Eating healthier in the US restaurants

Working with restaurant managers and owners to improve children’s menus: A Best Food for Families, Infants, and Toddlers (Best Food FITS) intervention

Improving food consumed away from home may help combat child obesity

Approximately 32% of US children ages 2-19 are overweight or obese1. In some communities, the obesity rate is even higher. For example, in San Marcos, a city located in South Central Texas, approximately 52% of children in fifth, seventh and ninth grades are overweight or obese2. Meals consumed away from home may contribute to childhood obesity, as they often include sugar-sweetened beverages, and lack the lower-calorie, nutrient-rich fruit and vegetables found more frequently in home-cooked meals3. While some interventions have attempted to improve restaurant menus, when we began this study in 2010, none had targeted children’s menus. The goal of our study was to seek voluntary assistance of restaurant managers and owners in San Marcos, Texas, to improve children’s menus by removing sugar-sweetened beverages, adding fruit and vegetables, and replacing at least some energy dense entrées. In particular, replacing sugar-sweetened beverages with water may be a promising strategy to reduce obesity risk4.

Creating our brand – Best Food FITS

The original study described in this summary was published in 2014 in Preventing Chronic Disease. We began this study by creating a community coalition dedicated to combatting childhood obesity. We leveraged grant funds from the Texas Department of State Health Services Nutrition, Physical Activity, and Obesity Prevention Program to develop and brand Best Food for Families, Infants, and Toddlers (Best Food FITS). In collaboration with the university marketing department, we created a logo and vegetable characters designed to be attractive to children, which we eventually included on t-shirts, menus, bumper stickers and other promotional items. The Best Food FITS logo and a popular graphic, “Broccolicious,” are shown in the Figure.

Approaching restaurants

All aspects of this study were approved by the university Institutional Review Board. We began this intervention by first reviewing a list of establishments that marketed prepared food items from the city’s environmental health department. After eliminating establishments that did not cater to children, including such places as bars and coffee shops, we had a list of 135 restaurants. We collected children’s menus from the 85 restaurants that had them, and then classified menu items such as entrées, fruit, vegetables, other sides, desserts and beverages according to healthfulness, as determined independently by three Registered Dietitians. For example, macaroni and cheese was considered to be an unhealthful side, whereas pinto beans were deemed healthful. We found that all children’s menus in San Marcos included sugar-sweetened beverages, with an average of three unhealthful entrées per menu.
We called or visited the remaining restaurants, attempting to schedule brief meetings with owners or managers; 65 of those were chain restaurants, and declined to participate citing corporate policy. During meetings with owners or managers from the remaining 70 restaurants, we described our project, educated about child obesity, and asked them to modify their menus. Seven agreed to create new children’s menus and ten agreed to revise their menus.

New menus

Teams of two graduate or undergraduate student researchers per restaurant worked iteratively with the 17 restaurant owners or managers who agreed to change menus. Our strategy was to create new menu offerings based on foods already included somewhere on existing menus. For example, in Mexican food restaurants we included avocado, tomato, and lettuce on the children’s menus. This allowed us to create menu items at no cost to the restaurant. Menus were originally created in PowerPoint, and then changed by the research team after consulting with owners or managers until they agreed on a final menu. The new menus were free of sugar-sweetened beverages, a criterion for participation, and offered more fruit and vegetables and fewer unhealthful entrées than did the children’s menus present in the community prior to this study.

Lessons learned

At the onset of this project, we had no idea whether and to what extent restaurant owners and managers would agree to work with us to improve menus. While many were too busy to participate in the project, we found that those who agreed to collaborate were enthusiastic about changing menus and concerned about the health of children in the community. We learned that it was important to be persistent in contacting these busy professionals, and respectful of their time. By the end of the project, there were friendships between the research teams and their restaurant partners.


While we did not quantitatively assess whether patrons purchased items from the new children’s menus, we did administer patron surveys 2-4 years after the menus were in place. We found that about half of the respondents had noticed the healthful menu items and reported that nutrition was an important factor when choosing foods for their children. At present, we do not know if having new menus in the community has had any effect on dietary intake of the community’s children. However, a recent study revealing that mothers use nutrition information on menus to choose healthier entrées for their children serves as a beacon of hope5.

Based on: Crixell S. H., Friedman B., Fisher D. T., Biediger-Friedman L. (2014), Improving children’s menus in community restaurants: Best Food for Families, Infants, and Toddlers (Best Food FITS) intervention, South Central Texas, 2010-2014. Prev Chronic Dis., 11:140361.

  1. Ogden C. L., Carroll M. D., Kit B. K., Flegal K. M. (2014), Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 311(8):806–14.
  2. Mapping FITNESSGRAM. fitnessgram. Accessed July 31, 2014.
  3. Batada A., Bruening M., Marchlewicz E. H., Story M., Wootan M. G. (2012), Poor nutrition on the menu: children’s meals at America’s top chain restaurants. Child Obes. 8:251–4.
  4. Muckelbauer R., Gortmaker S.L., Libuda L., Kersting M., Clausen K, Adelberger B., Müller-Nordhorn J. (2016), Changes in water and sugar-containing beverage consumption and body weight outcomes in children. Br J Nutr. 115:2057-66.
  5. Domoff S. E., Kiefner-Burmeister A., Hoffmann D.A., Musher-Eizenman D. (2015), Maternal feeding goals and restaurant menu choices for young children. Child Obes. 11:484-8.