approximately 30% of a la carte entrees and appetizers exceeded the DRV for saturated fat and sodium; only 20% of items met recommended fiber minimums. Meals that were composed of an adult entree, side dish, and a shared appetizer totaled approximately 1,495 kcal, 28 g saturated fat, 3,312 mg sodium, and 11 g fiber; adding a beverage (nonalcoholic) and shared dessert totaled approximately 2,020 kcal, 39 g saturated fat, 3,760 mg sodium, and 12 g fiber.
      Table 1Number of Items and Means (SD), by Menu Category, Full-service Restaurant Chains, 2011
      CaloriesCalories From FatSaturated FatSodiumSodium Density
      Sodium density is milligrams of sodium per 1,000 calories
      Fiber
      Items, nMean (SD)Items, n
      Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%
      Percentage Mean (SD)Items, n
      Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%
      Grams, Mean (SD)Items, n
      Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%
      Milligrams, Mean (SD)Milligrams, Mean (SD)Items, n
      Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%
      Grams, Mean (SD)
      A la carte entrees
      All entrees shown are a la carte, which signifies that the entree is without side dishes or accompaniments
      1,342804 (180)1,05146 (7)1,24715 (4)1,3341,792 (553)2,380 (547)1,0285 (2)
       Burgers and sandwiches180879 (210)14447 (6)16015 (6)1801,971 (887)2,334 (711)1495 (2)
       Other entrees (not burger or sandwich)1,162797 (187)90746 (8)1,08715 (5)1,1541,769 (507)2,383 (564)8795 (2)
       Entrees targeted at seniors
      Entrees targeted at seniors and “healthy choice” entrees are not unique to this row. The items are included in entree categories above. Nineteen percent of chains listed entrees targeted to seniors (n = 4) and 52% of chains tagged entrees as “healthy choice” (n = 11) (see Supplement Table 2)
      48528 (135)4846 (6)489 (3)481,173 (242)2,209 (55)483 (2)
       Healthy choice entrees
      Entrees targeted at seniors and “healthy choice” entrees are not unique to this row. The items are included in entree categories above. Nineteen percent of chains listed entrees targeted to seniors (n = 4) and 52% of chains tagged entrees as “healthy choice” (n = 11) (see Supplement Table 2)
      74517 (132)7134 (15)517 (8)741,567 (432)3,154 (1110)716 (2)
      Appetizers297804 (323)22449 (5)27714 (8)2951,896 (682)2,605 (523)2075 (2)
      Adult side dishes563289 (71)48945 (12)5226 (2)545772 (154)3,101 (918)4383 (1)
      Children's a la carte entrees
      Not all chains had nutritional values for these categories. The proportion (and number) of chains are as follows: children's a la carte entrees, 25% (n = 5); desserts, 86% (n = 18); alcoholic beverages, 38% (n = 8); nonalcoholic beverages, 71% (n = 15); and dessert-like beverages (milkshakes, floats, malts, and smoothies), 24% (n = 5).
      166464 (154)14139 (7)1468 (4)159993 (358)2,294 (712)1443 (1)
      Desserts
      Not all chains had nutritional values for these categories. The proportion (and number) of chains are as follows: children's a la carte entrees, 25% (n = 5); desserts, 86% (n = 18); alcoholic beverages, 38% (n = 8); nonalcoholic beverages, 71% (n = 15); and dessert-like beverages (milkshakes, floats, malts, and smoothies), 24% (n = 5).
      171724 (310)13643 (9)15820 (10)170365 (161)530 (190)1382 (1)
      Beverages, alcoholic
      Not all chains had nutritional values for these categories. The proportion (and number) of chains are as follows: children's a la carte entrees, 25% (n = 5); desserts, 86% (n = 18); alcoholic beverages, 38% (n = 8); nonalcoholic beverages, 71% (n = 15); and dessert-like beverages (milkshakes, floats, malts, and smoothies), 24% (n = 5).
      247244 (48)1291 (2)225125 (71)523 (349)151 (0)
      Beverages, nonalcoholic (not milkshakes)
      Not all chains had nutritional values for these categories. The proportion (and number) of chains are as follows: children's a la carte entrees, 25% (n = 5); desserts, 86% (n = 18); alcoholic beverages, 38% (n = 8); nonalcoholic beverages, 71% (n = 15); and dessert-like beverages (milkshakes, floats, malts, and smoothies), 24% (n = 5).
      369161 (72)2996 (5)3421 (2)35666 (48)631 (527)
      Dessert-like beverages (milkshakes, floats, malts, and smoothies)
      Not all chains had nutritional values for these categories. The proportion (and number) of chains are as follows: children's a la carte entrees, 25% (n = 5); desserts, 86% (n = 18); alcoholic beverages, 38% (n = 8); nonalcoholic beverages, 71% (n = 15); and dessert-like beverages (milkshakes, floats, malts, and smoothies), 24% (n = 5).
      22696 (195)2141 (8)2221 (9)22230 (101)322 (104)
      a Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%
      b Sodium density is milligrams of sodium per 1,000 calories
      c All entrees shown are a la carte, which signifies that the entree is without side dishes or accompaniments
      d Entrees targeted at seniors and “healthy choice” entrees are not unique to this row. The items are included in entree categories above. Nineteen percent of chains listed entrees targeted to seniors (n = 4) and 52% of chains tagged entrees as “healthy choice” (n = 11) (see Supplement Table 2)
      e Not all chains had nutritional values for these categories. The proportion (and number) of chains are as follows: children's a la carte entrees, 25% (n = 5); desserts, 86% (n = 18); alcoholic beverages, 38% (n = 8); nonalcoholic beverages, 71% (n = 15); and dessert-like beverages (milkshakes, floats, malts, and smoothies), 24% (n = 5).
      Table 2Proportion of Items That Exceeded Healthier Criteria, by Menu Category, Full-service Restaurant Chains, 2011
      Proportion of Calories (%) ExceedingProportion of Fat Calories (%) ExceedingProportion of Saturated Fat (%) ExceedingProportion of Sodium (%) Exceeding
      Items, n
      Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%
      Criteria for Healthier Items
      Criteria for “healthier items” and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and “healthier” limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for “healthier items,” used recommendations to not exceed 2,300 mg sodium/d
      Maximum Daily Limit
      Criteria for “healthier items” and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and “healthier” limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for “healthier items,” used recommendations to not exceed 2,300 mg sodium/d
      Criteria for Healthier Items
      Criteria for “healthier items” and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and “healthier” limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for “healthier items,” used recommendations to not exceed 2,300 mg sodium/d
      Maximum Daily Limit
      Criteria for “healthier items” and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and “healthier” limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for “healthier items,” used recommendations to not exceed 2,300 mg sodium/d
      Criteria for Healthier Items
      Criteria for “healthier items” and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and “healthier” limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for “healthier items,” used recommendations to not exceed 2,300 mg sodium/d
      Maximum Daily Limit
      Criteria for “healthier items” and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and “healthier” limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for “healthier items,” used recommendations to not exceed 2,300 mg sodium/d
      Criteria for Healthier Items
      Criteria for “healthier items” and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and “healthier” limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for “healthier items,” used recommendations to not exceed 2,300 mg sodium/d
      Maximum Daily Limit, Based on ≥ 1,500 mgMaximum Daily Limit, Based on ≥ 2,300 mgProportion of Fiber Under Minimum Criteria for Healthier Items
      Criteria for “healthier items” and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and “healthier” limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for “healthier items,” used recommendations to not exceed 2,300 mg sodium/d
      Average across categories50%0%60%7%72%21%79%61%19%80%
      A la carte entrees
      All entrees shown are a la carte, which signifies that the entree is without side dishes or accompaniments
      1,34249%0%60%8%72%27%78%52%25%86%
       Burgers and sandwiches18059%0%72%12%73%34%88%61%30%97%
       Other entrees (not burger or sandwich)1,16247%0%58%7%72%26%77%51%24%85%
       Entrees targeted at seniors
      Entrees targeted at seniors and healthy choice entrees are not unique to this row; the items are included in entree categories above.
      486%0%31%0%44%2%58%29%4%100%
       Healthy choice entrees
      Entrees targeted at seniors and healthy choice entrees are not unique to this row; the items are included in entree categories above.
      743%0%6%0%12%2%80%43%8%89%
      Appetizers29747%3%68%20%68%27%84%63%32%83%
      Adult side dishes56362%0%65%0%76%3%81%87%1%60%
      Children's a la carte entrees16631%0%38%2%55%14%70%38%13%96%
      a Overall, the percentage of items that displayed calories was 100%, total fat (to compute fat calories) was 78%, saturated fat was 93%, sodium was 99%, and fiber was 77%
      b Criteria for “healthier items” and the maximum daily limit vary for adults and children and are listed in Supplementary Table 2 (Dietary reference values and “healthier” limits for full-service restaurant menus). The fourth column from the right, displaying the proportion of items exceeding sodium criteria for “healthier items,” used recommendations to not exceed 2,300 mg sodium/d
      c All entrees shown are a la carte, which signifies that the entree is without side dishes or accompaniments
      d Entrees targeted at seniors and healthy choice entrees are not unique to this row; the items are included in entree categories above.
      Calorie values were highly correlated with most other nutrients. For the a la carte entree category, Pearson correlations with calories were r = 0.76 for saturated fat, r = 0.60 for sodium, r = 0.67 for carbohydrates, and r = 0.49 for fiber (all P < .001, not shown in tables).

      Items Targeted to Seniors and Children

      Twenty percent of menus had sections that targeted seniors (ie, “Senior Fare,” “55 Plus Specialty Entrees,” “Guests 60 plus”). A la carte entrees in this section had lower calories than other entree categories but still exceeded the DRV for saturated fat and sodium, and approximately 33% contained sodium in excess of the maximum recommended intake for an entire day. A total of 75% of menus had sections that targeted children. Children's a la carte entrees had a mean of 464 kcal, with 31% and 70% exceeding healthier calorie and sodium DRVs, respectively. If one half of an adult side dish and one half of an adult-sized nonalcoholic beverage were added to the children's entree, mean calories would be approximately 690 kcal.

      “Healthy Choice” Tags

      Overall, half of the restaurants (n = 11) tagged menu items by name (eg, “Simple and Fit”), or symbol (eg, a halo over a chili pepper) to indicate that the company considered it to be a healthy choice item. The proportion of adult a la carte entrees tagged as “healthy choice” ranged from 0% to 25% (mean, 10%) (Supplement Table 2). Among restaurants with “health choice” tags, most used calories alone as the basis for these tags (n = 7; 64%); calorie criteria ranged from < 550 to < 750 calories. Entrees tagged as “healthy choice” had healthier nutrient content profiles than other entrees, with the exception of sodium density (approximately 3,100 mg/1,000 kcal) (see details in Table 1).

      Variation Within and Between Restaurants

      Regression model variance decomposition analyses found that about 20% of a la carte entree variability in calories and nutrients resulted from between-restaurant variability, with the rest of the variation found within restaurants (Supplement Table 3). Overall, restaurants differed most on entree calories and percentage of fat calories (about 24% of total variation) and were more similar on sodium, fiber, and saturated fat (16%, 18%, and 7%, respectively). Relative to the higher priced restaurants, lower-price restaurants had 772 mg higher sodium values (95% confidence interval [CI], 208–1,336) and mid-priced restaurants had entrees with 942 mg higher sodium values (95% CI, 441–1,472). However, relative to the higher-priced restaurants, entrees in lower and mid-priced restaurants were lower in saturated fat by 5.5 g (95% CI, −9.2 to −1.8) and −6.1 g (95% CI, −9.6 to −2.5), respectively. Restaurant entree calories, fiber, and percent calories from fat did not statistically significantly differ by restaurant price point (P ≥ .06). Because of the small numbers of restaurants in each price category, price-point regression results are exploratory and results have wide confidence intervals.

      Discussion

      This study of 21 full-service restaurant chain menus found that calories and nutrients were high. Values exceeded appropriate levels for a single meal, and under common meal scenarios, exceeded maximum recommended intakes for an entire day, particularly for sodium and saturated fat. Consumers tend to view full-service restaurants as superior in quality and healthfulness compared with quick-service restaurants.
      • Duarte Alonso A.
      • O'Neill M.
      • Liu Y.
      • O'Shea M.
      Factors driving consumer restaurant choice: an exploratory study from the Southeastern United States.
      • Kim D.
      • Leigh J.P.
      Are meals at full-service and fast-food restaurants “normal” or “inferior”?.
      Because of sample and classification differences, it is difficult to make comparisons across studies. However, a few studies contrasted nutritional values by restaurant types and found much higher calories and nutrients at full-service restaurants. For example, Breummer et al
      • Bruemmer B.
      • Krieger J.
      • Saelens B.E.
      • Chan N.
      Energy, saturated fat, and sodium were lower in entrees at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in king county, washington.
      reported that median values for entrees (some of which included side dishes) at quick-service vs full-service chains had 620 vs 1,010 kcal, 1,480 vs 1,930 mg sodium, and 16.5 vs 10.0 g saturated fat. The regression analysis of Wu and Sturm
      • Wu H.W.
      • Sturm R.
      What's on the menu? A review of the energy and nutritional content of US chain restaurant menus.
      found that relative to fast-food restaurants, entrees at full-service family style restaurants had 1,100 more kcal, 5 g more saturated fat, and 400 mg more sodium. Other studies have noted that relative to quick-service restaurants, full-service restaurants had less healthy profiles for children's entrees: larger portion sizes, more calories,
      • Reeves S.
      • Wake Y.
      • Zick A.
      Nutrition labeling and portion size information on children's menus in fast-food and table-service chain restaurants in London, UK.
      and a lower proportion of healthier items.
      • Saelens B.E.
      • Glanz K.
      • Sallis J.F.
      • Frank L.D.
      Nutrition Environment Measures Study in restaurants (NEMS-R): development and evaluation.
      The current study found that the prevalence of “healthy choice” tags was low: only 50% of chains tagged items, and among those, only about 10% of a la carte entrees were tagged. Historically, the restaurant industry has reported that customer demand for healthier items is low.
      • Glanz K.
      • Resnicow K.
      • Seymour J.
      • et al.
      How major restaurant chains plan their menus: the role of profit, demand, and health.
      However, a recent study

      Auchincloss AH, Mallya GG, Leonberg BL, Glanz K, Ricchezza A, Schwarz DF. Customer responses to mandatory menu labeling at full-service restaurants. Am J Prev Med. 2013;45:710–719.

      along with industry reports

      Horovitz B. Restaurants say consumers are finally ordering healthier meals. USA Today. Published April 13, 2011. http://usatoday30.usatoday.com/money/industries/food/2011-04-12-healthy-food-restaurants-applebees.htm. Accessed October 1, 2013.

      Davidson/Freundlich Co. Inc
      Restaurant Briefing.
      suggests that healthy choice items account for about 8% to 15% of sales, which is similar to the average proportion of healthy choice offerings found on menus in this study. Future research could examine whether offering a larger percentage of healthy options would proportionally increase sales of healthy choice items.
      • Glanz K.
      • Bader M.D.
      • Iyer S.
      Retail grocery store marketing strategies and obesity: an integrative review.
      In the US, average diets exceed 4,000 mg of sodium per day
      • Hill J.O.
      Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council.
      ; historically, average sodium consumption is even higher in many European countries.

      Public Health Agency of Canada, Penney S. Dropping the salt. http://www.paho.org/english/ad/dpc/nc/salt-mtg-phac-paper.pdf. Accessed October 1, 2013.

      The US-based National Salt Reduction Initiative has set goals to reduce salt in processed and restaurant food by 25% by 2014. However, current sodium levels at full-service restaurants are so high that even after a reduction of 25%, mean sodium in a la carte entrees would still be about 1,300 mg.
      Chains dominate the full-service restaurant industry, capturing 70% of market share,
      The NPD Group
      US Independent Restaurants Account for 87 Percent of Industry Traffic Losses Since 2008.
      and their ubiquity in the US points to their potential contribution to dietary intake.
      • Frieden T.R.
      A framework for public health action: the health impact pyramid.
      Although this study's sample of restaurants does not necessarily represent nutritional values in all full-service chains, the companies in this sample owned or operated over 12,000 outlets and reported sales exceeding $30 billion in 2010.
      Technomic.
      This study relied on nutrition information that may have had some inaccuracies; nevertheless, nutrition information provided by restaurants has been found to have good agreement with laboratory measurements,
      • Urban L.E.
      • McCrory M.A.
      • Dallal G.E.
      • et al.
      Accuracy of stated energy contents of restaurant foods.
      despite some variation by country.
      • Stender S.
      • Dyerberg J.
      • Astrup A.
      Fast food: unfriendly and unhealthy.
      The present study found sodium to be high at all restaurants, but it was considerably lower at higher-priced full-service restaurants compared with other restaurants, although items at higher-priced restaurants were higher in saturated fat. However, the analysis only included 2 higher priced restaurants, and both featured steak; thus, the generalizability of these results is uncertain.

      Implications for Research and Practice

      The need to educate customers about the nutritional content of restaurant foods is acute because consumers increasingly eat away from home,
      • Bowman S.A.
      • Gortmaker S.L.
      • Ebbeling C.B.
      • Pereira M.A.
      • Ludwig D.S.
      Effects of fast-food consumption on energy intake and diet quality among children in a national household survey.
      • Guthrie J.F.
      • Lin B.H.
      • Frazao E.
      Role of food prepared away from home in the American diet, 1977-78 versus 1994-96: changes and consequences.
      restaurants serve large portions of energy-dense and high-sodium foods, and the prevalence of obesity and other diet-related diseases are high.
      • Wang Y.
      • Beydoun M.A.
      The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis.
      Nutrition educators and other health professionals can promote awareness of recommended intakes of calories, fat, saturated fat, and sodium and instruct consumers on how to use menu labeling to make healthier choices when dining at restaurants that display labels. Nutrition educators working in the hospitality industry could advocate for expanding healthy choice offerings and incorporating a range of nutritional criteria into “healthy choice” tags. Educators can use findings from this and similar studies
      • Wu H.W.
      • Sturm R.
      What's on the menu? A review of the energy and nutritional content of US chain restaurant menus.
      • Bruemmer B.
      • Krieger J.
      • Saelens B.E.
      • Chan N.
      Energy, saturated fat, and sodium were lower in entrees at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in king county, washington.
      • Glanz K.
      • Resnicow K.
      • Seymour J.
      • et al.
      How major restaurant chains plan their menus: the role of profit, demand, and health.
      • Glanz K.
      • Hoelscher D.
      Increasing fruit and vegetable intake by changing environments, policy and pricing: restaurant-based research, strategies, and recommendations.
      to plan interventions and advocate for public policies that encourage restaurant chains to make healthier choices the standard through product reformulation and portion downsizing. Researchers can use findings reported here as baseline data to assess whether the healthfulness of menus improves over time in response to consumer demand, regulatory activity,
      • Stein K.
      A national approach to restaurant menu labeling: the Patient Protection and Affordable Health Care Act, Section 4205.
      • Pomeranz J.L.
      • Teret S.P.
      • Sugarman S.D.
      • Rutkow L.
      • Brownell K.D.
      Innovative legal approaches to address obesity.
      or other factors.
      • Glanz K.
      • Resnicow K.
      • Seymour J.
      • et al.
      How major restaurant chains plan their menus: the role of profit, demand, and health.

      Acknowledgments

      The authors thank Jessica Clark for assistance with compiling data for this project. Funding was made possible, in part, by Cooperative Agreement 1U58DP002626-01 from the Centers for Disease Control and Prevention, US Department of Health and Human Services; and Get Healthy Philly, an initiative of the Philadelphia Department of Public Health. The views expressed in this report do not necessarily reflect the official policies of the Department of Health and Human Services or the Philadelphia Department of Public Health. Mention of trade names, commercial practices, or organizations does not imply endorsement by the authors, the institutions where the authors work, or the funding entities.

      Supplementary Data

      References

        • Swinburn B.
        • Sacks G.
        • Ravussin E.
        Increased food energy supply is more than sufficient to explain the US epidemic of obesity.
        Am J Clin Nutr. 2009; 90: 1453-1456
        • Bowman S.A.
        • Gortmaker S.L.
        • Ebbeling C.B.
        • Pereira M.A.
        • Ludwig D.S.
        Effects of fast-food consumption on energy intake and diet quality among children in a national household survey.
        Pediatrics. 2004; 113: 112-118
        • Bassett M.T.
        • Dumanovsky T.
        • Huang C.
        • et al.
        Purchasing behavior and calorie information at fast-food chains in New York City, 2007.
        Am J Public Health. 2008; 98: 1457-1459
        • Johnson C.M.
        • Angell S.Y.
        • Lederer A.
        • et al.
        Sodium content of lunchtime fast food purchases at major US chains.
        Arch Intern Med. 2010; 170: 732-734
        • Wu H.W.
        • Sturm R.
        What's on the menu? A review of the energy and nutritional content of US chain restaurant menus.
        Public Health Nutr. 2012; 16: 1-10
        • Binkley J.K.
        Calorie and gram differences between meals at fast food and table service restaurants.
        Applied Economic Perspectives and Policy. 2008; 30: 750-763
        • Reeves S.
        • Wake Y.
        • Zick A.
        Nutrition labeling and portion size information on children's menus in fast-food and table-service chain restaurants in London, UK.
        J Nutr Educ Behav. 2011; 43: 543-547
        • Saelens B.E.
        • Glanz K.
        • Sallis J.F.
        • Frank L.D.
        Nutrition Environment Measures Study in restaurants (NEMS-R): development and evaluation.
        Am J Prev Med. 2007; 32: 273-281
        • Jones J.L.
        • Krummel D.A.
        • Wheeler K.
        • Forbes B.
        • Fitch C.
        The prevalence of heart-healthy menu items in West Virginia restaurants.
        Am J Health Behav. 2004; 28: 328-334
        • Drewnowski A.
        Obesity, diets, and social inequalities.
        Nutr Rev. 2009; 67: S36-S39
      1. US Food and Drug Administration, Division of Dockets Management, Food and Drug Administration. New menu and vending machines labeling requirements. FDA-2011-F-0172 (menu). http://www.fda.gov/food/ingredientspackaginglabeling/labelingnutrition/ucm217762.htm. Accessed October 1, 2013.

        • Burton S.
        • Howlett E.
        • Tangari A.H.
        Food for thought: how will the nutrition labeling of quick service restaurant menu items influence consumers' product evaluations, purchase intentions, and choices?.
        Journal of Retailing. 2009; 85: 258-273
        • Elbel B.
        Consumer estimation of recommended and actual calories at fast food restaurants.
        Obesity (Silver Spring). 2011; 19: 1971-1978
        • Condrasky M.D.
        • Obbagy J.E.
        • Ledikwe J.H.
        • Flood J.
        • Rolls B.J.
        Chefs' opinions about reducing the calorie content of menu items in restaurants.
        Obesity (Silver Spring). 2007; 15: 2086-2094
        • Pulos E.
        • Leng K.
        Evaluation of a voluntary menu-labeling program in full-service restaurants.
        Am J Public Health. 2010; 100: 1035-1039
      2. Philadelphia Department of Public Health. Philadelphia Menu Labeling Ordinance [Code §§ 6-102, 6-308]. http://www.phila.gov/health/pdfs/MenuLabelinguideFINAL2010-27.pdf. Accessed October 1, 2013.

      3. US Department of Agriculture, Dietary Guidelines for Americans Committee. Dietary Guidelines for Americans, 2010. Washington, DC: US Dept of Agriculture; 2011.

      4. Committee on Obesity Prevention Policies for Young Children, Institute of Medicine. Early childhood obesity prevention policies, goals, recommendations, and potential actions. http://www.iom.edu/Reports/2011/Early-Childhood-Obesity-Prevention-Policies/Recommendations.aspx. Accessed October 1, 2013.

        • Wellard L.
        • Glasson C.
        • Chapman K.
        Fries or a fruit bag? Investigating the nutritional composition of fast food children's meals.
        Appetite. 2012; 58: 105-110
        • de Castro J.M.
        The time of day of food intake influences overall intake in humans.
        J Nutr. 2004; 134: 104-111
        • Mancino L.
        • Todd J.
        • Lin B.-H.
        Separating what we eat from where: measuring the effect of food away from home on diet quality.
        Food Policy. 2009; 34: 557-562
      5. US Department of Agriculture, Hoy MK, Goldman JD, Murayi T, Rhodes DG, Moshfegh AJ. Sodium intake of the U.S. population what we eat in America, NHANES 2007-2008. http://www.ars.usda.gov/Services/docs.htm?docid=19476. Accessed October 1, 2013.

        • Merlo J.
        • Chaix B.
        • Yang M.
        • Lynch J.
        • Rastam L.
        A brief conceptual tutorial of multilevel analysis in social epidemiology: linking the statistical concept of clustering to the idea of contextual phenomenon.
        J Epidemiol Commun Health. 2005; 59: 443-449
        • Snijders T.A.B.
        • Bosker R.J.
        Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling.
        2nd ed. Sage, Thousand Oaks, CA2012
        • Duarte Alonso A.
        • O'Neill M.
        • Liu Y.
        • O'Shea M.
        Factors driving consumer restaurant choice: an exploratory study from the Southeastern United States.
        Journal of Hospitality Marketing and Management. 2012; 22: 547-567
        • Kim D.
        • Leigh J.P.
        Are meals at full-service and fast-food restaurants “normal” or “inferior”?.
        Popul Health Manag. 2011; 14: 307-315
        • Bruemmer B.
        • Krieger J.
        • Saelens B.E.
        • Chan N.
        Energy, saturated fat, and sodium were lower in entrees at chain restaurants at 18 months compared with 6 months following the implementation of mandatory menu labeling regulation in king county, washington.
        J Acad Nutr Diet. 2012; 112: 1169-1176
        • Glanz K.
        • Resnicow K.
        • Seymour J.
        • et al.
        How major restaurant chains plan their menus: the role of profit, demand, and health.
        Am J Prev Med. 2007; 32: 383-388
      6. Auchincloss AH, Mallya GG, Leonberg BL, Glanz K, Ricchezza A, Schwarz DF. Customer responses to mandatory menu labeling at full-service restaurants. Am J Prev Med. 2013;45:710–719.

      7. Horovitz B. Restaurants say consumers are finally ordering healthier meals. USA Today. Published April 13, 2011. http://usatoday30.usatoday.com/money/industries/food/2011-04-12-healthy-food-restaurants-applebees.htm. Accessed October 1, 2013.

        • Davidson/Freundlich Co. Inc
        Restaurant Briefing.
        Carlson Restaurants Worldwide: American Express Travel Related Services Company, Inc, Carrollton, TX2008
        • Glanz K.
        • Bader M.D.
        • Iyer S.
        Retail grocery store marketing strategies and obesity: an integrative review.
        Am J Prev Med. 2012; 42: 503-512
        • Hill J.O.
        Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council.
        Am J Clin Nutr. 2009; 89: 477-484
      8. Public Health Agency of Canada, Penney S. Dropping the salt. http://www.paho.org/english/ad/dpc/nc/salt-mtg-phac-paper.pdf. Accessed October 1, 2013.

        • The NPD Group
        US Independent Restaurants Account for 87 Percent of Industry Traffic Losses Since 2008.
        The NPD Group, Port Washington, NY2012
        • Frieden T.R.
        A framework for public health action: the health impact pyramid.
        Am J Public Health. 2010; 100: 590-595
      9. Technomic.
        Top 500 chain restaurant report, full-service chain share by menu category (Appendix E) and glossary of terms. Technomic, Inc, Chicago, IL2011
        • Urban L.E.
        • McCrory M.A.
        • Dallal G.E.
        • et al.
        Accuracy of stated energy contents of restaurant foods.
        JAMA. 2011; 306: 287-293
        • Stender S.
        • Dyerberg J.
        • Astrup A.
        Fast food: unfriendly and unhealthy.
        Int J Obes. 2007; 31: 887-890
        • Guthrie J.F.
        • Lin B.H.
        • Frazao E.
        Role of food prepared away from home in the American diet, 1977-78 versus 1994-96: changes and consequences.
        J Nutr Educ Behav. 2002; 34: 140-150
        • Wang Y.
        • Beydoun M.A.
        The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis.
        Epidemiol Rev. 2007; 29: 6-28
        • Glanz K.
        • Hoelscher D.
        Increasing fruit and vegetable intake by changing environments, policy and pricing: restaurant-based research, strategies, and recommendations.
        Prev Med. 2004; 39: S88-S93
        • Stein K.
        A national approach to restaurant menu labeling: the Patient Protection and Affordable Health Care Act, Section 4205.
        J Am Diet Assoc. 2010; 110 (1288-1289): 1280-1286
        • Pomeranz J.L.
        • Teret S.P.
        • Sugarman S.D.
        • Rutkow L.
        • Brownell K.D.
        Innovative legal approaches to address obesity.
        Milbank Q. 2009; 87: 185-213