Original Article

European Journal of Clinical Nutrition (2016) 70, 97–103; doi:10.1038/ejcn.2015.104; published online 1 July 2015

Epidemiology

Fast-food and full-service restaurant consumption and daily energy and nutrient intakes in US adults

R An1

1Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA

Correspondence: Professor R An, Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, 1206 South 4th Street, Champaign, IL 61820, USA. E-mail: ran5@illinois.edu

Received 18 August 2014; Revised 5 May 2015; Accepted 2 June 2015
Advance online publication 1 July 2015

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Abstract

Background/Objectives:

 

Calorie intake and diet quality are influenced by the source of food and the place of consumption. This study examines the impacts of fast-food and full-service restaurant consumption on daily energy and nutrient intakes in US adults.

Subjects/Methods:

 

Nationally representative data of 18098 adults 18 years of age and above from the National Health and Nutrition Examination Survey 2003–2010 waves were analyzed. Outcomes included daily intake of total calories and 24 nutrients of public health concern. The key predictors were any food/beverage consumption in a day from fast-food or full-service restaurant, differentiated by consumption at home versus away from home. First-difference estimator addressed confounding bias from time-invariant unobservables such as personal food/beverage preferences by using within-individual variations in diet and restaurant consumption status between two nonconsecutive 24-h dietary recalls.

Results:

 

Fast-food and full-service restaurant consumption, respectively, were associated with a net increase in daily total energy intake of 190.29 and 186.74kcal, total fat of 10.61 and 9.58g, saturated fat of 3.49 and 2.46g, cholesterol of 10.34 and 57.90mg, and sodium of 297.47 and 411.92mg. The impact of fast-food and full-service restaurant consumption on energy and nutrient intakes differed by sex, race/ethnicity, education, income and weight status. Increased total energy, total fat, saturated fat, cholesterol and sodium intake were substantially larger when full-service restaurant food was consumed away from home than at home.

Conclusions:

 

A holistic policy intervention is warranted to target the American’s overall dining-out behavior rather than fast-food consumption alone.

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Introduction

Improving diet quality is a key health promotion strategy. Since 1980, a major theme of the US federal dietary guidelines has been to increase consumption of nutrient-rich foods and reduce consumption of energy-dense foods.1 However, a large majority of the American population fail to meet those guidelines, with insufficient consumption of nutrient-rich foods and excessive discretionary calorie intake.2 The source of food (for example, home-made versus restaurant) and place of consumption (at home versus away from home) have been linked with diet quality.3, 4 As lifestyles turn more hectic, eating out at fast-food restaurant or other food venues has become a growing part of the American diet.5, 6 During 2007–2010, US adults on average consumed over 11% of their daily total calories from fast food.7 Fast-food consumption has been consistently associated with higher energy intake and elevated risk for obesity in children and adults.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18

Despite the growing body of literature linking fast-food consumption with poorer diet quality, several issues are yet to be adequately addressed. Most studies used cross-sectional methods and/or non-nationally representative data. Dietary outcomes typically limited to total calories, fats and sugar, whereas many other nutrients (fiber, vitamins and minerals) essential to physical/mental functioning and overall health were underexamined. Besides fast-food outlets, full-service restaurants also profoundly have an impact on the American’s dietary patterns,19 but relevant studies remain lacking. Various genetic and socio-behavioral factors such as metabolism, diet habits, health attitudes, nutrition knowledge and affordability may contribute to the differential impact of restaurant consumption on energy and nutrient intake across population subgroups. Understanding population heterogeneity is essential in designing targeted policy interventions.

This study examined the relationship between fast-food and full-service restaurant consumption and nutrient takes among US adults using data from a nationally representative survey. We used within-individual variations in diet and restaurant consumption status based on twp nonconsecutive 24-h dietary recalls, which addressed the confounding issue due to unobservable individual characteristics such as taste preferences. In addition, restaurant use was differentiated by consumption at home versus away from home. Daily intake of total energy and the 24 nutrients of major public health concern were studied for the entire adult population and by sex, race/ethnicity, education, income and body weight status.

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Materials and methods

Data

Individual-level data came from the National Health and Nutrition Examination Survey (NHANES) 2003–2004, 2005–-2006, 2007–2008 and 2009–2010 waves. NHANES is a program of studies conducted by the National Center for Health Statistics to assess the health and nutritional status of children and adults. Since 1999, NHANES has been conducted continuously in 2-year cycles and has focused on a variety of health and nutrition measurements. A complex multistage probability sampling design is used to select participants representative of the civilian, non-institutionalized US population.

Except for the NHANES 1999–2000 wave where all respondents were asked to complete a single 24-h dietary recall interviews, all subsequent waves incorporated two dietary recalls, with the first collected in-person and the second by telephone 3–10 days later. In both interviews, each food or beverage item and corresponding quantity consumed by a respondent from midnight to midnight on the day before the interview was recorded. The in-person dietary recall (day 1) was conducted by trained dietary interviewers in the Mobile Examination Center with a standard set of measuring guides. On completion of the in-person interview, participants were provided measuring cups, spoons, a ruler and a food model booklet, which contained two-dimensional drawings of the various measuring guides available in the Mobile Examination Center, to use for reporting dietary intake during the telephone interview (day 2).

Since 2002, the dietary interviews include a question on the source of each food or beverage item consumed (where it was obtained, such as store, fast-food/pizza restaurant, restaurant with waiter/waitress and so on). As the question was not asked in 2001, the National Center for Health Statistics decided not to include its response data in the public version of the NHANES 2001–2002 wave. However, the data are released to the public for all subsequent waves.

The key predictors in the regression analyses are two dichotomous variables for consumption of any food or beverage item on a given day from a fast-food restaurant (fast food/pizza) or a full-service restaurant (restaurant with waiter/waitress, bar/tavern/lounge, or restaurant with no additional information). The dietary interviewers also asked whether a food or beverage item was consumed at home or away from home. We thus further differentiated the source of a food or beverage item by its place of consumption. Nonrestaurant food away from home was controlled in the regression analyses, which included all food and beverage items consumed away from home that were not from a fast-food or full-service restaurant.

The outcome variables in the regression analyses are daily intake of total energy, total fat, saturated fat, long-chain omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid), cholesterol, sodium, sugar, fiber, vitamin A, vitamin B1, vitamin B2, vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, vitamin K, calcium, copper, iron, magnesium, phosphorus, potassium, selenium and zinc.

To examine the potential population heterogeneity in the relationship between fast-food and full-service restaurant consumption and daily nutrient intakes, subgroup analyses were conducted based on stratified samples by sex (male and female), race/ethnicity (non-Hispanic White, non-Hispanic African American and Hispanic; other races/ethnicities were excluded due to insufficient sample size), education attainment (high school or lower education and college or higher education), income level (poverty to income ratio <130%, greater than or equal to130% but <300% and greater than or equal to300%) and body weight status. NHANES respondents’ body weight and height were measured by a digital scale and stadiometer in the Mobile Examination Center. Body mass index (BMI) is defined by weight in kilograms divided by height in meters squared. Body weight status was classified into normal weight (18.5 less than or equal to BMI < 25), overweight (25 less than or equal to BMI < 30) and obesity (BMI greater than or equal to 30). Underweight (BMI less than or equal to 18.5) was excluded due to insufficient sample size.

Among the 19303 NHANES participants aged 18 years and older, who participated in both day 1 and day 2 dietary interviews during 2003–2010, 18098 who were not pregnant, lactating or were on a special diet to lose weight at the time of interview were included in the analyses.

Statistical analyses

First-difference estimator was performed based on data from day 1 and day 2 dietary interview that provided two observations per person. The outcome (intake of total energy or a specific nutrient) of participant i in day t (t=12) is denoted by yit. We let vector Xi represent the set of variables that vary by participant (for example, sex and race/ethnicity) but remain constant within participants between the two dietary interviews. Given the short recall time interval of 3–10 days, Xsi includes individual characteristics that vary only in the longer term, such as age, education attainment, marital status, income level, body weight and so on. Indicator variables ffit and fsit denote whether any food or beverage consumed came from a fast-food or full-service restaurant, respectively. Two indicator variables that vary within participants between the two dietary interviews were controlled—nrit for any nonrestaurant food or beverage consumed away from home and weit for whether the dietary recall day was a weekend (versus a weekday).

A pooled cross-sectional setup specifies the outcome yit as a function of an unobservable term that varies by participant αi, observable variables that vary by participant Xi, observable variables that vary within participants between the two dietary interviews ffit, fsit, nrit and weit, and an independently distributed unobservable disturbance term εit.

Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Owing to the presence of the unobservable term αi (for example, personal food and beverage preferences), estimating equation (1) by controlling for the observables Xi only is prone to omitted variable bias. The first-difference estimator eliminates the bias by taking the difference between the 2 days of data within each participant, so that αi and μXi that are common within participants are removed.

Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

We further examined whether restaurant consumption away from home versus at home had different impacts on daily nutrient intakes using the following first-difference setup.

Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

where ffafhit and ffahit denote whether foods or beverages from a fast-food restaurant, if any, were consumed away from home or at home, respectively, and fsafhit and fsahit denote whether foods or beverages from a full-service restaurant, if any, were consumed away from home or at home, respectively.

The NHANES 2003–2010 multiyear complex sampling design was accounted for in both descriptive statistics and regression analyses. All statistical procedures were performed in Stata 13.1 SE version (StataCorp, College Station, TX, USA).

NHANES was approved by the National Center for Health Statistics Research Ethics Review Board, and this study used NHANES de-identified public data and was exempt from human subjects review.

Code availability

Stata programming codes used to generate the modeling outputs are available on request. Interested readers are encouraged to contact the author of the study.

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Results

Table 1 reports restaurant consumption prevalence and nutrient intakes in day 1 and day 2 dietary interview. About 32.2% and 26.0% of survey participants in day 1 reported fast-food and full-service restaurant consumption, respectively, compared with 29.1% and 19.9% in day 2. This difference in prevalence is likely to be due to a higher proportion of weekend intake interviewed in day 1 (38.7% versus 21.2% in day 2). Daily intake of total energy, total fat, saturated fat, cholesterol, sodium and sugar were also modestly higher in day 1.


Table 2 reports the estimated effects of fast-food and full-service restaurant consumption on daily nutrient intakes using first-difference approach. Fast-food and full-service restaurant consumption, respectively, was associated with a net increase in daily total energy intake of 190.29 and 186.74kcal, total fat of 10.61 and 9.58g, saturated fat of 3.49 and 2.46g, cholesterol of 10.34 and 57.90mg, and sodium of 297.47 and 411.92mg. Both fast-food and full-service restaurant consumption were associated with increased daily intake of phosphorus (74.98 and 58.57mg, respectively) and selenium (5.98 and 7.50mcg, respectively). Fast-food but not full-service restaurant consumption was significantly associated with increased daily intake of sugar (4.00g), vitamin B1 (0.12mg), vitamin B2 (0.09mg), calcium (77.96mg) and iron (0.82mg), and decreased daily intake of fiber (0.38g), vitamin A (64.61mcg), vitamin C (5.21mg), vitamin D (0.44mcg), vitamin K (9.22mcg), copper (0.04mg) and magnesium (5.30mg). Conversely, full-service but not fast-food restaurant consumption was significantly associated with increased daily intake of long-chain omega-3 fatty acids (31.86mg), vitamin B6 (0.07mg), vitamin E (0.55mg), vitamin K (8.87mcg), copper (0.06mg), potassium (61.47mg) and zinc (0.89mg).


The impact of fast-food and full-service restaurant consumption on daily nutrient intakes to some extent differed by sex, race/ethnicity, education, income and body weight status. For example, men had higher daily intake of total energy, total fat, saturated fat and sodium attributable to fast-food or full-service restaurant consumption than women. Compared with their Caucasian and Hispanic counterparts, daily total energy consumption as well as intake of total fat, saturated fat, sodium and sugar associated with fast-food and full-service restaurant consumption were noticeably higher in African Americans. The effect of fast-food restaurant consumption on daily total energy intake appeared larger among people with lower education attainment. In contrast to their poorer and richer counterparts, people in the middle income range had higher daily intake of total energy, total fat, saturated fat and sodium associated with full-service restaurant consumption. The influence of full-service restaurant consumption on daily intake of total energy, total fat, saturated fat, cholesterol and sodium appeared larger in the obese population compared with their normal weight and overweight counterparts.

Table 3 reports the estimated effects of fast-food and full-service restaurant consumption at home and away from home on daily nutrient intakes. Daily intakes of total energy, total fat, saturated fat and sodium were similar between fast food consumption away from home and at home, whereas cholesterol and sugar intake appeared higher away from home. Conversely, increased total energy, total fat, saturated fat, cholesterol and sodium intake were substantially larger when full-service restaurant food was consumed away from home than at home.


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Discussion

This study confirmed findings from previous literature on the positive association between fast-food consumption and daily total calorie, fat and sugar intake.8, 9, 10, 11 Fast-food consumption was also linked with higher intake of cholesterol and sodium, and lower intake of fiber, vitamin A, vitamin C, vitamin D, vitamin K, copper and magnesium. American adults’ daily total energy intake from fast food experienced a modest decline from 12.8% to 11.3% during 2003–2010 but remains high.7 It is unclear to what extent sociopolitical campaigns against fast food (for example, ban on new fast-food restaurants in South Los Angeles or soft drink size limit in New York),20, 21 federal menu labeling laws22 or fast-food industry self-regulations in response to mounting public concern have a role in changing the landscape of fast-food consumption in the United States.23 In their 2010 report to the President, the White House Task Force on Childhood Obesity recommended state and local sales taxes on fast food, soft drinks and snacks.24 However, as the snack food tax in Maine and the District of Columbia was repealed in early 2000s, no states currently levy taxes on snacks or fast food.25 Although a majority of states have a sales tax on sugar-sweetened beverages at a higher rate than the tax on other types of food,26 the tax rate is still believed to be too low to induce a meaningful change in beverage consumption27 and no tax revenue is earmarked for subsidizing healthier food purchases or physical activity programs.28

As fast food becomes a synonym for ‘junk food’ or ‘sin food’, a less asked follow-up question is whether food from full-service restaurant proves any healthier. Although full-service restaurant outperformed fast-food outlet in lower daily intake of sugar and higher intake of long-chain omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid), certain vitamins and minerals, the incremental daily consumption of total calories, total fat and saturated fat were fairly comparable between fast-food and full-service restaurant, whereas that of cholesterol and sodium were noticeably higher for full-service restaurant. Current national and local policies mainly target fast-food restaurant consumption. For example, the federal menu labeling regulations implemented by the US Food and Drug Administration only apply to chain restaurants with 20 or more locations.29 A temporary ordinance in 2008 prohibited the establishment of new stand-alone fast-food restaurants in South Los Angeles.20 Built on previous literature,3, 6, 30, 31, 32, 33 our findings underline the importance of a holistic public health intervention addressing the overall dining-out behavior rather than fast-food restaurant consumption alone.

Some heterogeneity in the relationship between restaurant consumption and nutrient intakes appeared present. Sex differences in dietary behavior and food choices have been documented.34, 35, 36 National surveys reported non-Hispanic African American adults to consume a higher proportion of calories from fast food compared with their non-Hispanic White and Hispanic counterparts.7 Possible reasons include greater exposure (higher fast food outlet density in African American neighborhoods),37 better taste, lower cost and lack of nutrition knowledge.38 The negative association between education attainment and fast-food consumption is not well understood, but is potentially attributable to better health awareness and knowledge.10 People in the middle-income range consumed more calories from fast-food and full-service restaurants compared with those in the low- and high-income category. This result partly coincides with findings from a national study, which documented fast-food dining became more common as earnings increased from low to middle income but decreased as earnings increased further.39 The cost range of full-service restaurant consumption tends to be much wider than that of fast food. It is possible that compared with the middle-income population, adults earning high income use full-service restaurant as or more often, but these two subpopulations differ profoundly in food choice and diet quality.40, 41 Consistent evidence links fast food with obesity.11, 15, 33 This study confirmed fast-food restaurant consumption to be associated with higher daily total calorie intake in obese adults. However, more importantly, compared with their normal weight and overweight counterparts, obese adults had the highest daily intake of total energy, total fat, saturated fat, cholesterol and sodium associated with full-service restaurant consumption. Unlike fast-food restaurant, which is notorious for energy-dense diet and where calorie and nutrition information is typically provided, obese individuals could be less alert of overeating in a full-service restaurant.

Dietary behavior is influenced by eating environment.42, 43 A study based on the NHANES 2003–2008 waves found soda consumption in adolescents doubled when consumed away from home than at home. Similar pattern was identified in our study, as fast food consumed away from home was associated with higher sugar and cholesterol intake. However, the larger discrepancy between adults’ dietary intake away from home and at home was with full-service restaurant consumption. Various factors such as longer dining time, socializing and greater variety might contribute to excess calorie intake when eating in a full-service restaurant.42

A few limitations of this study should be noted. NHANES is a probability sample of the US noninstitutionalized population and the dietary intakes among patients in penal/mental facilities, institutionalized older adults and/or military personnel on active duty are not represented. Dietary intakes in NHANES were self-reported and subject to measurement error, in particular, underreporting, and the discrepancy between self-reported and estimated intake was found to peak among obese respondents.44 First-difference estimator eliminated confounding bias from unobservable factors that remained constant within participants between the two dietary interviews, but could not control for more transient factors such as daily variations in physical activity, appetite or emotions. Overall, daily dietary intake rather than meal occasion (for example, breakfast, lunch or dinner) was the unit of analysis. Future research needs to examine the possible differential impact of fast-food and full-service restaurant consumption on energy and nutrient intakes by meal time. Energy in animal products is influenced by means of production. There is evidence on the increasing fat content among intensively reared animals with little exercise and high-energy feeds.45 It is plausible that red meat and poultry sold in fast-food outlets (and in some full-service restaurants) are from the cheaper end of the market, which are likely the fattest, but our analyses could not adjust for this difference due to lack of data.

In conclusion, both fast-food and full-service restaurant consumption were associated with excess calorie intake and, in general, poorer diet quality. A comprehensive policy intervention is warranted to target American’s overall dining-out behavior rather than fast-food consumption alone.

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Conflict of interest

The authors declare no conflict of interest.

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