Comprehensive Restaurant-Sector Changes Are Essential to Reduce Obesity Risk for All Americans

Advocates celebrated a victory when the 111th US Congress enacted the Affordable Care Act, Public Law 111-148 (HR 3590), which was signed into law on March 23, 2010.¹ Section 4205 mandated that food vendors and quick-service restaurant, fast-casual restaurant, and full-service restaurant chains with more than 20 US locations would be required to disclose calories on menus and menu boards and make other nutrition information available to customers upon request (bit.ly/2y8d403). The law directed the Food and Drug Administration to provide guidance and oversight for industries affected by the law.¹

Public health advocates could not have predicted that it would take 15 years to champion this legislation—seven years to translate local advocacy efforts into a national law and eight years to finalize the regulatory guidance requiring chain restaurants to post calorie information starting May 7, 2018.

In this issue of AJPH, using geocoded data for 1753 restaurant outlets in four New Jersey cities in 2014, Gruner et al. (p. 234) report on the predicted impact of the Food and Drug Administration’s menu-labeling regulation. The results showed that 84% of independent nonchain restaurants in the four large cities would not need to comply with the restaurant menu-labeling law unless they voluntarily choose to do so. These results have important implications for other locations that operate profitable restaurant franchises and small restaurant businesses across the country.

Gruner et al. also found that people with a median income at or higher than $52 560 are more likely to see and benefit from restaurant menu labeling than Americans living in low-income communities with a median income less than $37 000 and majority Hispanic track neighborhoods. They acknowledged health equity concerns for low-income adults disproportionately impacted by higher obesity rates and diet-related noncommunicable diseases who are less likely to use menu labeling.

Mandatory restaurant menu labeling is necessary but insufficient to raise consumers’ awareness and influence restaurant policies and practices to reformulate and market healthy offerings to reduce obesity and noncommunicable disease risks among Americans. This editorial describes opportunities and challenges for the US restaurant sector to make transformative changes that promote healthy choices as the norm and not the exception.

PRESENCE OF RESTAURANTS IN AMERICANS’ LIVES

The National Restaurant Association, which is the major trade association representing more than 500 000 food-service businesses, projected US eating establishment sales to exceed $551 billion in 2017, representing 48% of household income spent on food.²

One in three Americans got their first job experience in a restaurant, and half of all adults have worked in the restaurant industry at some point during their lives.² A majority of adults report that dining out with friends and family is preferable to cooking at home and cleaning up.²

A 2017 market research survey found that Americans who frequent quick-service restaurant chains prioritize staff friendliness, value for money spent, food quality, service speed, cleanliness, and atmosphere over the healthfulness of food offerings.³ Given these trends, one can understand why nearly two thirds of American adults visit quick-service restaurant chains and 40% visit fast-casual restaurant chains weekly, and 30% to 40% of children and adolescents visit quick-service restaurant chains daily.⁴

RECOMMENDED NUTRIENT TARGETS

Between 2006 and 2016, 16 government, industry, and expert public health bodies recommended nutrient targets for the US restaurant sector, including standardizing portions and reducing the total energy to 700 or fewer calories per meal for adults and adolescents and 600 or fewer calories per meal for children younger than 12 years.⁵ Most restaurant offerings still exceed the Dietary Guidelines for Americans and other recommended targets for calories (≤ 600 to 700 calories/meal), fat (≤ 35% total calories), saturated fat (≤ 10% total calories), added sugars (≤ 35% total calories), and sodium (≤ 210 mg to 410 mg/meal item).⁵

US RESTAURANT SECTOR PROGRESS

US chain and nonchain restaurants can make voluntary changes by using comprehensive marketing-mix and choice-architecture strategies to normalize healthy options. These include changes to place (ambience and atmospherics), profile (nutrient composition), portion, pricing, promotion (responsible marketing), healthy default picks, priming or prompting (information and labeling), and proximity (positioning; bit.ly/2zGCTks).⁴

A US restaurant-sector progress evaluation (2016–2017) used 12 performance metrics developed from the recommended nutrient targets for these eight strategies. Results showed that the restaurant sector made limited progress to use profile, pricing, promotion, healthy default picks, and priming or prompting, and only some progress to reduce and standardize portion sizes.⁵ Nutrient-profile changes examined in 18 out of 25 studies documented either a modest or no reduction in total calories to meet the recommended 700 or fewer calories per adult meal or 600 or fewer calories per child meal. Three studies found that chain restaurants that had introduced new items between 2012 and 2015 had 26 to 67 fewer calories. Few restaurants have met the targets for percentage of calories from fat and saturated fat.⁵ Nine studies showed either no reduction, a modest decline, or an increase in the sodium content of menu items.⁵

CHILDREN’S MEALS AND RESPONSIBLE MARKETING

Restaurants that participated in the National Restaurant Association’s Healthy Dining Kids LiveWell Program were more likely to have reduced children’s entrees by about 40 calories per meal between 2012 and 2014. Nevertheless, less than 11% of children’s meals met recommended healthy nutrition criteria by 2013.⁵ Most chains used marketing practices not covered by voluntary pledges to target children younger than 12 years, and no pledges protect adolescents, aged 12 to 17 years, from marketing of unhealthy products.⁵

Americans will accept healthy default choices such as fruit or vegetables instead of fries or water instead of sweetened soda.⁵ Between 2008 and 2016, 38 chains with children’s menus had reduced sugary beverage availability from 93% to 74%, accompanied by modest replacement of water and low-fat milk as default beverages.⁶ No similar actions were taken by restaurant chains to create healthy defaults for adolescents or adults. A separate 2016 Rudd Center evaluation of six leading quick-service restaurant chains found that voluntary pledges to offer healthy side dishes and to remove unhealthy beverages as the default for children’s meals were implemented inconsistently at different restaurant chains.⁷ Only McDonald’s, Subway, and Panera had established fruits and vegetables as healthy side dishes for children’s meals by 2016.⁵ Pricing is a powerful policy tool to address population-based health disparities.⁴ Yet no major quick-service restaurant or fast-casual restaurant chain has reduced price promotions on large portions or used competitive or proportionate pricing to encourage healthy purchases.⁵

LEADERSHIP TO NORMALIZE HEALTHY CHOICES

The underwhelming progress made by the US restaurant sector demonstrates that the National Restaurant Association and leading quick-service restaurant, fast-casual restaurant, and full-service restaurant chains are not yet fully committed to change industry-wide practices that drive poor diet quality, obesity, and noncommunicable disease rates. Mandatory menu-labeling law is important but insufficient to change social norms and customers’ expectations. Bold leadership and technical assistance provided by the National Restaurant Association and leading chains could change industry-wide expectations and chain and nonchain restaurant practices to promote healthy and profitable choices. Civil society organizations and citizens could use their purchasing power to demand smaller and standardized portions and use social media to hold restaurants accountable for promoting healthy and affordable choices that establish a healthy restaurant culture for all Americans.