Results confirm that American children are consuming food from restaurants frequently and provide new evidence that the majority report non-negative attitudes about receiving FV side dishes with kids' meals. An analysis of online menus from leading QSR and FSR showed that nearly all were offering FV side dishes in April 2013. Yet these options were typically offered alongside energy-dense options, like French fries, and only a minority of restaurants offered a FV item as the default side dish. These results reflect recent efforts to improve children’s menus but also illustrate that more can be done to shift norms around "children's food" and encourage healthy eating in restaurant contexts.
While the current results suggest that many children would accept FV side dishes, they also highlight that tailored strategies may be warranted to promote FV acceptance in certain subgroups: namely, boys, children eating at restaurants less frequently, and children eating take-out more frequently. Findings that these subgroups were less likely to endorse FV side dishes could be used to shape strategies to encourage increased acceptance of these foods, such as incorporating children from these demographics into advertisements and public service announcements promoting FV. In some ways, these subgroup differences are good news: for example, the relationship between a higher frequency of eating at restaurants and increased likelihood of accepting FV side dishes is promising in terms of the potential public health impact of adding more healthy options. It is important to acknowledge that results were in the opposite direction when investigating the frequency of eating take-out; more research is needed to explore relationships between these two modalities of consuming restaurant-prepared food, demographics, food preferences, and intake. Eating food from restaurants may be perceived as a special occasion [36, 37], so nutrition may not be a main concern of families in these contexts; yet, this view may not be warranted when children consume restaurant foods frequently. The results linking higher frequency of eating take-out with a lower likelihood of selecting healthy options highlights the possibility that a reframing of our view of take-out foods in particular may be warranted. Findings also showed that, while younger children were more likely to accept French fries, they were also more likely to accept fruit, possibly demonstrating a cohort effect where younger children have become accustomed to recent menu changes incorporating fruits as side dishes.
The open-ended portion of the current results provides additional insights into children’s attitudes about substituting FV side dishes in place of French fries. Consistent with past research, taste emerged as a key factor influencing children's food preferences [32, 33, 38]; this was true for both children who would be happy and those who would be unhappy about the substitution. For the former group, this meant that children would be happy because they like or prefer vegetables or fruits, and for the latter, this meant that children would be unhappy because they like or prefer French fries. While liking/taste was a popular reason overall, younger children were more likely than teens to discuss liking or taste in their open-ended response. Together, these findings suggest that emphasizing flavor may be an effective means of increasing children’s consumption of FV side dishes, particularly among younger children. Besides liking/taste, another factor that emerged as a common reason that children would be happy about FV side dishes was health, and this reason was more common among teens than tweens. Yet we argue that taste remains the most important factor, given its prevalence among both the happy and unhappy children, its increased importance in the younger children who were more likely to order kids' meals, and evidence showing that short-term rewards like taste often outweigh long-term rewards like health in decision making, particularly in those who find palatable foods to be highly reinforcing . Still, it is encouraging to find that health concerns resonate with some children in the context of the childhood obesity epidemic.
Children's perceptions about healthier side dish options can inform action during a time in which it is important to encourage improvements to children's dietary intake in restaurant settings. Our analysis of menus at leading QSR and FSR showed that there has been some progress in this area since earlier assessments ; for example, FV side dishes were available at nearly all restaurants in April 2013. However, these were the default side dish at the minority of restaurants in both restaurant segments. Fruits or vegetables were more likely to be default side dishes at QSR than FSR, but there was a smaller variety of FV offerings at QSR, with a notable dearth of vegetable offerings, such that only one QSR studied offered any non-fried vegetable side dishes. Additionally, even though the majority of children expressed non-negative attitudes about FV side dishes, more than 85% of children reported that they would be likely to order French fries as a side dish, suggesting that promoting healthier side dishes necessitates strategies that go beyond simply offering a FV option in direct competition with palatable, energy-dense alternatives. Given children’s focus on taste and their past experiences with these energy-dense options, simply making FV sides available is unlikely to maximize the ordering and consumption of these options.
Instead, one potential way to promote the consumption of FV side dishes is repeatedly exposing children to FV when they order food from restaurants, by making FV default side dishes that automatically come with their meal. This strategy may be particularly important for younger children, who were more likely to order from children's menus, were more likely to endorse French fries, and for whom there is evidence that taste preferences are modifiable through strategies like repeated exposure . Increased adoption of this strategy could shift perceived norms around restaurant meals and children's food. It could also be particularly important for increasing acceptance and consumption of vegetables, given that children's intake of vegetables is further from dietary recommendations compared to fruits , and given the dearth of default vegetable offerings on children's menus.
Our analysis of nutrition information shows that FV defaults have the potential to lower the energy density of children's meals. Substituting commonly offered FV side dishes for French fries could achieve average reductions of 171 to 300 calories per meal. This change, aggregated over repeat visits, could have a measurable impact on energy balance. We also noted variability in energy content across FV items and within the same type of item across restaurants. For example, the energy content of apple slices depended on portion size and whether they were served alone, with a dipping sauce, or baked with other ingredients (range: 15–270 calories). Similarly, given different portion sizes across establishments, the energy in a child’s serving of French fries could quadruple from one restaurant to the next, ranging from 100 to 440 calories, the latter of which contributes the amount of energy appropriate for an entire meal for a sedentary 8-year-old child . These estimations suggest that incorporating healthier side dish options, particularly those of a moderate portion size that are not prepared with added energy-dense ingredients, and encouraging children to consume them, by making them the only option, the default option, or the most attractive option, could have a measurable impact on intake.
In estimating the potential energy reductions afforded by FV default sides, there are two important caveats to note. First, previous research has demonstrated that energy content information from restaurants is accurate on average, but that there are discrepancies between stated and actual energy content on some types of menu items. It has been shown that, in FSRs, energy content was understated for higher-energy items and overstated for lower-energy items . Thus, for some restaurants in our sample, it is possible that the estimated energy reductions when substituting FV for French fries may be overstated. Additionally, it is important to note that substituting FV for French fries will result in an actual, net decrease in energy intake only if patrons do not compensate for the energy reductions through other meal components. The actual impact of such substitutions on children's consumption has yet to be determined, and current evidence supports competing hypotheses. On one hand, experimental research on energy density suggests that children consume a consistent weight of food, and thus, it follows that substituting less energy-dense foods for more energy-dense foods should decrease total energy intake [43, 44]. On the other hand, it could be argued that substituting FV for French fries is a more salient shift than those represented by the conditions in energy density experiments, and perceiving side dishes as healthy may lead to overeating : for example, the child and/or parent may choose to order an energy-dense dessert or sugar-sweetened beverage to accompany a "healthier" kid's meal. Future research should use objective methods to explore the extent to which the incorporation of FV side dishes impacts the energy consumed by children within a meal and throughout the day.
Limitations of the current study include potential social desirability in children’s reports, which could result in a discrepancy between what was reported and children’s actual behaviors and preferences. Lower reported frequencies of eating food from restaurants, compared to other national data , suggest that this may have occurred, although it is also possible that these differences emerged for reasons besides social desirability. While the use of sampling weights make results generalizable to US children ages 8 to 18 years based on demographics, it is possible that representativeness in terms of restaurant patronage was not achieved, which would affect the generalizability of the current results. Alternatively, it is possible that the discrepancy is due to methodological differences or historical trends. It is not possible to parse these possibilities apart in the current study. Another limitation is the lack of a priori measurement work on the survey, although results provide initial evidence of reliability and validity of survey questions. Finally, publically available menus and nutrition information may not fully reflect children's experiences in restaurant settings. As mentioned, stated energy content does not always match actual energy content . Further, the depiction of side dishes on online menus may not reflect the meal pairings that are most salient to children via advertisements or sensory experiences in restaurants. Additional research using a mixture of methodologies can contribute to a comprehensive picture of children's current experiences in restaurants, including how their attitudes and experiences translate into behaviors and consumption patterns.
Making FV side dishes more prevalent and automatic and evaluating the impact of such changes could increase the momentum following initial, positive changes that restaurants have made in recent years . There is evidence to suggest that a focus on healthier children's meals has the potential to be well-received and economically sustainable , highlighting the potential value of such shifts from the restaurant perspective. While the focus of this study was on side dishes, this is only one aspect of the energy consumed in restaurants and only one part of the overall secular trend toward healthier menus for children. In order to accelerate progress in this area, a comprehensive consideration of all aspects of restaurant meals is warranted. Other meal components that could contribute excess energy include, but are not limited to, sugar-sweetened beverages, desserts, and main dishes . Additionally, while some older children reported ordering kids' meals, this was more likely in the younger age group. This finding suggests that efforts to impact energy intake in restaurants across child age groups necessitates a consideration of the overall menu, which could have a positive impact on the family more broadly. The age group differences found in this study also suggest that subsequent research may benefit from a more in-depth consideration of issues impacting younger vs. older children, including their engagement with "adult" menu items, the role of price and financial independence, and developmental changes in attitudes about restaurant foods.