Promoting Healthier Eating Among Children in Restaurants

Restaurants are normative eating contexts for many families. Restaurant meals tend to be higher in calories and lower in nutritional quality than those prepared at home. Targeting children's food selection in restaurants has the potential to improve diet quality, attenuate excess energy intake, and shape healthy habits. The objective of this study is to make healthier kids' meal options more appealing and easier to choose via an in-restaurant intervention that combines repeated exposure and choice architecture strategies. Six locations of a quick-service restaurant will be paired based on income levels in the surrounding census tracts. A location from each pair will be randomized to each study group (intervention, control). Recruitment and data collection will be conducted across 3 cohorts, with recruitment conducted during a family's regular visit. Study participation will involve 7 more visits to the location where the family was recruited, 6 of which will be during an exposure period of about 2 months. Families in intervention restaurants will receive placemats promoting healthier featured kids' meals. Participating families will also receive a frequent diner card which, after purchasing one of the featured healthier kids' meals across 6 occasions, makes them eligible for a free kids' meal of their choice during a predetermined redemption period. In the control group, generic placemats will be provided, and participating families will be provided with frequent diner cards that can be used for any kids' meals. The aims of this study are: (1) to test effects of a healthier kids' meal intervention on children's meal orders, and (2) to test effects of a healthier kids' meal intervention on children's dietary intake. It is hypothesized that (1a) children in the intervention restaurants will be more likely than controls to select one of the promoted healthier kids' meals at post-test, (1b) children in the intervention group will order fewer calories and desserts and less saturated fat, sodium, and sugar at post-test versus controls, (1c) the promoted healthier meals will make up a greater percentage of kids' meals ordered in intervention restaurants versus controls, based on sales data across the study period, and (2) compared to controls, children in the intervention group will consume fewer calories and less saturated fat, sodium, and sugar in the restaurant at post-test.

Study Overview

• Status: Completed
• Conditions: Diet, Healthy
• Intervention / Treatment: Behavioral: Choice architecture + repeated exposure; Behavioral: Active comparator

Detailed Description

Restaurants are normative eating contexts for many families. Restaurant meals tend to be higher in calories and lower in nutritional quality than those prepared at home. Targeting children's food selection in restaurants has the potential to improve diet quality, attenuate excess energy intake, and shape healthy habits. The objective of this study is to make healthier kids' meal options more appealing and easier to choose via an in-restaurant intervention that combines repeated exposure and choice architecture strategies.

Six locations of a quick-service restaurant will be paired based on income levels in the surrounding census tracts. A location from each pair will be randomized to each study group (intervention, control). Recruitment and data collection will be conducted across 3 cohorts. After recruitment, families will be asked to order and eat like they normally would. All participating families will then complete measures of children's orders, intake, and demographics. Then families will receive placemats and frequent diner cards. Families in intervention restaurants will receive placemats promoting healthier featured kids' meals. These families will also receive a frequent diner card, which after purchasing one of the featured healthier kids' meals across 6 occasions, makes them eligible for a free kids' meal of their choice during a predetermined redemption period. In the control group, generic placemats will be provided following baseline data collection, and families will also be provided with frequent diner cards that can be used for any kids' meals. During subsequent exposure periods, lasting about 2 months per cohort, families will return to the restaurant location where they were recruited on a weekly basis. Placemats will be available at the restaurant entrance, and corresponding signage will be displayed in the restaurant. In intervention restaurants, signs will advertise promoted meals and the option to select a toy in place of dessert. Participating children will be able to use their frequent diner card during this time to earn a free meal during the subsequent redemption period. Families will also be asked to complete a brief online survey once per week to monitor restaurant patronage. In each restaurant, study staff will conduct observations of a subsample of participating family and server interactions. Finally, post assessments will be completed during predetermined redemption periods, lasting about 3 months per cohort. Placemats and signage will still be available in restaurants during this time. Study staff will collect the frequent diner cards and ask families to order and eat like they normally would and to not throw out any food or leftovers. Families will be able to redeem any earned free kids' meals during this time. When the family is done eating, study staff will approach the table to administer study measures assessing orders, perspectives on the meal, and intake. Finally, families will also be prompted to complete an online dietary recall (ASA24) after their post assessment.

The specific aims of this study are: (1) to test effects of a healthier kids' meal intervention on children's meal orders, and (2) to test effects of a healthier kids' meal intervention on children's dietary intake. It is hypothesized that (1a) children in the intervention restaurants will be more likely than controls to select one of the promoted healthier kids' meals at post-test, (1b) children in the intervention group will order fewer calories and desserts and less saturated fat, sodium, and sugar at post-test versus controls, (1c) the promoted healthier meals will make up a greater percentage of kids' meals ordered in intervention restaurants versus controls, based on sales data across the study period, and (2) compared to controls, children in the intervention group will consume fewer calories and less saturated fat, sodium, and sugar in the restaurant at post-test.

• Study Type: Interventional
• Enrollment (Actual): 554
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • New York
    • Buffalo, New York, United States, 14214
      • State University of New York at Buffalo

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 6 months to 4 years (Child)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Fluent in English (parent/guardian & child)
• 18 years or older (parent/ guardian)
• Between the ages of 4-8 years (child)
• Eats food from restaurants at least 2-3 times per month (child)
• Does not have allergies that preclude safe participation in the study (child)
• Eating a meal in the restaurant at the time of recruitment/baseline assessment
• Did not participate in pilot phase of this study, which involved taste tests of possible healthier meal options at the same restaurant chain

Exclusion Criteria:

• Is under 18 years of age (parent/ guardian)
• Does not have a child in the range of 4-8 years
• Does not speak English fluently (parent/guardian & child)
• Does not eat food from a restaurant at least 2-3 times per month (child)
• Has food allergies that preclude safe participation in the study (child)
• Not eating a meal in the restaurant at recruitment/baseline
• Participated in pilot phase of this study, which involved taste tests of possible healthier meal options at the same restaurant chain

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Placemats and frequent diner cards promoting healthier meals; Participants will receive placemats promoting healthier featured kids' meals and the opportunity to redeem their kids' meal token for a toy instead of dessert. Families will also receive a frequent diner card, which after purchasing one of the featured healthier kids' meals across 6 occasions, makes them eligible for a free kids' meal of their choice during a predetermined redemption period. Corresponding signage will be displayed in the restaurant.	Behavioral: Choice architecture + repeated exposure; Participants will receive placemats promoting healthier featured kids' meals and the opportunity to redeem their kids' meal token for a toy instead of dessert. Families will also receive a frequent diner card, which after purchasing one of the featured healthier kids' meals across 6 occasions, makes them eligible for a free kids' meal of their choice during a predetermined redemption period.
Active Comparator: Generic placemats and frequent diner cards; Participants will receive generic placemats listing all of the restaurant's kids' meals. Families will also receive a generic frequent diner card, which after purchasing (any) kids' meals across 6 occasions, makes them eligible for a free kids' meal of their choice during a predetermined redemption period. Corresponding signage will be displayed in the restaurant.	Behavioral: Active comparator; Participants receive generic placemats and frequent diner cards that do not promote any specific kids' meal.
No Intervention: Pilot phase; Pilot (taste testing) phase completed before the trial to finalize the healthier meals that would be promoted in the intervention.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Meal Type Ordered for Child in Restaurant	Whether a healthier children's meal or other children's meal was ordered (bundled meal including promoted healthy main dish, healthy side, and healthy beverage). Counts reported indicate the number of children who ordered a healthy bundled meal.	Post-test (about 4 months after recruitment)
Change in Meal Type Ordered for Child in Restaurant	Whether a healthier children's meal or other children's meal was ordered. Counts reflect the raw change in number of participants ordering the bundled healthy meal from baseline to post-test, by group.	Baseline, midpoints 1-9 (weekly assessments about 2 months after recruitment), post-test (about 4 months after recruitment)
Total Calories Ordered for Child in Restaurant	Nutrition information provided by the restaurant will be combined with parent report of children's orders to calculate total calories ordered	Post-test (about 4 months after recruitment)
Change in Total Calories Ordered for Child in Restaurant	Nutrition information provided by the restaurant will be combined with parent report of children's orders to calculate total calories ordered	Baseline, midpoints 1-9 (weekly assessments about 2 months after recruitment), post-test (about 4 months after recruitment)
Total Saturated Fat Ordered for Child in Restaurant	Nutrition information provided by the restaurant will be combined with parent report of children's orders to calculate total saturated fat ordered.	Post-test (about 4 months after recruitment)
Change in Total Saturated Fat Ordered for Child in Restaurant	Nutrition information provided by the restaurant will be combined with parent report of children's orders to calculate total saturated fat ordered.	Baseline, midpoints 1-9 (weekly assessments about 2 months after recruitment), post-test (about 4 months after recruitment)
Total Sugar Ordered for Child in Restaurant	Nutrition information provided by the restaurant will be combined with parent report of children's orders to calculate total sugar ordered.	Post-test (about 4 months after recruitment)
Change in Total Sugar Ordered for Child in Restaurant	Nutrition information provided by the restaurant will be combined with parent report of children's orders to calculate total sugar ordered.	Baseline, midpoints 1-9 (weekly assessments about 2 months after recruitment), post-test (about 4 months after recruitment)
Total Sodium Ordered for Child in Restaurant	Nutrition information provided by the restaurant will be combined with parent report of children's orders to calculate total sodium ordered.	Post-test (about 4 months after recruitment)
Change in Total Sodium Ordered for Child in Restaurant	Nutrition information provided by the restaurant will be combined with parent report of children's orders to calculate total sodium ordered.	Baseline, midpoints 1-9 (weekly assessments about 2 months after recruitment), post-test (about 4 months after recruitment)
Dessert Ordered for Child in Restaurant	Whether or not a dessert was ordered. Counts below reflect the number of children ordering a dessert at post-test.	Post-test (about 4 months after recruitment)
Change in Dessert Ordered for Child in Restaurant	Whether or not a dessert was ordered. Numbers below reflect change in likelihood of ordering dessert from baseline to post-test in the context of the generalized linear mixed model with all time points (baseline, midpoints 1-9, post-test).	Baseline, midpoints 1-9 (weekly assessments about 2 months after recruitment), post-test (about 4 months after recruitment)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Calories Consumed at Restaurant by Child in Restaurant	Children's dietary intake will be measured using plate waste methodology. Grams consumed will be converted to percentages using total grams from pre-weights, and these percentages will be multiplied by the total calories in the full item to calculate calories consumed.	Post-test (about 4 months after recruitment)
Changes in Calories Consumed at Restaurant by Child in Restaurant	Children's dietary intake will be measured using plate waste methodology. Grams consumed will be converted to percentages using total grams from pre-weights, and these percentages will be multiplied by the total calories in the full item to calculate calories consumed.	Baseline, post-test (about 4 months after recruitment)
Saturated Fat Consumed at Restaurant by Child in Restaurant	Children's dietary intake will be measured using plate waste methodology. Grams consumed will be converted to percentages using total grams from pre-weights, and these percentages will be multiplied by the total saturated fat in the full item to calculate saturated fat consumed.	Post-test (about 4 months after recruitment)
Changes in Saturated Fat Consumed at Restaurant by Child in Restaurant	Children's dietary intake will be measured using plate waste methodology. Grams consumed will be converted to percentages using total grams from pre-weights, and these percentages will be multiplied by the total saturated fat in the full item to calculate saturated fat consumed.	Baseline, post-test (about 4 months after recruitment)
Sugar Consumed at Restaurant by Child in Restaurant	Children's dietary intake will be measured using plate waste methodology. Grams consumed will be converted to percentages using total grams from pre-weights, and these percentages will be multiplied by the total sugar in the full item to calculate sugar consumed.	Post-test (about 4 months after recruitment)
Changes in Sugar Consumed at Restaurant by Child in Restaurant	Children's dietary intake will be measured using plate waste methodology. Grams consumed will be converted to percentages using total grams from pre-weights, and these percentages will be multiplied by the total sugar in the full item to calculate sugar consumed.	Baseline, post-test (about 4 months after recruitment)
Sodium Consumed at Restaurant by Child in Restaurant	Children's dietary intake will be measured using plate waste methodology. Grams consumed will be converted to percentages using total grams from pre-weights, and these percentages will be multiplied by the total sodium in the full item to calculate sodium consumed.	Post-test (about 4 months after recruitment)
Changes in Sodium Consumed at Restaurant by Child in Restaurant	Children's dietary intake will be measured using plate waste methodology. Grams consumed will be converted to percentages using total grams from pre-weights, and these percentages will be multiplied by the total sodium in the full item to calculate sodium consumed.	Baseline, post-test (about 4 months after recruitment)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Healthier Children's Meals Ordered at Aggregate Level	Aggregated sales data from the restaurant will be collected to monitor sales of healthier kids' meals across all patrons in Anderson's restaurants by study group during the study period. Children's orders were studied in aggregate; thus individual study participants were not studied here.	Through study completion, an average of 3 years
Healthier Children's Meals Ordered at Aggregate Level	Aggregated sales data from the restaurant will be collected to monitor sales of healthier kids' meals across all patrons in Anderson's restaurants by study group during the exposure period. Given that the intervention experienced by the general population (as opposed to study participants) is the same during midpoints and post-test, note that here exposure refers to midpoints plus post-test as described in a priori published protocol paper. Children's orders were studied in aggregate; thus individual study participants were not studied here.	Exposure period (lasting from about 2 to about 4 months after participant recruitment)
Healthier Children's Meals Ordered at Aggregate Level	Aggregated sales data from the restaurant will be collected to monitor sales of healthier kids' meals across all patrons in Anderson's restaurants by study group during the baseline period. Only aggregate data were recorded here; no data for individual child participants are available.	Baseline
Changes in Kids' Meals Ordered at Aggregate Level	Aggregated sales data from the restaurant will be collected to monitor sales of kids' meals across all patrons in Anderson's restaurants during time points parallel to the exposure period, 1 and 2 years prior to the study (for historical comparison). 2 years was added after original study planning but before study completion, given that 1 year prior to the study was 2020, a year impacted by the COVID-19 pandemic. Only aggregate data were recorded here (no individual participant data). Values from the two time points (1 year prior and 2 years prior) are summed.	1 and 2 years prior to study exposure period
Total Daily Calories Consumed by Child	Parents will report children's daily dietary intake using the Automated Self-administered 24-hour Dietary Assessment Tool (ASA24) the day after the in-restaurant part of the post-test assessment.	Post-test (about 4 months after recruitment)
Total Saturated Fat Consumed by Child	Parents will report children's daily dietary intake using the Automated Self-administered 24-hour Dietary Assessment Tool (ASA24) the day after the in-restaurant part of the post-test assessment.	Post-test (about 4 months after recruitment)
Total Sugar Consumed by Child	Parents will report children's daily dietary intake using the Automated Self-administered 24-hour Dietary Assessment Tool (ASA24) the day after the in-restaurant part of the post-test assessment.	Post-test (about 4 months after recruitment)
Total Sodium Consumed by Child	Parents will report children's daily dietary intake using the Automated Self-administered 24-hour Dietary Assessment Tool (ASA24) the day after the in-restaurant part of the post-test assessment.	Post-test (about 4 months after recruitment)

Collaborators and Investigators

• Sponsor: State University of New York at Buffalo
• Collaborators: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
• Investigators: Principal Investigator: Stephanie Anzman-Frasca, PhD, University at Buffalo

Publications and helpful links

General Publications

• Anzman-Frasca S, Tauriello S, Epstein L, Ferrante MJ, Gampp A, Goldsmith J, Haines J, Leone LA, Paluch R. Promoting Healthier Meal Selection and Intake Among Children in Restaurants: Protocol for a Cluster-Randomized Trial. JMIR Res Protoc. 2025 Oct 10;14:e73618. doi: 10.2196/73618.

Study record dates

Study Major Dates

• Study Start (Actual): November 13, 2019
• Primary Completion (Actual): November 22, 2024
• Study Completion (Actual): November 24, 2024

Study Registration Dates

• First Submitted: March 31, 2020
• First Submitted That Met QC Criteria: April 2, 2020
• First Posted (Actual): April 6, 2020

Study Record Updates

• Last Update Posted (Actual): June 10, 2026
• Last Update Submitted That Met QC Criteria: May 13, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: health; child; diet; restaurant; nudging; repeated exposure
• Other Study ID Numbers: STUDY00003356; 1R01HD096748-01A1 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No