Qualities of the Restaurant Food Environment: A Direct Observation Pilot Study of Restaurants Located Near High Schools

Abstract

Objective:

This study aimed to identify and describe healthful and youth-oriented qualities of the restaurant food environment around high schools.

Methods:

Using direct observation data from 58 restaurants located within a half-mile (804.5 meters) of all high schools in a single district, two index measures of the restaurant food environment were created: healthfulness index and youth-oriented index. Wilcoxon signed-rank order was used to examine differences in restaurant features according to index scores.

Results:

Mean healthfulness score was 8.9 (range = 2–14, max = 19) and mean youth-oriented score was 5.5 (range = 0–11, max = 12). Differences were found in signed-rank order of healthfulness and youth-oriented index restaurant scores (p = 0.02).

Conclusion:

Results suggest that restaurants have room for improvement in offering customers a healthful environment, some restaurants are more likely to appeal to youth, and that youth-oriented restaurants were different than restaurants with high healthfulness scores. Further qualitative exploration of food environment features will help contextualize the influence of restaurants on youth eating behaviors.

Introduction

Youth-focused food environment research has primarily examined associations between the food environment and youth weight status,^1–5 given the high prevalence of childhood obesity.⁶ Specifically, research often considers associations between food outlet availability around a youth's home, school, or neighborhood, and obesity, yet findings have been mixed. Some studies suggest that there is an inverse association between food outlet availability and childhood obesity,^1,2,7 while others find positive⁸ or no association with food outlet availability and childhood obesity.

It is possible that current field limitations including heavy reliance on secondary data, oversimplified outlet categorization, and limited attention given to qualitative differences contribute to mixed findings regarding associations with youth with obesity. Secondary data sources often under-represent food outlets overall⁹ and are particularly poor when considering unique food environments such as those in minority or rural areas.¹⁰ Dichotomizing food outlets according to their healthfulness (e.g., healthy vs. unhealthy)^2,3 may be inappropriate, as most food outlets sell a mix of both healthy and less healthy food. Lastly, youth-oriented features of restaurants have rarely been examined within the food environment literature even though advertising research indicates that food and beverage advertisements are often targeted toward youth using youth-oriented features.¹¹ Given field limitations, careful consideration of healthful and youth-oriented qualities of restaurants may provide a better characterization of food outlets.

Therefore, the purpose of this study was to qualitatively describe the restaurant food environment of youth through primary data collection on restaurants located within a half-mile of high schools with specific attention to features of the restaurant food environment that may be youth oriented or supportive of healthful choices.

Methods

Restaurant location data used for this study were generated by a larger study that collected primary data with a reliable data collection tool on restaurants located within one-half mile of all high schools within a single district.^12,13 This resulted in the known location of 58 restaurants located within a one-half mile of all high schools (n = 9) within a single urban district in central Texas. According to publicly 2014–2015 Texas Education Agency School Report Cards, 59.1% of students attending schools were economically disadvantaged (range = 26.8%–86.1%) and, on average, ∼59.0% (range = 32.0%–85.5%) of the students were Hispanic.¹⁴ Data collection and coding of restaurant features were completed during June 2015 by the primary author. Restaurant features included on the coding tool were created based on responses to a survey, which asked registered dietitians to list the most important factors and qualities in determining the healthfulness of a restaurant. Additional codes were developed based on current findings within the literature. Additional details on development of the coding tool can be found in a previous publication.¹³ This study did not meet the requirement for human subjects research, so therefore, an IRB was not required.

Healthfulness Index

To examine the healthfulness of a restaurant, a healthfulness index was created. Variables included on the healthfulness identified through collaborative team discussions with a registered dietitian, public health expert, and epidemiologist. To be included, each variable had to be represented in the literature as associated with eating patterns among children or adults. Each variable included within the index was coded so that a higher score would indicate a healthier restaurant feature. Variables included availability of side salads, vegetarian/vegan entrees, promotion of unprocessed vegetables, meal deals, meal deals with vegetables, and low-cost menus, promotion of whole foods and local/sustainable/farm-to-table foods, accessibility of free fountain drink refills, and presence of a drive thru. Several of these variables were reverse coded to reflect healthfulness. A single index score was created for each restaurant. A higher index score indicates the restaurant has more features supportive of healthy weight status. See Table 1 for descriptions, definitions, and coding.

Table 1.

Coding of Restaurant Features and Qualities for the Healthfulness Index and Youth-Oriented Index

Variable description	Variable definition	Healthfulness scale values (19 max)	Youth-oriented scale values (12 max)
Are salads able to be included as a side?	A side salad is a small portion of leafy greens served alongside an entree.	0 = Not available 1 = Up charge 2 = Free substitution	N/A
Are whole unprocessed vegetables available?	Whole unprocessed vegetables are vegetables that have been fresh cut and minimally prepared.	0 = Not available 1 = Sides 2 = Entrees 3 = Entrees and sides	N/A
Are vegetarian or vegan entrees available?	Vegetarian entrees are main dishes that do not include meat. Vegan entrees are main dishes that do not include any animal product (e.g., meat, cheese, egg).	0 = No 1 = Yes	N/A
Is advertising or promotion of unprocessed whole foods visible?	Advertising or promotion of whole unprocessed foods is foods including meats, grains, vegetables, and fruit that are available to purchase in their original form or minimally processed.	0 = No 1 = Sides 2 = Entrees 3 = Entrees and sides	N/A
Is advertising or promotion of locally sourced, sustainable, or farm-to-table foods visible?	Advertising or promotion of locally sourced foods are those that are grown, cooked, or made near the location of the restaurant. Sustainable foods are those that have been grown or made using sustainable practices. Farm-to-table foods are foods that have been grown or produced near the restaurant location.	0 = No 1 = Yes	N/A
Which best describes access to free fountain drink refills?	Fountain drinks are beverages that are dispensed through a machine that includes a variety of faucets, most often dispensing soda, drinks, and water. Free refills were defined as only purchasing one beverage, but having the ability to replenish beverage for free.	3 = Fountain drinks not available 2 = Refills not available 1 = Free, behind counter 0 = Free, ready access	0 = Fountain drinks not available 1 = Refills not available 2 = Free, behind counter 3 = Free, ready access
Does this restaurant have a menu of single low-cost items?	A single low-cost item menu is a menu of single food or beverage items that are typically less than $3, often as low as $1 (e.g., Dollar Menu, Right Size Right Price Menu).	1 = No 0 = Yes	0 = No 1 = Yes
Does this restaurant have meals with varying sizes?	Meal deals are a common way a restaurant promotes a single entree, side, and beverage for a single price that is often less expensive than purchasing each item separately.	3 = Not available 2 = No 1 = Drinks only 0 = Food and drinks	0 = Not available 1 = No 2 = Drinks only 3 = Food and drinks
If yes, are whole unprocessed vegetables available?	Whole unprocessed vegetables are vegetables that have been fresh cut and minimally prepared.	0 = No 1 = Yes	N/A
Does this restaurant have a drive thru?	A drive thru is any window or ordering station where food is ordered and delivered to the customer without the customer needing to leave his or her vehicle.	1 = No 0 = Yes	0 = No 1 = Yes
Where do you order and receive food?	Ordering food is when a customer verbally requests specific food items. Receiving food is when the consumer obtains the foods purchased. Order location was coded to reflect a higher score for restaurants that offered a faster speed of service.	N/A	0 = Table (order and receive) 1 = Counter order, table receive 2 = Counter order, counter pick-up
Is this restaurant good for groups?	Group dining or “good for groups” is often facilitated by large spaces, tables that accommodate many chairs, picnic-style tables, and restaurants that are willing to split food bills.	N/A	0 = No 1 = Yes
Does this restaurant have outdoor seating?	Outdoor seating is the availability of chairs, benches, and tables outside on restaurant property, and was coded to reflect a higher score for restaurants that had access to outdoor seating.	N/A	0 = No 1 = Yes

N/A, not applicable.

When coding for the healthfulness, it should be noted that not all vegetarian and vegan entrees are considered healthy, nor are all foods that are considered local, sustainable, or farm-to-table, yet the Dietary Guidelines for Americans¹⁵ and a recent EAT-Lancet publication further emphasize the importance of sustainable plant-based food consumption on diet and health.¹⁶ Therefore, we considered this appropriate to include as one component of the overall score for the healthfulness index.

Youth-Oriented Index

To identify restaurants that may be more likely to be visited by youth, a youth-oriented index was created. These items included the availability of free fountain drink refills, meal deals, a low-cost menu, drive-thru window, outdoor seating, ordering location, and whether the restaurant is good for groups. Each of these variables was selected though a literature review, discussion with key informants, and reviewed by childhood obesity experts (n = 5) to confirm face validity of included measures. A single index score was created for each restaurant. A higher index score indicates a youth-oriented restaurant. See Table 1 for descriptions, definitions, and coding.

Statistical Analyses

Frequencies were run to identify the prevalence of each of the restaurant features in this sample. The Wilcoxon signed-rank test was used to determine whether there was a difference in rank order of the restaurants by the healthfulness and youth-oriented index measures. Owing to overlapping variables within index measures, repeated items were removed from the healthfulness index when testing rank order to prevent relationship inflation.

Results

Fifty-eight restaurants around nine high schools were documented. The mean number of restaurants located within one-half mile was 4.5 (median = 5, range = 0–10). Among the 58 restaurants in the sample, 91.4% offered unprocessed vegetables, yet 63.8% did not have a side salad available (Table 2). Vegetarian or vegan entrees were available in 84.5% of restaurants. Most restaurants did not advertise whole foods (60.3%) or local/sustainable/farm-to-table foods (93.1%). Free fountain drink refills were common (39.7% behind the counter, 31.0% ready access), although 19.0% of restaurants did not offer any fountain drinks. Few restaurants offered low-cost menus (8.6%), meal deals with varying sizes (31.1%), meal deals with vegetables (13.8%), or drive-thru windows (17.2%). Restaurants were generally good for groups (70.7%), although less than a third had outdoor seating (29.3%).

Table 2.

Prevalence of Restaurant Factors and Qualities (n = 58 Restaurants)

Variable	n	%
Side salad
Not available	37	63.8
Up charge	15	25.9
Free substitution	6	10.3
Unprocessed vegetables
Not available	5	8.6
Sides	11	19.0
Entrees	16	27.6
Entrees and sides	26	44.8
Vegetarian and vegan entrees
No	9	15.5
Yes	49	84.5
Whole foods advertising
No	35	60.3
Sides	7	12.1
Entrees	11	19.0
Entrees and sides	5	8.6
Local/sustainable/farm-to-table advertising
No	54	93.1
Yes	4	6.9
Free fountain drink refills
Fountain drinks not available	11	19.0
Free fountain drink refills not available	6	10.3
Free, behind the counter	23	39.7
Free, ready access	18	31.0
Single item/low-cost menu
No	53	91.4
Yes	5	8.6
Meal deal with varying sizes
Not available/no	10/30	17.2/51.7
Drinks only	4	6.9
Food and drinks	14	24.1
Meal deal veggies
No	50	86.2
Yes	8	13.8
Drive thru
No	48	82.8
Yes	10	17.2
Order location
Table (TT)	25	43.1
Counter order, table receive (CT)	8	13.8
Counter order, counter receive (CC)	25	43.1
Good for groups
No	17	29.3
Yes	41	70.7
Outdoor seating
No	41	70.7
Yes	17	29.3
Index measures
Healthfulness index (mean/range)	8.90	2–14 (19 max)
Youth oriented (mean/range)	5.46	0–11 (12 max)

Index measures were calculated based on identified restaurant factors and qualities. For the healthfulness index, a higher score for a restaurant represented a restaurant more supportive of healthy choices. On average, the mean healthfulness index score was 8.9 (range = 2–14, maximum = 19). For the youth-oriented index, a higher score represented a restaurant that had more factors or qualities that appeal to youth. The mean youth-oriented index score was 5.5 (range = 0–11, maximum = 12). (Table 2).

The Wilcoxon signed-rank test found a significant difference in the rank order of healthfulness and youth-oriented index scores for restaurants (Z = −2.28, p = 0.02), suggesting that restaurants ranked higher on the healthfulness index were different from those that ranked higher on the youth-oriented index. High-ranking restaurants on the healthfulness index included restaurants such as Delaware Sub Shop, Denny's^®, and Luby's^® as well as pizza restaurants such as Domino's^® and Pizza Hut^®. High-ranking restaurants on the youth-oriented index included Taco Cabana^®, Jack in the Box^®, McDonald's^®, and Dairy Queen^®.

Discussion

Results found that restaurants around high schools scored relatively low on both the healthfulness and youth-oriented indices. The mean healthfulness index score was 8.9 out of 19, which suggests restaurants likely do not present customers with an environment particularly supportive of healthy eating. The most common healthful features of restaurants were the availability of unprocessed vegetables in a side, entree, or side and entree (91.4%), and vegetarian/vegan entrees (72.1%). These findings are similar to previous research that suggests that although restaurant menus have improved to include healthier choices (e.g., unprocessed vegetables), many still offer and advertise unhealthy food options.^17,18

The mean score on the youth-oriented index was 5.5 out of 12, suggesting that restaurants documented may also not be particularly youth oriented or that we have appropriately identified salient restaurant environment features. The most common youth-oriented restaurant features documented by this study were good for groups (70.7%) and availability of free fountain drink refills (70.7%). Additional research is needed to further identify and describe features of the restaurant food environment that influence youth's dietary patterns.

Results indicate that restaurants that ranked higher on the healthfulness index were different than those that ranked higher on the youth-oriented index. Specifically, full-service restaurants and pizza restaurants ranked highest on the healthfulness index, whereas traditional fast food (excluding pizza) ranked higher on the youth-oriented index. This is not unexpected as fast-food restaurants are frequented by youth¹⁹ and often serve low-cost processed foods that youth perceive as a good value.²⁰ Although pizza restaurants are often considered fast food,² pizza restaurants often have fresh vegetables available in the form of salads and vegetable topping options for pizzas. Furthermore, pizza restaurants often do not have drive-thru windows or low-cost menus, two key youth-oriented features.

This study has key strengths and limitations to consider. First, this study leveraged primary data that were collected using a reliable electronic data collection tool and documented qualitative features of the restaurant food environment, such as access to free fountain drink refill. Furthermore, by using an index measure provides flexibility and variability in identifying features and qualities of restaurants, instead of relying on oversimplified classification methods. A primary limitation is that this study only included restaurants and did not include outlets such as grocery stores, convenience stores, or general merchants (e.g., General Dollar^®), all of which sell food and may shape choices youth make about what to eat.²¹ Nonetheless, restaurants are common food outlets that youth visit, particularly if the restaurants are located near their school making it easy for youth to frequent on their way to or from school.

This study also has policy implications important for school officials and health authorities to consider. First, it used a tool¹³ that aligns with the Healthy People 2020 objectives focused on improving healthy food access and begins to identify salient features of the restaurant environment for understanding youth's dietary patterns. Second, it provides local school leaders and public health professionals a reference for beginning how to evaluate their local food environment around schools. Together, with reliable data and information on the healthfulness of restaurants near schools, school leaders and public health officials will be better equipped to advocate for improved healthful zoning near schools to better support youth's dietary patterns.

Conclusion

This study addressed areas within the food environment literature that need improvement, such as the use of primary data collection and attention to youth-oriented features of the food environment. Future research should continue to explore how these measures and others can be used to better characterize restaurants. For example, a more diverse view of the food environment such as including corner and convenience stores, dollar stores, and general merchants in addition to restaurants. Furthermore, additional work is needed to identify what youth perceive as the most salient factors for choosing where to purchase food. Ultimately, a comprehensive view of the food environment that includes youth's voices is needed to further understand the food environments influence on youth's dietary patterns.

Disclaimer

The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.

Authors' Contributions

All authors contributed significantly to the work of this article including development, data collection, analysis, and writing.

Funding Information

This research was funded, in part, through a grant to K.E.P. from the National Cancer Institute (Grant No. R03CA158962).

Author Disclosure Statement

No competing financial interests exist.