Rudd Report UCONNRUDDCENTER.ORG August 2017 Are Fst-Food Resturnts Keeping Their Promises to Offer Helthier Kids Mels? AUTHORS: Jennifer Hrris, PhD, MBA Mi Hyry, MPA Nicole Seymour, MSW Yoon-Young Choi, MS ACKNOWLEDGMENTS: Support for this study ws provided by Helthy Eting Reserch, ntionl progrm of the Robert Wood Johnson Foundtion. Peer review ws provided by Christin D. Economos, PhD, Professor, Friedmn School of Nutrition Tufts University, Director, ChildObesity180; nd Brin Elbel, PhD, MPH, NYU School of Medicine, nd NYU Wgner School of Public Service. Summry To ddress public helth concerns bout the negtive impct of children s fst food consumption, some of the lrgest U.S. fst-food resturnts McDonld s, Burger King, Subwy, Wendy s, KFC, nd Diry Queen hve pledged to remove sugr-sweetened fountin drinks from menu bords nd / or offer helthier drinks nd side dishes with kids mels. In this reserch, we evluted resturnts implementtion of their helthier kids mel pledges by nlyzing: (1) kids mel drink nd side items listed on resturnts websites; (2) kids mel drink nd side items listed nd pictured on menu bords nd fetured on signs inside nd outside resturnts; nd (3) drinks nd sides offered by resturnt personnel t the point-of-sle with kids mel orders. To ssess chnges over time, dt were collected in 2010, 2013, nd 2016. In 2016, kids mel menus on resturnt websites consistently reflected resturnts helthier kids mel pledges. As pledged, none of the websites listed fountin drinks s prt of their kids mel online menus, notble improvement compred with 2013. Subwy lone pledged to offer only helthier kids mel sides, nd ws the only resturnt tht did not list unhelthy sides (such s french fries nd desserts) on its kids mel online menu. McDonld s fulfilled its pledge to introduce new helthier kids mel sides, while ll resturnts in this evlution listed t lest one helthier kids mel side option (such s pplesuce or pple slices) on their websites. In contrst, some individul loctions of ll resturnt chins evluted continued to promote unhelthy kids mel drinks nd sides on menu bords nd / or signs inside the resturnts, including items tht were not listed on their kids mel online menus. Approximtely one-third of McDonld s, Burger King, Wendy s, nd Subwy resturnts visited in 2016 listed fountin drinks with kids mels on their menu bords, despite their pledges to remove them from menu bords. In ddition, some Burger King nd Subwy loctions fetured unhelthy sides on kids mel menu bords nd signs tht were not included on their kids mel online menus. 1
Fst-food resturnts including McDonld s, Subwy, Burger King, Wendy s, KFC, nd Diry Queen hve promised to remove sugry drinks from kid s mel menu bords. However, resturnts did not consistently implement their pledges t ll resturnt loctions. When mystery shoppers visited individul resturnts nd ordered kids mel, there ws wide vrition in how often resturnt personnel offered helthier kids mel drink nd side options. In 2016, resturnt personnel offered t lest one helthier drink option with more thn 80% of kids mel orders t McDonld s, Burger King, nd Subwy resturnts, compred with 56% of orders t Wendy s nd KFC nd 33% t Diry Queen. Yet, some personnel t ll resturnt chins continued to utomticlly provide customers with cup for fountin drink without offering ny helthier drink options, including one-hlf of orders t Diry Queen. There ws even more vrition in how often resturnts offered ny of their helthier side options with kids mel orders, rnging from 80% or more of orders t McDonld s, Subwy, nd KFC, to 22% t Wendy s nd 8% t Burger King. Although Burger King hd removed french fries from its kids mel online menu, resturnt personnel utomticlly provided fries with 90% of Burger King kids mel orders. Furthermore, ll McDonld s orders included reduced-portion size of french fries, in ddition to helthier sides. These results indicte tht resturnts listed helthier drinks nd / or sides on their kids mel online menus s promised, but pledges to remove unhelthy drinks from kids mel menus were inconsistently implemented t individul resturnts. Mny of these resturnts continued to offer fountin drinks nd french fries s the defult with kids mels t the point-of-sle, wheres helthier options usully were offered s choice (often together with unhelthy options). Advoctes should continue to work with resturnts to encourge expnsion of helthier kids mel policies, focusing on removing unhelthy sides nd min dishes in ddition to drinks, nd mking helthier options the defult, not one of both helthy nd unhelthy choices. They must lso monitor implementtion t individul resturnts nd insist tht resturnts consistently implement the helthier kids mel pledges tht they publicly promote, s well s introduce cmpigns to increse prents demnd for helthier kids mel choices. Policy mkers should lso consider legisltion or regultion to require tht ll resturnts serve helthier kids mels. 2
Bckground One-third of children consume fst food on given dy, nd frequent fst food consumption negtively ffects children s diets nd increses clories consumed. Frequent fst food consumption negtively ffects children s diets, weight, nd helth. One-third of children consume fst food on given dy, 1 contributing 126 dditionl clories, incresed sugr, sturted ft, sodium nd sugry drink intke, nd reduced milk intke on those dys. 2 Furthermore, mjority of kids mel min dishes offered by top fst-food resturnts exceed dietry recommendtions for the percent of clories from ft, sturted ft, nd sodium. 3,4 A recent study concluded tht fst-food mels purchsed for children contining sugr-sweetened beverges dded n verge of 179 clories to the mel nd incresed dded sugr consumption when compred to mels purchsed without these drinks. 5 Fst food consumption lso contributes to helth disprities ffecting blck nd Hispnic youth 6 due to greter ccess to fst food nd more negtive effects of fst food consumption on diet qulity for lower-income children. 7,8 Therefore, policies tht reduce clories nd improve the nutritionl qulity of foods nd beverges consumed by children t fst-food resturnts will likely improve children s helth, with even greter benefits for lower-income, blck, nd Hispnic popultions. Some fst-food resturnts hve dded helthier side nd drink menu items on kids mel menus, but the mjority of options remin nutritionlly indequte. 9 A Rudd Center nlysis of kids mel menu items offered in 2013 found improvements in kids mel options compred with 2010, with most resturnts dding new helthy drinks nd sides. 10 However, nerly ll kids mel items exceeded recommended levels of clories, sturted ft, sodium, nd / or sugr, while fewer thn 1% of kids mel combintions met recommended nutrition stndrds. A recent study of chnges in the nutrient content of menu items in children s mels t 45 chin resturnts from 2012 to 2015 found reduction in sod on children s menus, which ws offset by n increse in flvored milk, nd few chnges in the nutrient content of min dish nd side items. 11 To dte, resturnts voluntry pledges hve been the primry mechnism for implementing helthier kids mel policies. Since 2013, McDonld s, 12 Burger King, 13 Wendy s, 14 nd Diry Queen 15 hve pledged to remove fountin drinks from their kids mel menu bords. McDonld s lso pledged to introduce nd dvertise new helthier kids mel drink nd side items. Subwy hs only listed helthier sides nd drinks s options with its kids mels since t lest 2010, 16,17 but the resturnt further committed to offering pples s side nd wter or low-ft milk s the defult drink with its kids mels fter joining the Prtnership for Helthier Americ in 2014. 18 In 2014, KFC introduced its Li l Bucket Kids Mel with helthier sides nd drinks. 19 Questions remin bout the effectiveness of fst-food resturnts pledges to offer helthier drinks nd / or sides with their kids mels. For exmple, do individul resturnts consistently implement these prctices? In ddition, do they ctively promote helthier items nd not promote unhelthy items in other wys, such s through signs t resturnts nd pictures on menu bords? Reserch is required to nswer these questions nd help determine the potentil effectiveness of voluntry resturnt policies, or whether government regultion is required. 3
Resturnts pledges to offer nd promote helthier drinks nd sides with their kids mels since 2013. Resturnt McDonld s Burger King Wendy s Subwy Diry Queen KFC Helthier kids mel pledges In September 2013, McDonld s issued pledge through the Allince for Helthier Genertion 20 to commit to the following ctions evluted in this report: Feture only wter, milk nd juice s the beverge in Hppy Mels on menu bords nd in-store nd externl dvertising directed to children. For Hppy Mels, remove ll sod logos nd imges of cups with sod from the Hppy Mel section of menu bords (where they exist) nd ll in-store nd externl dvertising directed to children. Sod will still be vilble s beverge option. Offer new fruit, vegetble, low- / reduced-ft diry or wter options in the Hppy Mel beginning in 2014. McDonld s pledge clled for phsing out the listing of sod on the Hppy Mel section of the menu bord, beginning in 2014, with interim gols for mrket-level complince in 2016 nd 2018. The finl gol is to fulfill ll commitments in 20 mjor mrkets, which represent more thn 85% of the compny s globl sles, by 2020.* In 2015, the President of Burger King North Americ emiled sttement, published in USA TODAY, 21 stting tht: Insted of soft drinks on menu bords, the BK menu for kids will offer ft-free milk, 100% pple juice, nd low-ft chocolte milk. In sttement emiled to Consumerist in Jnury 2015, 22 Wendy s representtive confirmed the following steps tken by the resturnt: Remove crbonted soft drinks from the kids mel listing on menu bords, both inside resturnts nd t pick-up windows (s of fll 2014). This pledge sttes, Beverge options now listed for kids mels re 1% white or chocolte milk, bottled wter nd 100% juice. In Jnury 2014, Subwy joined the Prtnership for Helthier Americ nd issued press relese 23 stting tht it would: Only offer items on its kids mel menu tht meet strong nutritionl guidelines informed by federl stndrds for the ntionl school lunch progrm, including offering pples s side nd low-ft or non-ft milk or wter s defult beverge. In My 2015, the Americn Diry Queen Corportion relesed letter 24 stting tht the following chnges would be effective September 1, 2015 when new menu bords rrive t frnchise loctions: Remove soft drinks from kids mel menu bords t Diry Queen loctions cross the U.S., nd drinks such s milk nd bottled wter would solely be listed s menu options t DQ loctions. In Mrch 2013, Ntion s Resturnt News published n rticle introducing the new KFC kids mels 25 nd in Mrch 2014, the Ntionl Resturnt Assocition provided comments to the Dietry Guidelines Committee citing the KFC kids mel. 26 KFC now offers the Li l Bucket Kids Mel tht comes with green bens, GoGo squeeze pplesuce, nd Cpri Sun Rorin Wter. * Although McDonld s gol ws to fulfill ll its pledges in 20 mrkets by 2020, 2014 progress report by the Allince for Helthier Genertion concluded tht these commitments were fulfilled in the U.S. by July 2014. 27 4
This reserch This evlution ssessed whether fst-food resturnts consistently implemented their helthier kids mel pledges nd promoted helthier choices t individul resturnts, including chnges from 2010 to 2016. The purpose of this evlution ws to determine whether resturnts consistently implemented their helthier kids mel pledges nd promoted helthier choices t individul resturnts in other wys. We exmined six resturnts tht hve mde pledges since 2013: McDonld s, Burger King, Wendy s, Subwy, Diry Queen, nd KFC. We collected dt in April 2016. We lso compred results for four resturnts (McDonld s, Burger King, Wendy s, nd Subwy) to results from dt collected in 2010 nd 2013, using the sme methods, to mesure chnges following policy implementtion. Appendix A provides detiled methods used in ech nlysis. Evluting helthier kids mel pledges Anlysis 1) Kids mel online menu listings 2) Menu bords nd signs t individul resturnts Methods Reserch personnel recorded ll drink nd side items listed on menus posted on the kids mel section of resturnts websites in Februry 2013 nd Mrch nd April of 2016, including nutrition informtion. Six resturnts were included in this nlysis: McDonld s, Burger King, Wendy s, Subwy, KFC, nd Diry Queen. Mystery shoppers from n independent mrket reserch firm were hired to visit representtive crosssectionl smple of McDonld s, Burger King, Wendy s, nd Subwy resturnts in 20 mrkets cross the U.S. in 2010, 2013, nd 2016 (n=100 resturnts per chin per yer). At ech resturnt, field personnel recorded ll menu items listed on the kids mel section of the menu bord, s well s menu items pictured on the kids mel menu bord. They lso recorded ll menu items pictured on signs inside nd outside the resturnt tht mentioned the kids mel. 3) Items offered with kids mel orders At subset of McDonld s, Burger King, Wendy s, nd Subwy resturnts visited for the menu bord nlysis, mystery shoppers lso plced n order for kids mel. This cross-sectionl smple included n=50 resturnts per chin per yer. Additionl dt were collected for KFC nd Diry Queen in 2016 only (n=18 resturnts per chin). At these resturnts, mystery shoppers ordered kids mel, but did not specify side or drink choice. After receiving their order, shoppers recorded ll side nd drink options offered by resturnt employees (i.e., choices) or whether they were utomticlly provided specific side or drink without being offered options (i.e., by defult). 5
To evlute resturnts helthier kids mel pledges, we designted sugr-sweetened sod nd other fountin drinks, diet sod, fried vegetbles, nd desserts s unhelthy options. Helthier drinks nd sides included wter, plin milk, non-fried fruits nd vegetbles, nd other options tht resturnts hve identified s helthier drinks nd sides. However, it should be noted tht not ll nutrition professionls gree tht some of these options such s 100% juice, flvored milk, nd Cpri Sun Rorin Wters (which contins non-nutritive sweeteners) re nutritious options for children. Helthier kids mel options offered by resturnt chins in 2016* Resturnt Helthier drinks Helthier sides McDonld's Plin 1% low-ft milk or skim, 100% juice, ft-free chocolte milk jug Mndrin ornges, pple slices, Go-Gurt Yogurt Burger King Cpri Sun 100% juice, low-ft chocolte milk, ft-free plin milk Applesuce Wendy's Plin 1% milk, 1% chocolte milk, bottled wter, Honest Kids Fruit Punch Apple slices Subwy Plin low-ft milk, chocolte flvored reduced ft milk Apple slices Diry Queen Plin 1% milk, bottled wter Applesuce, bnn KFC Cpri Sun Rorin' Wters Tropicl Fruit, 1% chocolte milk, plin 2% milk, plin 1% milk Green bens, GoGo squeez pplesuce, sweet kernel corn, corn on the Cob, BBQ bked bens, coleslw, mshed pottoes without grvy *Includes menu items listed on resturnt chins online menus in the kids mel section of their websites nd / or items offered t resturnts. 6
Results The evlution of helthier kids mel pledges included three prts: 1) Drink nd side options listed on resturnt chins kids mel online menus; 2) Drink nd side items listed nd pictured on menu bords nd signs t individul resturnts; nd 3) Drink nd side options offered by resturnt personnel with kids mel orders. All kids mel drink options listed on the websites of resturnts in our evlution were helthier choices including low-ft milk, 100% fruit juice, nd plin wter significnt improvement from 2013 to 2016. Kids mel online menus Kids mel items listed on resturnt chins websites (i.e., kids mel online menus) reflected their pledges to remove fountin drinks nd dd helthier side options to their kids mels. However, in 2013 nd 2016 ll resturnts except Subwy lso continued to list fried pottoes nd other unhelthy sides or desserts on their kids mel menus. Drink options All drink options listed on kids mel online menus in 2016 were helthier choices for children (see Tble 1 nd detils in Appendix Tble B1). All resturnts offered low-ft plin milk. Four resturnts (McDonld s, Burger King, Wendy s, nd KFC) lso offered flvored milk, while two (McDonld s nd Burger King) offered 100% juice. Two resturnts (Wendy s nd Diry Queen) introduced plin bottled wter to their kids mel menus fter 2013. Two resturnts lso offered fruit drinks without dded sugr Honest Kids Super Fruit Punch t Wendy s ( juice drink with wter nd fruit juice concentrte) nd Cpri Sun Rorin Wters t KFC ( low-clorie flvored wter with fruit juice nd non-nutritive sweeteners). Tble 1. Drink options on kids mel online menus 2013 2016 Resturnt Clories # helthier* (totl) drinks Clories # helthier* (totl) drinks McDonld s 0-135 3 (5) 80-130 3 (3) Burger King 0-160 2 (4) 80-160 3 (3) Wendy s 140 3 (5) 150 4 (4) Subwy 100-300 3 (3) 100 1 (1) KFC 0-170 2 (4) 30-180 4 (4) Diry Queen 0-190 1 (3) 0-110 2 (2) * Helthier options include low-ft flvored nd plin milk, 100% juice, wter, nd other options resturnts hve identified in their pledges (e.g., Cpri Sun Rorin Wters nd Honest Kids Fruit Punch). 7
There ws n increse in the number of helthier drink options between 2013 nd 2016, while the number of resturnts serving zero-clorie options decresed s result of removing diet fountin drinks from their menus. None of the resturnts listed fountin drinks (sugr-sweetened or diet) on their kids mel online menus in 2016, notble improvement compred to 2013 when ll resturnts except Subwy listed them. Notbly, Wendy s beverge menu continued to list kids mel sizes for ll sugr-sweetened nd diet sod fountin drinks, even though these drinks were not listed on its Wendy s Kids Mel menu on the resturnt s website. Although Frosty Jr. s (frozen drink) were not listed s beverge on the kids mel online menu, Frosty Jr. s cn be substituted for drink. Side nd other options Only McDonld s nd Subwy explicitly pledged to offer helthier sides with kids mels (see Resturnts pledges). Yet ll resturnts offered t lest one helthier side with their kids mels in 2016. KFC nd McDonld s offered the gretest number of helthier side options, seven nd three, respectively. In 2016, the number of side nd dessert options offered by resturnts in our nlysis vried widely, rnging from one option (Subwy) to twelve options (KFC) (see Tble 2 nd detils in Appendix Tble B2). Tble 2. Side nd dessert options on kids mel online menus 2013 2016 Resturnt Clories # helthier* (totl) options Clories # helthier* (totl) options McDonld s Hppy Mel 15-100 1 (2) 15-110 3 (4) McDonld s Mighty Kids Mel 15-230 1 (2) 15-230 3 (4) Burger King 30-240 1 (2) 50-190 1 (3) Wendy s 40-230 1 (2) 50-190 1 (2) Subwy 35 1 (1) 35 1 (1) KFC 25-290 6 (14) 25-270 7 (12) Diry Queen 90-240 2 (8) 80-250 2 (6) * Helthier items include fresh fruit, pplesuce, yogurt, nd non-fried vegetbles. A nutrition profiling model ws used to identify helthier KFC side items (see Appendix A for detiled methods). 8
In 2016, the mjority of menu bords t the resturnts visited listed helthier kids mel drinks, but pproximtely one-third or more of resturnt menu bords lso listed unhelthy drinks for kids mels. However, ll resturnts except Subwy lso listed t lest one unhelthy side on their kids mel online menus. Burger King ws the only other resturnt tht did not list french fries or nother type of fried pottoes s kids mel side, but it did list cookies nd soft-serve ice crem s kids mel items (on PDF, vilble on its website, with nutrition informtion for ll menu items). Diry Queen lso offered n ice crem cone s tret with its kids mel. McDonld s provided two sides with its kids mels: helthier side together with kids size fries in Hppy Mels nd lrger-portion smll fries in Mighty Kids mels. All resturnts except Subwy nd Burger King lso offered kids mel sides with more thn 200 clories, including McDonld s smll fries (included in Mighty Kids Mels); Wendy s nd Diry Queen kids fries; nd KFC bked bens nd potto wedges. Compred with 2013, McDonld s, Burger King, nd KFC dded new helthier kids mel side options (mndrin ornges nd yogurt t McDonld s nd pplesuce t Burger King nd KFC). In ddition, Wendy s reduced the sturted ft nd sodium in its french fries, Burger King removed french fries from its kids mel online menu, nd KFC reduced sturted ft or sodium or incresed fiber in severl of its side items. In contrst, Diry Queen incresed the size of its kids fries (from 190 kcl to 250 kcl), nd Burger King introduced two new dessert items. Menu bords nd signs t individul resturnts Kids mel drinks nd sides listed on menu bords nd ppering on signs t individul resturnt loctions in our smple i often did not correspond to the kids mel items listed on resturnts online menus. Resturnts t ll chins consistently listed helthier drink options on kids mel menu bords. However, despite their pledges to remove fountins drinks from their kids mel menus (see Resturnt pledges), pproximtely one-third or more of resturnts in ech chin lso continued to list fountin drinks on kids mel menu bords inside the Tble 3. Drinks on kids mel menu bords in 2016 Helthier drinks Fountin drinks Resturnt Avg # listed on menu bords % of menu bords with pictures % of menu bords listing McDonld s 2.50 21% 32% Burger King 2.38 12% 30% Wendy s 3.22 61% 42%* Subwy 1.57 41% 39% * A Frosty Jr. cn be substituted for drink nd ws listed on 36% of kids mel menu bords. i Only McDonld s, Burger King, Wendy s, nd Subwy were included in the nlysis of menu bords nd signs t individul resturnts. 9
resturnts. There ws significnt vrition between resturnt chins in the number of helthier nd unhelthy kids mel sides listed on menu bords, s well s in helthier drinks nd sides fetured on kids mel signs inside nd outside individul resturnts. Drinks nd sides listed nd pictured on kids mel menu bords Only McDonld s nd Subwy pledged to offer helthier sides with kids mels. However, ll resturnts exmined offered t lest one helthier kids mel side. While ll resturnts (including McDonld s nd Subwy) lso continued to list unhelthy kids mel side options on menu bords inside resturnts. The four resturnts in the menu bord nlysis listed pproximtely two or more helthier drinks for kids mels on menu bords inside resturnts (see Tble 3 nd detils in Appendix Tble B3). Some menu bords lso listed helthier drinks tht were not included on resturnts kids mel online menus, including plin bottled wter (McDonld s, Burger King, nd Subwy) nd flvored milk nd juice t Subwy. However, there ws wide vrition between resturnts in how often menu bords included pictures of helthier kids mel drinks. The most frequently pictured kids mel drinks on menu bords included Honest Kids Super Fruit Punch t Wendy s (pictured on 48% of menu bords) nd low-ft milk t Subwy nd McDonld s (36% nd 18% of menu bords, respectively). Although none of the resturnt chins listed fountin drinks s n option on their kids mel online menus, pproximtely one-third of resturnts t ech chin listed fountin drinks s kids mel option on their menu bords. Wendy s lso listed its Frosty Jr. (frozen drink) on 36% of menu bords. Tble 4 detils the number of helthier nd unhelthy sides listed nd pictured on kids mel menu bords inside resturnts (see Appendix Tble B4 for detils). McDonld s resturnts listed the gretest number of helthier sides nd the fewest unhelthy sides compred with the other resturnts. The mjority of Wendy s resturnts listed both pple slices nd french fries on their menu bords. However, t both McDonld s nd Wendy s, more thn one-hlf of menu bords pictured helthier sides, nd just 5 to 6% pictured french fries (the only unhelthy side vilble) with kids mels. Of note, the mjority of Burger King menu bords listed both pplesuce nd french fries s kids mel options, even though the resturnt did not list french fries s n option on its kids mel online menu. Some Burger King resturnts lso listed desserts s kids mel options, while just 6% pictured its helthier kids mel side on the menu bord. Approximtely three-qurters of Subwy menu bords listed pple slices s kids mel Tble 4. Side items on kids mel menu bords in 2016 Helthier sides Unhelthy sides Resturnt Avg # listed on menu bords % of menu bords with pictures Avg # listed on menu bords % of menu bords with pictures McDonld s 2.50 62% 0.53 5% Burger King 0.88 6% 1.11 12% Wendy s 0.93 55% 0.89 6% Subwy 0.78 37% 1.04 9% 10
option, nd 37% included pictures. However, Subwy menu bords lso frequently listed chips nd cookies s kids mel side options, even though the resturnt does not list these sides s options on its kids mel online menu. Helthier sides nd drinks on kids mel signs In 2016, McDonld s resturnts fetured the most kids mel menu items on signs t resturnts, nd Burger King resturnts fetured the fewest. Helthier drinks nd sides comprised 56% of kids mel menu items on signs in McDonld s, followed by 48% t Wendy s nd 45% t Subwy (see Tble 5). The mjority of drinks pictured on kids mel signs were helthier options, but ll resturnts continued to include fountin nd other drinks on kids mel signs in some resturnts. The mjority of sides pictured on kids mel signs t McDonld s, Wendy s, nd Subwy were helthier options. However, two-thirds of sides fetured on kids mel signs t Burger King were unhelthy options. Notbly, few Subwy resturnts lso fetured unhelthy sides on their kids mel signs. Tble 5. Menu items fetured on kids mel signs t resturnts* Totl menu items Helthier drinks Helthier sides Resturnt Avg # of menu items fetured on kids mel signs** Avg # of helthier drinks % of ll drinks fetured Avg # of helthier sides % of ll sides*** fetured McDonld s 2.61 0.60 80% 0.86 81% Burger King 1.21 0.25 58% 0.10 32% Wendy s 1.82 0.42 76% 0.46 88% Subwy 1.92 0.50 72% 0.36 73% *Per resturnt in our smple (n=100 ech) **Includes min dishes, sides, nd drinks. ***Dessert items (e.g., ice crem, cookies) re included s sides. 11
Items offered with kids mel orders In 2016, resturnt personnel offered helthier drink choices with most kids mel orders t the point-of-sle. However, some personnel t ll resturnt chins continued to utomticlly offer unhelthy drinks s the defult. There ws lso wide vrition between resturnt chins in the frequency tht resturnt personnel offered helthier drinks nd / or sides with kids mel orders t individul resturnts smpled. At most resturnt chins, the mjority of orders were offered t lest one helthier drink nd side. However, the mjority of orders lso were offered n unhelthy side choice, nd some resturnt personnel t ll chins continued to provide fountin drinks s the defult with kids mel orders. Drinks offered with kids mel orders In 2016, resturnt personnel offered t lest one helthier drink option with 82 to 84% of kids mel orders t McDonld s, Burger King, nd Subwy. Significntly fewer orders t Wendy s (56%), KFC (56%), nd Diry Queen (33%) were offered helthier drink ii (see Figure 1). However, t most resturnts fewer thn 10% of orders utomticlly received helthier drink (i.e., resturnt personnel provided the helthier drink by defult without sking the customer wht option he / she wnted). Most of the time, resturnt personnel offered choice of more thn one helthier drink, with McDonld s nd Subwy offering significntly greter number of helthier drink options (2.4 nd 2.2, respectively) thn the other resturnts. Figure 1. Helthier drinks offered with kids mel orders Helthier defult Offered ny helthier drink(s) 100% 90% 80% 70% b b, x b, x b, x 60% 50% 40% 30% 20% 10% 0% Avg # of helthier drinks offered 80% 74% 80% 76% 70% 64% 54% 40% 28% 34% 26% 26% 8% 4% 2% 4% 2% 2% 4% 4% 2% 4% 4% 2010 1.7 2013 2016 2010 2013 2016 2010 2013 2016 2010 2013 2016 2016 1.9 2.4 bx 2.0 1.8 1.6 y 1.5 1.9 1.9 xy 1.8 2.0 b 2.2 bx 1.7 McDonld s Burger King Wendy s Subwy Diry Queen Letters, b, c denote sttisticlly significnt difference between 2010, 2013, nd 2016 for the resturnt, p<.05. Letters x, y, z denote sttisticlly significnt difference between resturnts in 2016, p<.05., b, y 62% 33% 39% 17% 2016 1.6 KFC ii These orders were offered t lest one helthier drink option, but my hve lso been offered n unhelthy option. 12
Between 2010 nd 2016, the proportion of kids mel orders tht were offered helthier drinks incresed t McDonld s nd Burger King, nd remined consistently high t Subwy. There ws no improvement t Wendy s. Compred with 2010, there ws significnt increse in the number of kids mel orders tht were offered ny helthier drinks t McDonld s, Burger King, nd Wendy s. This improvement occurred from 2010 to 2013 for McDonld s nd Wendy s nd from 2013 to 2016 for Burger King. The verge number of helthier drink options offered t McDonld s nd Subwy lso incresed from 2013 to 2016. In ll three yers exmined, 80% or more of orders t Subwy were offered helthier drink options. However, personnel t ll resturnts chins continued to offer fountin nd other unhelthy drink options with some kids mel orders in 2016, rnging from 16 to 18% of orders t McDonld s, Burger King, nd Subwy, to 44% of orders t KFC nd Wendy s, nd 67% of Diry Queen orders. iii At McDonld s, Burger King, nd KFC, resturnt personnel only offered unhelthy drink options by defult (i.e., typiclly providing the customer with cup to select their own fountin drinks) (see Figure 2). At Wendy s nd Diry Queen, some resturnt personnel offered choice of different unhelthy drink options, without offering ny helthier options (18% nd 17% of orders, respectively). In 2016, there ws no significnt difference between resturnts offering unhelthy drinks s the defult, but Wendy s personnel were more likely to offer only unhelthy drink options compred with the other resturnts. There ws significnt reduction in the percent of orders providing unhelthy drinks s the defult for McDonld s (compred with 2010) nd for Burger King (compred with 2013). In contrst, the percent of kids mel orders t Wendy s tht were provided unhelthy drinks s the defult declined significntly from 2010 to 2013 nd then returned to 2010 levels in 2016. The proportion of orders t Subwy tht were only offered unhelthy drinks did not chnge over the three yers. Figure 2. Kids mel orders tht were only offered fountin nd/or other unhelthy drinks Unhelthy defult Offered only unhelthy drink(s) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 12% 18% 6% 17%, b, y 34% b 60% b 18% 50% 52% 50% 10% b, x b, x 20%, x 6% 28% 26% 2% 44% 18% 16% 18% 12% 14% 12% 14% 17% 2010 2013 2016 2010 2013 2016 2010 2013 2016 2010 2013 2016 2016 2016 McDonld s Burger King Wendy s Subwy Diry Queen Letters, b, c denote sttisticlly significnt difference between 2010, 2013, nd 2016 for the resturnt, p<.05. Letters x, y, z denote sttisticlly significnt difference between resturnts in 2016, p<.05. KFC iii These orders were only offered unhelthy drink options; no helthier options were offered. 13
Sides offered with kids mel orders Although vilble on the menu, resturnt personnel did not offer helthier kids mel side options with most orders t Burger King, Wendy s, or Diry Queen. Although ll resturnts listed helthier side options on their kids mel online menus in 2016, not ll resturnts regulrly offered these options s choice with kids mel orders. Resturnt personnel t McDonld s, Subwy, nd KFC iv resturnts offered helthier side option with 80 to 94% of orders, significntly more often thn did the other resturnts. In contrst, personnel t Wendy s nd Diry Queen offered t lest one helthier side option in just 22% nd 44% of kids mel orders, respectively, nd Burger King personnel offered one in just 8% of orders (see Figure 3). Compred with 2010, McDonld s ws the only resturnt with significnt increse in the percentge of orders offered t lest one helthier side. Furthermore, ten McDonld s kids mel orders cme with two helthy sides in 2016, compred with just one order in 2013. McDonld s ws lso the only resturnt with significnt increse in the number of helthier side options offered per order (from 2013 to 2016). Wendy s personnel offering helthier sides incresed from 2010 to 2013, but then declined in 2016. However, few resturnts offered helthier choice s the defult. In 2013, 88% of McDonld s kids mel orders utomticlly included helthier side (pple slices) by defult in 2013, but this percentge declined to 2% with the ddition of mndrin ornge nd yogurt side options in 2016. Even Subwy did not regulrly offer pple slices utomticlly s the side with its kids mels, even though pple slices ws the only side option listed on the resturnt s kids mel online menu. Figure 3. Helthier sides offered with kids mel orders Helthier defult Offered ny helthier side(s) 100% 90% 80% 70% b 12% b, x, x 60% 50% 40% 88% 88% b 62% 45% 66% 94% 30% 20% 10% 0% Avg # of helthier sides offered 8% 2010 1.0, b, y 44% 34% 35% 16%, y 22% 8% 8% 6% 12% 14% 4% 2% 2% 2013 1.0 2016 2.3 bx 2010 1.0 2013 1.0 2016 1.0 y 2010 1.0 2013 1.0 2016 1.0 y 2010 1.3 2013 1.0 b 2016 1.0 bx 2016 1.9 McDonld s Burger King Wendy s Subwy Diry Queen 2016 3.9 KFC Letters, b, c denote sttisticlly significnt difference between 2010, 2013, nd 2016 for the resturnt, p<.05. Letters x, y, z denote sttisticlly significnt difference between resturnts in 2016, p<.05. iv Anlysis of helthier sides offered with KFC kids mels included six of twelve side items. Mshed pottoes were coded s unhelthy becuse the mjority of orders cme with grvy nd therefore did not meet the helthier side criteri ccording to the nutrient profiling model used. 14
In 2016, resturnt personnel utomticlly provided unhelthy sides with the mjority of kids mel orders t McDonld s, Burger King, nd Wendy s. With the exception of Subwy, ll resturnts continued to offer unhelthy side options in the mjority of kids mel orders. In most instnces, resturnt personnel utomticlly provided unhelthy sides by defult, including 68% of McDonld s, 90% of Burger King, 76% of Wendy s, nd 44% of Diry Queen orders (see Figure 4). Both McDonld s nd KFC offered two sides with most kids mel orders. The mjority of McDonld s orders included both french fries nd choice of helthier sides (in complince with the resturnt s pledge), while KFC offered choice of both helthy nd unhelthy sides with most orders. Resturnt personnel t Subwy were significntly less likely to offer n unhelthy side compred with other resturnts, lthough personnel offered chips or cookies with 20% of Subwy kids mel orders even though the resturnt did not officilly offer these sides on its kids mel online menu. From 2010 to 2013, the percentge of orders tht were offered only unhelthy side options declined significntly t Wendy s, while the percentge of orders t McDonld s tht utomticlly received n unhelthy side declined from 2013 to 2016. However, there were no other chnges in unhelthy side options offered with kids mel orders during the time periods exmined. Figure 4. Kids mel orders tht were only offered unhelthy sides* Unhelthy defult Offered unhelthy side(s) 100% 90% 80% 70% 6% 10% 4%, x 2% 10% b b, x 2% 60% 50% 40% 30% 20% 10% 0% 86% 88% 90% 90% 84% 11% 100% 76% 76% 68% 66%, y 44% 16% 10% 10% 10% 10% 10% 17% 2010 2013 2016 2010 2013 2016 2010 2013 2016 2010 2013 2016 2016 2016 McDonld s Burger King Wendy s Subwy Diry Queen KFC *McDonld s nd KFC kids mels come with two sides; this figure shows results for the second side t these resturnts Letters, b, c denote sttisticlly significnt difference between 2010, 2013, nd 2016 for the resturnt, p<.05. Letters x, y, z denote sttisticlly significnt difference between resturnts in 2016, p<.05. 15
Implementtion of helthier kids mel pledges Resturnt Helthier kids mel pledges 2016 evlution results McDonld s Burger King Feture only wter, milk, nd juice s the beverge in Hppy Mels on menu bords nd phse out the listing of sod on the Hppy Mel section of the menu bord. For Hppy Mels, remove ll sod logos nd imges of cups with sod from the Hppy Mel section of menu bords. For Hppy Mels, remove ll sod logos nd imges of cups with sod from ll in-store nd externl dvertising directed to children. Offer new fruit, vegetble, low- / reduced-ft diry or wter options in the Hppy Mel. Remove fountin drinks from kids mel menu bords Insted of soft drinks, the BK menu for kids will offer ft-free milk, 100% pple juice, nd low-ft chocolte milk. McDonld s did not list ny fountin drinks s options on its kids mel online menu in 2016, but 32% of kids mel menu bords t McDonld s loctions visited (n=100) listed fountin drinks s kids mel option. Kids mel menu bords pictured fountin drinks t 9% of loctions, while 21% pictured helthier drinks. The mjority of drinks fetured on kids mel signs t resturnts were for helthier options (80%). Compred with 2013, McDonld s introduced new helthier kids mel side options (mndrin ornges nd yogurt) to its kids mel online menu. Menu bords t the mjority of resturnts visited listed these new side items, nd 11% listed bottled wter s drink option. Burger King did not list ny fountins drinks s options on its kids mel online menu in 2016, but 31% of kids mel menu bords t Burger King loctions visited (n=100) listed fountin drinks. The mjority of kids mel menu bords listed helthier drinks s n option. Wendy s Beverge options now listed for kids mels re 1% white or chocolte milk, bottled wter, nd 100% juice. Remove crbonted soft drinks from kids mels on menu bords. Wendy s only listed helthier drinks s options on its kids mel online menu in 2016, nd the mjority of kids mel menu bords t Wendy s loctions visited (n=100) listed helthier drinks s n option. Approximtely one-third of kids mel menu bords t loctions visited listed fountin drinks s n option, nd 36% listed Frosty Jr. s n option. Furthermore, 22% of drinks pictured on kids mel menu bords were fountin drinks or Frosty Jr. s. Subwy Only offer pple slices s side with kids mels. Only offer low-ft or non-ft milk or wter s the defult beverge with kids mels. In 2016, 80% of kids mel orders t Subwy resturnts visited (n=50) were offered helthier side, but just 14% of orders utomticlly cme with pple slices nd 20% were offered chips or cookie. Kids mel menu bords t Subwy listed on verge one unhelthy side option. Resturnt personnel offered customers t lest one helthier drink with 84% of kids mels orders, but just 4% of orders were provided helthier drink s the defult nd 16% were offered n unhelthy drink. In ddition, 39% of kids mel menu bords t Subwy fetured fountin drinks. 16
Conclusions These results indicte tht the resturnt chins exmined hve fulfilled prts of their helthier kids mel pledges, but tht implementtion t individul resturnt loctions ws inconsistent. All resturnts removed fountin drinks from the kids mel online menus posted on their websites, significnt improvement from 2013 to 2016. Most resturnts lso dded helthier side options to their kids mels, including resturnts tht did not pledge to do so. However, pproximtely one-third of menu bords inside resturnts t ll chins continued to list unhelthy drinks s n options with kids mels, despite resturnts pledges to remove them. Subwy ws the only chin pledging to offer only helthier kids mel sides, but some individul Subwy resturnt loctions lso listed unhelthy sides on their kids mel menu bords nd signs. In ddition, some resturnt loctions t other chins listed unhelthy kids mel side items on menu bords nd signs tht were not on the resturnts online menus. Furthermore, there ws wide vrition between resturnt chins in how often resturnt personnel offered helthier drinks nd sides with kids mel orders. Only Subwy nd McDonld s offered both helthier drinks nd sides with the mjority of kids mel orders plced in this nlysis. These results lso demonstrte tht voluntry helthier kids mel pledges by fst-food resturnts hve incresed the number of helthier options vilble, but inconsistent implementtion t resturnts suggest considerble room for improvement. Although ll resturnts now offer helthier sides nd drinks, the ctul choices vilble nd promoted t resturnts were not lwys the sme options listed on resturnt chins officil kids mel online menus. Furthermore, most of the helthier options were offered s choice (tht often included unhelthy choices s well) not by defult, while the mjority of resturnts t most fst-food chins continued to utomticlly provide fountin drinks or french fries s the defult with kids mel orders. Resturnt chins lso vried widely in how well individul loctions implemented their stted policies. We cnnot determine the resons tht individul resturnts did not consistently offer the chin s helthier kids mel options or continued to offer unhelthy options tht were not listed on their online menus. Perhps resturnt stff were not properly trined or mngement or frnchise owners t individul resturnts my hve chosen to continue to offer fountin drinks nd / or unhelthy sides with kids mels. However, this finding demonstrtes tht voluntry policies my disdvntge resturnts tht implement their policies well, compred with resturnts with poor or inconsistent policy implementtion. It is interesting to note tht Subwy nd McDonld s were the only resturnts to publish officil helthier kids mel policy sttements tht re publicly vilble, nd these resturnts lso offered helthier drinks nd sides with kids mel orders more consistently compred with the other resturnts tht hve not published officil sttements. 17
Recommendtions Recent helthier kids mel pledges nd helthier kids mel drinks nd sides introduced by fst-food resturnts re ludble. However, dvoctes should continue to encourge resturnts to introduce more effective helthy kids mel policies, including Focus on improving the nutrition of ll side options nd min dish items, in ddition to drinks; Fst food resturnts hve not consistently implemented their helthier kids mel pledges. Policy mkers should consider legisltion or regultion to require tht ll resturnts offer helthier kids mels. Encourge resturnts to introduce helthier options s the defult, not just nother choice mong both helthy nd unhelthy options, nd remove unhelthy items from menu bords nd kids mel online menus; Insist tht resturnts provide written policy sttements tht re vilble to the public, in ddition to mking sttements to press outlets; Monitor nd insist tht resturnts consistently implement their helthier kids mel pledges t individul loctions; nd Educte consumers bout helthier choices in kids mels to increse demnd nd purchses of these items. Policy mkers should lso consider legisltion or regultion to require tht ll resturnts deliver helthier kids mels. For exmple, municiplities in Cliforni (including Dvis nd Stockton) hve pssed helthy defult kids beverge ordinnces. 28 However, these policies must be crfted to ccount for possible unintended responses from resturnts tht could reduce their effectiveness, such s resturnts deciding to discontinue offering smller-sized kids mels (s Tco Bell did in 2013 29 ) or offering free dessert in plce of kids mel toy (s did some Burger King resturnts in this nlysis). The findings in this report suggest tht both voluntry industry nd government-initited policies to promote helthier kids mel options t fst-food resturnts could positively impct children s diets nd helth. However, ll policies must be monitored for successful implementtion. 18
REFERENCES: 1 Powell L, Nguyen BT, Hn E (2012). Energy intke from resturnts: Demogrphic nd socioeconomics, 2003-2008. Americn Journl of Preventive Medicine, 43(5), 498-504. 2 Powell LM, Nguyen BT (2013). Fst-food nd full-service resturnt consumption mong children nd dolescents: Effect on energy, beverge nd nutrient intke. JAMA Peditrics, 167(1), 14-20. 3 Deierlein AL, Pet K, Cludio L (2015). Comprison of the nutrient content of children s menu items t US resturnt chins, 2010 2014. Nutrition Journl, 14(1), 1-7. 4 Quder Z, Gillespie C, Sliw SA, et l. (2017). Sodium intke mong U.S. school-ged children: Ntionl Helth nd Nutrition Exmintion Survey, 2011-2012. Journl of the Acdemy of Nutrition nd Dietetics, 117(1), 36-47. 5 Cntor J, Breck A, Elbel B (2016). Correltes of sugr-sweetened beverges purchsed for children t fst-food resturnts. Americn Journl of Public Helth, 106(11), 2038-2041. 6 Kumnyik SK, Grier S (2006). Trgeting interventions for ethnic minority nd low-income popultions. The Future of Children, 16(1), 187-207. 7 Powell & Nguyen (2013). 8 Fleischhcker SE, Evenson KR, Rodriguez DA, Ammermn AS (2011). A systemtic review of food ccess studies. Obesity Reviews, 12(5), e460-e471. 9 Deierlein et l. (2015). 10 Hrris JL, Schwrtz MB, Munsell C, et l. (2013). Fst Food FACTS 2013: Mesuring progress in nutrition nd mrketing to children nd teens. www.fstfoodmrketing.org. 11 Morn AJ, Block JP, Goshev SG, Bleich SN, Roberto CA (2017). Trends in nutrient content of children s menu items in U.S. chin resturnts. Americn Journl of Preventive Medicine, in press. 12 McDonld s-allince prtnership (2014). Executive Summry. 2014 Progress report. corporte.mcdonlds. com/content/dm/aboutmcdonlds/ 2.0/pdfs/McDonlds_Allince_ Prtnership_on_CGI_Commitment_ Executive_Summry.pdf 13 Horovitz B (Mrch 9, 2015). Burger King drops soft drinks from kids mels. USA TODAY. www.ustody. com/story/money/2015/03/09/burgerking-fst-food-resturnts-soft-drinksbeverges/24661959/ 14 Morrn C (Jnury, 15 2015) Wendy s Dropping Sod From Kids Mels. Consumerist. consumerist.com/2015/01/ 15/wendys-reportedly-droppingsod-from-kids-mels/ 15 Americn Diry Queen Corportion (My 11, 2015). f118515d0e792f78-c27fdbe952dfc357fe25ebf5c8897ee.ssl. cf5.rckcdn.com/1927/dqresponse-5-11.pdf 16 Hrris JL, Schwrtz MB, Brownell KD, et l. (2010). Fst Food FACTS: Evluting fst food nutrition nd mrketing to youth. www.fstfoodmrketing.org. 17 Subwy (2014). Subwy Resturnts Answers First Ldy Michelle Obm s Cll to Mrket Helthier Choices to Kids [Press relese]. www.subwy.com/ PressReleses/PHA.pdf 18 ibid 19 Brndu M (Mrch 28, 2013). KFC introduces kids mels. Ntion s Resturnt News. www.nrn.com/ ltest-hedlines/kfc-introduceskids-mels 20 McDonld s-allince prtnership (2014). 21 Horovitz (2015). 22 Morrn (2015). 23 Subwy (2014). Subwy Resturnts Answers First Ldy Michelle Obm s Cll to Mrket Helthier Choices to Kids [Press relese]. Retrieved from http://www.subwy.com/pressreleses/ PHA.pdf 24 Americn Diry Queen Corportion. (2015). 25 Brndu (2013). 26 Ntionl Resturnt Assocition (Mrch 3,2014). http://www. resturnt.org/downlods/pdfs/ dvoccy/201403_dgc_nr_ comments_industryprogress 27 McDonld s-allince prtnership (2014). 28 Public Helth Advoctes (2016). City of Stockton psses second in ntion helthy-by-defult kids beverge ordinnce. www.public helthdvoccy.org/2016/06/pressrelese-city-stockton-psses-secondntion-helthy-defult-kids-bevergeordinnce/ 29 Tuttle B (July 25, 2013). The rel reson Tco Bell killed kids mels. Time. business.time.com/2013/07/25/therel-reson-tco-bell-killed-kids-mels/ 19
Methods Utilizing the sme methods s previous Rudd Center reserch on fst food kids mels conducted in 2010 nd 2013, 1 we mesured chnges over time for the four lrgest fst-food resturnts pledging to offer helthier drinks with their kids mels: McDonld s, Burger King, Wendy s, nd Subwy. We supplemented these nlyses with dditionl exmintions of Diry Queen nd KFC, which lso now offer helthier sides nd/or beverges with their kids mels. Kids mel menu listings online We identified ll items vilble on kids mels from the resturnts in our nlysis s indicted on resturnt websites s of Mrch to April 2016. All items were coded s min dish, drink, side item, or other. Reserchers lso obtined nutrition informtion for ech kids mel item listed, including serving size (g), clories (kcl), ft (g), sturted ft (g), sugr (g), sodium (mg), fiber (g), nd protein (g). Reserchers clled compnies customer service helplines when nutrition nd/ or serving size ws not provided online. One resturnt (Wendy s) did not provide serving size in grms, so reserchers purchsed kids mel items t locl resturnt to determine serving size. We designted ll sugr-sweetened sod nd other fountin drinks, diet sod, fried vegetbles, nd desserts s unhelthy options. We lso identified side nd drink items tht resturnts designted s helthier choices, including wter, plin nd flvored milk, nd fruits. However, it should be noted tht not ll nutrition professionls gree tht some of these options -- such s 100% juice, flvored milk, nd Cpri Sun Rorin Wters (which contins dded sugr nd non-nutritive sweetener) -- re nutritious options for children. In ddition, we used nutrient profiling model (NPI score) to evlute the nutrition of KFC s side items, which included number of different non-fried vegetble options but tht the resturnt did not specificlly indicte were helthy options. A detiled nlysis of the model nd its dvntges is vilble in the previous Rudd Center Fst Food FACTS report. 2 According to the model, foods with n NPI score of 64 or higher qulify s helthy food nd KFC side items with n NPI score of 64 or higher were designted s helthier options in this nlysis. Menu bords nd signs t individul resturnts nd items offered with kids mel orders To evlute the menu bords nd signs t individul resturnts nd the items offered with kids mel orders, we conducted two nlyses. We mesured the number nd proportion of helthier versus unhelthy drinks nd sides fetured with kids mels on menu bords nd signs in resturnts. We lso conducted n udit of the drinks nd sides offered by resturnt personnel when kids mels were ordered. This nlysis identified the proportion of kids mel orders tht received helthy drink utomticlly, were offered t lest one helthy option, or were not offered ny helthy options. Helthy side offerings were ssessed similrly. Outcomes were compred cross resturnt chins nd to 2013 outcomes for McDonld s, Burger King, Wendy s, nd Subwy. 20
We collected these dt using two ntionl mrket reserch firms specilizing in this type of reserch. At McDonld s, Burger King, Wendy s, nd Subwy, we utilized Test Trck, the sme firm tht conducted the reserch in 2010 nd 2013. The firm mintins ntionwide network of trined, experienced field personnel in mjor metropolitn res. To exmine kids mel mrketing t KFC nd Diry Queen resturnts, we crowdsourced dt collection through Field Agent, firm specilizing in retil reserch conducted through ntionwide network of smrtphone users in mjor metropolitn res. Users downlod the Field Agent pp nd re ble to select projects bsed on their geogrphic loction nd bility to execute the tsk. Both firms mintin comprehensive qulity control progrm to ensure the collection of ccurte dt, which includes spot checking the originl dt nd clcultions, nd resturnt rechecks when necessry. As in 2010 nd 2013, we evluted kids mel signs nd menu bords in representtive smple of 400 fst-food resturnts in 20 mrkets cross the United Sttes, including 100 different loctions for McDonld s, Burger King, Wendy s, nd Subwy. Dt were collected from Mondy through Fridy during the week of April 25, 2016. Kids mel order udits were conducted t one-hlf of the sme resturnts (50 resturnts per chin). Kids mel order udits were lso conducted t 18 KFC nd Diry Queen loctions ech from July 1 to July 10, 2016. Kids mel menu bords nd signs To identify helthy kids mel drinks nd sides fetured on menu bords nd signs inside the resturnt, field personnel received detiled field forms customized by resturnt tht listed 20 kids mel menu items, including ll helthier drinks nd sides, compiled from the resturnts online menus. The form included spce to write in ny individul menu items tht were not listed on the field form. Field personnel recorded ll menu items listed on the kids mel section of the menu bord, ll menu items pictured on the kids mel section of the menu bord, nd ll menu items pictured on signs inside or outside the resturnt tht mentioned the kids mel. Kids mel menu signs were identified in three res of the resturnt: 1) ordering/counter re, which included ll res in front of, round nd behind the counter inside the resturnt, s well s ll signs in direct view of customers stnding in line; 2) ll other indoor res, which included ll other res inside the loction other thn the ordering/counter re; nd 3) outdoor res, which included the prking lot, min mrquee sign, roof, ground nd ny signs posted in the resturnt windows fcing the outside, but excluded the drive-thru re. Audit of kids mel orders Field personnel plced orders for predetermined kids mel without specifying desired side or beverge. They followed detiled script nd used the sme dt collection methods nd forms used in 2010 nd 2013. Forms did not differ by resturnt, with the exception of the type of kids mel ordered. Similr kids mels were ordered t ll resturnts: hmburger kids mel t McDonld s, Burger King, nd Wendy s; rost beef mini for kids t Subwy; chicken little kids mel t KFC; nd cheeseburger kids mel t Diry Queen. If the employee sked whether the customer wnted prticulr side(s) or drink(s) (e.g., Would you like fries or onion rings 21