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Position of the Society for Nutrition Education and Behavior: Healthful Food for Children is the Same as Adults

      INTRODUCTION

      A long-held belief in the US is that children need different types of food than adults do. Now ingrained in American culture, the concept of children's food, or a kids’ menu, began more than a century ago when the hospitality, agriculture, and food industries promoted this new social norm to generate revenue. Today, the modern food industry continues to perpetuate demand and explicitly names food for children kids’ food as demonstrated by the title of the Global Kids’ Food and Beverage Products and Marketing for Preschoolers, Younger Kids, and Tweens

      HTF Market Intelligence. Global kids food and beverage market research report 2019 - market size, share, price, trend and forecast. https://www.htfmarketreport.com/enquiry-before-buy/2407311-global-kids-food-and-beverages-market-5. Accessed August 18, 2021.

      market report. Thus, throughout this position statement, we refer to food for children and youth as kids’ food. Unfortunately, these products are often ultraprocessed and high in saturated fat, sodium, and added sugar while providing a narrow range of nutrients.
      • Siegel BE
      Kid Food: the Challenge of Feeding Children in a Highly Processed World.
      Moreover, exposure to food-related advertisements and promotion packaging, particularly advertisements related to fast food and sugar-sweetened beverages, is significantly higher in areas with families with low income and racial and ethnic minorities.
      • Powell LM
      • Wada R
      • Kumanyika SK
      Racial/ethnic and income disparities in child and adolescent exposure to food and beverage television ads across the US media markets.
      • Fleming-Milici F
      • Harris JL
      Television food advertising viewed by preschoolers, children and adolescents: contributors to differences in exposure for black and white youth in the United States.
      • Elliott C
      ‘Big Food’ and ‘gamified’ products: promotion, packaging, and the promise of fun.
      • Alfaro B
      • Rios Y
      • Arranz S
      • Varela P
      Understanding children's healthiness and hedonic perception of school meals via structured sorting.
      • Monteiro CA
      • Moubarac JC
      • Cannon G
      • Ng SW
      • Popkin B
      Ultra-processed products are becoming dominant in the global food system.
      • Nicklaus S
      • Boggio V
      • Chabanet C
      • Issanchou S
      A prospective study of food variety seeking in childhood, adolescence and early adult life.
      • Skinner JD
      • Carruth BR
      • Bounds W
      • Ziegler P
      • Reidy K
      Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children?.
      • Devine CM
      • Connors M
      • Bisogni CA
      • Sobal J
      Life-course influences on fruit and vegetable trajectories: qualitative analysis of food choices.
      • Yan Y
      • Zheng W
      • Ma Q
      • et al.
      Child-to-adult body mass index trajectories and the risk of subclinical renal damage in middle age.

      Hastings G, McDermott L, Angus K, Stead M, Thomson S. The Extent, Nature, and Effects of Food Promotion to Children: A Review of the Evidence - Technical Paper Prepared for the World Health Organization. World Health Organization; 2006.http://apps.who.int/iris/bitstream/handle/10665/43627/9789241595247_eng.pdf. Accessed August 18, 2021.

      • Smith R
      • Kelly B
      • Yeatman H
      • Boyland E
      Food marketing influences children's attitudes, preferences and consumption: a systematic critical review.
      • Lafraire J
      • Rioux C
      • Giboreau A
      • Picard D
      Food rejections in children: cognitive and social/environmental factors involved in food neophobia and picky/fussy eating behavior.
      • Conrad P
      • Barker KK
      The social construction of illness: key insights and policy implications.
      This exposure encourages diets with limited varieties of healthy options, which can create children's resistance to new food and tastes.
      • Alfaro B
      • Rios Y
      • Arranz S
      • Varela P
      Understanding children's healthiness and hedonic perception of school meals via structured sorting.
      Ultraprocessed food is readily available, further reinforcing unhealthy food preferences,
      • Monteiro CA
      • Moubarac JC
      • Cannon G
      • Ng SW
      • Popkin B
      Ultra-processed products are becoming dominant in the global food system.
      which can persist into later childhood and even adulthood, ultimately increasing lifetime risks of obesity, chronic disease, and other adverse health outcomes.
      • Nicklaus S
      • Boggio V
      • Chabanet C
      • Issanchou S
      A prospective study of food variety seeking in childhood, adolescence and early adult life.
      • Skinner JD
      • Carruth BR
      • Bounds W
      • Ziegler P
      • Reidy K
      Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children?.
      • Devine CM
      • Connors M
      • Bisogni CA
      • Sobal J
      Life-course influences on fruit and vegetable trajectories: qualitative analysis of food choices.
      • Yan Y
      • Zheng W
      • Ma Q
      • et al.
      Child-to-adult body mass index trajectories and the risk of subclinical renal damage in middle age.
      However, nutrition educators can encourage more healthful dietary choices by shifting core beliefs about children's food and educating about how children can eat the same foods as adults. For example, situating the social construct of kids’ food within a social ecological context may help identify and leverage modifiable factors to challenge assumptions about the kids’ food archetype and improve the overall quality of food for children. In sum, the position of the Society for Nutrition Education and Behavior is that there are no differences between healthful food for children aged 2 and older than those for adults, except for age-appropriate adjustments in texture and portion size.

      THE ORIGINS OF KIDS’ FOOD AS A SOCIAL NORM

      For the purposes of this position statement, kids’ food is operationally defined as food likely to be consumed by children aged 2–14 years, either at home or in the community. The prevailing social construct is that such food is highly processed; energy-dense; and high in saturated fat, sodium, and added sugar.
      • Siegel BE
      Kid Food: the Challenge of Feeding Children in a Highly Processed World.
      A diet favoring these foods can have significant detrimental effects on children's preferences and tastes and may exacerbate food neophobia or picky eating behavior sometime seen in children.

      Hastings G, McDermott L, Angus K, Stead M, Thomson S. The Extent, Nature, and Effects of Food Promotion to Children: A Review of the Evidence - Technical Paper Prepared for the World Health Organization. World Health Organization; 2006.http://apps.who.int/iris/bitstream/handle/10665/43627/9789241595247_eng.pdf. Accessed August 18, 2021.

      • Smith R
      • Kelly B
      • Yeatman H
      • Boyland E
      Food marketing influences children's attitudes, preferences and consumption: a systematic critical review.
      • Lafraire J
      • Rioux C
      • Giboreau A
      • Picard D
      Food rejections in children: cognitive and social/environmental factors involved in food neophobia and picky/fussy eating behavior.
      To replace this construct with a healthier norm, it is important to understand how the concept of a separate diet for children originated. To that end, social constructionism can illuminate the socioecological etiologies by explaining how behaviors become integrated into everyday social norms.
      • Conrad P
      • Barker KK
      The social construction of illness: key insights and policy implications.
      ,
      • Goffman E
      Frame Analysis: An Essay on the Organization of Experience.
      In the US, the concept that food for children is distinct from food for adults has origins in the Volstead Act, enacted in 1919, which prohibited the sale of alcohol.

      Kelly K. The Volstead Act. US National Archives.https://www.archives.gov/education/lessons/volstead-act. Accessed April 28, 2018.

      Before Prohibition, only wealthy families dined at expensive hotel restaurants, as it was considered inappropriate to bring children to a restaurant where alcohol was consumed.
      • Siegel BE
      Kid Food: the Challenge of Feeding Children in a Highly Processed World.
      During Prohibition, the hospitality industry attempted to offset lost liquor revenue by expanding their clientele to include children. At the same time, a popular book by pediatrician L. Emmett Holt, The Care and Feeding of Children, recommended a restrictive diet for young children, including delaying certain fruits until age 5 and certain meats and vegetables until age 10, based on the belief that chewing and digestive abilities need to mature.

      Humes M. Feeding the kiddie: a brief history of the children's menu. Slate.http://www.slate.com/articles/life/food/2013/08/children_s_menu_history_how_prohibition_and_emmett_holt_gave_rise_to_kid.html. Accessed May 16, 2017.

      • Haley AP
      Dining in high chairs: children and the American restaurant industry, 1900–1950.
      • Holt LE
      The Care and Feeding of Children: A Catechism for the Use of Mothers and Children's Nurses.
      In a 1920 editorial in a restaurant trade magazine, Ethel Maude Colson even suggested a special menu for children.
      • Siegel BE
      Kid Food: the Challenge of Feeding Children in a Highly Processed World.
      Toward the end of World War II, pediatrician Benjamin Spock's
      • Spock B
      book, The Common Sense Book of Baby and Child Care, became the de facto guide for parents. Spock's
      • Spock B
      infant and child feeding guidelines, which are much less restrictive than those of Holt,
      • Holt LE
      The Care and Feeding of Children: A Catechism for the Use of Mothers and Children's Nurses.
      also align more closely with current child feeding recommendations of the American Academy of Pediatrics and the US dietary guidelines.

      U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. 9th Ed. 2020.

      ,
      American Academy of Pediatrics
      Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.
      These recommendations include introducing solid food when the child is developmentally ready, usually around 4–6 months, and providing food that is appropriate for the child's oral motor development stage.
      American Academy of Pediatrics
      Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.
      Notwithstanding the complex interplay of factors such as parenting style and feeding practices, energy requirements, choking hazards, and taste preferences, by the age of 2 years, most children can eat a diet that is similar to that of adults.

      U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. 9th Ed. 2020.

      ,
      • Birch LL
      • Doub AE
      Learning to eat: birth to age 2 y.
      ,
      • Riley LK
      • Rupert J
      • Boucher O
      Nutrition in toddlers.
      Yet, kids’ food and menus persist, mainly because families are accustomed to them, because restaurants and the food industry in general benefit from marketing to children, and because parents like the low prices.

      Kelly K. The Volstead Act. US National Archives.https://www.archives.gov/education/lessons/volstead-act. Accessed April 28, 2018.

      The concept of kids’ food, thus, is a strongly rooted and predominant social norm in US culture. Most people are likely familiar with typical kids’ menu items (eg, chicken nuggets or tenders, hamburgers, grilled cheese, french fries, hot dogs, and macaroni and cheese).
      • Eissa MA
      • Hearne K
      • Saavedra N
      Comparison of children's menu items at full- and quick-service restaurants.
      ,
      • DuBreck CM
      • Sadler RC
      • Arku G
      • Seabrook J
      • Gilliland J
      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.
      These types of food are heavily marketed to children in media advertisements including YouTube, packaging, and grocery store promotions; are highly palatable; and are readily available in most US restaurants and grocery markets.
      • Elliott C
      ‘Big Food’ and ‘gamified’ products: promotion, packaging, and the promise of fun.
      ,
      • Tan L
      • Ng SH
      • Omar A
      • Karupaiah T
      What's on YouTube? A case study on food and beverage advertising in videos targeted at children on social media.
      • Elliott C
      Tracking kids’ food: comparing the nutritional value and marketing appeals of child-targeted supermarket products over time.
      • Harris JL
      • LoDolce M
      • Dembek C
      • Schwartz MB
      Sweet promises: candy advertising to children and implications for industry self-regulation.
      During the Green Revolution in the 1960s and 1970s, new agricultural technologies led to the development of high-yield crops. Norman Borlaug, the Father of the Green Revolution, received a Nobel Peace Prize in 1970 for his contributions to agricultural advancement, which resulted in substantial production increases and shifts from family farms to agribusiness.
      • Conway G
      The Doubly Green Revolution: Food for All in the Twenty-First Century.
      ,
      • Paarlberg R
      Food Politics.
      Since then, food prices have dropped further: the share of household income spent on food decreased from 17.5% in 1960 to 6.7% in 2015, and Americans spend less household income on food than any country in the world.

      World Economic Forum. Which countries spend the most on food? This map will show you. 2015.https://www.weforum.org/agenda/2016/12/this-map-shows-how-much-each-country-spends-on-food/. Accessed November 12, 2021.

      Today, Americans spend less household income on food than any country in the world.

      World Economic Forum. Which countries spend the most on food? This map will show you. 2015.https://www.weforum.org/agenda/2016/12/this-map-shows-how-much-each-country-spends-on-food/. Accessed November 12, 2021.

      The low prices and mass production of food, along with technological innovations, have spurred increases in the development and marketing of ultraprocessed food.
      Access to and consumption of processed food and sugar-sweetened beverages have increased as low food prices allow supermarkets, food retailers, and fast-food restaurants to offer this food in abundance.
      • James P
      • Seward MW
      • James O'Malley A
      • Subramanian SV
      • Block JP
      Changes in the food environment over time: examining 40 years of data in the Framingham Heart Study.
      • Piernas C
      • Popkin BM
      Increased portion sizes from energy-dense foods affect total energy intake at eating occasions in US children and adolescents: patterns and trends by age group and sociodemographic characteristics, 1977–2006.
      • Nielsen SJ
      Popkin BM. Patterns and trends in food portion sizes, 1977–1998.
      • Lin B
      • GJ
      • Frazao E
      Away-From-Home Foods Increasingly Important to Quality of American Diet.
      • Almeida J
      • Duncan DT
      • Sonneville KR
      Obesogenic behaviors among adolescents: the role of generation and time in the United States.
      • Powell LM
      • Nguyen BT
      Fast-food andfull-service restaurant consumption among children and adolescents: effect on energy, beverage, and nutrient intake.
      • Bhutani S
      • Schoeller DA
      • Walsh MC
      • McWilliams C
      Frequency of eating out at both fast-food and sit-down restaurants was associated with high body mass index in non-large metropolitan communities in midwest.
      Some retailers use opportunistic marketing to draw customers. For example, the first kids’ Fun Meal was introduced at Burger Chef in 1973, and the McDonald's Happy Meal debuted in 1978.
      • Spartos C
      MC in a Box: scarfing down 30 years of happy meals.
      In addition, unlike earlier eras when a single pediatrician's book was considered the predominant source of medical information for families, such information now comes from books, social media, and other conflicting sources. Embedded marketing techniques, such as product placements and toy incentives, can be sophisticated, with claims and promises that are difficult to assess. Despite the potential adverse effects of such marketing to kids, the First Amendment of the US Constitution protects it as commercial speech unless deemed deceptive by the Federal Trade Commission.
      Federal Trade Commission
      A Review of Food Marketing to Children and Adolescents: A Follow-Up Report.
      • Sonneville KR
      • Long MW
      • Ward ZJ
      • et al.
      BMI and healthcare cost impact of eliminating tax subsidy for advertising unhealthy food to youth.
      • Burd G
      Fast food, families and advertising as a cultural site.
      These factors generate a confluence of circumstances that perpetuate harmful social norms and archetypes around the concept of kids’ food.

      COUNTERING THE KIDS’ FOOD ARCHETYPE

      Improving children's diets may require explicating the associated risks and reframing solutions to include community, state, national, and societal involvement in addition to personal behavior. Nutrition educators can address multiple levels of the social ecological model to facilitate healthy adaptation and resilience within the current food environment.
      • Story M
      • Kaphingst KM
      • Robinson-O'Brien R
      • Glanz K
      Creating healthy food and eating environments: policy and environmental approaches.
      The American food environment has changed dramatically in the past 50 years, and increasing child and adult obesity rates indicate unhealthy societal adaptation to these changes.
      • Zhang Y
      • Yang J
      • Hou W
      • Arcan C
      Obesity trends and associations with types of physical activity and sedentary behavior in US adults: National Health and Nutrition Examination Survey, 2007-2016.
      By promoting resilience, which is the capacity of a dynamic system to adapt successfully to threats and to harness resources for sustained well-being, these unhealthy adaptations can be redirected.
      • Southwick SM
      • Bonanno GA
      • Masten AS
      • Panter-Brick C
      • Yehuda R
      Resilience definitions, theory, and challenges: interdisciplinary perspectives.
      Unfortunately, as ultraprocessed kids’ food becomes more socially accepted, the perceived risks from eating this food weakens such that the risks are not sufficient to promote transformative change. In the field of nutrition education, several models and theories have been used to address these risk perceptions, including self-regulation and motivational theory, the Health Belief Model, and the Health Action Approach Model.
      • Contento I
      Foundation in Theory and Research: Increasing Awareness andEnhancing Motivation.
      These frameworks can help identify and mitigate risks and ultimately improve children's health. By raising awareness about the health risk of certain food, particularly as they relate to the kids’ food archetype, nutrition educators can promote a combination of behavioral and societal solutions to increase individual and community resilience, adaptation, and transformative change.
      • Ellis WR
      • Dietz WH
      A new framework for addressing adverse childhood and community experiences: the building community resilience model.
      Many factors determine food choices and nutrition-related behaviors.
      • Contento IR
      Nutrition Education: Linking Research, Theory, and Practice.
      The Figure summarizes the framework that nutrition educators can use to identify areas of focus. It includes components from social ecological models based on healthy eating
      • Story M
      • Kaphingst KM
      • Robinson-O'Brien R
      • Glanz K
      Creating healthy food and eating environments: policy and environmental approaches.
      ,
      • Contento IR
      Nutrition Education: Linking Research, Theory, and Practice.
      and pediatric-based obesity prevention,
      • Harrison K
      • Bost KK
      • McBride BA
      • et al.
      Toward a developmental conceptualization of contributors to overweight and obesity in childhood: the six-Cs model.
      a multisystem model of resilience,
      • Liu JJW
      • Reed M
      • Girard TA
      Advancing resilience: an integrative, multi-system model of resilience.
      the Cultural Capital Framework,
      • Cuy Castellanos D
      • Miller ME
      Exploration of sugar-sweetened beverage intake in a Latinx population.
      and an integrative study of developmental competencies in minority children.
      • García Coll C
      • Lamberty G
      • Jenkins R
      • et al.
      An integrative model for the study of developmental competencies in minority children.
      Using this framework, nutrition educators can develop interventions directed at building healthy resilience and adaptation to the food environment. This work involves transforming food-related norms and behaviors to prioritize accessibility to and preferences for appropriate healthy food at all ages.
      Figure
      FigureFramework for nutrition educators to identify modifiable focus areas to counter the kids’ food archetype.
      A literature search was conducted by a professional librarian using Medline, Cumulative Index of Nursing and Allied Health Literature, and Business Premiere. The search terms included child-oriented food, children's menu, kid's food, kid's menu, children's meals, child nutrition, pediatric obesity, feeding behavior, fast foods, restaurants, marketing, healthy menu, healthy diet, food preferences, and family meals. The focus areas that the authors derived from the main thematic results of the literature review described herein are not exhaustive. However, they do provide example strategies that nutrition educators can use to challenge the current kids’ food archetype.

       Renaming Kids’ Food

      A key first step in the effort to reframe a social norm is to rename it. Over time, societal understandings of issues become more narrowly focused around the most dominant and consistent messaging.
      • Foley K
      • Ward P
      • McNaughton D
      Innovating qualitative framing analysis for purposes of media analysis within public health inquiry.
      Nutrition educators can widen this focus by avoiding terms such as kids’ food or kids’ meal in all nutrition-related education materials and replacing them with terms such as moderate plates, moderate portions, or Family Meals. These substitutions can signal positive changes in behaviors and feeding practices. Over time, as the terminology transmits from nutrition educators to parents and the community at large, the social constructs of food behavior also begin to change.
      • Conrad P
      • Barker KK
      The social construction of illness: key insights and policy implications.
      ,
      • Goffman E
      Frame Analysis: An Essay on the Organization of Experience.

       Building Cultural Capacity

      Given the rich multicultural traditions and family histories in America, it makes sense to capitalize on existing healthy cultural food practices and traditions while also avoiding subjective norms and unhealthy acculturation practices.
      • Cuy Castellanos D
      • Miller ME
      Exploration of sugar-sweetened beverage intake in a Latinx population.
      ,
      • García Coll C
      • Lamberty G
      • Jenkins R
      • et al.
      An integrative model for the study of developmental competencies in minority children.
      ,
      • Kaplan SG
      • Arnold EM
      • Irby MB
      • Boles KA
      • Skelton JA
      Family systems theory and obesity treatment: applications for clinicians.
      When using a family-centered approach, health inequities and injustices should be recognized and mitigated. In addition to proximate causes of health, such as diet and physical activity,
      • Ranjbar N
      • Erb M
      • Mohammad O
      • Moreno FA
      Trauma-informed care and cultural humility in the mental health care of people from minoritzed communities focus.
      • Felitti VJ
      Origins of the ACE study.
      • Sallis JF
      • Saelens BE
      • Frank LD
      • et al.
      Neighborhood built environment and income: examining multiple health outcomes.
      • Cronholm PF
      • Forke CM
      • Wade R
      • et al.
      Adverse childhood experiences: expanding the concept of adversity.
      cultural histories should be respected, and distal causes of health inequity should be considered, such as adverse childhood experiences, trauma, structural racism,
      • Bailey ZD
      • Krieger N
      • Agénor M
      • Graves J
      • Linos N
      • Bassett MT
      Structural racism and health inequities in the USA: evidence and interventions.
      discrimination, socioeconomic status, and lifestyle preferences. Addressing distal causes of health inequity, identifying family strengths, and incorporating healthy cultural legacies may also lead to expanded nutrition education repertoires, shifts in health equity, and increased uptake of inclusive and healthy social norms, including shifting the kids’ food archetype.
      • Ranjbar N
      • Erb M
      • Mohammad O
      • Moreno FA
      Trauma-informed care and cultural humility in the mental health care of people from minoritzed communities focus.

       Promoting Healthy Restaurant Menu Options for Children

      Kids’ food is a significant contributor to the US economy and food industry. At non–fast-food outlets, most children order from a children's menu,
      • Wolfson JA
      • Moran AJ
      • Jarlenski MP
      • Bleich SN
      Trends in Sodium Content of Menu Items in Large Chain Restaurants in the U.S. American.
      whose child-friendly choices have received well-founded criticism from advocacy groups for their poor nutrient quality. In response to this criticism, the industry has attempted to make some public health improvements.
      • Kraak V
      • Englund T
      • Misyak S
      • Serrano E
      Progress evaluation for the restaurant industry assessed by a voluntary marketing-mix and choice-architecture framework that offers strategies to nudge American customers toward healthy food environments, 2006–2017.
      A notable legislative effort is section 4205 of the 2010 Patient Protection and Affordable Care Act, which includes menu labeling laws. In 2011, the National Restaurant Association launched Kids LiveWell, a voluntary program for restaurants that want to include healthier menu choices. The Kids LiveWell criteria stipulates that at least 2 full-serving menu items aimed at kids contain no more than 600 kcal per meal, where ≤ 35% of the kilocalories are from fat, ≤ 10% from saturated fat, ≤ 0.05% from artificial trans-fat, and ≤ 35% from total sugars, as well as no more than 770 mg sodium and at least 2 food groups.

      National Restaurant Association. National Restaurant AssociationLaunches Kids LiveWell 2.0.https://restaurant.org/research-and-media/media/press-releases/national-restaurant-association-launches-kids-livewell-2/. Accessed November 12, 2021.

      More recent criteria have been established for side items as the default options, and the default options for beverages include water, nonfat or 1% milk, or 100% fruit juice. However, it does not appear that US restaurants are fully committed to meeting these guidelines. Studies examining the kilocalorie and macro- and micronutrient content of menu offerings demonstrate that restaurants may offer children's meal combinations that are fewer than 600 kcals, but the macro- and micronutrient content have not changed significantly with fat, saturated fat, and sodium exceeding national recommendations.
      • Wolfson JA
      • Moran AJ
      • Jarlenski MP
      • Bleich SN
      Trends in Sodium Content of Menu Items in Large Chain Restaurants in the U.S. American.
      ,
      • Deierlein AL
      • Peat K
      • Claudio L
      Comparison of the nutrient content of children's menu items at US restaurant chains, 2010–2014.
      • Hill JL
      • Olive NC
      • Waters CN
      • Estabrooks PA
      • You W
      • Zoellner JM
      Lack of healthy food options on children's menus of restaurants in the health-disparate Dan River region of Virginia and North Carolina, 2013.
      • Sliwa S
      • Anzman-Frasca S
      • Lynskey V
      • Washburn K
      • Economos C
      Assessing the availability of healthier children's meals at leading quick-service and full-service restaurants.
      Restaurants participating in the Kids LiveWell program have shown no substantial changes in kids’ meals across multiple years.
      • Wolfson JA
      • Moran AJ
      • Jarlenski MP
      • Bleich SN
      Trends in Sodium Content of Menu Items in Large Chain Restaurants in the U.S. American.
      ,
      • Moran AJ
      • Block JP
      • Goshev SG
      • Bleich SN
      • Roberto CA
      Trends in nutrient content of children's menu items in US Chain restaurants.
      One study showed that kids’ menu items in the US had fewer kilocalories than kids’ menu items in Australia, Canada, New Zealand, Australia, or the United Kingdom.
      • Hobin E
      • White C
      • Li Y
      • Chiu M
      • O'Brien MF
      • Hammond D
      Nutritional quality of food items on fast-food ‘kids’ menus’: comparisons across countries and companies.
      Several studies have assessed restaurant economic and service trends in kids’ meals. In a longitudinal study of menu-ordering patterns among 687,401 children after the initiation of the Kids LiveWell program, the findings showed that children ordered healthier options and that restaurants maintained revenue growth that was consistent with growth before the program was initiated.
      • Ayala GX
      • Castro IA
      • Pickrel JL
      • et al.
      A cluster randomized trial to promote healthy menu items for children: the kids’ choice restaurant program.
      Studies aimed at promoting sales of healthful menu items indicate that the restaurant industry is willing to collaborate on public health nutrition initiatives.
      • Ayala GX
      • Castro IA
      • Pickrel JL
      • et al.
      A restaurant-based intervention to promote sales of healthy children's menu items: the Kids’ Choice Restaurant Program cluster randomized trial.
      • Ferrante MJ
      • Johnson SL
      • Miller J
      • Moding KJ
      • Bellows LL
      Does a vegetable-first, optimal default strategy improve children's vegetable intake? A restaurant-based study.
      • Frelier JM
      • Moran AJ
      • Vercammen KA
      • Jarlenski MP
      Bleich SN. Trends in calories and nutrients of beverages in US chain restaurants,2012–2017.
      Nutrition educators can leverage this willingness to promote local and state participation in Kids LiveWell and to advocate that the requirements be expanded to apply to all kids’ meals and side dishes rather than just 2 meals on the menu. Considering that sales of sugar-sweetened beverages have increased at chain restaurants in the US, another strategy could include advocating for restaurants to remove soda from children's menus and to include a default non–sugar-sweetened beverage option instead.
      • Moran AJ
      • Subramanian SV
      • Rimm EB
      • Bleich SN
      Characteristics associated with household purchases of sugar-sweetened beverages in US restaurants.
      • Mueller MP
      • Wilde P
      • Folta SC
      • Anzman-Frasca S
      • Economos CD
      Availability of healthier children's menu items in the top selling quick service restaurant chains (2004–2015).
      • Ribakove S
      • Wootan MG
      Soda Still on the Menu.
      • Yang YT
      • Benjamin-Neelon SE
      Recent progress in children's meals law in restaurants in Baltimore City and California State: making a healthy beverage option the default choice.
      • Lynskey VM
      • Anzman-Frasca S
      • Harelick L
      • et al.
      Low parental awareness about energy (calorie) recommendations for children's restaurant meals: findings from a national survey in the USA.

       Promoting Policy and Legislative Solutions

      As fast-food purchases continue to increase, it is important that parents understand the energy and nutrition recommendations for children.
      • Harris JL
      • Hyary M
      CY SN
      Rudd Report: Parents’ Reports of Fast-Food Purchases for Their Children: Have They Improved?.
      ,
      • Soo J
      • Harris JL
      • Davison KK
      • Williams DR
      • Roberto CA
      Changes in the nutritional quality of fast-food items marketed at restaurants, 2010 v.
      Despite the occasional fruit or vegetable offering on a fast-food menu, most items still contain high calories, fat levels, and sodium levels.

      National Restaurant Association. National Restaurant AssociationLaunches Kids LiveWell 2.0.https://restaurant.org/research-and-media/media/press-releases/national-restaurant-association-launches-kids-livewell-2/. Accessed November 12, 2021.

      ,
      • Moran AJ
      • Block JP
      • Goshev SG
      • Bleich SN
      • Roberto CA
      Trends in nutrient content of children's menu items in US Chain restaurants.
      ,
      • Bleich SN
      • Moran AJ
      • Jarlenski MP
      • Wolfson JA
      Higher-calorie menu items eliminated in large chain restaurants.
      ,

      Uniform Compliance Date for Food Labeling Regulations. 21 CFR §101;2021. https://www.federalregister.gov/documents/2021/01/06/2020-29273/uniform-compliance-date-for-food-labeling-regulations. Accessed November 2, 2021.

      In 2018, in accordance with the US Food and Drug Administration Code of Federal Regulations Title 21 101.11, menu labeling laws were enacted for chain restaurants with 20 or more locations.
      • Alexander E
      • Rutkow L
      • Gudzune KA
      • Cohen JE
      • McGinty EE
      Healthiness of US chain restaurant meals in 2017.
      ,
      • Long MW
      • Gortmaker SL
      • Ward ZJ
      • et al.
      Cost Effectiveness of a Sugar-Sweetened Beverage Excise Tax in the U.S. American.
      Such policies and legislation affect large numbers of people. Studies examining national pricing, labeling laws, and food marketing strategies show that these policies can promote large-scale positive social and behavior changes.
      • Sonneville KR
      • Long MW
      • Ward ZJ
      • et al.
      BMI and healthcare cost impact of eliminating tax subsidy for advertising unhealthy food to youth.
      ,
      • Bleich SN
      • Moran AJ
      • Jarlenski MP
      • Wolfson JA
      Higher-calorie menu items eliminated in large chain restaurants.
      ,

      Uniform Compliance Date for Food Labeling Regulations. 21 CFR §101;2021. https://www.federalregister.gov/documents/2021/01/06/2020-29273/uniform-compliance-date-for-food-labeling-regulations. Accessed November 2, 2021.

      Nutrition educators, thus, can use current data to advocate for these changes, but more research is needed to assess the population-level impacts of food labeling on children's menus, as these policies may help identify opportunities for healthier food choices.
      • Crockett RA
      • King SE
      • Marteau TM
      • et al.
      Nutritional labelling for healthier food or non-alcoholic drink purchasing and consumption.
      ,
      • Anzman-Frasca S
      • Folta SC
      • Glenn ME
      • et al.
      Healthier children's meals in restaurants: an exploratory study to inform approaches that are acceptable across stakeholders.

       Creating Mutually Beneficial Consumer Food Options

      Anzman-Frasca et al
      • Hay B
      Why do kids’ menus always have chicken nuggets?’: children's observations on the provision of food in hotels on family holidays.
      reported that restaurant executives implement menu changes on the basis of profitability, consumer demand, regulation, and corporate social responsibility. Yet, in a hospitality industry study examining children's perceptions of children's menus, Hay
      • Lee K
      • Conklin M
      • Bordi P
      • Cranage D
      Restaurants’ healthy eating initiatives for children increase parents’ perceptions of CSR, empowerment, and visit intentions.
      reported that children felt that kids’ menus restricted their food choices and regulated entry into the adult world. The author concluded that separate menus for children may therefore become irrelevant or even deterrents in consumers’ choices about where to eat and shop. Such evidence provides a rationale for restaurants to include moderate plates or moderate portions vs a children's menu to meet consumer demand. Consumer demand is also increased when parent's perceive restaurant corporate social responsibility, and this perception mediates both healthy eating and willingness to be a customer at a restaurant.
      • Turnwald BP
      • Jurafsky D
      • Conner A
      • Crum AJ
      Reading between the menu lines: are restaurants’ descriptions of “healthy” foods unappealing?.
      These aims are mutually beneficial.
      Still, more work is needed to improve menu options. Nutrition educators can contribute to this effort by collaborating with the food industry to improve perceptions and selections of healthy options. For example, in a study examining 38,343 restaurant menu descriptions, the healthy food was significantly more likely to be described in less appealing ways than unhealthy food on the menu.
      • Grossman CI
      • Stangl AL
      Editorial: Global action to reduce HIV stigma and discrimination.
      For example, engaging words such as crazy, bites, dangerous, and adventure were more likely to describe standard menu items, but words such as simple, mild, plain, fit, and nutritional were more likely to occur on the healthy menu items.
      • Elliott C
      ‘Big Food’ and ‘gamified’ products: promotion, packaging, and the promise of fun.
      By conducting research, raising awareness, and collaborating with the restaurant industry, nutrition educators can help incorporate more appealing language and advocate for a wider variety of healthy options.

       Developing Strategic Health Messaging

      When behavioral outcomes are viewed as personal failures, it results in stigma, such as the blame and lack of empathy associated with human immunodeficiency virus infection, mental illness, substance abuse, and obesity (particularly in adults).
      • Pescosolido BA
      • Martin JK
      The stigma complex.
      • Hatzenbuehler ML
      • Phelan JC
      • Link BG
      Stigma as a fundamental cause of population health inequalities.
      • Sun Y
      • Krakow M
      • John KK
      • Liu M
      • Weaver J
      Framing obesity: how news frames shape attributions and behavioral responses.
      Deeply ingrained values in Western culture, such as independence, free choice, and self-governance, further influence how blame is attributed to individuals.
      • Kim SH
      • Willis LA
      Talking about obesity: news framing of who is responsible for causing and fixing the problem.
      The media commonly cites individual behavior as causes of poor diet and food choices.
      • Barry CL
      • Gollust SE
      • Niederdeppe J
      Are Americans ready to solve the weight of the nation?.
      The pervasive and widespread influence of this messaging could be leveraged to mobilize collective efforts aimed at improving social constructs, particularly those related to kids’ food.
      • Foley K
      • Ward P
      • McNaughton D
      Innovating qualitative framing analysis for purposes of media analysis within public health inquiry.
      ,
      • Kim SH
      • Willis LA
      Talking about obesity: news framing of who is responsible for causing and fixing the problem.
      Even more fundamentally, this messaging should frame childhood nutrition as a societal issue in which individuals work with the government, schools, and industry to identify and implement solutions.
      • Smith R
      • Kelly B
      • Yeatman H
      • et al.
      Advertising placement in digital game design influences children's choices of advertised snacks: a randomized trial.
      ,
      • Prowse RJL
      • Naylor PJ
      • Olstad DL
      • et al.
      Impact of a capacity-building intervention on food marketing features in recreation facilities.
      Nutrition educators can help shape health promotion messaging about kids’ meals to include societal-level policy solutions, such as healthy default menu options and menu labeling. They can also promote marketing regulation and work with families to create awareness about advertising and marketing strategies that promote unhealthy food to children.
      • Prowse RJL
      • Naylor PJ
      • Olstad DL
      • et al.
      Impact of a capacity-building intervention on food marketing features in recreation facilities.
      ,
      • Ray C
      • Campbell K
      • Hesketh KD
      Key messages in an early childhood obesity prevention intervention: Are they recalled and do they impact children's behaviour?.
      Even children who do not regularly eat processed and unhealthy food are regularly exposed to it in the forms of marketing and observations of peers who consume these items. This exposure makes it difficult for most parents to introduce and maintain a healthy variety of minimally processed and whole foods, such as fruits, vegetables, and milk. Nutrition educators can help families recognize that healthy food for children is the same as healthy food for adults. Given the influence of marketing and messaging, there are ample opportunities for nutrition educators to develop strategic and effective health promotion messaging.
      • Sigman-Grant M
      • Hayes J
      • VanBrackle A
      • Fiese B
      Family resiliency: a neglected perspective in addressing obesity in young children.

       Working With Communities and Families

      Building resilience and heathy adaptation to the food environment includes helping families cope with challenges by identifying assets and supportive factors, including responsive feeding practices, family cohesion, positive emotional regulation, and structure.
      • Skouteris H
      • Bergmeier HJ
      • Berns SD
      • et al.
      Reframing the early childhood obesity prevention narrative through an equitable nurturing approach.
      ,
      • Fulkerson JA
      • Larson N
      • Horning M
      • Neumark-Sztainer D
      A review of associations between family or shared meal frequency and dietary and weight status outcomes across the lifespan.
      For example, the concept of the Family Meal when families eat together is associated with better diet quality for children and healthy weight maintenance over time.
      • Utter J
      • Larson N
      • Berge JM
      • Eisenberg ME
      • Fulkerson JA
      • Neumark-Sztainer D
      Family meals among parents: associations with nutritional, social and emotional wellbeing.
      ,
      • Larson N
      • Fulkerson JA
      • Berge JM
      • Eisenberg ME
      • Neumark-Sztainer D
      Do parents perceive that organized activities interfere with family meals? Associations between parent perceptions and aspects of the household eating environment.
      Nutrition educators, thus, can work with busy parents to create sustainable strategies, such as preparing meals in advance.
      • Ford DE
      The community and public well-being model: a new framework and graduate curriculum for addressing adverse childhood experiences.
      They can also work with families to reframe concepts of kids’ food to exclude ultraprocessed and sugary food and instead incorporate a variety of fruits and vegetables along with adequate water intake. The regular practice of eating a diverse, healthy diet at home could promote better food choices when eating out, which in turn encourages restaurants to include these items in their offerings.
      Poverty and household stressors are factors associated with high levels of social vulnerability and low community resilience. Nutrition educators can work within the community to strengthen capacity to limit these adverse effects and overcome challenges.
      • Ellis WR
      • Dietz WH
      A new framework for addressing adverse childhood and community experiences: the building community resilience model.
      A first step in this endeavor is connecting cross-sector partnerships to address nutrition problems in different domains of the social ecological model (Figure). Creating strategically coordinated services that address social determinants of health, such as reframing the social construct of kids’ food, requires situating interventions within the context of the community and family using a transgenerational, lifestyle-based approach.
      • Ellis WR
      • Dietz WH
      A new framework for addressing adverse childhood and community experiences: the building community resilience model.
      ,
      • Ford DE
      The community and public well-being model: a new framework and graduate curriculum for addressing adverse childhood experiences.
      For example, in immigrant families, young children may develop preferences for food served in school rather than the cultural foods served at home. In response, parents may begin to prepare separate meals for their children and to think of their culturally traditional foods as for adults only, thus perpetuating the kids’ food archetype. Nutrition educators can intervene here and work with the family and school to honor healthy cultural food practices. This population-based health approach to nutrition practice involves understanding the family and community context and developing community partnerships to create social change.
      • Ellis WR
      • Dietz WH
      A new framework for addressing adverse childhood and community experiences: the building community resilience model.

      Conclusion

      Nutrition educators play key roles in shifting consumer demand and cultural norms about food choices. As such, they can help improve the unhealthy aspects of the kids’ food archetype. By shifting norms about kids’ food toward healthy food that both adults and children can enjoy (while accounting for age-appropriate and nutrition requirements), nutrition educators can promote healthy social and behavior changes at the individual, family, and community levels. Specific areas of focus explicitly renaming kids’ meal items as moderate plates, family meals, or moderate portions; building cultural capacity around healthful food for children; collaborating with policy makers and the restaurant industry to promote and conduct research on healthy menu options and improve menu labeling; promoting mutually beneficial relationships between food consumers and the industries that serve them; developing strategic health promotion messaging; and working with families and communities to reframe the kids’ food archetype. By recognizing the challenges of the current food environment and by partnering with governments, legislators, schools, and industries to address these challenges, nutrition education can play an integral role in decreasing lifetime risks of obesity, chronic disease, and other adverse health outcomes related to diet and food choices.

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