ABSTRACT
Background
Meals from full-service restaurants (FS) and fast-food restaurants (FF) are an integral part of US diets, but current levels and trends in consumption, healthfulness, and related sociodemographic disparities are not well characterized.
Objectives
We aimed to assess patterns and nutritional quality (using validated American Heart Association [AHA] diet scores) of FS and FF meals consumed by US adults.
Methods
Serial cross-sectional investigation utilizing 24-h dietary recalls in survey-weighted, nationally representative samples of 35,015 adults aged ≥20 y from 7 NHANES cycles, 2003–2016.
Results
Between 2003 and 2016, American adults consumed ∼21 percent of energyfrom restaurants (FS: 8.5% in 2003–2004, 9.5% in 2015–2016, P-trend = 0.38; FF: 10.5%; 13.4%, P-trend = 0.31). Over this period, more FF meals were eaten for breakfast (from 4.4% to 7.6% of all breakfasts, P-trend <0.001), with no changes for lunch (15.2% to 15.3%) or dinner (14.6% to 14.4%). In 2015–2016, diet quality of both FS and FF were low, with mean AHA diet scores of 31.6 and 27.6 (out of 80). Between 2003 and 2016, diet quality of FF meals improved slightly, (the percentage with poor quality went from 74.6% to 69.8%; and with intermediate quality, from 25.4% to 30.2%; P-trend <0.001 each). Proportions of FS meals of poor (∼50%) and intermediate (∼50%) quality were stable over time, with <0.1% of consumed FS or FF meals meeting ideal quality. Disparities in FS meal quality persisted by race/ethnicity, obesity status, and education and worsened by income; whereas disparities in FF meal quality persisted by age, sex, and obesity status and worsened by race/ethnicity, education, and income.
Conclusions
Between 2003 and 2016, FF and FS meals provided 1 in 5 calories for US adults. Modest improvements occurred in nutritional quality of FF, but not FS, meals consumed, and the average quality for both remained low with persistent or widening disparities. These findings highlight the need for strategies to improve the nutritional quality of US restaurant meals.
Keywords: diet quality, full-service restaurant meals, fast-food restaurant meals, trends, American adults, NHANES
Introduction
Over the past 3 decades, meals in the USA have substantially shifted away from home-prepared meals and toward dining out at restaurants (1). Meals consumed from both full-service restaurants (FS) and fast-food (also termed fast-casual or quick-serve) restaurants (FF) accounts for a substantial proportion of American diets (2). Approximately one-third of the average American's daily calories come from food purchased from restaurants (3–5); whereas spending on food away from home has risen to more than half of all food dollars (3). According to the US Census Bureau, restaurant sales in the US reached $315 billion for FS and $311 billion for FF in 2018; these sales increased by ∼37% and 45% from 2000, respectively (6).
With the rapid rise in sales, FS and FF meals have become the largest contributor to the average energy intake among foods prepared away from home (7). Several studies have evaluated different aspects of US restaurant meal consumption. Kant et al. reported null associations between eating frequency at restaurants and mortality using NHANES 1999–2004 linked with the 2011 National Death Index (8). In contrast, Krishnan et al. reported positive associations of frequent consumption of restaurant meals of hamburgers, fried chicken, fried fish, and Chinese food with incidence of type 2 diabetes using the prospective Black Women's Health Study (9). An et al. evaluated NHANES 2003–2012 to assess how eating frequency at restaurants associated with total daily consumption of selected nutrients, finding positive associations with energy, fat, saturated fat, cholesterol, and sodium (10). Similar findings were reported by Nguyen et al. using NHANES 2003–2010 (11). Together, these studies suggest that the frequency of restaurant eating may be associated with metabolic outcomes and other dietary habits. However, fewer studies have evaluated the actual dietary quality of different restaurant meals. Bleich et al. investigated the calorie and selected nutrient profiles of restaurant menus offered by large chain restaurants using the MenuStat database (12). They found meals offered by large US chain restaurants are high in calories, sodium, saturated fat, and sugar. Additionally, available data suggested the nutritional content of meals obtained from both FF and FS restaurants were poorer for low-income individuals and ethnic minorities (13–15).
Growing evidence suggests that food choices, not merely nutrients, are essential for health and well-being (16, 17). Yet, the overall dietary quality of meals consumed from restaurants among US adults, including both foods and nutrients, and the trends and sociodemographic disparities in such quality over time, are not well established. To address these questions, we investigated the dietary quality of meals consumed from FS and FF restaurants among US adults, including the trends and associated disparities over time, in a nationally representative sample.
Methods
Data source, study population, and dietary assessment
NHANES is a series of stratified, multistage probability surveys conducted in a 2-y cycle and designed to be nationally representative of the US civilian, noninstitutionalized population (18, 19). Dietary information were collected through a 24-h recall method. The first dietary recall was collected in-person using USDA's Automated Multiple-Pass Method (AMPM), with 3-dimensional measuring tools to assist participants in reporting quantities. The second dietary recall, available from the cycle of 2003–2004 and onward, was collected over the telephone using the same method for a nonconsecutive day, with a reference booklet provided to aid participants in describing food and the amounts consumed. The NHANES interviewers and diet recall participants were monitored with established criteria to evaluate data accessibility and collect detailed dietary information. Given the sources of foods are available after the cycle of 2001–2002 (20), data from 7 cycles of NHANES from 2003–2004 to 2015–2016 with reliable dietary recalls, which met the minimum criteria including the completed first 4 steps of the 5-step AMPM and identified eating occasion for each consumed food/beverages, were included in the present study. Dietary data from the first recall was used for individuals with a single recall; and 2-d means for those with 2 recalls. Group means of either a single recall or multiple recalls provide unbiased estimates of stratum means (21). The protocol and data collection methods have been published (5). NHANES was approved by the National Center for Health Statistics Review Board, and all participants provided written informed consent.
For each food and beverage item reported by each participant, the source of the food was recorded during the interview-administered 24-h dietary recalls. More than 20 sources were available, including different types of restaurants, food prepared at home, etc. (Supplemental Text). FS meals were identified as food items consumed at “restaurant with waiter/waitress” whereas FF meals were identified as those consumed at “restaurant fast food/pizza”. A small number of food items (<0.01% of total) consumed at “restaurant no additional information” were not included in either FS or FF meals. However, specific types of restaurants, such as chain versus nonchain restaurants, fast-casual restaurants, could not be differentiated based on the current information provided by the NHANES. In addition to source, each meal setting such as breakfast, lunch, dinner, or snack was reported by the respondent.
American Heart Association diet score
To assess FS and FF meal quality, we used the American Heart Association (AHA) diet score, a summary indicator based on the AHA 2020 Strategic Impact Goals for diet, which has been validated as a risk factor for cardiovascular and metabolic outcomes in multiple diverse populations (22, 23). Such dietary pattern scores also allow an integrated assessment which takes into account foods, nutrients, and their interactions, and are also a major focus of the Dietary Guidelines for Americans (DGA) (24). In brief, the primary diet score included 5 components [total fruits and vegetables, fish/shellfish, whole grains, sodium, and sugar-sweetened beverages (SSBs)], whereas the secondary score added 3 additional components (nuts/seeds/legumes, processed meat, and saturated fat). To best assess changes and trends, we utilized continuous scoring for the primary and secondary AHA diet scores as previously described (23). Based on the AHA 2020 Strategic Goals, we estimated the proportion of FS and FF meals with poor diet quality [defined as a score of <20 (of 50 possible points) for the primary score or <40% adherence], an intermediate diet (score of 20–39.9 or 40–79.9% adherence), or an ideal diet (score of ≥40 or ≥80% adherence). Because the optimal intake levels for each component in the AHA scores are based on a 2000 kcal/d diet, the score is adjusted for the energy content of the meals so that the nutritional quality of each FS and FF meal in proportion to energy (e.g. servings of fruits per 2000 kcal) may be examined.
Food groups and nutrients
In addition to the AHA 2020 Goals, we evaluated individual food and nutrient components linked to major chronic diseases as well as those of current policy or general public interest. Foods and nutrients in FS and FF meals were derived from the USDA Food Patterns Equivalents Database (FPED) (25) and MyPyramid Equivalents Database (MPED) (26), which disaggregate mixed foods into their component parts. Food groups of interest included fruits, vegetables, nuts/seeds, whole grains, unprocessed red meat, processed meat, poultry, refined grains, fish/shellfish, legumes, dairy, SSBs, and added sugar. Nutrients of interest included saturated fat, unsaturated fats, seafood ω-3 fats, potassium, and sodium. Standard serving sizes have been documented (23) and are consistent as measured in the FPED developed by USDA; examples are provided in Supplemental Table 1. All intakes of meals were adjusted to 2000 kcal/d to account for varying serving sizes and amounts as well as facilitate interpretation of the overall nutritional quality and food and nutrient components of different FS and FF meals as compared with diet quality scores and national dietary recommendation.
Disparities by population subgroups
To assess potential disparities in key population subgroups, findings were stratified by age (20–34, 35–49, 50–64, ≥65 y); sex (men, women); race/ethnicity (non-Hispanic white, non-Hispanic black, Mexican American, other Hispanic, other/mixed race); education level (<high school graduate, high school graduate or general equivalency diploma (GED), some college, ≥4 y of college); and family income (ratio of family income to the federal poverty level (PIR) <1.30, 1.30–1.84, 1.85–2.99, and ≥3.00; the lowest category is used as a criterion for eligibility for the federal Supplemental Nutrition Assistance Program). Participants were groups as underweight (BMI ≤18.5 kg/m2), normal weight (BMI, 18.5–24.9), overweight (BMI, 25.0–29.9), and obese (BMI, ≥30). We also assessed whether quality of FS and FF meals vary according to the amount of meals consumed from FS or FF, categorizing calories consumed from FS or FF into tertiles.
Statistical analysis
Nationally representative findings were estimated separately for each NHANES cycle, accounting for complex survey weights and analytic procedures (27). Means and proportions of calories consumed from FS or FF were assessed among individual participants; and AHA diet scores and component food and nutrient quantities for each daily reported amount of FS and FF meals. Trends over time were assessed as both absolute and percentage change. The statistical significance of trends was assessed by treating survey year as a continuous variable in a survey-weighted linear regression model. To assess statistical heterogeneity of trends by subgroups, a survey-weighted Wald test was used to test for an interaction term between year and categorical variables (age, sex, race/ethnicity) or ordinal variables (income level, education level, and FS or FF meal calorie tertile levels). Due to the nature of NHANES sampling and 24-h recall dietary data, the results of this investigation can be considered as nationally representative of different population subgroups and of average FS and FF meals in the USA, rather than of any individual participant in NHANES. All analyses were performed using Stata version 14.0 (StataCorp). A 2-sided α = 0.05 was used to determine the statistical significance (28, 29).
Results
Population characteristics
Characteristics of the 35,015 US sampled adults from 2003–2016, survey-weighted to be nationally representative, are shown in Table 1. On any given day during this period, 29.8% of US adults consumed an FS meal, 46.4% consumed an FF meal, and 14.7% consumed both. Compared with the overall US adult population, those consuming FS meals were more likely to be men, non-Hispanic white, have some college education or more, and have higher income. In contrast, those consuming FF meals were more likely to be men, younger, non-Hispanic black, and obese.
TABLE 1.
Sociodemographic characteristics of US adults and adults consuming meals from full-service restaurants and fast-food restaurants, 2003–20161
| Survey-weighted % (95% CI)2 | ||||
|---|---|---|---|---|
| Characteristics | All US adults (N = 35,015)2 | Adults consuming meals from full-service restaurants3 (N = 10,448)2 | Adults consuming meals from fast-food restaurants4 (N = 16,264)2 | Adults consuming meals from both restaurants5 (N = 5154)2 |
| Age group, y | ||||
| 20–39 | 37.1 (35.9, 38.3) | 37.1 (35.7, 38.6) | 45.0 (43.4, 46.5) | 43.8 (42.0, 45.8) |
| 40–64 | 44.7 (43.8, 45.6) | 45.8 (44.3, 47.3) | 44.0 (42.7, 45.3) | 44.6 (42.7, 46.4) |
| ≥65 | 18.2 (17.4, 18.9) | 17.0 (15.9, 18.1) | 11.0 (10.3, 11.8) | 11.6 (10.5, 12.8) |
| Sex | ||||
| Men | 48.1 (47.5, 48.7) | 50.1 (48.9, 51.2) | 50.8 (49.8, 51.8) | 52.5 (50.6, 54.4) |
| Women | 51.9 (51.3, 52.5) | 49.9 (48.8, 51.0) | 49.2 (48.2, 50.1) | 47.5 (45.6, 49.4) |
| Race/ethnicity | ||||
| Non-Hispanic white | 68.6 (65.9, 71.2) | 74.5 (72.0, 76.8) | 66.6 (63.7, 69.4) | 72.3 (69.5, 75.0) |
| Non-Hispanic black | 11.3 (10.0, 12.8) | 7.43 (6.46, 8.53) | 13.5 (11.9, 15.3) | 9.12 (7.86, 10.6) |
| Mexican American | 8.39 (7.11, 9.87) | 7.01 (5.75, 8.51) | 8.65 (7.32, 10.2) | 7.48 (6.02, 9.26) |
| Other Hispanic | 4.87 (4.12, 5.75) | 4.30 (3.54, 5.21) | 4.87 (4.11, 5.77) | 4.47 (3.63, 5.50) |
| Other/mixed race | 6.82 (6.13, 7.58) | 6.77 (5.96, 7.69) | 6.38 (5.70, 7.13) | 6.60 (5.67, 7.67) |
| Education | ||||
| <High school | 16.9 (15.8, 18.1) | 11.1 (10.0, 12.3) | 15.1 (13.9, 16.3) | 10.4 (9.2, 11.8) |
| High school | 23.2 (22.3, 24.2) | 20.7 (19.3, 22.2) | 23.4 (22.1, 24.8) | 20.1 (18.2, 22.2) |
| Some college | 31.9 (31.0, 32.8) | 32.9 (31.4, 34.4) | 33.5 (32.3, 34.8) | 34.1 (31.9, 36.2) |
| College graduate and above | 28.0 (26.3, 29.7) | 35.3 (33.1, 37.5) | 27.9 (26.1, 29.8) | 35.4 (32.9, 37.9) |
| Ratio of family income to poverty level | ||||
| <1.30 | 20.6 (19.4, 22.0) | 13.1 (11.9, 14.3) | 20.2 (18.7, 21.8) | 12.9 (11.3, 14.6) |
| 1.30–1.849 | 9.75 (9.20, 10.3) | 7.99 (7.22, 8.84) | 9.24 (8.55, 9.98) | 7.83 (6.77, 9.03) |
| 1.85–2.99 | 17.2 (16.3, 18.1) | 15.8 (14.7, 17.0) | 17.5 (16.4, 18.6) | 16.4 (14.9, 19.1) |
| ≥3.00 | 52.5 (50.7, 54.2) | 63.1 (61.3, 64.9) | 53.0 (51.1, 54.9) | 62.8 (60.6, 65.0) |
| BMI, kg/m2 | ||||
| Underweight (BMI of ≤18.5) | 1.62 (1.42, 1.83) | 1.17 (0.94, 1.46) | 1.61 (1.34, 1.92) | 0.97 (0.71, 1.31) |
| Normal weight (BMI of 18.5–<25) | 29.1 (28.2, 30.0) | 29.1 (27.8, 30.4) | 27.6 (26.3, 28.9) | 28.6 (26.7, 30.4) |
| Overweight (BMI of 25–<30) | 33.0 (32.2, 33.8) | 34.5 (33.2, 35.9) | 32.6 (31.4, 33.9) | 34.2 (32.2, 36.1) |
| Obese (BMI of ≥30) | 36.2 (35.3, 37.3) | 35.2 (33.6, 36.8) | 38.2 (36.8, 39.5) | 36.3 (34.2, 38.5) |
Among adults aged ≥20 y.
The number of participants sampled are reported. All analyses are weighted to be nationally representative.
Meals from full-service restaurants are identified as food items consumed at “Restaurant with waiter/waitress”.
Meals from fast-food restaurants are identified as food items consumed at “Restaurant fast food/pizza”.
Representing Americans who consume meals at both locations in any given day, a subset of each of the prior 2 columns.
%, proportion.
Calories and eating occasions from restaurant meals
Between 2003 and 2004 to 2015 and 2016, American adults consumed ∼9% of total energy (% energy) from FS (range over time: 8.5% to 9.5%, P-trend = 0.38) and ∼12% energy from FF (range over time: 10.5% to 13.4%, P-trend = 0.31) (Supplemental Table 2). A decreasing trend was observed in total calories consumed from all sources (change: −121 kcal, 95% CI: −174, −69; P-trend <0.001) including calories from FS (change: −28, 95% CI: −51, −5; P-trend = 0.04). Among adults who ate meals from FS and/or FF, more than one-quarter of their total calories was consumed from restaurants, a proportion which remained stable over the study period for FS meals (P-trend = 0.44) and FF meals (P-trend = 0.66). Over the study period, an increasing number of FF meals were eaten for breakfast (increasing from 4.4% to 7.6% of all breakfasts) (P-trend <0.001), with relatively stable consumption for lunch (15.2% to 15.3%) and dinner (14.6% to 14.4%). Although there was some variation from year to year, these proportions remained relatively stable for FS meals at breakfast (2.93% to 2.90%), lunch (9.46% to 7.68%), and dinner (13.4% to 11.3%) (P-trend >0.05 for each) (Supplemental Tables 3–6).
Trends in overall diet quality of restaurant meals
In 2015–2016, diet quality of consumed FS and FF meals were both low, with mean primary AHA scores of 17.3 and 14.7 (out of 50), respectively; and secondary AHA scores of 31.6 and 27.6 (out of 80). Between 2003 and 2016, diet quality of FS remained stable; whereas FF quality was similar over time per the primary score and modestly improved per the secondary score (improvement of 4.2%; P-trend <0.001), largely due to increased nuts/seeds/legumes and decreased saturated fat, and (to a lesser extent) increased whole grains. The proportion of consumed FF meals with poor quality (<40% adherence to the AHA secondary score) declined from 74.6% to 69.8%, whereas the proportion with intermediate quality (40–79.9% adherence) increased from 25.4% to 30.2% (both P-trend <0.001) (Figure 1,Supplemental Table 7). The proportions of FS meals with poor (∼50%) and intermediate (∼50%) quality were stable over the study period. Notably, <0.1% of consumed FS or FF meals met ideal quality (>80% adherence).
FIGURE 1.
Trends in proportions of meals with intermediate or poor diet quality according to the American Heart Association Secondary Diet Score of 2020 Strategic Impact Goals Consumed at Restaurants (bottom) (left for full-service restaurants, P-trend = 0.63 for intermediate, and 0.63 for poor; right for fast-food restaurants, P-trend <0.001 for both intermediate and poor) by NHANES cycle from 2003 to 2016 (see Supplemental Table 6 for details). Data on the percentage meeting an ideal diet (≥40 points or ≥80% adherence) are not presented due to very small numbers (most of them are zeros) and large statistical uncertainty. Data are weighted to be nationally representative. AHA, American Heart Association.
Trends in individual food and nutrient components
Among individual components of the AHA score in 2015–2016, highest (most optimal) FS meal scores were seen for processed meat, SSBs, and saturated fat; and lowest scores for whole grains, nuts/seeds/legumes, and fish/shellfish (Table 2,Supplemental Figure 1). FF meal scores were generally lower than FS meal scores for every component. Between 2003 and 2004 to 2015 and 2016, a small improvement was seen in the score for whole grains for both FS and FF meals, although the absolute score remained low: the whole grain score increased from 0.58 (out of 10) to 1.0 for FS (P-trend <0.001) and from 0.21 to 0.62 for FF (P-trend = 0.001) meals. SSB scores also modestly improved for FS meals (from 7.8 to 8.3; P-trend = 0.02) with a nonsignificant trend for FF meals (from 7.1 to 7.4; P-trend = 0.055). Scores increased for nuts/seeds/legumes (from 0.67 to 1.2; P-trend <0.001) and saturated fat (from 3.4 to 3.8; P-trend <0.001); although both scores remained lower for FF versus FS meals. In contrast, scores for fruits and vegetables decreased for both FS meals (from 5.1 to 4.2; P-trend <0.001) and FF meals (from 3.6 to 2.9; P-trend <0.001), whereas scores for sodium worsened in FS meals (from 2.7 to 2.2; P-trend = 0.03) with a nonsignificant trend for FF meals (from 3.4 to 3.2; P-trend = 0.17).
TABLE 2.
Trends in quality of dietary components consumed from full-service and fast-food restaurants based on the American Heart Association 2020 Strategic Impact Goals Among US Adults, 2003–2016
| Dietary consumption | Survey-weighted AHA mean score ± SE1 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| AHA intake target (range) | Max points | 2003–2004 (n1 = 1405; n2 = 2010) | 2005–2006 (n1 = 1375; n2 = 2122) | 2007–2008 (n1 = 1566; n2 = 2374) | 2009–2010 (n1 = 1631; n2 = 2408) | 2011–2012 (n1 = 1465; n2 = 2401) | 2013–2014 (n1 = 1546; n2 = 2607) | 2015–2016 (n1 = 1460; n2 = 2342) | P-trend | |
| AHA Primary Individual Diet Score | ||||||||||
| Fruits and vegetables | ≥4.5 cup/d (0–≥4.5 cup/d) | 10 | ||||||||
| Full-service restaurant | 5.08 ± 0.15 | 5.06 ± 0.13 | 4.79 ± 0.09 | 4.77 ± 0.13 | 4.84 ± 0.08 | 4.62 ± 0.11 | 4.18 ± 0.17 | <0.001 | ||
| Fast-food restaurant | 3.62 ± 0.07 | 3.58 ± 0.08 | 3.16 ± 0.05 | 3.22 ± 0.07 | 3.01 ± 0.09 | 2.94 ± 0.09 | 2.94 ± 0.08 | <0.001 | ||
| Whole grains | ≥3 oz equivalents/d (0–≥3 oz equivalents/d) | 10 | ||||||||
| Full-service restaurant | 0.58 ± 0.07 | 0.53 ± 0.05 | 0.63 ± 0.05 | 0.55 ± 0.04 | 0.82 ± 0.09 | 0.81 ± 0.08 | 1.00 ± 0.16 | 0.001 | ||
| Fast-food restaurant | 0.21 ± 0.03 | 0.33 ± 0.05 | 0.28 ± 0.03 | 0.24 ± 0.05 | 0.52 ± 0.07 | 0.62 ± 0.07 | 0.62 ± 0.08 | <0.001 | ||
| Fish and shellfish | ≥2 oz/d (0–≥2 oz/d) | 10 | ||||||||
| Full-service restaurant | 1.64 ± 0.17 | 1.72 ± 0.13 | 1.72 ± 0.16 | 1.76 ± 0.14 | 1.54 ± 0.16 | 1.74 ± 0.16 | 1.54 ± 0.12 | 0.57 | ||
| Fast-food restaurant | 0.64 ± 0.05 | 0.63 ± 0.06 | 0.67 ± 0.09 | 0.63 ± 0.08 | 0.47 ± 0.07 | 0.60 ± 0.06 | 0.59 ± 0.04 | 0.15 | ||
| Sugar-sweetened beverages | ≤36 fl oz/wk (≤36→16 fl oz/wk) | 10 | ||||||||
| Full-service restaurant | 7.81 ± 0.15 | 8.13 ± 0.13 | 7.99 ± 0.22 | 8.13 ± 0.12 | 8.21 ± 0.15 | 8.34 ± 0.14 | 8.32 ± 0.22 | 0.02 | ||
| Fast-food restaurant | 7.09 ± 0.17 | 7.33 ± 0.13 | 7.41 ± 0.10 | 7.25 ± 0.12 | 7.40 ± 0.14 | 7.68 ± 0.15 | 7.39 ± 0.18 | 0.055 | ||
| Sodium | ≤1500 mg/d (≤1500→4500 mg/d) | 10 | ||||||||
| Full-service restaurant | 2.72 ± 0.08 | 2.39 ± 0.13 | 2.33 ± 0.09 | 2.37 ± 0.11 | 2.48 ± 0.08 | 2.43 ± 0.07 | 2.23 ± 0.14 | 0.03 | ||
| Fast-food restaurant | 3.39 ± 0.13 | 2.92 ± 0.07 | 3.01 ± 0.07 | 2.90 ± 0.08 | 3.51 ± 0.17 | 3.33 ± 0.07 | 3.18 ± 0.09 | 0.17 | ||
| AHA Secondary Individual Diet Score | ||||||||||
| Nuts, seeds, and legumes | ≥4 servings/wk (0–≥4 servings/wk) | 10 | ||||||||
| Full-service restaurant | 1.23 ± 0.16 | 1.21 ± 0.17 | 1.42 ± 0.16 | 1.20 ± 0.14 | 1.57 ± 0.17 | 1.47 ± 0.15 | 1.47 ± 0.14 | 0.08 | ||
| Fast-food restaurant | 0.67 ± 0.07 | 0.74 ± 0.08 | 0.72 ± 0.08 | 0.67 ± 0.10 | 0.92 ± 0.08 | 0.89 ± 0.08 | 1.16 ± 0.11 | <0.001 | ||
| Processed meat | ≤0.5 oz/d (≤0.5→1.76 oz/d) | 10 | ||||||||
| Full-service restaurant | 8.52 ± 0.12 | 8.47 ± 0.10 | 8.25 ± 0.10 | 8.22 ± 0.14 | 8.08 ± 0.16 | 8.54 ± 0.11 | 8.44 ± 0.17 | 0.73 | ||
| Fast-food restaurant | 7.51 ± 0.14 | 7.68 ± 0.13 | 7.91 ± 0.09 | 7.91 ± 0.14 | 7.76 ± 0.22 | 7.80 ± 0.12 | 7.92 ± 0.12 | 0.08 | ||
| Saturated fat | ≤7% (≤7%→15%) | 10 | ||||||||
| Full-service restaurant | 4.60 ± 0.16 | 4.64 ± 0.13 | 4.25 ± 0.14 | 4.62 ± 0.22 | 5.24 ± 0.16 | 5.20 ± 0.16 | 4.42 ± 0.18 | 0.06 | ||
| Fast-food restaurant | 3.36 ± 0.10 | 3.17 ± 0.13 | 3.13 ± 0.10 | 3.76 ± 0.08 | 3.72 ± 0.14 | 3.72 ± 0.12 | 3.79 ± 0.16 | <0.001 | ||
All dietary variables were scaled-up to 2000 kcal for analysis to account for varying serving sizes and amounts as well as facilitate interpretation of the overall nutritional quality and food and nutrient components of different FS and FF meals as compared to diet quality scores and national dietary recommendations, all intakes were adjusted to 2000 kcal/d. The sample sizes for full-service restaurants and fast-food restaurants are indicated by n1 and n2, respectively; all analyses are survey-weighted to be nationally representative. Each AHA consumption target was evaluated based on a continuous scoring system. Intake of each dietary component was scored from 0 to 10 (beneficial components) and from 10 to 0 (harmful components). For beneficial dietary components, individuals with zero intake received the lowest score (0). For harmful dietary components, the lowest score (0) was assigned to a higher level approximately equivalent to the 80th to 90th percentile of intake among US adults and rounded to a practical value (e.g. 4500 mg/d of sodium, 1 50-g serving/d of processed meat, 2 8-oz servings/d of sugar-sweetened beverages, and 15% energy of saturated fat). Intermediate dietary intake was scored linearly between 0 and 10. For example, an adult consuming 3000 mg/d of sodium would receive 5 sodium points (i.e. his or her sodium consumption was halfway between 1500 mg/d and the maximum value of 4500 mg/d). Details appear in Methods.
AHA, American Heart Association.
Given the potentially surprising high (more optimal) absolute scores for processed meat and SSBs in restaurant meals, we evaluated the proportions of these foods consumed from FS and FF sources versus all other sources among US adults. In 2015–2016, 76% of SSBs were consumed from other sources, with only 7% consumed in FS and 14% consumed in FF meals; whereas 74% of processed meat was consumed from other sources, with 8% consumed in FS and 7% consumed in FF meals.
Adjusted to a 2000 kcal/d diet, whole grains increased between 2003 and 2016 from 0.22 to 0.49 servings/d in FS and 0.08 to 0.31 servings/d in FF meals (P-trend <0.001 each) (Table 3). Conversely, fruits and vegetables decreased from 2.8 to 2.2 servings/d in FS (P-trend = 0.001) and from 1.8 to 1.5 servings/d in FF meals (P-trend <0.001). SSBs decreased from 1.1 to 0.7 servings/d in FS (P-trend <0.001) and 1.5 to 1.2 servings/d in FF meals (P-trend = 0.02). Adjusted to a 2000 kcal/d diet, sodium in FF meals decreased from 3819 to 3773 mg/d (P-trend = 0.003) and saturated fat from 13.4 to 13.1% energy (P-trend = 0.03), whereas nuts/seeds/legumes increased from 0.07 to 0.15 servings/d (P-trend <0.001).
TABLE 3.
Trends in American Heart Association scores and adjusted quantities of American Heart Association dietary components consumed from full-service and fast-food restaurants among US adults, 2003–2016
| Survey-weighted mean ± SE1,2 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Dietary targets3 | 2003–2004 (n1 = 1405; n2 = 2010) | 2005–2006 (n1 = 1375; n2 = 2122) | 2007–2008 (n1 = 1566; n2 = 2374) | 2009–2010 (n1 = 1631; n2 = 2408) | 2011–2012 (n1 = 1465; n2 = 2401) | 2013–2014 (n1 = 1546; n2 = 2607) | 2015–2016 (n1 = 1460; n2 = 2342) | P-trend | Mean change4 from 2003–2004 to 2015–2016 | Percent change4 from 2003–2004 to 2015–2016 |
| AHA scores | ||||||||||
| Primary (range: 0–50)5 | ||||||||||
| Full-service restaurant | 17.8 ± 0.24 | 17.8 ± 0.20 | 17.5 ± 0.21 | 17.6 ± 0.24 | 17.9 ± 0.27 | 17.9 ± 0.28 | 17.3 ± 0.40 | 0.52 | — | — |
| Fast-food restaurant | 14.9 ± 0.18 | 14.7 ± 0.19 | 14.5 ± 0.15 | 14.2 ± 0.23 | 14.9 ± 0.21 | 15.2 ± 0.23 | 14.7 ± 0.23 | 0.58 | — | — |
| Secondary (range: 0–80)6 | ||||||||||
| Full-service restaurant | 32.2 ± 0.45 | 32.1 ± 0.39 | 31.4 ± 0.30 | 31.6 ± 0.49 | 32.8 ± 0.44 | 33.1 ± 0.51 | 31.6 ± 0.48 | 0.45 | — | — |
| Fast-food restaurant | 26.5 ± 0.28 | 26.4 ± 0.31 | 26.3 ± 0.26 | 26.6 ± 0.40 | 27.3 ± 0.41 | 27.6 ± 0.28 | 27.6 ± 0.44 | <0.001 | — | — |
| AHA Primary Component Goals | ||||||||||
| Fruits and vegetables (adjusted servings/d) | ||||||||||
| Full-service restaurant | 2.77 ± 0.13 | 2.69 ± 0.11 | 2.45 ± 0.08 | 2.64 ± 0.15 | 2.66 ± 0.12 | 2.38 ± 0.08 | 2.18 ± 0.14 | 0.001 | −0.59 (−0.96, −0.21) | −21.2 (−33.4, −8.94) |
| Fast-food restaurant | 1.76 ± 0.04 | 1.81 ± 0.08 | 1.51 ± 0.03 | 1.56 ± 0.06 | 1.47 ± 0.05 | 1.48 ± 0.05 | 1.47 ± 0.06 | <0.001 | −0.29 (−0.43, −0.15) | −16.4 (−23.9, −8.99) |
| Whole grains (adjusted servings/d) | ||||||||||
| Full-service restaurant | 0.22 ± 0.03 | 0.19 ± 0.02 | 0.25 ± 0.03 | 0.23 ± 0.02 | 0.34 ± 0.04 | 0.36 ± 0.04 | 0.49 ± 0.09 | <0.001 | 0.27 (0.08, 0.47) | 125 (18.68, 231) |
| Fast-food restaurant | 0.08 ± 0.01 | 0.16 ± 0.03 | 0.12 ± 0.02 | 0.11 ± 0.02 | 0.28 ± 0.06 | 0.30 ± 0.04 | 0.31 ± 0.05 | <0.001 | 0.23 (0.13, 0.33) | 305 (113, 497) |
| Fish and shellfish (adjusted servings/d) | ||||||||||
| Full-service restaurant | 0.37 ± 0.06 | 0.42 ± 0.04 | 0.39 ± 0.04 | 0.48 ± 0.05 | 0.40 ± 0.05 | 0.46 ± 0.05 | 0.53 ± 0.09 | 0.09 | 0.16 (−0.04, 0.37) | 44.2 (−20.1, 108) |
| Fast-food restaurant | 0.10 ± 0.01 | 0.08 ± 0.007 | 0.11 ± 0.01 | 0.15 ± 0.05 | 0.11 ± 0.03 | 0.10 ± 0.01 | 0.09 ± 0.01 | 0.73 | −0.008 (−0.04, 0.02) | −8.12 (−36.2, 20.0) |
| Sugar-sweetened beverages (adjusted servings/d) | ||||||||||
| Full-service restaurant | 1.10 ± 0.08 | 0.90 ± 0.11 | 0.91 ± 0.12 | 0.84 ± 0.06 | 0.83 ± 0.07 | 0.62 ± 0.05 | 0.72 ± 0.10 | <0.001 | −0.33 (−0.58, −0.07) | −31.3 (−52.5, −10.0) |
| Fast-food restaurant | 1.47 ± 0.09 | 1.25 ± 0.09 | 1.18 ± 0.07 | 1.22 ± 0.09 | 1.28 ± 0.09 | 1.07 ± 0.08 | 1.21 ± 0.08 | 0.02 | −0.26 (−0.50, −0.02) | −17.6 (−32.1, −3.01) |
| Sodium (adjusted g/d) | ||||||||||
| Full-service restaurant | 4.34 ± 0.10 | 4.38 ± 0.09 | 4.42 ± 0.09 | 4.55 ± 0.11 | 4.41 ± 0.06 | 4.31 ± 0.06 | 4.40 ± 0.07 | 0.98 | 0.06 (−0.18, 0.30) | 1.36 (−4.14, 6.85) |
| Fast-food restaurant | 3.82 ± 0.06 | 3.97 ± 0.04 | 3.91 ± 0.05 | 4.03 ± 0.08 | 3.70 ± 0.10 | 3.74 ± 0.05 | 3.77 ± 0.30 | 0.003 | −0.05 (−0.19, 0.10) | −1.21 (−4.86, 2.44) |
| AHA Secondary Component Goals | ||||||||||
| Nuts, seeds, and legumes (adjusted servings/d) | ||||||||||
| Full-service restaurant | 0.17 ± 0.03 | 0.16 ± 0.02 | 0.16 ± 0.02 | 0.16 ± 0.03 | 0.16 ± 0.02 | 0.26 ± 0.05 | 0.25 ± 0.04 | 0.03 | 0.07 (−0.03,0.18) | 40.9 (−27.5, 109) |
| Fast-food restaurant | 0.07 ± 0.01 | 0.09 ± 0.02 | 0.10 ± 0.02 | 0.07 ± 0.01 | 0.12 ± 0.02 | 0.14 ± 0.01 | 0.15 ± 0.02 | <0.001 | 0.08 (0.03, 0.13) | 122 (21.8, 223) |
| Processed meat (adjusted servings/d) | ||||||||||
| Full-service restaurant | 0.22 ± 0.03 | 0.22 ± 0.02 | 0.23 ± 0.03 | 0.24 ± 0.03 | 0.27 ± 0.03 | 0.20 ± 0.02 | 0.21 ± 0.04 | 0.94 | −0.003 (−0.10, 0.1) | −1.20 (−47.8, 45.4) |
| Fast-food restaurant | 0.32 ± 0.03 | 0.32 ± 0.03 | 0.29 ± 0.02 | 0.30 ± 0.03 | 0.32 ± 0.04 | 0.32 ± 0.03 | 0.27 ± 0.02 | 0.53 | −0.05 (−0.12, 0.02) | −14.8 (−34.9, 5.28) |
| Saturated fat (% of energy) | ||||||||||
| Full-service restaurant | 11.8 ± 0.20 | 12.0 ± 0.17 | 12.2 ± 0.17 | 11.8 ± 0.30 | 11.1 ± 0.18 | 11.1 ± 0.20 | 12.2 ± 0.35 | 0.19 | 0.39 (−0.41, 1.2) | 3.31 (−3.44, 10.1) |
| Fast-food restaurant | 13.4 ± 0.14 | 13.6 ± 0.15 | 13.7 ± 0.16 | 12.8 ± 0.13 | 13.2 ± 0.20 | 13.1 ± 0.22 | 13.1 ± 0.25 | 0.03 | −0.30 (−0.87, 0.27) | −2.24 (−6.44, 1.97) |
The majority of means were adjusted for energy to 2000 kcal/d by scaling. The means for saturated fat were adjusted as percentage of corresponding total energy from full-service restaurants or fast-food restaurants. Supplemental Tables 7 and 8 provide additional data.
To account for varying serving sizes and amounts as well as facilitate interpretation of the contents of these foods and nutrients in different FS and FF meals and as compared to national dietary recommendations, all intakes were adjusted to 2000 kcal/d. The sample sizes for full-service restaurants and fast-food restaurants were indicated by n1 and n2, respectively.
Serving sizes were derived based on the standards from the USDA's Food Pattern Equivalent Database, which has no direct conversion and details were reported elsewhere (23).
Values represent means or proportions (95% CIs).
The primary total diet score is the sum of the scores for the 5 dietary components included in the primary score.
The secondary total diet score is the sum of the scores for all 8 components included in the primary and secondary scores.
AHA, American Heart Association.
Trends in other foods and nutrients
Trends in intakes of other foods and nutrients from FS and FF meals are detailed in Supplemental Tables 8and 9. For example, intakes of poultry and fish were relatively stable at ∼0.70 and 0.45 servings/d, respectively, in FS meals; and 0.65 and 0.10 servings/d in FF meals. Intakes of unprocessed red meat from FF meals decreased from 0.61 to 0.50 servings/d (P-trend <0.001). Consumption of added sugar remained stable in FS meals whereas it increased in FF meals (P-trend <0.001).
Population disparities
Trends in characteristics of FF and FS meals consumed between 2003 and 2016 in key population subgroups are shown in Figure 2 and Supplemental Figures 2 and 3. In general, there were no significant trends over time in mean overall FS meal quality by population subgroups, except for a downward (negative) trend among Mexican-American adults (P-trend = 0.001). However, persistent disparities in overall FS meal quality were evident, with relatively lower quality among younger adults, men, non-Hispanic blacks, overweight adults, and those with lower education and higher frequency of consumption. Similarly, the proportion of FS meals with poor diet quality remained stable among non-Hispanic whites and non-Hispanic blacks, but increased among Mexican Americans (from 44.7% to 61.7%) (P-interaction = 0.01); and decreased slightly among those with higher income (PIR ≥3.0) (from 50.0% to 48.3%), but remained stable (49.1% to 60.9%) among those with low income (PIR <1.30) (P-interaction = 0.04) (Supplemental Tables 10 and 11).
FIGURE 2.
Trends in the American Heart Association Secondary Diet Score of 2020 Strategic Impact Goals for Meals by education, income, and frequency for full-service restaurant (left side) and fast-food restaurant (right side). Data are weighted to be nationally representative. AHA, American Heart Association; GED, general equivalency diploma; PIR, ratio of family income to poverty level.
For FF meals, modest improvements in average nutritional quality were observed for all ages, both sexes, and all BMI categories; yet with persistent disparities in that younger adults, males, obese adults, and frequent FF consumers tended to consume lower quality FF meals (Figure 2, Supplemental Figures 2 and 3). Disparities in average FF meal quality worsened by race/ethnicity, with significant improvements among non-Hispanic whites (P-trend = 0.003) and Mexican Americans (P-trend = 0.015) but no change among non-Hispanic blacks (P-trend = 0.26). Similarly, disparities worsened by education and income, with significant improvements only among adults with the highest education (P-trend = 0.001) and family income (P-trend <0.001). Consistent with this, evaluating the proportions of FF meals with poor diet quality (Supplemental Tables 10 and 11), disparities by education and income worsened over time. For example, larger reductions in FF meals of poor diet quality occurred among individuals of highest education (73.7% to 59.5%) compared with lowest education (70.6% to 75.7%; P-interaction = 0.003); with similar worsening disparities by income (P-interaction <0.001).
Discussion
Based on nationally representative data between 2003 and 2004 to 2015 and 2016, American adults consumed ∼1 in 5 total calories from FS and FF restaurants, with ∼9% energy from FS and 12% energy from FF meals. During this period, the overall nutritional quality of FF, but not FS, meals consumed improved modestly, largely owing to increased nuts/seeds/legumes and decreased saturated fat, and (to a lesser extent) increased whole grains. Conversely, amounts of fruits and vegetables decreased in both FS and FF meals, whereas sodium increased in FS and remained high in FF meals. Notably, overall diet quality scores remained low for both FS and FF restaurant meals, with 50% of FS meals and 70% of FF meals consumed in 2015–2016 having poor diet quality. In addition, persistent or worsening disparities were evident in key population subgroups.
Our study evaluated the dietary quality of meals actually consumed from FS and FF restaurants in the USA, rather than all the available menu options at these restaurants. It is likely that other options, which could be either healthier or unhealthier than those selected, were available. Thus, our findings represent the combined influence of the quality of available meals and the selection of those meals by US adults, representing 2 different and complementary potential targets—the restaurant offerings and consumer choices—for change. To our knowledge, these findings represent the most current evaluation of the diet quality of FS and FF restaurant meals consumed by US adults between 2003 and 2016. The nutritional quality of FF meals modestly improved over time, although it remained lower than that of FS meals. These trends in FF meals might partly relate to both government and industry efforts during this time. For example, New York City implemented mandatory calorie menu labeling in 2003; and California did so in 2008 (30). Industry was aware by at least 2010 that federal legislation would follow, although this was not fully implemented until 2018. The potential influence of these relatively recent calorie labeling laws on restaurant offerings and consumer choices has only begun to be investigated (31–35). In addition, certain FF chains separately pledged in 2011 to improve the nutritional quality of their offerings, such as reducing the portion size of French fries (36 ). Because we analyzed actual consumption, not menu offerings, consumer choices may be playing the largest role. For example, an analysis of US chain restaurant menus between 2012 and 2017 found a 1.5-fold increase in new beverage offerings, with about half being SSBs (37). However, our investigation found modest declines in servings of SSBs actually consumed by US adults from both FS and FF restaurants. This suggests that menu offerings alone may not be reliable indicators of choices by US consumers.
We identified persistent or worsening disparities in the nutritional quality of both FS and FF meals consumed. Disparities in FS meal quality persisted by sex, race/ethnicity, obesity status, education, and frequency of consumption, and worsened by income; whereas disparities in FF meal quality persisted by age, sex, obesity status, and frequency of consumption, and worsened by race/ethnicity, education, and income. Two prior reports (11, 13) using NHANES 2003–2010 identified disparities by race/ethnicity, education, and income in restaurant consumption of daily energy and certain individual nutrients. These prior studies did not evaluate overall nutritional quality of FS and FF meals consumed by US adults. Our novel findings build upon and greatly extend these prior studies by evaluating diet quality using validated scores, extending the findings through 2016, and investigating multiple other relevant food groups and nutrients.
Our results highlight specific priorities for improving the healthfulness of restaurant meals consumed by US adults, including greater availability and selection of fruits, vegetables, whole grains, fish/shellfish, and nuts/seeds/legumes. Potential strategies could include altering the “default” sides for major menu items, e.g. offering fruits or vegetables in place of French fries (36 , 38). Marketing and pricing are also powerful tools to influence choice, and should be leveraged by restaurants to improve the nutritional quality of meals consumed in their establishments (38 , 39 ).
Adjusted to 2000 kcal/d, FS meals provided an average of 4500 mg/d of sodium (with significant increases over time), whereas FF meals provided 3800 mg/d, far exceeding the National Academies of Sciences, Engineering, and Medicine (NASEM) 2019 adult DRI of 2300 mg/d (40 , 41). The lack of progress in sodium consumed at restaurants identified by our study suggests the need for new actions to encourage salt reformulation/reduction and/or different consumer choices. In 2015, New York City became the first city in the nation to require chain restaurants to post a warning icon next to high sodium menu items together with a message about the health risks of high sodium intake (42). Philadelphia passed a similar sodium warning law in 2018, implemented in September 2019 (43). Whether these measures will encourage restaurants to lower sodium in their meals or consumers to choose alternate items remains to be seen. As some foods consumed from restaurants may also be packaged (e.g. chips or other salty snacks) (44), our findings also support the need for allowing the FDA voluntary sodium targets for packaged foods and restaurant foods to move forward (45). Implementation of these voluntary targets was blocked by Congress in 2016, awaiting the new NASEM DRI and potentially related to industry pressure (46). The recent release of the 2019 DRI and our present findings together support the need for full implementation of the FDA targets.
Other potential policy and environmental approaches to improve nutritional quality of restaurant meals include taxation and other pricing incentives/disincentives (39 , 47–50). Although such strategies have not yet been implemented in the US restaurants, they have been proposed for the USA (39, 47) and tested in other nations such as India (51). Our findings support the need for implementation research to evaluate the effectiveness and legal and political feasibility of such strategies in the USA to improve the diet quality of restaurant meals and also reduce dietary disparities. Nutritional targets to guide the US restaurant sector to reformulate and use other strategies to transform consumer choices can be based on the US DGA, supplemented by other sources such as the National Salt and Sugar Reduction Initiative, the AHA's Heart Healthy Program, the National Restaurant Association and Healthy Dining's Kids LiveWell Program, and the NIH and Research and Development (RAND) Corporation Expert Panel for Healthy Restaurant Meal Standards (52).
This investigation has several strengths. We utilized nationally representative data on American diets and meals consumed at restaurants between 2003 and 2004 to 2015 and 2016, providing an up-to-date picture of patterns, characteristics, and trends of both FS and FF meals. Diet quality was evaluated using an established diet pattern score, which has been validated against the future risk of clinical endpoints in diverse populations (22). Multiple relevant food groups and nutrients were also assessed, providing a detailed evaluation of the components of FS and FF meals. We also focused on disparities in several key population subgroups, crucial to assessing and promoting equity in diets and health in the USA.
Potential limitations should be noted. As with all nationally representative data, dietary information was self-reported; although the use of interviewer-administered 24-h dietary recalls and >1 recall for most participants reduces measurement error and bias. Nonetheless, consumption of less healthy foods might be underreported, or more healthy items overreported, due to social desirability bias. A range of diet quality scores exist; however, the AHA scores are validated, and it is unlikely that qualitative findings would be substantially different from other scoring systems. NHANES does not provide information to differentiate chain from nonchain restaurant types. Our data sources cannot provide explanations for the observed results; and our findings support the need for other focused or national representative assessments, such as using USDA's National Household Food Acquisition and Purchase Survey, to assess the reasons for our observed trends in meals consumed at FS and FF restaurants (53). This investigation focused on adults, and future studies can evaluate patterns and trends of restaurant meals consumed by US children.
In conclusion, restaurant meals provide a substantial portion of calories for US adults. Modest improvements in diet quality were observed in FF meals; but average quality for both FS and FF meals remained low, and with persistent or growing sociodemographic disparities. These findings highlight the specific challenges and opportunities for improving the nutritional quality of restaurant meals consumed by US adults, which could be achieved by separate or joint actions by consumers, governments, and the restaurant industry.
Supplementary Material
Acknowledgments
The authors thank all the collaborators and advisory groups in the Food Policy Review and Intervention Cost-Effectiveness (Food-PRICE) project (www.food-price.org). All authors report support from NIH grants during the conduct of the study. In addition, JL was supported by a postdoctoral fellowship award (17POST33670808) from the American Heart Association. The authors’ responsibilities were as follows—JL and DM: designed the research; JL and CD: conducted the research; JL: analyzed data; JL and DM: wrote the manuscript; DM: had primary responsibility for final content; and all authors read and approved the final manuscript.
Notes
This research was supported by a postdoctoral fellowship award (17POST33670808) from the American Heart Association (JL) and the NIH, NHLBI R01 HL 130735, Principal Investigator (RM). The funding agencies did not contribute to the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Author disclosures: all authors report support from NIH grants during the conduct of the study. In addition, CDR reports consulting fees from the National Dairy Council, PepsiCo, General Mills, State of Florida Department of Citrus, and Unilever; Dr Micha reports research funding from Bill & Melinda Gates Foundation, Nestle and Danone, and personal fees from Bunge and Development Initiatives for the Global Nutrition Report; all outside the submitted work; and DM, personal fees from Astra Zeneca, Acasti Pharma, GOED, DSM, Haas Avocado Board, Nutrition Impact, Pollock Communications, Boston Heart Diagnostics, Bunge, and UpToDate; and scientific advisory board, Elysium, DayTwo, and Filcitrine; and all outside the submitted work.
Supplemental Text, Supplemental Tables 1–11, and Supplemental Figures 1–3 are available from the “Supplementary data” link in the online posting of the article and from the same link in the online table of contents at https://academic.oup.com/jn.
Abbreviation used: AHA, American Heart Association; AMPM, Automated Multiple-Pass Method; DGA, Dietary Guidelines for Americans; FF, fast-food restaurants; FPED, Food Patterns Equivalents Database; FS, full-service restaurants; NASEM, National Academies of Sciences, Engineering, and Medicine; SSB, sugar-sweetened beverage.
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