Stanford, UAMS Study Offers First Look at Restaurants’ Response to Prohibiting Toys With Unhealthy Meals

By David Robinson

The study examining the impact of a new ordinance in Santa Clara County was published today by the American Journal of Preventive Medicine. Rebecca Krukowski, Ph.D., an assistant professor in the UAMS College of Public Health, is among the study authors. She provided the study’s evaluation response tool called the Children’s Menu Assessment, which was developed at UAMS by Krukowski and Delia West, Ph.D., a professor in the College of Public Health.

Led by the Stanford University School of Medicine, the study, though small, provides the first insights into how fast-food restaurants may respond to legislation intended to prevent restaurants from using toys to make unhealthful food items appealing to children.

“The study found that the restaurants were able to respond rapidly and in positive and meaningful ways to the new ordinance,” Krukowski said. “The restaurants involved are global and national franchises, so the responses here could have wide-reaching implications.”

Fast-food restaurants have become a high-profile target in the effort to decrease childhood obesity rates, mostly because of concerns that the companies use toys and other giveaways that draw children to meals that are high in calories and low in nutrition.

A 2010 analysis by Yale University’s Rudd Center on Food Policy and Obesity found that of 3,039 possible kids’ meal combinations available at large fast-food chains, only 12 combinations met the nutrition criteria for preschoolers and just 15 for older children.

Jennifer Otten, Ph.D., a postdoctoral scholar at the Stanford Prevention Research Center, is the lead author of the study, which tracked the reaction by fast-food restaurants in the four months immediately after Santa Clara County’s ordinance took effect in August 2010.

The policy — the first of its kind in the nation — prohibited the use of toys and other incentives to children along with food items that didn’t meet minimal nutritional criteria.

The criteria for the Santa Clara law are based on nutrient recommendations and standards for children provided by the Institute of Medicine of The National Academies and the U.S. federal government’s 2005 Dietary Guidelines for Americans.

For instance, a meal must have less than 485 calories and fall within limits on fat, salt and added sweeteners.

The restaurants had options for complying with the ordinance. As an example, they could meet the nutritional standards and continue to offer a free toy with a children’s meal, or cease offering promotional items with meals that didn’t.

Santa Clara’s ordinance applied only to unincorporated regions of the county, and therefore a limited number of restaurants. The researchers visited four major fast-food outlets affected by the law as well as four nearby, same-chain restaurants that weren’t. The restaurant chains are not identified in the study because the researchers were not attempting to compare chains, but rather wanted to measure the outcomes across a particular class of restaurants — fast-food outlets — known to heavily market toys to children.

In the months before and after the law took effect, the team documented the nutritional content of the menu items for children, the prices, whether toys or other incentives were offered and how the signage within the restaurants promoted the offerings for children, among other criteria.

The study found that before and after the law took effect, only 4 percent of the children’s meal combinations at the restaurants met the nutritional standards.

While none of the restaurants added healthier options to their menus or reformulated existing items, they did make other changes. For example, two of the four affected restaurants removed toy marketing posters, and two offered toys separately at an additional cost. Some restaurants eliminated toys completely. One restaurant singled out the children’s meals that met the ordinance criteria as “promoting good nutrition” on its menu boards.

There were minimal changes at the restaurants not affected by the ordinance.

“Before, parents had no idea which meals met the nutritional criteria. After the law was implemented, one restaurant made it clear which ones did,” Otten said. “In addition, there was a clear decrease in toy marketing and advertising at some of the affected restaurants.”

Otten said the study shows that this type of ordinance can help “de-link” the distribution of toys with unhealthy food items. She and her colleagues have continued to monitor the Santa Clara County restaurants to assess the longer-term responses to the legislation.

Additionally, they surveyed almost 900 families before and after the ordinance took effect to determine whether it affected their fast-food purchases. They plan to publish the findings related to the family surveys and the longer-term restaurant responses in future papers.

The team is also collecting data from families and fast-food restaurants in San Francisco, where a similar law took effect on Dec. 1.

With more communities contemplating how to address the issue of childhood obesity, the researchers hope their studies will help guide communities toward steps that achieve the desired results.

UAMS is the state’s only comprehensive academic health center, with colleges of Medicine, Nursing, Pharmacy, Health Related Professions and Public Health; a graduate school; a hospital; a statewide network of regional centers; and seven institutes: the Winthrop P. Rockefeller Cancer Institute, the Jackson T. Stephens Spine & Neurosciences Institute, the Myeloma Institute for Research and Therapy, the Harvey & Bernice Jones Eye Institute, the Psychiatric Research Institute, the Donald W. Reynolds Institute on Aging and the Translational Research Institute. Named best Little Rock metropolitan area hospital by U.S. News & World Report, it is the only adult Level 1 trauma center in the state. UAMS has more than 2,800 students and 775 medical residents. It is the state’s largest public employer with more than 10,000 employees, including about 1,000 physicians and other professionals who provide care to patients at UAMS, Arkansas Children’s Hospital, the VA Medical Center and UAMS’ Area Health Education Centers throughout the state. Visit or