Marketing to Children Inside Quick Service Restaurants: Differences by Community Demographics

Abstract

Introduction:

In the U.S., children regularly consume foods from quick service restaurants (QSRs), but little is known about the marketing strategies currently used inside QSRs. This study aims to validate a child-focused Environmental Assessment Tool (EAT) for QSRs, evaluate marketing strategies inside and on the exterior of QSRs, and examine differences by community race/ethnicity or income.

Methods:

The inter-rater and test–retest reliability of EAT were assessed across the top 5 national QSR chains. Marketing techniques in 165 QSRs (33 per national chain) in socioeconomically and racially/ethnically diverse communities throughout New England were examined in 2018–2019. Mixed methods ANOVA examined differences in marketing techniques in 2020.

Results:

The inter-rater and test-retest reliability of the EAT were high (Cohen’s κ>0.80). Approximately 95% of QSRs marketed less healthy foods whereas only 6.5% marketed healthy options. When examining differences by community demographics, there were significantly more price promotion ads inside and on the exterior of QSRs in lower-income communities. Additionally, there was a greater number of child-directed ads with cartoon or TV/movie characters, as well as fewer healthy entrée options and more sugar-sweetened beverage and dessert options on the children’s menu inside QSRs in communities with higher minority populations.

Conclusions:

EAT is a valid tool to evaluate marketing inside QSRs. Results suggest there is a substantial amount of unhealthy food and beverage marketing inside QSRs, with differences in the number and types of techniques used in lower-income and minority communities. Policies that limit QSR marketing to children should be considered.

INTRODUCTION

In the U.S., consumption of foods from quick service restaurants (QSRs), commonly referred to as fast food, is increasing among children.¹ This can have important consequences as children consume significantly more calories, saturated fat, sodium, sugar, and sugar-sweetened beverages (SSBs), and conversely fewer fruits and vegetables on days they have QSR foods.^2,3 Consequently, research suggests a positive association between children’s QSR food consumption and BMI.^4–7

Research indicates that Black and Hispanic adolescents consume a greater percentage of calories from QSRs compared with their non-Hispanic White peers.¹ Disparities may be partially due to differences in QSR locations skewed toward lower-income and predominantly Black neighborhoods.^8,9 Lower-income and minority youth are also exposed to more QSR marketing through billboards and targeted screen-based advertisements.^10–12

Although parents typically report that cost, taste, convenience, and nutrition determine food selections for children, behavior change techniques (i.e., marketing and advertising strategies including posters, displays, promotions, and verbal prompts) used in restaurants may have a stronger influence.^13,14 Previous surveys have examined marketing techniques aimed at adults inside QSRs and adult menus (with limited information related to children).^15–17 Others only examined children’s menus with limited information related to marketing techniques.¹⁸ As children regularly order from both the children’s and adult menus, it is important to have a tool that encompasses both when examining QSR environments.^19,20 Additionally, recent technological updates, such as electronic menu boards and kiosks, have not been examined.¹⁵ Therefore, it is currently unknown what types of behavior change strategies are currently used in QSRs that may influence children, and little is known regarding whether marketing techniques differ by community demographics.²¹

To address these gaps, an updated and expanded child-focused QSR environmental assessment tool was developed, validated, and implemented to evaluate behavior change techniques currently employed by QSRs that may influence children and parent’s meal selections and to examine differences by race/ethnicity and the percentage of the population below the poverty line.

METHODS

Study Sample

Drawing from the top 5 national QSR chains, a list was compiled for all locations within New England (excluding those examined for the validation of the assessment tool), and demographic characteristics (e.g., percentage below the poverty line and percentage by race/ethnicity based on population level Census tract data by ZIP code) were collected.³⁰ QSRs were categorized into 3 groups: (1) higher percentage White (≥70%)/higher income (<10% below the poverty line), (2) higher percentage White/lower income (≥10% below the poverty line), and (3) lower percentage White (<60% White)/lower income. A category representing a lower percentage White/higher income was not included owing an insufficient number of QSRs. Within each category, 11 QSRs were randomly selected for each of the 5 chains (33 QSRs/chain; n=165 QSRs total).

Measures

The Environmental Assessment Tool (EAT) (Appendix Figure 1) was adapted from the validated Nutrition Environment Measures Study in Restaurants (NEMS-R).²² EAT emphasized children’s foods and behavior change techniques (i.e., marketing and advertising strategies such as posters, displays, promotions, table tents, and verbal prompts) potentially influencing children’s selections inside QSRs. An instrument was developed based on the NEMS-R, behavior change technique research, and in consultation with public health experts. Because many children do not order from the children’s menu,^19,20 general images promoting foods visible to children (e.g., images of soda) were included.

Investigators used EAT to assess behavior change techniques by quantifying the number of advertisements throughout the interior and exterior of QSRs. If the same image was in >1 location (i.e., if posters with the same image were located on the exterior and on the interior) they were counted as 1 poster on the exterior and 1 poster on the interior. Exceptions were made for table tent ads (i.e., the presence of table tents counted as 1 ad), as a customer would likely only see the 1 ad located at the table where they were sitting. Compared with the NEMS-R, EAT included an expanded children’s menu section with detailed questions about sides (e.g., fruit with or without added sugar), whole grains, and beverages (e.g., SSBs and chocolate milk). EAT also quantified the number of items on the children’s menu by food categories and the different types of child-directed marketing techniques (e.g., ads with cartoon characters, toys, TV and movie characters). Additionally, EAT encompassed a broader set of marketing techniques including modern technology (e.g., electronic menu boards and ordering kiosks) and differentiated between ad placements (e.g., visible waiting in line to order, on the menu board, in other areas inside the QSR, and around the exterior). Lastly, EAT assessed environmental social features based on existing measures of perceived neighborhood disorder, including security features (e.g., security cameras), disorder inside (e.g., foul odor), employee behavior (e.g., inappropriate language), and disorder outside (e.g., graffiti).^23–25

On the EAT, both individual foods and meals were categorized as “standard” (i.e., unhealthy) or “healthier.” Healthier meals (i.e., entrée, side, and beverage) were those in alignment with RAND Corporation’s Healthier Restaurant Meal Guidelines for Children, which was developed by national public health experts.²⁶ The standards included limits on calories, saturated fats, total sugar, and sodium. Healthier meals also excluded SSBs and included ≥2 additional components: fruit, non-fried vegetable, whole grain, lean protein, or skim/1% dairy. These standards were nearly identical to the Kids LiveWell program, developed by the National Restaurant Association, which provided voluntary standards for healthy children’s menu items.²⁷ The Kids LiveWell standards were used to categorize individual sides as “healthier” or “standard.” Individual healthier entrées were defined as those that could align with the healthier meal standards (i.e., meet the nutrient criteria for meals) if combined with healthier sides/beverages. These standards were applied to both the children’s and adult menus.

Validation procedures for EAT were based on methodology from the NEMS-R.¹⁵ College-educated research assistants (RAs) without prior relevant experiences completed training sessions (approximately 10 hours total) that included the project’s background information, a review of EAT, and practice sessions with feedback from the evaluation lead at local QSRs (that were not part of the main study). EAT was tested in New England by 2 RAs in 10 QSRs, each representing 1 of the top 5 U.S. QSR chains. The top 5 QSR chains were chosen because they account for >45% of the entire U.S. fast food industry and have locations within all 50 states.^28,29 The RAs visited each QSR independently on the same day. The test—retest reliability was conducted by having 1 RA return to the 10 QSRs within 3–4 weeks of the initial assessment. The RAs conducted site visits at each QSR during lunch (11:00AM–1:00PM) or dinner hours (4:30PM–8:00PM) using standard mystery shopper protocols and compliance standards in 2018–2019.³¹ Before placing an order, RAs discretely observed behavior change techniques while entering the main entrance and standing in line. RAs examined the menu board for ads, including multiple ads that changed on electronic menu boards. Additionally, RAs listened for cashiers’ verbal prompts (e.g., “Would you like fries with that?”). After placing an order, RAs sat in the dining area to record their observations. They then discreetly examined any remaining visual displays and assessed QSR size based on seating capacity (10–50 seats or >50 seats). RAs walked to other areas (e.g., to a restroom or out a back entrance) to ensure all images were recorded. If a QSR had electronic ordering kiosks, the RAs simulated placing orders for both the children’s and adult menus to view potential marketing techniques (observing all sections within the ordering process). When leaving, RAs examined the QSR’s exterior for visible ads. Measures of social disorder were also observed both inside and outside of the QSRs. This study was approved by Merrimack College’s IRB.

Statistical Analysis

The inter-rater and test—retest reliability of EAT was assessed by Cohen’s κ coefficients. Kappa values >0.80 were considered strong (i.e., acceptable).³² Mixed methods ANOVA was used to examine differences in the number of behavior change techniques promoting healthy or standard options by community demographics (percentage below the poverty line [based on a 10% change] and percentage White [based on a 20% change]), with QSR chain as a random effect.

Logistic regression (with QSR chain as a random effect) was used to examine differences in the presence of verbal prompts or electronic menu boards. All models included both the poverty and race/ethnicity variables and adjusted for QSR size based on seating capacity. Other demographic characteristics (e.g., median household income, percentage of the community with less than a high school education, and percentage unemployed) were strongly correlated with poverty level (Pearson’s correlation coefficient > ±0.8) and not statistically significant, and therefore were not included in the final models. Analyses were conducted in 2020.

RESULTS

The inter-rater reliability of EAT was consistently strong (Cohen’s κ>0.80) (Table 1). The Pricing section had perfect agreement (κ=1.00) whereas the Social Disorder section had the lowest agreement, but was still considered strong (κ=0.81). Similarly, the test—retest values had high agreement for all items (κ>0.80), ranging from κ=0.86 (Interior: Counter Area section) to κ=0.95 (Pricing section).

Table 1.

Inter-Rater and Test–Retest Reliability of the Environmental Assessment Tool (EAT) in QSRs

Section	Item content	Inter-Rater reliabilitya	Test–Retest reliabilityb
Interior: Counter area	Ads/marketing in all areas in front of, around, and behind the counter as well as anything in direct view of customers standing in line to order (not including the menu board)	0.83	0.86
Interior: Other indoor areas	Ads/marketing in areas other than the ordering/counter area (not including the menu board)	0.92	0.90
Menu board: General	Ads/marketing on the menu board	0.91	0.89
Menu board: Standard menu	Number/type of food items (e.g., entrées, sides, beverages) on the standard menu	0.89	0.90
Menu board: Children’s menuc	Number/type of food items (e.g., entrées, sides, beverages) on the children’s menu	0.99	1.00
Pricing	Price for individual items, combos, and promotions	1.00	0.95
Exterior: Signage/Promotions	Ads/marketing in all areas outside of the QSR (parking lot, main marquee sign, roof, ground, restaurant windows facing to the outside)	0.93	0.90
Social features	Security features, employee behavior, and disorder inside/outside the QSR	0.81	0.88

^aMeasured using Cohen’s Kappa in n=5 QSRs by 2 research assistants who independently completed the assessment at differing times on the same day.

^bMeasured using Cohen’s Kappa in n=5 QSRs by 1 research assistant who completed the assessment at each QSR and then returned within a month to the same n=5 QSRs.

^cOne QSR without a children’s menu was excluded.

QSRs, quick service restaurants.

The community demographics for the 165 QSRs are presented in Table 2. The average percentage of the population below the poverty line was between 11.7% and 15.4% for the QSR chains (range=1.8%–37.9%). The median household incomes ranged from $18,300 to $129,000 (average=$60,600–$69,100) and the percentage with less than a high school education ranged from 2.0% to 15.5% (average=10.9%-15.5%). The average percentage unemployed varied from 11.7% to 15.4% (range=1.8%–37.9%). The average percentage of the population that was White was 74.6%–80.2% (range=32.8%–98.7%), the percentage Black varied from 4.5% to 7.9% (range=0.1%–44.1%), and the percentage Hispanic was between 10.5%–19.8% (range=0.2%-85.9%).

Table 2.

Demographic Characteristics of QSR Locations^a

Characteristic	QSR Chain 1 (n=33)	QSR Chain 2 (n=33)	QSR Chain 3 (n=33)	QSR Chain 4 (n=33)	QSR Chain 5 (n=33)
Median household income, $, mean (range)	68,400 (18,300–129,000)	60,600 (18,300–123,100)	62,800 (18,300–108,000)	63,100 (18,300–123,100)	69,100 (31,000–120,500)
Below poverty level, %	12.6 (2.6–32.8)	15.4 (2.6–37.9)	13.7 (2.6–34.1)	14.2 (2.6–36.6)	11.7 (1.8–36.6)
Less than high school education, %	12.1 (2.5–39.4)	15.5 (3.1–39.4)	14.2 (3.8–39.4)	14.2 (3.1–39.4)	10.9 (2.0–27.0)
Unemployed, %	5.7 (3.1–15.1)	6.5 (3.5–15.1)	8.5 (4.9–15.1)	8.4 (3.1–16.9)	5.9 (1.8–11.6)
Race/Ethnicity, %
White	80.2 (39.3–97.5)	74.6 (32.8–98.2)	76.1 (32.8–98.7)	74.7 (39.3–98.7)	79.7 (41.5–96.8)
Black	4.5 (0.1–18.4)	6.3 (0.3–26.4)	6.8 (0.3–25.1)	7.9 (0.1–42.1)	7.3 (0.1–44.1)
Hispanic	14.9 (2.9–85.9)	19.8 (1.2–85.9)	16.7 (2.6–57.5)	17.1 (1.2–85.9)	10.5 (0.2–63.4)

^aBased on population level census tract data by ZIP code.

QSR, Quick Service Restaurant.

When examining the behavior change techniques visible while standing in line to order (excluding the menu board), only 6.5% of QSRs had ads promoting healthy foods (“healthy ads”), with a maximum of 1 ad observed (Table 3). However, 94.7% of QSRs had ads promoting standards foods (“unhealthy ads”), with an average of 4 unhealthy ads observed (range=0–14 ads). Among unhealthy ads, one third of QSRs had price promotion ads (range=0–3) and 14% had limited time ads (range=0–2). More than half (55%) had ads that promoted overeating (range=0–3). When examining ads marketed to children visible while waiting in line, 5.9% of QSRs had ads with cartoon characters (range=0–1), 12.4% had ads with toys (range=0–2), and 11.2% had ads with TV or movie characters (range=0–1). Verbal prompts by QSR employees were observed in 13% of QSRs. When examining differences by QSR location demographics, there were significantly more price promotion ads in lower-income areas; each 10% increase in the percentage of the population below the poverty line was associated with 1.6 additional price promotion ads (p=0.01). When examining differences by race/ethnicity, QSRs in communities with a greater percentage White population had significantly fewer ads with cartoon characters; each 20% increase in the percentage of the population that was White was associated with a reduction in 0.7 ads with cartoon characters (p=0.02). A similar association was observed between community race/ethnicity and ads with TV/movie characters (β= −0.6, p=0.01). There were no other significant differences among ads visible while waiting in line nor with verbal prompts by community demographics.

Table 3.

Marketing Inside of QSRs in New England by Location and Demographics (n=165 QSRs)

		All QSRS	% Below poverty-line		Race (% White)
Variable	%	Mean (Range)	β (SE)a	p-value	β (SE)b	p-value
Marketing visible while standing in line to order (excluding menu board)
Healthier adsc	6.5	0.1 (0–1)	0.2 (0.3)	0.5	0.4 (0.3)	0.2
Unhealthy ads	94.7	4.0 (0–14)	−1.8 (2.4)	0.5	−0.3 (2.6)	0.9
Price promotion ads	33.5	0.4 (0–3)	1.6 (0.6)	0.01	1.1 (0.7)	0.1
Limited time ads	14.1	0.2 (0–2)	−0.6 (0.5)	0.3	0.4 (0.6)	0.5
Ads promoting overeating	55.3	0.7 (0–3)	1.3 (0.9)	0.1	1.4 (1.0)	0.1
Ads with cartoon characters	5.8	0.6 (0–1)	−0.4 (0.3)	0.2	−0.7 (0.3)	0.02
Ads with toy	12.4	0.1 (0–2)	−0.05 (0.4)	0.9	0.1 (0.5)	0.8
Ads with TV/movie characters	11.2	0.1 (0–1)	0.5 (0.2)	0.05	−0.6 (0.2)	0.01
Marketing on menu board
Healthier ads	7.1	0.1 (0–1)	0.2 (0.3)	0.4	−0.2 (0.2)	0.3
Unhealthy ads	98.8	6.3 (0–27)	−1.8 (3.4)	06	−0.2 (3.6)	0.9
Price promotion ads	72.4	1.6 (0–6)	−0.4 (0.9)	0.7	−1.0 (1.0)	0.3
Limited time ads	20.7	0.5 (0–5)	0.4 (1.0)	0.7	1.1 (1.1)	0.3
Ads promoting overeating	97.7	2.8 (0–10)	−0.4 (1.4)	0.8	0.3 (1.5)	0.8
Ads with cartoon characters	37.9	0.4 (0–2)	−0.1 (0.6)	0.8	−0.3 (0.7)	0.6
Ads with toy	40.6	0.5 (0–3)	0.1 (0.7)	0.9	0.2 (0.8)	0.8
Ads with TV/movie characters	30.6	0.4 (0–3)	0.5 (0.6)	0.4	0.7 (0.6)	0.2
Marketing in all other areas inside of the QSR (excluding areas visible while standing in line to order/menu board)
Healthier ads	5.3	0.1 (0–3)	0.2 (0.7)	0.7	−0.2 (0.7)	0.8
Unhealthy ads	92.9	3.5 (0–22)	3.1 (2.9)	0.3	3.4 (3.0)	0.3
Price promotion ads	11.2	0.2 (0–13)	4.4 (1.5)	0.005	0.9 (0.9)	0.3
Limited time ads	7.7	0.1 (0–6)	2.0 (0.7)	0.01	1.8 (0.8)	0.03
Ads promoting overeating	41.2	0.6 (0–4)	−0.3 (0.8)	0.7	0.2 (0.5)	0.7
Ads with cartoon characters	28.2	0.4 (0–4)	1.2 (0.6)	0.06	0.6 (0.7)	0.4
Ads with toy	25.9	0.3 (0–3)	0.8 (0.5)	0.1	0.4 (0.5)	0.5
Ads with TV/movie characters	21.2	0.3 (0–3)	1.0 (0.6)	0.3	0.7 (0.7)	0.3

Note: Boldface indicates statistical significance (p<0.05).

^aRepresents a 10% change in the percent below the poverty level based on population level census tract data by ZIP code.

^bRepresents a 20% change in percent White based on population level census tract data by ZIP code.

^cHealthier ads were defined as those promoting meals or beverages in alignment with the RAND Corporation’s Healthier Restaurant Meal Guidelines for Children’s Meals or sides in alignment with the Kids LiveWell program standards. Healthier entrées were defined as those that could align with the healthier meal standards (i.e., meet the nutrient criteria for meals) if combined with healthier sides/beverages.

QSRs, Quick Service Restaurants.

When examining behavior change techniques on menu boards, only 7% promoted healthy foods (range=0–1). However, nearly all QSRs had unhealthy ads (average=6, range=0–27). More than half (55%) of QSRs had electronic menu boards, and they had on average 4 additional unhealthy ads compared with traditional menu boards (p<0.0001). No differences in menu board type was observed by community demographics. The majority (72%) of menu boards had price promotion ads for unhealthy foods (range=0–6), nearly all (97.7%) included ads that promoted overeating (range=0–10), and approximately one fifth had limited-time ads (range=0–5). Nearly half of menu boards had at least 1 child-directed ad; 38% had ads with cartoon characters (range=0–2), 41% had ads with toys (range=0–3), and 31% had ads with TV/movie characters (range=0–3). There were no significant differences by community demographics. Less than 5% of QSRs (n=6) had electronic kiosks.

When examining behavior change techniques in other areas throughout QSRs, only 5.3% of QSRs had healthy ads (range=0–3). Conversely, 93% of QSRs had unhealthy ads (mean=4, range=0–22). Slightly less than half of QSRs (41%) had ads that promoted overeating (range=0–4). On average, 11% of QSRs had price promotion ads with significantly more observed in lower-income communities (β= 4.4, p=0.005). Similar differences were observed in the number of limited time ads by income (β= 2.0, p=0.01). Roughly a quarter of all QSRs also had child-directed marketing in other areas throughout QSRs, including 28% with ads containing cartoon characters (range=0–4), 26% with ads promoting toys (range=0–3) and 21% with ads that included TV/movie characters (range=0–3). No differences in marketing to children by community demographics were observed.

When observing marketing around the exterior of QSRs, nearly all QSRs (96%) had ads promoting unhealthy foods (mean=5, range=0–14) (Appendix Table 1). No ads promoting healthy foods were observed. However, approximately 20% of QSRs had child-directed marketing on their exterior, including ads with cartoon characters, toys, or TV/movie characters (each ranging from 0 to 2 ads). Additionally, 63% had ads promoting overeating (range=0–4), 15% had limited-time ads (range=0–4), and 71% of had price promotion ads. When examining differences by community demographics, significantly more price promotion ads were observed in lower-income communities (β=3.1, p=0.04). No other differences were observed by community demographics.

Lastly, the quantity and types of foods were examined on children’s and adult menus. On the children’s menu, there were on average 5 entrées (range=3–7) and the majority (mean=4, range=2–7) had the potential to meet the Kids Live Well standards if combined with healthier sides/beverages. However, differences in the availability of healthier entrées were observed by the race/ethnicity of the location; there were significantly more healthy options in communities where the percentage White was greater (β=0.6, p=0.04). Children’s menus also had on average 2 side options (range=1–3), and typically 1–2 were healthy. Beverage choices ranged from 1 to 10 choices, with typically 1–3 healthier options (e.g., milk, water, 100% fruit juice), although many QSRs also had SSBs (range=0–7) and desserts (range=0–2). The number of SSBs and desserts on the children’s menu were significantly lower in communities with a higher percentage White population (β= −0.5, p=0.02 and β= −0.3, p=0.03, respectively). When examining the adult menu, there were on average 37 entrée choices (range=25–47), with a greater number of options in communities with a higher percentage White population (β=0.2, p=0.03). Less than 15% of entrées had the potential to align with the healthier meal standards (if combined with healthier beverages/sides). Similarly, there were many sides (mean=12, range=2–20) and beverages (mean=22, range=12–37), but typically <15% of options were healthy. There were no significant differences by community demographics when examining sides or beverages on the adult menu.

DISCUSSION

This study found that EAT had high inter-rater and test—retest reliabilities. Using this tool, results suggested that nearly all QSRs marketed unhealthy menu items both inside and outside whereas <10% of QSRs marketed healthier options despite having several children’s meals options with the potential to align with healthier meal standards. Electronic menu boards were present in roughly half of QSRs and had substantially more unhealthy behavior change techniques compared with standard menus. Importantly, this study found a greater number of price promotion ads inside and around the exterior of QSRs in lower-income communities. In communities with higher racial/ethnic minority populations, there were a greater number of child-directed ads (e.g., with cartoon or TV/movie characters) visible while waiting in line to order. Additionally, children’s menus in these communities had on average fewer healthy entrées and more SSB and dessert options.

Price is a primary influence on food choices and may partially explain disparities in diet quality.^19,33–35 Previous QSR research has found price frequently influences orders among lower-income customers.¹⁹ The present study found that price promotion ads for unhealthy food items were used more often in lower-income areas, which may increase diet-related health disparities by SES. Given that price promotions are already prevalent in QSRs, future research should examine the acceptability and effectiveness of price promotions for healthier items.

This study also observed differences in behavior change techniques in minority communities. Previous research has found that food companies have increased their advertising spending aimed at Black and Hispanic consumers to >$1 billion, and unhealthy food marketing is greater among minority communities, although this may be partially explained by demographic shifts within the U.S.^12,30,36,37 Additionally, minority children frequently view twice as many food advertisements compared with their White peers.^11,12,38 The present study expands on previous research conducted inside QSRs, and found that QSRs located in predominantly minority communities had more child-directed marketing and fewer healthy children’s menus. Overall, this can have important health implications as previous research has found that child-directed marketing can influence food preferences and future brand loyalty; this may increase the risk of poor diet and health outcomes often experienced disproportionately by lower-income and minority communities.^1,39–44

Limitations

This study had several limitations. First, EAT was used only in the top 5 QSR chains in New England, which has higher incomes and population densities, and lower percentage minority populations than national averages.³⁰ However, this study was strengthened by the socioeconomically, ethnically/racially, and geographically diverse examined areas. Future studies should examine if similar advertising trends exist in other regions and in other QSRs, fast casual, or full service restaurants. Additionally, drive-thru menus were not examined. Future studies should consider examining drive-thru marketing techniques. Lastly, the present study was cross-sectional and descriptive. Future research should examine interventions to nudge consumers toward healthier QSR options.

CONCLUSIONS

The updated environmental assessment tool adds to the field of behavioral change research, including comprehensive sections on child-directed marketing, children’s menus, and marketing techniques more broadly including modern technology in QSRs. Study findings suggest that there is substantial unhealthy marketing inside and around QSRs, with more price promotions in lower-income communities. Additionally, this study indicates that there may be more child-directed marketing and more unhealthy options on QSR children’s menus in minority communities. These findings have important public health implications, and policies that limit marketing to children should be considered. Researchers, policymakers, and restaurants should consider ways to use price promotions to encourage healthier diets, especially among more vulnerable populations.

Table 4.

The Types of Foods Available on Children’s and Standard Menus in n=165 QSRs

	All QSRS	% Below poverty-line		Race (% White)
Variable	Mean (Range)	β (SE)a	p-value	β (SE)b	p-value
Children’s menu
Entrees	4.8 (3–7)	−0.9 (2.2)	0.7	−3.1 (2.4)	0.2
Healthier entréesc	4.4 (2–7)	1.2 (2.7)	0.6	0.6 (0.3)	0.04
Sides	2.3 (1–3)	0.4 (0.6)	0.6	0.7 (0.7)	0.3
Healthier sides	1.5 (1–2)	0.3 (0.7)	0.7	0.2 (0.8)	0.8
Beveragesd	4.5 (1–10)	−1.9 (4.2)	0.7	−0.8 (0.4)	0.06
Healthier beverages	2.2 (1–3)	0.03 (0.9)	0.9	1.2 (1.0)	0.2
SSBse	2.3 (0–7)	0.3 (0.2)	0.1	−0.5 (0.2)	0.02
Desserts	0.8 (0–2)	0.7 (1.1)	0.5	−0.3 (0.1)	0.03
Standard menu
Entrees	37.3 (25–47)	0.1 (0.1)	0.2	0.2 (0.1)	0.03
Healthier entrees	5.4 (0–14)	0.1 (0.1)	0.3	0.1 (0.1)	0.2
Sides	11.6 (2–20)	−0.5 (0.7)	0.9	−1.3 (0.8)	0.09
Healthier sides	0.4 (0–2)	0.4 (0.6)	0.5	0.3 (0.7)	0.7
Beverages	22.8 (12–37)	8.8 (10.2)	0.4	3.1 (10.5)	0.8
Healthier beverages	3.0 (1–5)	0.3 (1.7)	0.8	0.8 (1.7)	0.6
SSBs	19.2 (7–33)	8.2 (9.9)	0.4	2.5 (10.3)	0.8

Note: Boldface indicates statistical significance (p<0.05).

^aRepresents a 10% change in the percent below the poverty level based on population level census tract data by ZIP code.

^bRepresents a 20% change in percent White based on population level census tract data by ZIP code.

^cHealthier was defined as meals or beverages in alignment with the RAND Corporation’s Healthier Restaurant Meal Guidelines for Children’s Meals or sides in alignment with the Kids LiveWell program standards. Healthier entrées were defined as those that could align with the healthier meal standards (i.e., meet the nutrient criteria for meals) if combined with healthier sides/beverages.

^dBeverages includes water, juice, milk, soda, diet soda, coffee, shakes, and smoothies (where applicable).

^eSSBs include soda, shakes, smoothies, and milk with added sugar (where applicable).

QSRs, quick service restaurants; SSBs, sugar sweetened beverages.