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Address for correspondence: Pamela Rothpletz-Puglia, EdD, RD, Associate Professor, School of Health Professions, Rutgers, The State University of New Jersey, Newark, NJ 07107
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
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.
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.
Television food advertising viewed by preschoolers, children and adolescents: contributors to differences in exposure for black and white youth in the United States.
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.
which can persist into later childhood and even adulthood, ultimately increasing lifetime risks of obesity, chronic disease, and other adverse health outcomes.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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,
cultural histories should be respected, and distal causes of health inequity should be considered, such as adverse childhood experiences, trauma, structural racism,
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.
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.
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.
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.
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.
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.
Studies aimed at promoting sales of healthful menu items indicate that the restaurant industry is willing to collaborate on public health nutrition initiatives.
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.
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.
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.
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.
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
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.
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.
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.
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).
Deeply ingrained values in Western culture, such as independence, free choice, and self-governance, further influence how blame is attributed to individuals.
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.
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.
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.
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.
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.
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.
Do parents perceive that organized activities interfere with family meals? Associations between parent perceptions and aspects of the household eating environment.
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.
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.
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.
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.
Television food advertising viewed by preschoolers, children and adolescents: contributors to differences in exposure for black and white youth in the United States.
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.
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.
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.
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.
Obesity trends and associations with types of physical activity and sedentary behavior in US adults: National Health and Nutrition Examination Survey, 2007-2016.
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.
Do parents perceive that organized activities interfere with family meals? Associations between parent perceptions and aspects of the household eating environment.
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