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\nVolume 10 \u2014 June 06, 2013
\nSuggested citation for this article: Krukowski RA, West D. No Financial Disincentive for Choosing More Healthful Entr\u00e9es on Children\u2019s Menus in Full-Service Restaurants. Prev Chronic Dis 2013;10:120266. DOI: http://dx.doi.org/10.5888/pcd10.120266.
\nPEER REVIEWED
\nChildren are eating restaurant foods more than ever before, and price is among the top considerations for food choices. We categorized and enumerated entr\u00e9es on children\u2019s menus from 75 full-service restaurant chains to compare prices of more healthful and less healthful entr\u00e9es to test the assumption that more healthful food is more expensive. The mean (standard deviation) price of more healthful entr\u00e9es ($5.38 [$2.01]) was not significantly different from the price of less healthful entr\u00e9es ($5.27 [$2.04]). In contrast to research demonstrating that more healthful foods tend to be more expensive in grocery stores, more healthful entr\u00e9es on children\u2019s menus in restaurants were not more expensive than less healthful entr\u00e9es.
\n \nChildren are eating foods away from home more frequently than ever before (1). Calories from full-service restaurants contribute 4% to American children\u2019s total intake, and calories from fast-food restaurants contribute 8% to 11% (1). In addition, among adults, price is second only to taste as a consideration in making food choices (2). Although research has demonstrated higher prices for more healthful foods than for less healthful foods in grocery stores (3,4), it is not known whether more healthful entr\u00e9es on restaurant children\u2019s menus are more expensive than less healthful entr\u00e9es.
\n \nIn this descriptive study, we used the Children\u2019s Menu Assessment (CMA) (5) to categorize and enumerate more healthful and less healthful entr\u00e9es on children\u2019s menus gathered from full-service restaurants in the 200 top-grossing restaurant chains identified in 2009 by Restaurants & Institutions (6). We used Hoover\u2019s (7) to identify restaurants classified as full-service (n = 90) according to code 722110 in the 2007 North American Industry Classification System (8). \u201cFull-service\u201d is defined as \u201cestablishments primarily engaged in providing food services to patrons who order and are served while seated (ie, waiter/waitress service) and pay after eating\u201d (9). Each restaurant chain was contacted to determine whether a children\u2019s menu was available, and if it was, a copy of the children\u2019s menu was requested (by mail or e-mail) or picked up from the restaurant in the Little Rock, Arkansas, area, where the research team was located. To reduce the potential effect of price variations due to geography, we made every attempt to obtain a menu in the Little Rock area. If the children\u2019s menu (including prices) was available only in print format and the nearest restaurant in the chain was located more than 50 miles from Little Rock, the children\u2019s menu was obtained at a restaurant by a colleague nearby. We excluded 15 restaurant chains that were closed or not classified as full-service according to CMA classification or that did not have a children\u2019s menu (Figure). Menus from the remaining 75 restaurant chains were collected in 2012, and entr\u00e9e prices were recorded.
\n \nFigure. Inclusion and exclusion criteria for study on children\u2019s menus. Abbreviations: NAICS, North American Industry Classification System; CMA, Children\u2019s Menu Assessment. [A text description of this figure is also available.]
\nCMA definitions of more healthful and less healthful entr\u00e9es (Box) were based on guidelines established by the Nutrition Environment Measures Study in Restaurants assessment (10). Examples of \u201cmore healthful\u201d entr\u00e9es are pasta with marinara sauce; roasted, baked, or grilled chicken (alone or in a sandwich or salad); grilled salmon; and salad bars. Examples of \u201cless healthful\u201d entr\u00e9es are hot dogs, hamburgers, macaroni and cheese, and fried chicken fingers. The CMA has high interrater and test\u2013retest reliability (5).
\nGuideline
\nPreparations such as \u201cgrilled,\u201d \u201cbaked,\u201d or \u201cbroiled\u201d generally are considered a healthful choice (eg, grilled chicken), with the exception of grilled sandwiches (eg, grilled cheese).
\nPreparations such as \u201cfried\u201d are not considered healthful. Unless otherwise noted, fish and chicken entr\u00e9es should be considered fried (eg, chicken fingers, chicken wings).
\nAn item with cheese, butter, or cream sauce as a significant ingredient (eg, macaroni and cheese, cheese ravioli, pasta with butter) is generally not considered healthful.
\nAn item with red meat is not considered healthful (eg, hamburger, taco, hotdog), unless it is specified that the meat is lower-fat or lower-calorie.
\nOnly rate a sandwich as healthful if it is modified to be made with whole wheat bread, lower-calorie/-fat condiments (eg, light mayo) or all fruit preserves (lower sugar).
\nOnly rate a daily entr\u00e9e soup special as a healthful entr\u00e9e if it is specified that the soup is consistent with the above guidelines for a healthful choice (ie, not made with cream, cheese, or red meat).
\nGreen salads are considered a healthful entr\u00e9e regardless of dressing, unless the protein source does not follow the other guidelines (eg, fried meat).
\nIf the restaurant specifically promotes the salad bar for children (eg, a lower price for children to choose this option) and the price for this option is similar to other main dishes on the menu, count it as a healthful entr\u00e9e salad, because the children are likely to have the option of choosing healthful components for their salad.
\nA vegetable plate can be counted as a healthful entr\u00e9e salad if it is possible for the child to select all more healthful items for this plate (ie, more healthful items include nonfried vegetables, fruits without added sugar, low-fat dairy products, and whole grain items).
\nWe enumerated the mean number of more healthful and less healthful entr\u00e9es offered and the proportion of more healthful to less healthful entr\u00e9es. Restaurants with the same price for all children\u2019s entr\u00e9es were identified. Salad entr\u00e9es and nonsalad entr\u00e9es were combined into 1 entr\u00e9e category. Only children\u2019s menus that had at least 1 more healthful and at least 1 less healthful entr\u00e9e (n = 58) were included in comparisons of the number of more healthful and less healthful entr\u00e9es and price comparisons of more healthful and less healthful entr\u00e9es. We compared the number of more healthful entr\u00e9es and mean price for the more healthful entr\u00e9e(s) within each restaurant, respectively, to the number of less healthful entr\u00e9es and mean price for the less healthful entr\u00e9es by using paired sample t tests, with restaurant as the unit of analysis. One restaurant with a single more healthful entr\u00e9e was excluded from the price comparison because the entr\u00e9e price was \u201cmarket price\u201d (for fish). Data were analyzed using SPSS 20.0 (IBM, Chicago, Illinois).
\n \nAll 75 restaurants had less healthful entr\u00e9es on their children\u2019s menu; 23% (n = 17) had only less healthful entr\u00e9es (mean price, $4.89; standard deviation [SD], $1.09). Seventy-seven percent (n = 58) had at least 1 more healthful entr\u00e9e and were thus included in the final analytic sample. On average, there were significantly fewer (P < .001) more healthful entr\u00e9es (mean, 1.8; SD, 1.0) than less healthful entr\u00e9es (mean, 8.2; SD, 3.9). The mean (SD) price of more healthful entr\u00e9es ($5.38 [$2.01]) was not significantly different (P = .20) from the mean (SD) price of less healthful entr\u00e9es ($5.27 [$2.04]). There was no price difference between more healthful and less healthful entr\u00e9es for 14 restaurants because all children\u2019s menu entr\u00e9es were available for the same price. When excluding restaurants that had the same price for all children\u2019s menu entr\u00e9es, we found no significant difference (P = .20) between the mean (SD) price of more healthful entr\u00e9es ($5.19 [$1.15]) and less healthful entr\u00e9es ($5.05 [$1.19]).
\n \nAlthough most full-service restaurant chains in this sample had at least 1 more healthful entr\u00e9e on their children\u2019s menu (77%), we found few more healthful entr\u00e9es on each children\u2019s menu; thus, choice among more healthful entr\u00e9es was limited. This is the first study to compare prices for making more healthful versus less healthful choices for entr\u00e9es on children\u2019s menus. We found no significant difference in mean price between more healthful and less healthful entr\u00e9es on full-service restaurant children\u2019s menus. However, it is still not known what other factors influence children\u2019s menu choices or how a choice is made when an order is placed (eg, child vs parent decision).
\nThis study had several limitations. The study did not examine prices for beverages, side dishes, or desserts; children\u2019s menus frequently used a unit price for a combination of entr\u00e9e, beverage, side dishes, and dessert and provided several options for side dishes or beverages at a constant price. Although the research team attempted to reduce the effect of potential price differences due to geographic location by using a standardized protocol for selecting proximal restaurant outlets, location-based price differences could have affected our results; other patterns may be found in other regions. In addition, this research focused on full-service restaurant chains that have a traditional handheld menu rather than a menu board (as fast-food and fast-casual restaurants do). It will be crucial in future research to examine whether prices differ between more healthful and less healthful entr\u00e9es in fast-food and fast-casual restaurant chains, given their increasing caloric contribution to children\u2019s diets (1).
\n \nCorresponding Author: Rebecca A. Krukowski, PhD, University of Tennessee Health Science Center, 66 N Pauline St, Memphis, TN 38163. Telephone: 901-448-5169. E-mail: rkrukows@uthsc.edu.
\nAuthor Affiliation: Delia West, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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