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Do Healthier Meals Cost More?

Huang, Yue, MS; Houser, Robert F., PhD; Roberts, Susan B., PhD; Lichtenstein, Alice H., DSc

doi: 10.1097/NT.0000000000000278
Food and Nutrition
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SDC

One barrier to achieving healthier eating patterns is the perceived higher cost of healthier food. The objective of this cross-sectional study was to investigate the potential association between cost and the nutrition quality among entrées from casual dining restaurants.

Nutrition and price information were collected from 11 restaurants in Boston metropolitan area. A nutrition quality metric (Estimated Nutrition Score [ENS]) was developed based on the 2015-2020 Dietary Guidelines for Americans to allow comparisons between more healthy and less healthy entrées. Associations between entrée price and ENS were assessed as continuous variables and dichotomized based on median ENS, availability of “small,” “half,” and “light” options, and with or without calories as a component of the score.

Of the 11 restaurant chains meeting the inclusion criteria, the association between ENS and price was significant for 6. Of those 6, more healthy options were less expensive at 4 restaurants, and more healthy options were more expensive at 2 restaurants. Eliminating small, half, and light options from the analyses resulted in a null association for 1 restaurant in the former category. Eliminating calories from the score resulted in loss of a significant association between price and ENS for all 6 restaurants, whereas for 2 additional restaurants, significant negative relationships were detected.

There was no consistent association between ENS and entrée price in the sample assessed. Hence, within the category of restaurants evaluated, customers can often choose healthier entrées that are priced less than or equal to less healthy entrées.

Yue Huang, MS, is a research scholar at the Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts.

Robert F. Houser, PhD, is an assistant professor and statistical programmer/analyst at the Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts.

Susan B. Roberts, PhD, is a senior scientist and director of the Energy Metabolism Laboratory at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University. She is also a Professor of Nutrition and Professor of Psychiatry at Tufts University, Boston, Massachusetts.

Alice H. Lichtenstein, DSc, is a senior scientist and director of the Cardiovascular Nutrition Laboratory at the Human Nutrition Research Center on Aging, as well as a Stanley N. Gershoff Professor of Nutrition Science and Policy at the Friedman School, Tufts University, Boston, Massachusetts.

The authors have no conflicts of interest to disclose.

Correspondence: Yue Huang, MS, Friedman School of Nutrition Science and Policy, Tufts University, 150 Harrison Ave, Room 275 Boston, MA 02111 (Yue.huang@Tufts.edu).

Author contributions: A.H.L. and Y.H. conceived and oversaw this research project; A.H.L., S.B.R., and R.F.H. provided expertise on research methods and design of the nutrition score; R.F.H. provided critical statistical support; Y.H. led data collection, analysis, and writing of the initial draft. All authors have reviewed and commented on subsequent drafts of the manuscript.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nutritiontodayonline.com).

Americans now spend more than half of their food expenditure on food away from home, up from 25% in 1960.1,2 This trend can have serious implications on overall caloric intake and diet quality, as foods consumed outside of home tend to be served in larger portions than at home and on average contain more calories, saturated fat, sodium, and added sugar.3–8 The 2015 Dietary Guidelines for Americans identified specific areas where the average American could improve their diet to reduce the risk of developing chronic diseases.9 These include shifting eating patterns to emphasize vegetables, fruits, whole grains, low-fat and fat-free dairy products, a variety of protein sources, and unsaturated fat, while limiting added sugars, saturated fat, trans-fat, and sodium.9

While determinants of food choices are multifaceted, cost is commonly cited as a barrier to healthful eating, particularly among individuals of low socioeconomic status.10–12 In addition, research finds that some consumers may perceive healthy food as more expensive13–15 and conversely believe that expensive foods must be more healthy,15 regardless of the evidence. Some data suggest that healthier dietary patterns and healthier grocery items may indeed be more costly than their less healthy counterparts.16–20 However, there are limited data on the relationship between nutrition quality and prices in the restaurant setting, which may be in part due to the lack of readily available restaurant nutrition information. While the national menu labeling law was passed as part of the 2010 Affordable Care Act, this policy has yet to be implemented at a national level.21 An evaluation of children's menus did not identify an association between nutrient quality and price22; similar studies for other types of food prepared outside the home were not identified.

There is no standard approach to evaluate the nutrition quality of restaurant meals. Challenges in creating a metric include lack of information for variables of interest (eg, added sugar) and portion sizes for each entrée component (eg, vegetables). The objective of this study was to develop a nutrition score based on the 2015-2020 Dietary Guidelines for Americans and use the metric to explore its relationship with entrée price in casual dining restaurants with a presence in the Boston metropolitan area. The hypothesis was that there would be a positive relationship between nutrition score and price.

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MATERIALS AND METHODS

Inclusion/Exclusion Criteria for Restaurants

Eligible restaurants were selected using the following criteria: included in the top 200 restaurant chains by Nation's Restaurant News' 2015 reports23,24; classified as “casual dining” by Nation's Restaurant News23,24; provided online nutrition information during the month of June 2015 that included calories, saturated fat, unsaturated fat, trans-fat, carbohydrate, protein, sugar, sodium, and fiber; and operated at least 1 restaurant in the Boston metropolitan area (Figure 1). Casual dining restaurants—a large restaurant category in the United States—were selected because they typically offer a wider variety of entrées than fast-food restaurants, and fewer opportunities to customize each order compared with fast-casual restaurants. A total of 11 restaurants were included in the analyses, designated A-K. Review by the institutional review board was not required for this study because human subjects were not involved, as per US Department of Health and Human Services guidelines.25

FIGURE 1

FIGURE 1

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Inclusion/Exclusion Criteria for Entrées

If classified as entrées, full (regular), “small,” “light,” and “half” portions were included, as were individual-size pizzas. Salads were included when listed as “entrée salads.” Seasonal and special entrées were included if nutrition information was available. Burgers and sandwiches were excluded because of the flexibility in customizing the order, generating a large number of potential combinations. Items labeled as appetizers, small plates, side dishes and desserts, and self-selected combo meals were excluded. Because of exclusion of burgers and sandwiches, up to one-third of entrées were excluded in 6 restaurant chains.

All components of the entrées encompassed by the base price were included in the nutrition score. Inclusion and exclusion criteria were established for restaurants that offered multiple options for single entrées (eg, choices of sides, sauces); details are available in Supplemental Digital Content 1, http://links.lww.com/NT/A20. To score the vegetable/fruit component for each entrée, the menu description was read in detail, and photographs of entrées as served from review Web sites (eg, Yelp) were reviewed to estimate serving size. Photographs were available for nearly all included entrées; 1 entrée was excluded because a photograph for reference was not available. In addition, 20 samples from 4 restaurant chains were purchased to validate the estimation of vegetable/fruit component size.

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Estimated Nutrition Score and Price Information

In the absence of a previously established rubric, a nutrition quality metric (Estimated Nutrition Score [ENS]) was created to allow for standardized comparisons between more healthy and less healthy entrées (Table 1). This score was largely based on the 2015-2020 US Dietary Guidelines for Americans,9 with necessary adaptations to assess a single entrée (vs overall dietary pattern) and to utilize available restaurant information. Nutrition information and prices were extracted from the restaurants' Web sites during June 2015 and, when possible, confirmed with printed material obtained from the restaurants. Energy data were cross-validated using the stated value and calculated from the information provided for grams of fat, carbohydrate, and protein, using factors 9, 4, and 4, respectively. Small discrepancies (<5%) were attributed to rounding errors; a greater discrepancy resulted in exclusion of the entrée.

TABLE 1

TABLE 1

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Statistical Analysis

For each restaurant, entrées were classified as “more healthy” and “less healthy” according to the median nutrition score. A Spearman rank correlation was used to test the association between entrée price and nutrition score. To determine whether these associations were driven by the availability of small, half, and light entrée options, the data were reanalyzed eliminating these options. To determine the role calories played in the score, Spearman rank correlation analyses were repeated after removing the energy criterion from the score. Additional regression analysis was conducted and is shown in Supplemental Digital Content 2, http://links.lww.com/NT/A21.

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RESULTS

A total of 619 entrées from 11 restaurants were analyzed. The least expensive entrée examined was $8.00 and most expensive was $46.95. The highest nutrition score was 100, and lowest was −75. A scatter plot showing entrée price and ENS is available in Supplemental Digital Content 3, http://links.lww.com/NT/A23. The entrée with the lowest number of calories was 284 kcal, and highest was 4100 kcal. Median nutrition score by restaurant ranged from 37.5 to 63.75.

The relationship between the nutrition score and entrée price was highly variable within restaurants (Figure 2) and among restaurants (Table 2, restaurants ordered from highest positive correlation to lowest negative correlation). Of the 11 restaurants, the association between nutrition score and entrée price was statistically significant for 6 (55%). Of those, for 4 restaurants (C, G, I, K), the more healthy options were less expensive, whereas for 2 restaurants (F, J), the more healthy options were more expensive (Table 2). To determine whether these associations were driven by the availability of small, half, and light entrée options available in 4 of the restaurants (C, E, G, K), the data were reanalyzed eliminating these options. There was little change in the strength of the associations, with the exception of restaurant K, where the inverse association between price and ENS was no longer significant, suggesting that the small, half, and light options were driving the relationship in that one restaurant.

FIGURE 2

FIGURE 2

TABLE 2

TABLE 2

By design, the energy content of an entrée represented a large percentage of ENS. When the analyses were repeated after removing the energy criterion, the relationship between price and nutrition score was no longer significant for those restaurants that had been significant and became significant for restaurants A and B, with an inverse relationship between price and score (see Table 1, Supplemental Digital Content 4, http://links.lww.com/NT/A22). These data suggested that calories were the main driver of the results in the previous analysis.

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DISCUSSION

While some consumers may perceive healthier food as more expensive,13–15 this study suggests that within the casual dining restaurants assessed entrée price and nutrition quality were not consistently correlated. Some of the higher-priced entrées (eg, prime rib, lobster) scored low because of high calorie and saturated fat content relative to unsaturated fat content and low fiber and vegetables. Conversely, some of the lower-priced salad entrées scored high if they included protein, fiber, and vegetables and contained moderate amounts of calories and nutrients of concern. Although the number of restaurants that met the inclusion criteria was small, primarily due to the limited availability of full nutrition information, these data are important because they suggest that within the type of restaurants assessed high price should not be perceived as a barrier to more healthful eating. These findings are consistent with those reported for children's menu options.22 In addition, overall nutrition quality of the entrées as measured by the nutrition score was low. Within components of the score, calories were shown to be the main driver, signaling that portion size in casual dining restaurants may be an issue of concern. These results suggest that healthy-eating strategies in the restaurant setting are needed, such as portion control, and more consumer education on how to select healthier meals, including how to create off-menu healthy options, as restaurants are increasingly offering the flexibility to customize.26

There was no established method for assessing the nutrient quality of entrées. A metric was created for this study based on the Dietary Guidelines for Americans, as adherence to national guidelines has commonly been used to assess dietary quality.27–30 The approach developed for this study may have application for other research questions. Included were selected criteria associated with underconsumption or overconsumption in the US diet as highlighted by the 2015 Dietary Guidelines for Americans9: total energy, vegetable and fruit servings, fiber, saturated and unsaturated fat, sugar, sodium, and trans-fat. While this metric and its point allocation are similar to validated scoring systems such as the Healthy Eating Index,31 ENS has not been validated. Another major limitation of this study was the relatively small number of restaurants meeting the inclusion criteria, primarily due to the limited availability of entrée nutrient information. Thus, the nature of this analysis is exploratory, and our findings based on data from 1 type of restaurants in 1 city may have limited validity and generalizability. Given casual dining restaurants were assessed, these findings were likely more relevant to higher-income Americans who may dine out more frequently at such establishments than lower-income Americans. When mandatory menu labeling among chain restaurants is implemented in the US, future research may repeat the present analysis with larger sample size and further explore the relationship between restaurant meal nutrition quality and price in other types of restaurants. In addition, future research may assess the potential impact of menu labeling on consumer attitudes, including whether consumers still perceive healthier foods as more expensive when objective nutrition information is available at point of purchase.

Other unexpected challenges arose in creating an estimated nutrition quality score and applying it to restaurant entrées. All nutrition quality metrics relied on nutrition information provided by vendors; errors in nutrition information or inconsistencies in portion sizes as served could bias outcomes. To address this issue, total calories and grams of macronutrients were reconciled, and restaurants that provided implausible data were eliminated. In addition, the possibility could not be ruled out that restaurants with healthier offerings are more likely to publicize their nutrition information, creating potential selection bias. For this study, total consumption of entrées was assumed. Not accounted for was the possibility that some consumers may request off-menu substitutions, add significant amounts of condiments, or choose to take portions of the entrée home. Sandwiches and burgers were excluded, which accounted for a significant portion of the menu in some casual dining restaurants because it was not possible to estimate vegetable servings in these items or whether and how consumers customized their order. This exclusion may have introduced bias in the analysis. Lastly, not only do restaurants provide a large variety of entrées, but also consumers are frequently given exchange and substitution options. This issue was addressed in this study by establishing criteria, a priori, for creating healthier and less healthy entrée versions, as available to the consumer. Yet, the flexibility in customization may provide opportunities for consumers to substitute for healthier options in restaurants.

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CONCLUSIONS

Based on data from the 11 casual dining restaurants in the Boston metropolitan area, there was no consistent association between ENS and entrée price. This exploratory analysis suggests that within the type of restaurants assessed customers can often choose healthier entrées that are priced less than or equal to less healthy entrées. From a translational perspective, this is an important issue to emphasize when developing actionable nutrition education messages. Our research additionally suggests that the overall nutrition quality in casual dining restaurants as measured by the nutrition quality score is low; researchers and practitioners should focus on developing strategies to help consumers eat more healthfully when dining out.

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