Evaluating Fast Food Nutrition and Marketing to Youth Jennifer L. Harris, Ph. D. , M. B. A. Marlene B. Schwartz, Ph. D. Kelly D. Brownell, Ph. D. Fast Food FACTS: Evaluating Fast Food Nutrition and Marketing to Youth Authors: Jennifer L. Harris, PhD, MBA Marlene B. Schwartz, PhD Kelly D. Brownell, PhD Vishnudas Sarda, MBBS, MPH Amy Ustjanauskas Johanna Javadizadeh, MBA Megan Weinberg, MA Christina Munsell, MS Sarah Speers Eliana Bukofzer, MPH Andrew Cheyne, MA Priscilla Gonzalez Jenia Reshetnyak, MS Henry Agnew Punam Ohri-Vachaspati, PhD Rudd Center for Food Policy and Obesity November, 2010 Revised December 3, 2010

Acknowledgements We would like to thank the following people for their valuable assistance in collecting data: Kelly Barrett Hannah Byrnes-Enoch, MPH Casey Carden Ashley Firth, MA Jay Imus Sharon Kirkpatrick, PhD, MHSc Sue Krebs-Smith, PhD, MPH, RD Carly Litzenberger Julie McComish Catherine Montgomery Kathryn O’Shaughnessy Doug Ranshaus Warren Sethachutkul Hannah Sheehy Kate Stearns Jill Reedy, PhD, MPH, RD Jackie Thompson Shannon Vargo Catherine Wright We would also like to thank our steering committee and other advisors: Frank Chaloupka, PhD William H.

Dietz, MD, PhD Lori Dorfman, DrPH Steve Fajen Corinna Hawkes, PhD Shiriki Kumanyika, PhD, MPH Tim Lobstein, PhD Susan T. Mayne, PhD C. Tracy Orleans, PhD Lisa M. Powell, PhD Amelie Ramirez, DrPH Mike Rayner, PhD Mary Story, PhD, RD Stephen Teret, JD, MPH Ellen Wartella, PhD James G. Webster, PhD Jerome D. Williams, PhD Thank you to our colleagues at the Rudd Center, especially Rebecca Oren, Andrea Wilson, Megan Orciari and Tricia Wynne. We thank Cavich Creative, LLC, Chris Lenz, and Marian Uhlman for their assistance in preparing the manuscript and website.

Finally, we thank the leadership and staff at the Robert Wood Johnson Foundation, with special thanks to the Childhood Obesity Team. Support for this project was provided by grants from the Robert Wood Johnson Foundation and the Rudd Foundation. Table of Contents List of Tables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Ranking Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Fast food menus and nutritional quality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Marketing practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Marketing outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Overview of fast food market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Fast food menu composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Menu items and special menus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Nutritional quality of all menu items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Dollar/value menus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Healthy menus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Kids’ meals nutritional quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Best and worst kids’ meal choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Traditional media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Advertising spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 TV advertising exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Content analysis of TV advertisements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Ethnic and racial targeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Internet and other digital media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Restaurant websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Banner advertising on third-party websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Social media marketing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Mobile marketing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Marketing inside restaurants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Restaurant signs audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Pricing analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Sales practices audit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Marketing outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Restaurant visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Special menus and menu items purchased . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Ranking Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 A. Fast food menu composition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 B. Traditional media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 C.

Internet and other digital media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 D. Marketing inside restaurants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 E. Marketing outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Fast Food FACTS iii List of Tables Table 1: Maximum acceptable calories and sodium for kids’ meals and individual menu items . . . . . . . . . . . . . . . . 20 Table 2: Sales of top 20 fast food restaurants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Table 3: Number of menu items per restaurant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Table 4: Special menus by restaurant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Table 5: Nutrient content of menu items by food category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Table 6: Nutrient content of menu items by restaurant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Table 7: Changes in sizes of soft drinks and french fries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Table 8: Number of menu items available on dollar/value menus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Table 9: Nutrient content of menu items available on dollar/value menus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Table 10: Number of menu items available on healthy menus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Table 11: Nutrient content of menu items available on healthy menus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Table 12: Number of menu items and combinations available for kids’ meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Table 13: Summary nutritional quality information for kids’ meal combinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Table 14: Total advertising spending by fast food restaurants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Table 15: Fast food restaurant TV advertising exposure for youth: Ads viewed in 2008 and 2009 . . . . . . . . . . . . . . . .52 Table 16: Fast food restaurant TV advertising exposure for adults: Ads viewed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Table 17: Change in TV advertising exposure from 2008 to 2009 by restaurant and age group . . . . . . . . . . . . . . . . . 54 Table 18: Youth exposure to TV advertising in 2009 by product category and age group . . . . . . . . . . . . . . . . . . . . . . 55 Table 19: Product categories by restaurant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Table 20: Restaurants and product categories targeted to children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Table 21: Restaurants and product categories targeted to teens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Table 22: African American youth exposure to fast food advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Table 23: Restaurants and product categories targeted to African American children and teens . . . . . . . . . . . . . . . . 64 Table 24: Hispanic youth exposure to fast food advertising on Spanish-language TV . . . . . . . . . . . . . . . . . . . . . . . . . 65 Table 25: Restaurants and product categories advertised on Spanish-language TV. . . . . . . . . . . . . . . . . . . . . . . . . . 66 Table 26: Three most frequently advertised menu items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Table 27: Total nutrient content of items in TV ads viewed by youth every day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Table 28: Nutrient content of menu items advertised on TV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Table 29: Nutrient content of fast food products presented daily in TV ads viewed by African American and white youth on English-language TV and Hispanic youth on Spanish-language TV . . . . . . . . . . . . . . . . . . . . . . . . 70 Table 30: Child-targeted websites ranked by level of engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Table 31: Main restaurant websites ranked by level of engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Table 32: Average monthly exposure to child-targeted websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Table 33: Average monthly exposure to main restaurant websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Table 34: Websites with a disproportionate number of African American youth visitors in 2009 . . . . . . . . . . . . . . . . . . 81 Table 35: Banner advertising exposure by restaurant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Fast Food FACTS iv Table 36: Exposure to child-targeted banner ads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Table 37: Banner ads with a high proportion of ads viewed on youth websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Table 38: Exposure to racial- and ethnic-targeted banner ads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Table 39: Facebook pages and fans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Table 40: Restaurant Twitter accounts and followers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Table 41: Specific menu items mentioned in Twitter accounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Table 42: Restaurant YouTube channels, viewers, and videos posted in 2009. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 Table 43: Ten mobile websites with the most frequent placement of restaurant banner ads . . . . . . . . . . . . . . . . . . . . 97 Table 44: Mobile banner ad placements by restaurant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97 Table 45: Top five monthly ad placements as measured by ad index for each restaurant . . . . . . . . . . . . . . . . . . . . . . 98 Table 46: Smartphone application functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Table 47: iPhone application demographic profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Table 48: Average number of featured menu items per restaurant by location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Table 49: Number of menu type signs per restaurant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Table 50: The percentage of menu item signs with theme and promotion messages . . . . . . . . . . . . . . . . . . . . . . . . 106 Table 51: Percentage of featured menu items on signs for each special menu and food category by restaurant. . . . 107 Table 52: Special menu and food category items featured on signs in different store locations . . . . . . . . . . . . . . . . 107 Table 53: NPI score, and weighted average calories and sodium content of menu items featured in signs at each restaurant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Table 54: The three menu items featured most frequently on signs at each restaurant . . . . . . . . . . . . . . . . . . . . . . . 109 Table 55: NPI score and weighted average calories and sodium content of menu items featured on restaurant signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Table 56: Menu items that appeared on signs with price promotions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Table 57: Average price, calories, and NPI scores for healthiest and less healthy options at restaurants. . . . . . . . . . . 111 Table 58: Restaurants with child-targeted marketing in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Ranking Tables 1: Nutritional quality of food item categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 2: Nutritional quality of beverage categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 3: Nutritional quality of kids’ meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 4: Advertising spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 5: Television advertising exposure to children by product category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 6: Television advertising exposure to teens by product category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 7: Television advertising exposure to African American and Hispanic youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 8: Radio advertising exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 9: Restaurant website exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 10: Banner advertising exposure by product. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 11: Social media exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 12: Restaurant signs and nutritional quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Fast Food FACTS v Appendix Tables A1: Adjustments to restaurant menus for menu standardization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 A2: Kids’ meal menu items and their nutrient information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 B1: Exposure data by demographic group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 B2: Content analysis of general audience TV ads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 B3: Content analysis of child-targeted TV ads. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 B4: Content analysis of Spanish-language TV ads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 B5: Nutritional quality of TV ads by age and race or ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189 C1: Content analysis of child-targeted websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 C2: Content analysis of main restaurant websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196 C3: Content analysis of banner ads on third-party websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 D1: Average number of featured items on signs by special menu and food category . . . . . . . . . . . . . . . . . . . . . . . . 200 D2: Individual menu item pricing analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 E1: Menu importance for all quickserve restaurants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 E2: Average calories and sodium per visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 List of Figures Figure 1: Spending by fast food restaurants on marketing directly targeted to children and adolescents . . . . . . . . . . 13 Figure 2: Model of fast food marketing components, strategies, and outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Figure 3: Proportion of menu items offered by food category for the twelve restaurants in our analysis . . . . . . . . . . . 37 Figure 4: Percentage of menu items by food category that met minimum NPI score, maximum calorie and sodium limits, and all three nutrition criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Figure 5: Percentage of menu items by restaurant that met minimum NPI, maximum calorie and sodium limits, and all three nutrition criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Figure 6: Soft drink sizes by restaurant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Figure 7: French fries sizes by restaurant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Figure 8: Proportion of dollar/value menu items offered by food category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Figure 9: Percentage of dollar/value menu items that met minimum NPI score, maximum calorie and sodium limits, and all three nutrition criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Figure 10: Proportion of healthy menu items offered by menu category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Figure 11: Percentage of healthy menu items that met minimum NPI score, maximum calorie and sodium limits, and all three nutrition criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Figure 12: Proportion of kids’ meal combinations that met maximum calories and sodium and all nutrition criteria for elementary and preschool-age children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Figure 13: Advertising spending in 2008 and 2009 by restaurant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Figure 14: Youth TV advertising exposure by restaurant in 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Figure 15: Increase in average annual advertising exposure by age group: 2003 to 2009 . . . . . . . . . . . . . . . . . . . . . 54 Figure 16: Composition of advertising exposure in 2009 by product category and age group . . . . . . . . . . . . . . . . . 56 Figure 17: Messages in general audience TV advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Fast Food FACTS vi Figure 18: Messages in child-targeted TV advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Figure 19: Messages in Spanish-language TV advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Figure 20: Calories viewed daily in fast food TV ads by age group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Figure 21: Calories viewed daily in fast food TV ads by age and race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Figure 22: Engagement techniques and featured third parties on child-targeted websites. . . . . . . . . . . . . . . . . . . . . . 73 Figure 23: Products and health messages promoted on child-targeted websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Figure 24: Most common products, selling points and messages appearing on main restaurant websites . . . . . . . . . 77 Figure 25: Engagement techniques and featured third parties on main restaurant websites. . . . . . . . . . . . . . . . . . . . 78 Figure 26: Products and nutrition promoted on main restaurant websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Figure 27: Product types featured in internet banner ads. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Figure 28: Selling points featured in internet banner ads . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83 Figure 29: Banner ads with specific engagement techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Figure 30: Frequency of posts and number of tabs on restaurant Facebook pages . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Figure 31: Facebook wall posts with outbound links to other internet pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Figure 32: Average number of videos and photo albums on Facebook pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Figure 33: Wall posts that mentioned specific products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Figure 34: Examples of customer service-oriented tweets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Figure 35: Examples of restaurant tweets with outbound links . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Figure 36: Examples of Twitter contests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Figure 37: Challenges issued in Wendy’s “Hunt for the Biggest Bacon Lover” contest . . . . . . . . . . . . . . . . . . . . . . . . . 93 Figure 38: Main products and messages in 2009 YouTube videos. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Figure 39: Restaurants with banner advertising on mobile websites by month in 2009 . . . . . . . . . . . . . . . . . . . . . . . . 96 Figure 40: Types of mobile websites on which restaurant banner ads appeared in 2009 . . . . . . . . . . . . . . . . . . . . . . . 97 Figure 41: Selling points and main products on mobile banner ads. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Figure 42: Social media footprint. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Figure 43: Location of signs at restaurants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Figure 44: Messages and promotions on menu item signs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Figure 45: Proportion of featured menu items on signs by special menu and food category . . . . . . . . . . . . . . . . . . 106 Figure 46: How sides were offered in kids’ meal orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Figure 47: Sides received with kids’ meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Figure 48: How beverages were offered in kids’ meal orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Figure 49: Beverages received with kids’ meal orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Figure 50: How sides were offered with combo meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Figure 51: Size of combo meals received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Figure 52: Cheese modifications in fast food orders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Figure 53: How often parents reported taking their children to the twelve fast food restaurants . . . . . . . . . . . . . . . . . 116 Figure 54: How often parents reported that their child asked to go to the twelve fast food restaurants. . . . . . . . . . . . 117

Fast Food FACTS vii Figure 55: Parents reporting visits to fast food restaurants a few time per month or more often: Restaurants with differences by race and ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Figure 56: Parents reporting that their child requested to go to fast food restaurants a few times per month or more: Restaurants with differences by race and ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Figure 57: Main reason that parents chose to go to fast food restaurants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Figure 58: All fast food restaurant visits by time of day for children and teens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Figure 59: Percentage of all fast food restaurant visits by place of consumption and ordering method for children and teens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Figure 60: Parents’ orders for their child by menu type, restaurant, and age of child . . . . . . . . . . . . . . . . . . . . . . . . . 21 Figure 61: Main reason parents reported choosing a kids’ meal for their child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Figure 62: Purchases from special menus by youth at all fast food and burger restaurants . . . . . . . . . . . . . . . . . . . . 122 Figure 63: Side dishes ordered with kids’ meals by restaurant and age of child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Figure 64: Beverages ordered with kids’ meals by restaurant and age of child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Figure 65: Beverages ordered with kids’ meals by race and ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Figure 66: Percentage of beverages ordered by size at all fast food restaurants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Figure 67: Percentage of french fries ordered by size at burger restaurants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Figure 68: Menu importance of food and beverage categories by age group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Figure 69: Menu importance of main dish items by age group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Figure 70: Menu importance of beverages by age group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Figure 71: Menu importance of food categories purchased by white, Hispanic, and African American youth (under 18 years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Figure 72: Menu importance of main dishes purchased by white, Hispanic, and African American youth (under 18 years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Figure 73: Menu importance of beverages purchased by white, Hispanic, and African American youth (under 18 years) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Figure 74: Excess calories in menu items purchased per visit by restaurant and age group . . . . . . . . . . . . . . . . . . . 128 Figure 75: Excess sodium in menu items purchased per visit by restaurant and age group . . . . . . . . . . . . . . . . . . . 129 Figure 76: Excess calories in menu items purchased per visit by restaurant and race/ethnicity . . . . . . . . . . . . . . . . . 129 Figure 77: Excess sodium in menu items purchased per visit by restaurant and age/ethnicity . . . . . . . . . . . . . . . . . . 130 Fast Food FACTS viii Executive Summary Why fast food? The research is clear. Eating fast food harms young people’s health. Children and adolescents who eat fast food consume more calories, fat, sugar, and sugar-sweetened beverages – and less fiber, milk, fruit, and vegetables – than peers who do not. 1-4 If they ate fast food only occasionally, this would not be problematic.

But every day, one-third of American children and adolescents eat fast food,5 and fast food contributes 16% to 17% of adolescents’ total caloric intake. 6 Fast food restaurants extensively market to young people.. In 2006, fast food restaurants spent approximately $300 million in marketing specifically designed to reach children and teens, and an estimated $360 million on toys distributed as premiums with children’s meals. 7 In 2007, young people viewed more TV ads for fast food than any other food category: 2. 9 fast food ads per day for the average child (6-11 years) and 4. per day for the average teen (12-17 years). 8 These marketing efforts are targeted even to preschoolers. 9 In addition, children’s exposure to fast food TV advertising increased by 12% from 2003 to 2007 at the same time that advertisers for most other food product categories reduced their TV ads to children. 10 The White House Task Force on Childhood Obesity has stated that restaurants “have an important role to play in creating a food marketing environment that supports, rather than undermines, the efforts of parents and other caregivers to encourage healthy eating among children and prevent obesity. 11 The fast food industry has responded to this and other calls for change. 12 Two of the largest fast food advertisers to children, McDonald’s and Burger King, have joined the Children’s Food and Beverage Advertising Initiative (CFBAI), pledging to advertise only “better-for-you” choices to children. 13 Most restaurants have also introduced more nutritious options for both children and adults to their menus. 14 But critical questions remain: Do these actions have a positive impact? Or, does the sheer volume of fast food marketing eclipse any of these industry initiatives? nd signs outside restaurants. We use syndicated media data from The Nielsen Company (Nielsen), comScore Inc. , and Arbitron Inc. When these data were not available, we commissioned or implemented our own studies to measure the extent that restaurants engaged in these practices. In addition, we conducted content analyses to assess the products, target audiences, messages, and techniques in the ads. ¦ In-store marketing presents data to assess marketing practices inside restaurants to push sales of individual menu items.

This research includes an audit of more than 1,000 restaurants nationwide to measure in-store signs, pricing practices, and the products and messages promoted. We also conducted a study of restaurant sales practices at 250 restaurants to document the products encouraged at the point-of-sale when ordering kids’ meals and combo meals. To measure the outcomes of these marketing practices, we purchased market research data from The NPD Group’s CREST service to quantify the types of products most often purchased. We also conducted a survey of parents of 2- o 11-year-olds to measure the frequency of their visits to fast food restaurants with their children, what menu items they buy, and why. Results Fast food marketing is relentless. ¦ The fast food industry spent more than $4. 2 billion in 2009 on TV advertising, radio, magazines, outdoor advertising, and other media. The average preschooler (2-5 years) saw 2. 8 TV ads for fast food every day in 2009; children (6-11 years) saw 3. 5; and teens (12-17 years) saw 4. 7. Young people’s exposure to fast food TV ads has increased.

Compared to 2003, preschoolers viewed 21% more fast food ads in 2009, children viewed 34% more, and teens viewed 39% more. McDonald’s and Burger King have pledged to improve food marketing to children. However, both restaurants increased their volume of TV advertising from 2007 to 2009. Preschoolers saw 21% more ads for McDonald’s and 9% more for Burger King, and children viewed 26% more ads for McDonald’s and 10% more for Burger King. Although McDonald’s and Burger King only showed their “better-for-you” foods in child-targeted marketing, their ads did not encourage consumption of these healthier choices.

Instead, child-targeted ads focused on toy giveaways and building brand loyalty. Children saw more than just child-targeted ads. More than 60% of fast food ads viewed by preschoolers and children promoted fast food items other than kids’ meals and promotions. ¦ ¦ Fast Food FACTS This report addresses the need for comprehensive, reliable, and current information about fast food marketing and how it affects young people. We focus our analyses on the twelve restaurants with the highest sales and advertising to youth in 2009 and document three components of their marketing plans: ¦ ¦ ¦

Menu composition provides nutrient content data and comparison of all menu items offered as of January 2010, including items on kids’ meal, dollar/value, and healthy menus. External advertising includes data to measure advertising practices that reach customers outside the restaurant to pull them inside. We examine advertising spending, TV ads, internet marketing, social media, viral marketing, ¦ ¦ Fast Food FACTS ix Executive Summary Youth-targeted marketing has spread to company websites and other digital media. ¦ McDonald’s web-based marketing starts with children as young as 2 at Ronald. om. McDonald’s and Burger King created sophisticated websites with 60 to 100 pages of advergames and virtual worlds to engage children (McWorld. com, HappyMeal. com, and ClubBK. com). McDonald’s thirteen websites attracted 365,000 unique child visitors and 294,000 unique teen visitors on average each month in 2009. Nine restaurant Facebook pages had more than one million fans as of July 2010, and Starbucks boasted more than 11. 3 million fans. Smartphone apps were available for eight fast food chains, providing another opportunity to reach young consumers anytime, anywhere.

Most restaurants do offer some healthful and lower-calorie choices on their regular and children’s menus, but unhealthy options are the default inside the restaurants. ¦ ¦ Just 12 of 3,039 possible kids’ meal combinations met nutrition criteria for preschoolers; 15 met nutrition criteria for older children. Just 17% of regular menu items qualified as healthful choices. Most of these items were low or no-calorie beverages (e. g. , coffee and diet soft drinks). In contrast, 12% of lunch/dinner sides met nutrition criteria, and 5% or less of lunch/dinner main dishes and breakfast items met the criteria.

Snacks and dessert items contained as many as 1,500 calories, which is five times more than the 200 to 300 calorie snack recommended by the American Dietetic Association for active teens. 15 The average restaurant had 15 signs promoting specific menu items, but just 4% promoted healthy menu items. When ordering a kids’ meal, restaurant employees at McDonald’s, Burger King, Wendy’s, and Taco Bell automatically served french fries or another unhealthy side dish more than 84% of the time. A healthy beverage was offered less than 50% of the time.

Subway offered apple slices or yogurt and low-fat plain milk or 100% juice with their kids’ meals 60% of the time, making it the only fast food restaurant in our study to routinely provide healthy choices. ¦ ¦ ¦ ¦ ¦ ¦ Fast food marketing also targets teens and ethnic and minority youth – often with less healthy items. ¦ ¦ Taco Bell TV and radio advertising reached more teens than adults and Burger King advertised teen-targeted promotions. Dairy Queen, Sonic, and Domino’s also reached teens disproportionately with ads for their desserts and snacks.

Hispanic preschoolers saw 290 Spanish-language fast food TV ads in 2009 and McDonald’s was responsible for onequarter of young people’s exposure to Spanish-language fast food advertising. African American children and teens saw at least 50% more fast food ads on TV than their white peers. That translated into twice as many calories viewed in fast food ads daily compared to white children. McDonald’s and KFC specifically targeted African American youth with TV advertising, websites, and banner ads. African American teens viewed 75% more TV ads for McDonald’s and KFC compared to white teens. ¦ As a result, ¦ ¦ At McDonald’s, Burger King and Wendy’s, approximately two-thirds of parents who ordered a kids’ meal for their child ordered french fries and one-third to one-half ordered a soft drink. In contrast, two-thirds ordered fruit or yogurt and juice or plain milk with a kids’ meal at Subway. Parents of elementary school-age children were more likely to order a combo meal or dollar/value menu items for their child than a kids’ meal. Teens between the ages of 13 and 18 ordered 800 to 1,100 calories in an average fast food visit.

This age group ordered many of the highest-calorie, nutrient-poor items on fast food menus, including large and extra-large french fries and soft drinks and large-sized burgers. Teens were also more likely to visit a fast food restaurant for an afternoon or evening snack compared to any other age group; and they purchased the most desserts, breads and sweet breads. At least 30% of calories in menu items ordered by children and teens were from sugar and saturated fat. At most restaurants, young people ordered at least half of their maximum daily recommended sodium intake in just one fast food meal. ¦ ¦ Fast food marketing works. ¦ Eighty-four percent of parents reported taking their child to a fast food restaurant at least once in the past week; 66% reported going to McDonald’s. Forty-seven percent of parents who went to McDonald’s reported that the main reason they went there was because their child likes it. This rate was significantly higher than the percent who reported that they took their child to Burger King, Subway, or Wendy’s primarily because their child likes it (31%, 20%, 19%, respectively) Forty percent of parents reported that their child asks to go to McDonald’s at least once a week; 15% of preschoolers ask to go every day. ¦ ¦ ¦ Fast Food FACTS x Executive Summary Recommendations Young people must consume less of the calorie-dense, nutrient-poor foods served at fast food restaurants. Parents and schools can do more to teach children how to make healthy choices. Above all, fast food restaurants must drastically change their current marketing practices so that children and teens do not receive continuous encouragement to seek out food that will severely damage their health. In addition, when young people visit, the restaurants should do more to encourage the purchase of more healthful options. Restaurants must increase the relative number of lowcalorie, more nutritious items on their menus. Popular items should be reformulated to decrease the saturated fat, sodium, and calories in the average entree. Kids’ meal options must be developed to meet the nutrition needs of both the preschoolers and older children who consume them. ¦ ¦ Fast food restaurants must establish meaningful standards for child-targeted marketing that apply to all fast food restaurants—not just those who voluntarily participate in the CFBAI ¦

Fast food restaurants must do more to push their lower-calorie and more nutritious menu items inside the restaurants when young people and parents make their final purchase decisions ¦ Restaurants must apply “better-for-you” standards to kids’ meals served, not just items pictured in child-directed marketing. Restaurants must redefine “child-directed” marketing to include TV ads and other forms of marketing viewed by large numbers of children but not exclusively targeted to them. Child-targeted marketing must do more to persuade children to want the healthy options available, not just to encourage them to visit the restaurants.

McDonald’s must stop marketing directly to preschoolers. ¦ Healthier sides and beverages must be the default option when ordering kids’ meals. Parents can request french fries and soft drinks if they want, but parents – not restaurants – should make that decision. McDonald’s claims that it sells millions of Happy Meals. Simply making the healthy option the default could reduce children’s consumption by billions of calories per year. The smallest size and most healthful version should be the default option for all menu items. Portion sizes (e. g. , small, medium, and large) should be consistent for similar menu items across restaurants. ¦ ¦ ¦ Fast food restaurants must do more to develop and promote lower-calorie and more nutritious menu items ¦ The focus in all forms of marketing must be reversed to emphasize the healthier options instead of the high-calorie poor quality items now promoted most extensively. According to the data in this report, fast food restaurants spend billions of dollars in marketing every year to increase the number of times that customers visit their restaurants, encourage visits for new eating occasions and purchases of specific menu items (rarely the healthy options), and create lifelong, loyal customers.

By creating more healthful items and marketing them more effectively, fast food restaurants could attract lifelong customers who will also live longer, healthier lives. Fast Food FACTS xi Introduction Restaurants “have an important role to play in creating a food marketing environment that supports, rather than undermines, the efforts of parents and other caregivers to encourage healthy eating among children and prevent obesity,”1 according to the White House Task Force on Childhood Obesity.

The harmful effects of food marketing on child and adolescent health have been discussed widely in recent years. In 2006 the Institute of Medicine (IOM) released a report about children’s food marketing beginning with two words, “marketing works. ”2 In the same year, the World Health Organization (WHO) issued a report, noting that “…exposure to the commercial promotion of energy-dense, micronutrient-poor foods and beverages can adversely affect children’s nutritional status. ”3 Both the IOM and WHO reports highlighted the dire state of children’s food marketing and called for sweeping changes.

These reports called into question the assertion by food industry proponents that food marketing to children only affects brand preferences (e. g. , purchases at McDonald’s instead of Burger King) and does not increase total purchases of food categories such as fast food. 4 However, they left open the possibility that food companies might be persuaded by good will, public pressure, or the threat of government regulation to change their marketing practices. Much has transpired since the release of the WHO and IOM reports.

In the fast food industry, two of the largest fast food advertisers (McDonald’s and Burger King) have joined the Children’s Food and Beverage Advertising Initiative (CFBAI) and pledged to advertise only “better-for-you” choices to children;5 the majority of restaurants have introduced more nutritious options to their menus for both children and adults;6 and most fast food restaurants will soon be required by federal law to post calories for all items on their menu boards. 7 The critical question is whether industry promises will reverse the unhealthy defaults that exist in the current fast food marketing environment. Consumption of fast food is associated with a number of negative health consequences, most notably unhealthy diet that increases risk for obesity. 9 10 Fast food restaurants spend more than $660 million each year to market their products and brands to children and adolescents. 11 This report describes what is being marketed by these restaurants, who they are targeting and how they reach them, and what happens when young people visit fast food restaurants. science-based evaluations of the marketing conducted by specific companies within different food categories, as well as the nutritional quality of the food products promoted.

In 2009, we published the Cereal FACTS report that provided a comprehensive review of cereal marketing targeted to children and adolescents (www. CerealFacts. org). We now focus on the fast food industry. Fast Food FACTS quantifies the nutritional quality of fast food restaurant menus and documents the full array of marketing practices used to promote these restaurants and their products to children and adolescents. The data presented in this report provide a means to evaluate current marketing practices and their impact, and offer a metric against which future changes can be monitored.

We incorporate the same media measurement data used by advertisers to quantify exposure to TV, radio, and digital marketing. We also include market research data used to monitor competitors’ product sales. In addition, we conducted our own quantitative and qualitative research to measure menu item nutritional quality; the messages and products presented in TV, internet and other forms of digital marketing; in-store marketing practices; and parent attitudes about fast food restaurants. When possible, we evaluated differences by target populations, focusing on children, adolescents, and African American and Hispanic youth.

Although this analysis is the most extensive of its type ever undertaken, we could not evaluate every fast food restaurant. Therefore, we focused our data collection on twelve fast food restaurants, including the ten largest sellers and/or marketers of fast food to young people. Why fast food? During the last several decades, food patterns have shifted in the United States with Americans consuming a greater proportion of their total calories outside the home. 12 13 In 1994-96, 10% of young people’s caloric intake came from fast food, a five-fold increase compared to twenty years earlier. 4 Data from the mid-1990s also showed that one third of young people (4-19 years) ate fast food every day. 15 Portion sizes offered by fast food restaurants also grew during this time period, with individual items from two to five times larger than they were when originally introduced. 16 More recent data from 2003-04 indicate that fast food now contributes 16% to 17% of adolescents’ total caloric intake,17 and each meal consumed in a fast food or other restaurant increases adolescents’ daily intake by 108 calories. 8 Given the considerable role fast food plays in young people’s diets, the nutritional quality of menu items offered in fast food restaurants is a critical concern. A recent study of the nutrient quality of children’s meals available at fast food restaurants found that only 3% met the nutrition standards set by the National School Lunch Program for foods served to children eight years of age and younger. 19 That study also found that less than one-third of these meals provided adequate calcium or iron and more than half exceeded recommended sodium Aims and context

In 2008, the Rudd Center for Food Policy and Obesity at Yale University received a grant from the Robert Wood Johnson Foundation to study the amount and impact of food marketing directed at children and youth. The goal was to highlight both helpful and harmful industry practices by conducting objective, Fast Food FACTS 12 Introduction levels. Additionally, restaurants encourage over-consumption of these nutrient-poor foods by promoting combination meals that offer price savings for larger portion sizes and in-store signs that encourage unhealthy eating and overeating. 0 There is reason to be concerned about the impact of fast food consumption on young people’s overall nutrition and health. Young people who eat fast food consume more total fat, added sugars, and sugar-sweetened beverages, and less fiber, milk, and fruits and vegetables compared to children who do not eat fast food. 21-23 Greater consumption of fast food is also associated with higher energy intake overall and greater risk of future obesity. 24-26 Adults who visit fast food restaurants and reside in neighborhoods with a high density of fast food restaurants and low walkability have increased blood pressure over time. 7 Furthermore, African American youth, a population that faces some of the highest risks of obesity and obesity-related diseases, consume more fast food compared to white children of the same age. 28 29 packaging and in-store marketing; and in-school and events marketing (see Figure 1). 35 Fast food brands also commonly use digital marketing techniques, including social media, ingame marketing, and viral media to increase the appeal of their products to young people. 36 Schools/events $18 mill. Packaging/in-store Other $22 mill. $7 mill. Promotions $30 mill. Radio $30 mill. Toy giveaways $360 mill. TV $187 mill. Marketing to young people

In light of increased consumption of fast food by young people and its negative influence on their diet and health, public health advocates and government officials have expressed concern about marketing that encourages young people to consume fast food. In 2006, fast food restaurants spent approximately $300 million in marketing specifically designed to reach young people, more than any food category except for carbonated beverages. 30 Fast food restaurants spent as much as marketers of juices, non-carbonated beverages and snack foods combined, and nearly two and a half times the amount spent for candy and frozen desserts.

In addition, fast food marketers spent an estimated $360 million on toys distributed as premiums with children’s meals. When added to their other marketing expenditures, spending on fast food marketing programs targeted to children and teens totaled $660 million. This amount is more than 200 times the $3 million communications budget for the “5 A Day” campaign, a joint venture with the National Cancer Institute (NCI) and the food industry, to encourage fruit and vegetable consumption. 1 Approximately two-thirds of fast food marketing budgets was spent on traditional TV and radio advertising. 32 In 2007, fast food advertising comprised 22% of TV food ads viewed by children (ages 6 to 11 years) and 28% of those viewed by adolescents. 33 Children and adolescents viewed more ads for fast foods than for any other food category. The average U. S. child viewed 1,058 TV ads for fast food annually, or 2. 9 ads every day, and adolescents viewed even more: almost 1,500 per year, or 4. 1 per day.

These marketing efforts begin as early as preschool: 66% of child-targeted advertising during preschool programming promoted fast food restaurants. 34 Fast food companies also spent considerable sums on youthtargeted radio advertising; cross-promotions, and other tieins with philanthropies and athletic sponsorships; product Figure 1: Spending by fast food restaurants on marketing directly targeted to children and adolescents There is considerable evidence that exposure to marketing for fast food is even higher among African American and Hispanic youth. 8 African American youth view almost 50% more TV advertisements for fast food than do white children and adolescents. 39 Although differences in advertising exposure can be attributed in large part to the greater amount of time that African American and Hispanic youth spend watching television,40 fast food restaurants appear to disproportionately target African Americans and Hispanics with their marketing efforts. For example, fast food ads appear more frequently during African American-targeted TV programming than during general audience programming. 1 Fast food advertisements are also prevalent on Spanish-language television networks, comprising nearly half of all ads. 42 Billboards for fast food restaurants appear significantly more often in low-income African American and Latino neighborhoods. 43 Fast food restaurants located in poorer African American neighborhoods also promote less-healthful foods and have more in-store advertisements compared to restaurants in more affluent, predominantly white neighborhoods. 4 The 2010 report by the White House Task Force on Childhood Obesity explicitly addresses the potentially harmful effects of fast food marketing, noting the frequency with which children eat at fast food restaurants and calling on restaurants to “consider their portion sizes, improve children’s menus, and make healthy options the default choice whenever possible. ”45 Fast Food FACTS 13 Introduction

Recent restaurant industry initiatives to address childhood obesity The restaurant industry has responded to concerns about the nutritional quality of their products and the volume of marketing targeted to young people. According to the National Restaurant Association, “two-thirds of quickserve operators offer more healthful choices for children than they did two years ago,”46 and McDonald’s says that, “any fair and objective review of our menu and the actions we’ve taken will demonstrate we’ve been responsible, we’re committed to children’s well-being, and we’ll continue to do more. 47 The two largest fast food marketers to children, McDonald’s and Burger King, joined the Children’s Food and Beverage Initiative (CFBAI), an industry-sponsored program to “change the landscape of child-directed advertising. ”48 As members of the CFBAI, these two restaurants have pledged to depict only “pledge-approved, better-for-you” products in their child-directed measured media (i. e. , television, radio, thirdparty internet and print), company-owned websites and interactive games. These pledges were fully implemented by the beginning of 2009.

While the CFBAI represents an industry-led effort to reduce unhealthy marketing to children, numerous omissions and loopholes raise questions about the fast food industry’s commitment to change the landscape of children’s food advertising. For example, only McDonald’s and Burger King had joined the initiative as of September 2010. 49 These two restaurants are the largest advertisers to children on television. However, other restaurants contribute more than half of the fast food ads children view. 50 Notably, Subway and YUM!

Brands, whose restaurants include KFC, Taco Bell, and Pizza Hut, had not joined the CFBAI at the time of this report’s publication. So in spite of reductions in children’s exposure to McDonald’s and Burger King advertising on television, children’s exposure to all fast food TV advertising increased by 12% from 2003 to 2007. 51 This increase occurred at the same time that children’s exposure to TV advertising for other product categories (including beverages, cereal, candy, and snacks) decreased. Another significant limitation of the CFBAI is that it only addresses advertising to children younger than age 12.

As discussed, adolescents view 40% more television advertising for fast food than children do,52 and many young people of this age have the means to visit these restaurants on their own. A survey of middle and high school students found that 77% of boys and 72% of girls reported visiting a fast food restaurant in the past week,53 and a more recent study indicated that 59% of adolescents (12-19 years) consumed fast food on at least one of the two previous days. 54 Finally, the CFBAI does not address all forms of marketing to young people.

For example, fast food restaurants spent $22 million on packaging and other marketing in the restaurant targeted to young people, as well as $9 million on marketing in schools. However, neither of these forms of marketing is covered by the CFBAI. The initiative also does not include the 91% of fast food restaurants’ spending on philanthropic marketing programs (more than $10 million) which was reported as youth-targeted marketing expenditures. Similarly, the CFBAI does not address marketing programs that disproportionately appeal to young people if they are not the primary target audience.

Examples include TV advertising on general audience programming with wide youth appeal, such as “American Idol” or “Glee,” and branded games on company websites (known as advergames). These limitations to the CFBAI and other fast food industry actions have led public health advocates to question whether restaurant industry initiatives are intended to improve public health or merely deflect concerns about their products and marketing efforts. For example, McDonald’s pledged to market only apple dippers and 1% low-fat white milk in their Happy Meal advertisements targeted to children.

However, a recent examination by the Center for Science in the Public Interest found that 93% of the time shoppers were automatically given french fries when ordering a Happy Meal. 55 In addition, the National Restaurant Association lobbied extensively against a recent bill passed in Santa Clara County, California that requires fast food kids’ meals that come with a toy to meet minimum nutrition standards. Meanwhile, purchases of unhealthy options continue to be the norm at fast food restaurants.

During 2008-2009, only 5% of children ordered fruit and 14% ordered plain milk or 100% juice at fast food restaurants. 56 Additionally, from 2005 to 2008, the ordering of kids’ meals by children (under 13 years) declined by 11% while orders of typically higher-calorie items from dollar or value menus increased by 9%, according to The NPD Group (NPD), a market research firm that tracks product purchases at restaurants by age group. 57 Snack food purchases also increased during the same period. “Kids today want more choices and sophisticated fare,” said an NPD spokesperson.

Given the damaging effects of fast food on young people’s health, it is imperative that young people consume less of the calorie-dense nutrient-poor foods served at fast food restaurants. The food ind