Marketing to Children Inside Quick Service Restaurants: Differences by Community Demographics


      In the U.S., children regularly consume foods from quick-service restaurants, but little is known about the marketing strategies currently used inside quick-service restaurants. This study aims to validate a child-focused Environmental Assessment Tool for quick-service restaurants, evaluate marketing strategies inside and on the exterior of quick-service restaurants, and examine differences by community race/ethnicity or income.


      The inter-rater and test–retest reliability of the Environmental Assessment Tool were assessed across the top 5 national quick-service restaurant chains. Marketing techniques in 165 quick-service restaurants (33 per national chain) in socioeconomically and racially/ethnically diverse communities throughout New England were examined in 2018–2019. Mixed methods ANOVA examined the differences in marketing techniques in 2020.


      The inter-rater and test–retest reliability of the Environmental Assessment Tool were high (Cohen's κ>0.80). Approximately 95% of quick-service restaurants marketed less healthy foods, whereas only 6.5% marketed healthy options. When examining the differences by community demographics, there were significantly more price promotion advertisements inside and on the exterior of quick-service restaurants in lower-income communities. In addition, there was a greater number of child-directed advertisements with cartoon or TV/movie characters as well as fewer healthy entrée options and more sugar-sweetened beverage and dessert options on the children's menu inside quick-service restaurants in communities with higher minority populations.


      Environmental Assessment Tool is a valid tool to evaluate marketing inside quick-service restaurants. Results suggest that there is a substantial amount of unhealthy food and beverage marketing inside quick-service restaurants, with differences in the number and types of techniques used in lower-income and minority communities. Policies that limit quick-service restaurant marketing to children should be considered.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Fryar CD
        • Carroll MD
        • Ahluwalia N
        • Ogden CL
        Fast food intake among children and adolescents in the United States, 2015-2018.
        NCHS Data Brief. 2020; : 1-8
        Date accessed: February 8, 2021
        • Bowman SA
        • Gortmaker SL
        • Ebbeling CB
        • Pereira MA
        • Ludwig DS
        Effects of fast-food consumption on energy intake and diet quality among children in a national household survey.
        Pediatrics. 2004; 113: 112-118
        • Powell LM
        • Nguyen BT
        Fast-food and full-service restaurant consumption among children and adolescents: effect on energy, beverage, and nutrient intake.
        JAMA Pediatr. 2013; 167: 14-20
        • Taveras EM
        • Berkey CS
        • Rifas-Shiman SL
        • et al.
        Association of consumption of fried food away from home with body mass index and diet quality in older children and adolescents.
        Pediatrics. 2005; 116: e518-e524
        • Braithwaite I
        • Stewart AW
        • Hancox RJ
        • et al.
        Fast-food consumption and body mass index in children and adolescents: an international cross-sectional study.
        BMJ Open. 2014; 4e005813
        • Thompson OM
        • Ballew C
        • Resnicow K
        • et al.
        Food purchased away from home as a predictor of change in BMI z-score among girls.
        Int J Obes Relat Metab Disord. 2004; 28: 282-289
        • Rosenheck R
        Fast food consumption and increased caloric intake: a systematic review of a trajectory towards weight gain and obesity risk.
        Obes Rev. 2008; 9: 535-547
        • Block JP
        • Scribner RA
        • DeSalvo KB
        Fast food, race/ethnicity, and income: a geographic analysis.
        Am J Prev Med. 2004; 27: 211-217
        • James P
        • Arcaya MC
        • Parker DM
        • Tucker-Seeley RD
        • Subramanian SV
        Do minority and poor neighborhoods have higher access to fast-food restaurants in the United States?.
        Health Place. 2014; 29: 10-17
        • Kumanyika S
        • Grier S
        Targeting interventions for ethnic minority and low-income populations.
        Future Child. 2006; 16: 187-207
        • Fleming-Milici F
        • Harris JL
        Television food advertising viewed by preschoolers, children and adolescents: contributors to differences in exposure for black and white youth in the United States.
        Pediatr Obes. 2018; 13: 103-110
        • Harris JL
        Targeted food marketing to Black and Hispanic consumers: the tobacco playbook.
        Am J Public Health. 2020; 110: 271-272
        • Tandon PS
        • Zhou C
        • Chan NL
        • et al.
        The impact of menu labeling on fast-food purchases for children and parents.
        Am J Prev Med. 2011; 41: 434-438
        • Wansink B
        Environmental factors that increase the food intake and consumption volume of unknowing consumers.
        Annu Rev Nutr. 2004; 24: 455-479
        • Saelens BE
        • Glanz K
        • Sallis JF
        • Frank LD
        Nutrition Environment Measures Study in Restaurants (NEMS-R): development and evaluation.
        Am J Prev Med. 2007; 32: 273-281
        • Horacek TM
        • Yildirim ED
        • Simon M
        • et al.
        Development and validation of the full restaurant evaluation supporting a healthy (FRESH) dining environment audit.
        J Hunger Environ Nutr. 2019; 14: 381-400
        • Lytle LA
        • Sokol RL
        Measures of the food environment: a systematic review of the field, 2007-2015.
        Health Place. 2017; 44: 18-34
        • Krukowski RA
        • Eddings K
        • West DS
        The children's menu assessment: development, evaluation, and relevance of a tool for evaluating children's menus.
        J Am Diet Assoc. 2011; 111: 884-888
        • Cohen JFW
        • Rimm EB
        • Davison KK
        • Cash SB
        • McInnis K
        • Economos CD
        The role of parents and children in meal selection and consumption in quick service restaurants.
        Nutrients. 2020; 12: 735
        • Cohen JF
        • Roberts SB
        • Anzman-Frasca S
        • et al.
        A pilot and feasibility study to assess children's consumption in quick-service restaurants using plate waste methodology.
        BMC Public Health. 2017; 17: 259
        • Hill JL
        • Olive NC
        • Waters CN
        • Estabrooks PA
        • You W
        • Zoellner JM
        Lack of healthy food options on children's menus of restaurants in the health-disparate Dan River region of Virginia and North Carolina, 2013.
        Prev Chronic Dis. 2015; 12: E40
      1. United States of America. United States Census Bureau. Updated 2019. Accessed February 8, 2021.

        • Rimkus L
        • Ohri-Vachaspati P
        • Powell LM
        • et al.
        Development and reliability testing of a fast-food restaurant observation form.
        Am J Health Promot. 2015; 30: 9-18
        • Ross CE
        • Mirowsky J
        Disorder and decay: the concept and measurement of perceived neighborhood disorder.
        Urban Aff Rev. 1999; 34: 412-432
        • Pruitt SL
        • Jeffe DB
        • Yan Y
        • Schootman M
        Reliability of perceived neighbourhood conditions and the effects of measurement error on self-rated health across urban and rural neighbourhoods.
        J Epidemiol Community Health. 2012; 66: 342-351
        • Izumi BT
        • Zenk SN
        • Schulz AJ
        • et al.
        Inter-rater reliability of the Food Environment Audit for Diverse Neighborhoods (FEAD-N).
        J Urban Health. 2012; 89: 486-499
        • Cohen D
        • Bhatia R
        • Story MT
        • et al.
        Performance standards for restaurants: a new approach to addressing the obesity epidemic.
        RAND Corporation, Santa Monica, CA2013 (Published)
      2. Kids LiveWell. National Restaurant Association. Accessed February 8, 2021.

      3. Ranking cities with the most and least fast food restaurants: largest fast food restaurant chains. Datafiniti. Updated March 16, 2018. Accessed February 8, 2021.

        • Lock S
        Number of quick service restaurants in the U.S. 2019, by state.
        Statista, New York, NY2020 (Published October 21)
      4. Allison DB Allison DB Baskin ML Handbook of Assessment Methods for Eating Behaviors and Weight-Related Problems: Measures, Theory, and Research. 2nd ed. Sage Publications, Inc., Los Angeles, CA2009
        • Landis JR
        • Koch GG
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Glanz K
        • Basil M
        • Maibach E
        • Goldberg J
        • Snyder D
        Why Americans eat what they do: taste, nutrition, cost, convenience, and weight control concerns as influences on food consumption.
        J Am Diet Assoc. 1998; 98: 1118-1126
        • Bleich SN
        • Jones-Smith J
        • Wolfson JA
        • Zhu X
        • Story M
        The complex relationship between diet and health.
        Health Aff (Millwood). 2015; 34: 1813-1820
        • Rao M
        • Afshin A
        • Singh G
        • Mozaffarian D
        Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis.
        BMJ Open. 2013; 3e004277
        • Grier SA
        • Kumanyika S
        Targeted marketing and public health.
        Annu Rev Public Health. 2010; 31: 349-369
        • Grier SA
        • Kumanyika SK
        The context for choice: health implications of targeted food and beverage marketing to African Americans.
        Am J Public Health. 2008; 98: 1616-1629
        • Powell LM
        • Szczypka G
        • Chaloupka FJ
        Adolescent exposure to food advertising on television.
        Am J Prev Med. 2007; 33: S251-S256
        • Min J
        • Wen X
        • Xue H
        • Wang Y
        Ethnic disparities in childhood BMI trajectories and obesity and potential causes among 29,250 U.S. children: findings from the Early Childhood Longitudinal Study-Birth and Kindergarten Cohorts.
        Int J Obes (Lond). 2018; 42: 1661-1670
        • Cooksey Stowers K
        • Jiang Q
        • Atoloye A
        • Lucan S
        • Gans K
        Racial differences in perceived food swamp and food desert exposure and disparities in self-reported dietary habits.
        Int J Environ Res Public Health. 2020; 17: 7143
        • Fang Zhang FF
        • Liu J
        • Rehm CD
        • Wilde P
        • Mande JR
        • Mozaffarian D
        Trends and disparities in diet quality among U.S. adults by Supplemental Nutrition Assistance Program participation status.
        JAMA Netw Open. 2018; 1e180237
        • Robinson TN
        • Borzekowski DL
        • Matheson DM
        • Kraemer HC
        Effects of fast food branding on young children's taste preferences.
        Arch Pediatr Adolesc Med. 2007; 161: 792-797
        • Ji MF
        Children's relationships with brands: “True love” or “one-night” stand?.
        Psychol Mark. 2002; 19: 369-387
        • Valkenburg PM
        • Buijzen M
        Identifying determinants of young children's brand awareness: television, parents, and peers.
        J Appl Dev Psychol. 2005; 26: 456-468