Trends in the Nutrition Profile of Menu Items at Large Burger Chain Restaurants

Abstract

Introduction:

Fast food restaurants, including top burger chains, have reduced calorie content of some menu items in recent years. However, the extent to which the nutrition profile of restaurant menus is changing over time is unknown.

Methods:

Data from 2,472 food items on the menus of 14 top-earning burger fast food chain restaurants in the U.S., available from 2012 to 2016, were obtained from the MenuStat project and analyzed in 2019. Nutrition Profile Index scores were estimated and used to categorize foods as healthy (≥64 of 100). Generalized linear models examined mean scores and the proportion of healthy menu items among items offered in all years (2012–2016) and items offered in 2012 only compared with items newly introduced in subsequent years.

Results:

Overall, <20% of menu items were classified as healthy with no change from 2012 to 2016 (p=0.91). Mean Nutrition Profile Index score was relatively constant across the study period among all food items (≈50 points, p=0.58) and children’s menu items (≈56 points, p=0.73). The only notable change in Nutrition Profile Index score or in proportion of healthy items was in the direction of menu items becoming less healthy.

Conclusions:

At large chain burger restaurants, most items were unhealthy, and the overall nutrition profile of menus remained unchanged from 2012 to 2016. Future research should examine the nutrition profile of restaurant menus in a larger, more diverse sample of restaurants over a longer timeframe and examine whether results are robust when other measures of nutritional quality are used.

INTRODUCTION

On a typical day, more than one third of Americans eat in a fast food restaurant.^1,2 Fast food consumption has been associated with poor diet quality, obesity, and other diet-related diseases.^3–8 Restaurant food, and fast food in particular, is high in calories, fat, and sodium,^9–11 though in recent years large chain restaurants, including large burger chains (which are some of the highest earning and most prevalent chain restaurants in the U.S.)¹² have introduced some new menu items that are lower in calories and sodium.^13–15 Thus, further exploration of the nutrition profile of chain burger-focused restaurant menus is warranted.

Recently, major burger chains in the U.S. have made small changes to their menus toward healthier items. For example, apple slices are now side options at Burger King and McDonalds.¹⁶ Salads, wraps, and more grilled (rather than fried) options have been introduced.¹⁷ Restaurants have focused on children’s menus, sometimes replacing less healthy alternatives as the default choice for kid’s meals.¹⁸ However, restaurants also have introduced new unhealthy items, and the calorie and nutrient composition of core menu items remain unchanged.^11,13,14,19 Other evidence using a comprehensive measure of healthfulness, the Nutrition Profile Index (NPI), shows that from 2010 to 2013 the proportion of menu items in top fast food restaurants that met guidelines to be considered healthy was unchanged,²⁰ and that in-store promotions focused on unhealthy menu items.²¹

It is important to understand trends in the nutrition profile of burger restaurants and whether restaurants are changing the composition and overall nutrient profile of their menus. Therefore, the objective of this study is to examine whether the overall nutrition profile of restaurant menu items offered in large burger chain restaurants in the U.S. changed from 2012 to 2016. The primary aim is to examine changes in the NPI score and the proportion of restaurant menus that met nutrition guidelines to be considered healthy on menus overall, among core items that remain on the menu in all years, and among newly introduced items.

METHODS

Study Sample

Data were obtained from the MenuStat project (menustat.org/).²² The MenuStat database contains annual calorie and nutrition data gathered from websites of the 100 largest restaurants in the U.S., as defined by sales volume. A more detailed description of MenuStat data collection methods is published elsewhere.²³ Because serving size information is required to compute the NPI score, the sample was limited to burger fast food chain restaurants that had the most complete serving size data. Owing to standardized recipes and centralized preparation, fast food restaurants have more complete, accurate, and reliable calorie and nutrition information than restaurants with onsite preparation.²⁴ To compare trends within a cohesive set of fast food restaurants offering similar types of food, the sample included the consistently highest grossing burger-focused fast food restaurants in the U.S. during the study period (with the exception of Wendy’s, which did not make sufficient serving size information available to be included).¹² A complete list of restaurants included in the sample and their characteristics is available in Appendix Table 1 (available online). Beverages and toppings/ingredients were excluded because of a high degree of missingness for serving size and other nutrient measures.

Of the 2,622 individual food items on the 14 restaurant menus from 2012 to 2016, a total of 338 (12.9%) were missing serving size or calorie information for at least 1 year. To address this, first, combo meals were excluded because their individual components were already included in the database (n=149). Missing serving size and calorie data were imputed through a two-step process involving finding missing information online where possible (serving size, n=53; calories, n=10), then data available in MenuStat from other years were used to impute serving size using a ratio of serving size to calories (n=88) using the most recent data possible (the Appendix, available online, provides more details). The final analytic sample included 2,472 food items across 14 large burger fast food chains from 2012 to 2016, of which 48 (0.02%) were missing serving size data in 1 year but did have serving size, calorie, and nutrient data in at least 1 other year. To retain these items, the previously available information was used to compute NPI.

Measures

The 2 outcome measures were NPI score and a binary measure of whether the item met the threshold for being considered healthy (NPI score ≥64 points).²⁰ NPI was chosen over other measures of nutritional quality because (1) the MenuStat data set had all the necessary measures to calculate NPI and (2) NPI has been validated previously and has been used to quantify the nutrition quality of chain restaurant menu items and packaged food items in the U.S. and United Kingdom.^21,25–29 The NPI score is based on the United Kingdom Ofcom nutrient profiling model³⁰ and provides a single score based on the amount of positive and negative nutrients per 100 grams of a given food item. Detailed instructions for the NPI scoring system are available elsewhere.^20,31 Briefly, a maximum of 5 points are awarded for each of the following positive ingredients: fruit, vegetables, and nuts; fiber; and protein. A maximum of 10 points are awarded for each of the following negative ingredients: energy, saturated fat, total sugar, and sodium. Negative points are subtracted from positive points. MenuStat provides data for all the measures needed to create the score with the exception of fruit, vegetables, and nuts. Key word searches of the item name, item description, and information about menu category were used to assign points for this category. Complete coding rules and the formula to calculate NPI scores are provided in the Appendix (available online). Following Harris et al.,²⁰ NPI score was converted to a 0–100 score (using the formula NPI score = [−2] × Ofcom NP score + 70), where 100 is best and a score of ≥64 or is considered healthy.

Both outcome measures were examined among (1) the full menu; (2) items on the menu in all years (2012–2016); and (3) items on the menu in 2012 only and newly introduced items in 2013, 2014, 2015, and 2016. New items were those that did not have an item name, description, or calories recorded in previous years. An item was defined as being available in 2012 only if it had a name, description, and calories in 2012 but not in subsequent years.

The key independent variables were either a year indicator or a categorical measure of whether an item was on the menu in 2012 only, newly introduced in 2013, newly introduced in 2014, newly introduced in 2015, or newly introduced in 2016. Menu items also were classified as an appetizer/side, a main course, or a dessert. A binary measure indicated children’s menu status. Items were defined as part of the children’s menu if the description contained the words “kid,” “kids,” “child,” or “children.”

Statistical Analysis

Generalized linear models were used to conduct the following analyses: (1) changes in per-item mean NPI score for the full set of menu items, (2) changes in per-item mean NPI score among items on the menu in all years (2012–2016), and (3) differences in mean NPI score for items new to the menu in 2013, 2014, 2015, and 2016 compared with items on the menu in 2012 only. These analyses were replicated using logistic models to examine the percentage of the menu items that met guidelines to be considered healthy. In each model, the key independent variable was the year indicator (for Analyses 1 and 2) and the years on menu indicator (Analysis 3). No other covariates were included. For all models, clustered SEs accounted for nonindependence of items within restaurants over time. Analyses were conducted among all food items (excluding children’s menu items), among children’s menu items only, and stratified by menu category (appetizer/side [including fried potatoes], main course, and dessert). Post-estimation margins were used to generate mean NPI score in each year and the proportion of the menu items that were classified as healthy in each year. Data were analyzed using Stata, version 15 in 2019. Significance was considered at p<0.05.

RESULTS

Characteristics of the 2,472 menu items included in the study are shown in Table 1. Of the 2,472 menu items, 36.4% of menu items were offered in all years, 16.8% were new in 2013, 10.5% were new in 2014, 10.9% were new in 2015, and 7.3% were new in 2016. Among food items, 202 (8.6%) were appetizers/sides, 160 (6.8%) were fried potatoes, 1,542 (65.6%) were main courses, and 448 (19.1%) were desserts. The mean NPI score was 51.1, and 23.0% of menu items met the criteria for being considered healthy (≥64).

Table 1.

Characteristics of Food Menu Items in Top Burger Chain Restaurants in the U.S., 2012–2016

Menu category	All items			Children’s menu items n (%)	Items offered in all years n (%)	Items new in 2013 n (%)	Items new in 2014 n (%)	Items new in 2015 n (%)	Items new in 2016 n (%)
	n (%)	NPI (SD)	% healthya
All items	2,472 (100)	51.1 (12.7)	23.1	120 (4.9)	899 (36.4)	416 (16.8)	259 (10.5)	270 (10.9)	181 (7.3)
Foodb	2,352 (95.2)	50.8 (12.6)	22.5	—	833 (35.4)	405 (17.2)	254 (10.8)	261 (11.1)	175 (7.4)
Children’s menu	120 (4.9)	55.8 (13.6)	31.7	120 (100)	66 (55.0)	11 (9.2)	5 (4.2)	9 (7.5)	6 (5.0)
Food menu category
Appetizers and sidesc	202 (8.6)	49.4 (11.5)	16.3	18 (8.2)	81 (40.1)	13 (6.4)	10 (4.6)	49 (24.3)	12 (5.9)
Fried potatoes	160 (6.8)	55.9 (9.5)	24.9	25 (14.5)	82 (51.3)	28 (17.5)	6 (3.8)	20 (12.5)	4 (2.5)
Main coursesd	1,542 (65.6)	52.1 (13.1)	28.5	71 (4.4)	536 (34.8)	237 (15.4)	182 (11.8)	149 (9.7)	140 (9.1)
Burgers	457 (19.4)	50.6 (11.3)	20.5	30 (6.2)	189 (41.4)	46 (10.1)	37 (8.1)	61 (13.4)	39 (8.5)
Entrees	267 (11.4)	54.3 (11.0)	31.9	28 (9.5)	90 (33.7)	39 (14.6)	18 (6.7)	34 (12.7)	35 (13.1)
Sandwich	685 (29.1)	48.4 (12.3)	20.8	13 (1.9)	214 (31.2)	129 (18.8)	101 (14.7)	53 (7.7)	59 (8.6)
Salads	97 (4.1)	74.2 (6.0)	97.3	0 (0)	24 (24.7)	23 (23.7)	22 (22.7)	1 (1.0)	7 (7.2)
Soups	36 (1.5)	64.9 (5.6)	63.4	0 (0)	19 (52.8)	0 (0)	4 (11.1)	0 (0)	0 (0)
Dessertse	448 (19.1)	44.4 (10.1)	2.8	6 (1.3)	134 (29.9)	127 (28.4)	57 (12.7)	43 (9.6)	19 (4.2)

NPI, Nutrition Profile Index.

^aNPI score ≥64.

^bIncludes all menu categories except children’s menu items.

^cExcludes fried potatoes and children’s menu items.

^dIncludes burgers, entrees, sandwiches, and salads and soups that are not categorized as appetizers or side dishes. Excludes children’s menu items.

^eIncludes desserts and other baked goods. Excludes children’s menu items.

Table 2 presents the trends in the mean NPI score for all menu items in each year. Among food items, mean NPI scores ranged from 50.56 points in 2012 to 50.77 points in 2016 with no change over time (p=0.58). The mean NPI score for children’s menu items ranged from 56.62 points in 2012 to 56.46 points in 2016 with no change over time (p=0.73). There was no change in NPI score over time among appetizers/sides, main courses, or desserts. The proportion of food items considered healthy was approximately 18% in each year with no change over time (p=0.91). The proportion of the children’s menu that was considered healthy increased from 20.4% in 2012 to 40.8% in 2014 (p=0.02) but then declined to 29.5% in 2016, and the trend over time was not significant (p=0.91).

Table 2.

Trends Among Items on Top Burger Restaurant Menus From 2012 to 2016, Overall and by Menu Category

Variable	n	2012	2013	2014	2015	2016	p-value for trend
Mean NPI score
Overall
Fooda	7,137	50.56	50.79	50.86	50.86	50.77	0.58
Children’s menu	451	56.62	57.32	57.49	57.02	56.46	0.73
Menu category
Appetizers and sidesb	1,151	52.53	53.13	53.16	53.14	52.85	0.49
Main coursesc	4,678	51.77	51.94	52.06	52.04	51.95	0.72
Dessertsd	1,308	44.90	44.92	44.80	44.91	45.02	0.53
Predicted % of the menu that meet healthy cut off (≥64 points)
Overall
Fooda	7,137	17.89	17.89	18.01	18.00	18.04	0.91
Children’s menu	451	20.35	36.86	40.80 *	22.30	29.53	0.91
Menu category
Appetizers and sidesb	1,151	17.87	17.84	17.86	17.85	17.85	0.99
Main coursesc	4,678	18.39	18.51	19.58	19.70	20.73	0.93
Dessertsd	1,308	3.06	2.99	3.42	2.99	2.31

Note: Boldface indicates statistically significant difference from 2012 (*p<0.05, **p<0.01, ***p<0.001). SEs are clustered to account for correlation of items within restaurants.

NPI, Nutrition Profile Index.

^aIncludes all menu categories except children’s menu items.

^bIncludes fried potatoes and other appetizers and sides. Excludes children’s menu items.

^cIncludes burgers, entrees, sandwiches, and salads and soups that are not categorized as appetizers or side dishes. Excludes children’s menu items.

^dIncludes desserts and other baked goods. Excludes children’s menu items.

Table 3 shows trends in mean NPI score and the proportion of menu items that are considered healthy among core items on the menu in all years from 2012 to 2016. Among food items that were included on the menu in all years, mean NPI score ranged from 49.95 points in 2012 to 50.10 points in 2016 (p=0.80). Among children’s menu items, mean NPI score ranged from 52.97 points in 2012 to 53.08 points in 2016 (p=0.98). There were no changes in mean NPI score within menu categories among core menu items. Among menu items in all years, for both food items and children’s menu items, approximately 18% of menu items met the criteria to be considered healthy in each year with no significant changes over time (food, p=0.94; children’s menu, p=0.75).

Table 3.

Trends Among Items on the Menu in All Years (2012–2016), Overall and by Menu Category

Variable	n	2012	2013	2014	2015	2016	p-value for trend
Mean NPI score
Overall
Fooda	4,126	49.95	50.28	50.15	50.10	50.10	0.80
Children’s menu	327	52.97	53.33	53.51	53.15	53.08	0.98
Menu category
Appetizers and sidesb	791	51.80	52.52	52.43	52.49	52.16	0.43
Main coursesc	2,680	50.56	50.87	50.72	50.57	50.61	0.79
Dessertsd	655	45.26	45.20	45.10	45.33	45.58	0.28
Predicted % of the menu that meet healthy cut off (≥64 points)
Overall
Fooda	4,126	17.83	17.83	17.84	17.84	17.84	0.94
Children’s menu	327	17.87	18.38	18.85	17.87	18.39	0.75
Menu category
Appetizers and sidesb	791	17.84	17.83	17.83	17.83	17.83	0.98
Main coursesc	2,680	18.12	18.24	18.47	18.55	18.60	0.22
Dessertsd	655	3.72	3.72	3.73	3.73	3.63	0.96

Note: Boldface indicates statistically significant difference from 2012 (*p<0.05, **p<0.01, ***p<0.001). SEs are clustered to account for correlation of items within restaurants.

NPI, Nutrition Profile Index.

^aIncludes all menu categories except children’s menu items.

^bIncludes fried potatoes and other appetizers and sides. Excludes children’s menu items.

^cIncludes burgers, entrees, sandwiches, and salads and soups that are not categorized as appetizers or side dishes. Excludes children’s menu items.

^dIncludes desserts and other baked goods. Excludes children’s menu items.

Table 4 displays the mean NPI score and the proportion of menu items considered healthy for newly introduced items in each year compared with items on the menu in 2012 only. Among food items, mean NPI score decreased from 51.05 points in 2012 to 47.63 points in 2015 (p=0.03). Among appetizers/sides, compared with items on the menu in 2012 only, mean NPI score was lower in 2015 (47.56 points vs 61.25 points, p<0.001) and in 2016 (52.13 points vs 61.25 points, p=0.02). Among food items, 24.7% of items on the menu in 2012 only and 24.5% of the items newly introduced in 2016 met healthy criteria. Among children’s menu items, 50% of items on the menu in 2012 only, 80% of items newly introduced in 2014, and 33.3% of items newly introduced in 2016 met the criteria to be considered healthy. For food items, children’s menu items, and menu subcategories, there were no significant differences in the proportion of menu items in each year that were considered healthy over time.

Table 4.

Trends Among Items on the Menu Only in 2012 Versus Newly Introduced Items

Variable	n	2012 only	New in 2013	New in 2014	New in 2015	New in 2016	Difference 2012–2016	p-value	OR 2012 vs 2016 (95% CI)
Mean NPI score
Overall
Fooda	1,196	51.05	52.74	50.71	47.63 *	50.13	−0.92	0.68	—
Children’s menu	37	57.75	63.78	56.20	65.33	59.00	1.25	0.78	—
Menu category
Appetizers and sidesb	159	61.25	58.54	61.14	47.56 ***	52.13 *	−9.13	0.02	—
Main coursesc	778	51.68	55.09	51.30	49.34	50.29	−1.39	0.58	—
Dessertsd	259	40.14	46.43	46.15	41.74	45.83	5.70	0.31	—
Predicted % of the menu that meet healthy cut off (≥64 points)
Overall
Fooda	1,196	24.70	26.50	23.01	12.08	24.50			0.99 (0.46, 2.14)
Children’s menu	37	50.00	66.67	80.00	66.67	33.33			0.50 (0.11, 2.20)
Menu category
Appetizers and sidesb	159	50.00	41.46	64.29	9.38	18.75			0.23 (0.06, 0.86)
Main coursesc	778	23.89	37.61	24.56	16.79	26.02			1.12 (0.46, 2.75)
Dessertsd	220	6.90	0.80	—	7.41	16.67			2.70 (0.29, 24.91)

Note: Boldface indicates statistically significant difference from 2012 (*p<0.05, **p<0.01, ***p<0.001). SEs are clustered to account for correlation of items within restaurants.

NPI, Nutrition Profile Index.

^aIncludes all menu categories except children’s menu items.

^bIncludes fried potatoes and other appetizers and sides. Excludes children’s menu items.

^cIncludes burgers, entrees, sandwiches, and salads and soups that are not categorized as appetizers or side dishes. Excludes children’s menu items.

^dIncludes desserts and other baked goods. Excludes children’s menu items.

DISCUSSION

This study examined the nutrition profile of food items on the menus of 14 large burger fast food chain restaurants in the U.S. from 2012 to 2016. Overall, there were no meaningful changes in the mean NPI score or the percentage of menu items that met the threshold to be considered healthy over time. Among items on the menu in all years, on the full menu, and on the children’s menu, <20% of items met the threshold to be considered healthy. The mean NPI score among newly introduced items declined by nearly 4 points compared with items on the menu in 2012 only. These findings suggest that the nutrition profile of top burger restaurant menus is not improving over time overall or among children’s menus. Restaurants are not reformulating existing menu items to make them healthier nor are they introducing enough healthy new items to shift the proportion of their menus that meet nutrition guidelines. This is problematic because Americans consume fast food frequently, and fast food consumption contributes to obesity and diet-related diseases.^1–3,8 Menus predominated with unhealthy items make it more difficult for consumers to make healthy choices.

These findings are illuminating in light of prior evidence, using MenuStat data, showing that restaurants have introduced new items that are lower in calories and sodium since 2012.^13,15,19 Other evidence examining macronutrient content of 37 fast food restaurant chains¹⁴ and NPI scores of fast food restaurants from 2010 to 2013^20,21 finds little change in the nutritional profile of fast food menus, though the NPI score of items marketed on menu boards and signs has marginally improved.²¹ This prior evidence is consistent with this study. Taken together, new menu items may be, on average, lower in calories since 2012, but the overall nutrition profile of top burger fast food menus is not improving. The previously documented trend of no notable changes in NPI scores in fast food restaurants from 2010 to 2013 has extended to 2016. Results from this study are consistent with another study showing little change in the calorie, sodium, and saturated fat content of children’s menus items over time.³² Over the long term, fast food restaurants are expanding the number of items offered, and menu items are increasing in portion size and energy content, all of which contributes to obesity risk.^{10,11,33–36}

In 2010, the Affordable Care Act mandated national menu labeling regulations with the goal of increasing transparency about the calorie content of foods sold in large chain restaurants.³⁷ The regulation was finalized and implemented in May 2018. Although the primary motivation of menu labeling was to enable consumers to make healthier food choices, another mechanism by which menu labeling could improve population health is through supply side changes on the part of the restaurants.^19,38,39 Though this study period ended before menu labeling being implemented nationally, results suggest that top burger restaurants had not started reformulating existing items or introducing healthier items in anticipation of menu labeling. This study also shows that it is not sufficient to examine only calorie content of menu items; the full nutrient profile of the food offered on fast food restaurant menus should be analyzed.

Voluntary commitments to improve children’s menu items, such as the Kids LiveWell pledge, have not resulted in meaningful improvements to children’s menus in large chain restaurants.³² The proportion of fast food restaurant menu items that meet the requirements to be considered healthy (NPI score ≥64) was consistently small on the menu overall and on children’s menus from 2012 to 2016. This is concerning especially in light of public commitments restaurants have made to improve the healthfulness of their menus (though the actual change required to meet the Kids LiveWell pledge is relatively minor) and positive public attention they receive for such commitments and changes. Unhealthy foods high in refined carbohydrates and fat may change reward systems in the brain in ways that enhance motivation for unhealthy foods and decrease motivation for healthier foods.^40–42 A few healthier items on a menu predominated by unhealthy foods is unlikely to facilitate healthier choices. Future research should investigate how ordering is influenced by different thresholds of healthy versus unhealthy items on menus. It would be ideal to identify the optimal menu composition in which the proportion of unhealthy to healthy foods can shift behavior toward healthier options. Future research is also needed to examine behavioral economics strategies to increase the healthfulness of consumer purchases including menu placement, pricing, and in-store signage.

Limitations

The results of this study should be considered in light of several limitations. First, sales, price, or consumption data were not available, so analyses were unable to examine purchases or consumption of menu items based on NPI score. Second, the high degree of missingness in the serving size data in 2017 and 2018 as well as among other restaurant chains included in the MenuStat database limited the analysis to fast food burger chains from 2012 to 2016. Because of this, the results of this study may not be generalizable to other fast food restaurants, fast casual restaurants, full-service restaurants, or smaller restaurant chains. However, the sample includes the largest and most popular chains (as rated by QSR)¹² in each year of the study period. Although 2017 and 2018 data were available at the time of analysis, the amount of missing serving size information was too high to be feasible to include those years in this analysis. Whether findings remain consistent in 2017 and 2018 is unknown. As data collection methods did not change in 2017 and were only slightly modified in 2018,²³ it appears the high missingness in serving size data is owing to restaurants not making that information available. It is an open question as to why some restaurant chains are not making full serving size information available for analysis. Third, nutrition and calorie information was recorded from restaurant websites; therefore, misreporting by the restaurants themselves or human error when entering the data could bias results. The measures available within the MenuStat data precluded use of other measures of diet quality. Analyses were at the item level and did not examine the NPI score of full meals (including beverages, entrees, and sides). Relatedly, NPI scores do not account for items served as larger versus smaller portions (as it measures nutrients per 100 grams). It will be important for future research to examine NPI scores of all menu items, and meals over time, particularly now that national menu labeling is fully implemented. It will also be important to examine trends in portion sizes of restaurant menu items. Examination of differences in NPI score based on price, marketing, sales, and consumption will also be informative to fully understand the potential for restaurant menu changes to influence population health.

CONCLUSIONS

Top burger fast food restaurants have not improved the nutritional profile of the items on their menus overall, among core menu items, among newly introduced items, or on children’s menus. To make positive changes, restaurants will have to make larger improvements to the nutritional composition of the foods they offer.