The Happy Meal[R] effect: the impact of toy premiums on healthy eating among children in Ontario, Canada.
Hobin, Erin P. ; Hammond, David G. ; Daniel, Samantha 等
The prevalence of overweight and obesity has risen dramatically
among Canadian children. Since 1981, childhood obesity rates have almost
tripled, with approximately 26% of Canadians aged 6-19 years currently
overweight or obese. (1) Childhood obesity is an important predictor of
adult obesity and significantly increases the risk of chronic disease,
including diabetes and cardiovascular disease. (2,3)
The increasing proportion of Canadian children who eat at fast-food
outlets as part of their regular diet has likely contributed to the
increase in obesity. (4) Food consumed at fast-food restaurants is
associated with higher caloric, higher fat, and saturated fat intake, as
well as lower intake of fruit and vegetables. (5-8) A recent study of
the nutrient quality of children's meals available at fast-food
restaurants in the US found that only 3% of available meals met
nutrition criteria for school-aged children. (9)
Toy premiums--providing toys with children's meals--are an
increasingly popular marketing practice used by the fast-food industry.
(10-12) In most cases, toy premiums consist of cross-promotions with the
entertainment industry and feature characters from popular
children's movies or TV programs. In 2006, fast-food outlets in the
US spent approximately $330 million on toy premiums with children's
meals. (13) More than 1.2 billion meals with toys were sold to children
under age 13, making these meals the top-selling fast-food item to
children. (13) Comparable sales data among Canadian fast-food outlets
are unavailable; however, toy premium marketing trends appear to be
similar.
Currently, Canada has very few regulations restricting food
marketing practices directed at children. (14) Quebec is the only
province to prohibit food marketing to children in schools as well as on
Canadian-based television and radio advertising. (14) Recently, Santa
Clara and San Francisco Counties in California became the first
jurisdictions in the world to regulate toy premiums provided by
restaurants. (15,16) The standards only allow toy premiums to be
provided with meals that meet certain nutritional criteria established
by the US Department of Agriculture. (15,16) Since the regulations were
passed, the food industry has actively lobbied state lawmakers in
Florida and Arizona to pre-empt similar legislation preventing toy bans
from reaching their states. (17)
Previous research has shown that children are exposed to high
levels of food marketing in general (18-22) and that exposure to
television advertising is associated with greater preference for
unhealthy foods and beverages. (22) However, to our knowledge, only a
single study has examined the effect of toy premiums on children's
food choices. (23) Results of this study suggest that children choose
healthier meal options if toy premiums are only provided with healthier
meals. However, the study did not examine actual meal selection or use
actual examples of fast-food meals or toys available in the marketplace,
and was conducted only with children age 5 years and under. As a result,
there is very little evidence on the potential impact of toy premium
regulations.
The primary objective of the current study was to examine whether
children select healthier food products when these are accompanied by
toy premiums offered by fast-food outlets in Ontario, Canada. The study
also examined whether the impact of restricting toy premiums to
healthier foods varied by gender and age.
METHODS
Overview and design
A between-groups experimental study was conducted with children
aged 6-12 years attending a YMCA camp in Ontario. Children were offered
four McDonald's Happy Meal[R] options as part of the lunch program
at the camp: two "healthier" Happy Meal[R] options that met
the nutritional requirements outlined in the San Francisco "Healthy
Food Incentives Ordinance" and two "less healthy" Happy
Meal[R] options that did not meet the criteria. Under the San Francisco
Ordinance, children's meals accompanied by toys must be less than
600 calories with less than 35% of total calories from fat, less than
10% of calories from saturated fat, less than 0.5 g of trans-fat, and
less than 640 mg of sodium. (16) In addition, at least 50% of bread
products must be whole wheat and the meal must include at least one-half
cup of fruit and of vegetables. (16) The two healthier Happy Meal[R]
options offered in this study met all of the criteria except the 50% of
bread products being whole wheat. However, when the nutritional value of
the McDonald's[R] hamburger bun and wrap are compared to the
nutritional value of 100% whole wheat hamburger buns and wraps, the
difference in the grams of fibre was relatively minimal (e.g., 1 g of
fibre in McDonald's[R] hamburger bun compared to 2 g of fibre in a
standard commercial 100% whole wheat hamburger bun). (24,25)
Children attending the YMCA camp were randomly assigned to either a
control or intervention condition according to week of camp attended. In
the control condition, all four meal options were offered with a toy. In
the intervention condition, the toy was only offered with the two
"healthier" meals. The toy premiums offered to children varied
each week according to the toys offered by McDonald's[R]
restaurants for the study dates. During four of the six study weeks,
gender-specific toys were provided, while a gender-neutral toy was
offered for the other two weeks.
Participants and recruitment
All children attending the YMCA camp in Ontario were invited to
participate in the study. Information letters with consent forms written
in English were mailed to parents one week prior to the study. The
letters informed parents that their child was being invited to
participate in research examining food marketing directed at children
without revealing the use of toys as the stimuli. In total, 64% of
children (n=337) were recruited from the camp over a 6-week period in
July and August 2011. Children were randomly assigned to either the
control condition or the intervention condition according to week of
camp attended so that all children attending camp in the same week were
assigned to the same condition. Children attending multiple weeks of
camp (13%) only participated in the study their first week of camp. The
study received clearance from the Office of Research Ethics, University
of Waterloo, and the parents of all study participants provided active
permission prior to the study.
Protocol
On the morning of data collection, camp staff read an information
letter to participating children introducing the study and what was
required to participate in the study. The camp staff then provided
children with a lunch meal order form. On the order form, children were
asked to include their name, age, gender, and to select one of four
Happy Meal[R] options. The four meal options included: A)
McDonald's[R] hamburger with ketchup, pickles and two slices of
onion, small French fries, and a can of Coke[R]; B) McDonald's[R]
grilled chicken wrap with a sodium-reduced tortilla, one-half cup of
lettuce, Monterey Jack and light cheddar cheese, and sodium-reduced
ranch sauce, small French fries, and a can of Coke[R]; C)
McDonald's[R] hamburger with ketchup, pickles, and two slices of
onion, apple slices with caramel dipping sauce, and a bottle of water;
and D) McDonald's[R] grilled chicken wrap with a sodium-reduced
tortilla, one-half cup of lettuce, Monterey Jack and light cheddar
cheese, and sodium-reduced ranch sauce, apple slices with caramel
dipping sauce, and a bottle of water.
Order forms were designed according to the experimental condition.
In the control condition, all four meal options were offered with a toy
premium. A picture of the toy premium was displayed next to each meal
option. In the intervention condition, the toy was only offered with the
two meal options that met nutritional criteria (options C and D).
Intervention menus displayed a picture of the toy premium for options C
and D, and indicated "No Toy" for options A and B (please
refer to http://davidhammond.ca/downloads/Nutrition%20Study/ for copies
of menus and toy information) (Accessed July 9, 2012). Completed order
forms were collected by the camp staff, sealed in an envelope, and
returned to the research assistants who then purchased meals and toy
premiums for consumption during the lunch hour. Training was provided to
all camp staff prior to the start of the study. Camp staff were
instructed to help children with order forms only as needed.
Measures
Outcome Measure
The proportion of children who ordered the "healthier"
Happy Meals[R] (options C and D) that met nutritional criteria compared
to children who ordered the "less healthy" Happy Meals[R]
(options A and B) served as the outcome measure.
Explanatory Variables
Gender and age were assessed using the information collected on the
children's order forms.
Analyses
Chi-square tests were used to examine potential differences in
gender and age between intervention and control conditions to evaluate
whether randomly assigning different weeks of camp was effective in
distributing potential confounders across experimental conditions.
Logistic regression models were used to test for differences between
study conditions, adjusting for age and gender. The outcome measure in
the model was whether or not the child chose the healthier meal option
(1) versus the less healthy meal option (0). Two-way interactions
between gender and condition and age and condition were also examined.
All analyses were conducted in SAS version 9.0 (Cary, NC).
RESULTS
Sample characteristics
Table 1 shows sample characteristics by condition. Overall, 167
children participated in the control condition and 170 children
participated in the intervention condition. Age varied by condition,
with a greater proportion of older children in the intervention
condition ([X.sup.2] = 15.0, p=0.02). There were no statistically
significant differences between the two conditions by gender.
Effect of toy premium on children's food choice
As shown in Figure 1, the proportion of children who ordered
healthier meals was 39.5% in the intervention condition and 19.4% in the
control condition. Table 2 shows the results of a logistic regression
model examining differences by experimental condition in the proportion
of children who ordered a healthier meal, adjusting for age and gender.
A significant main effect of condition was found, in which children in
the intervention condition were significantly more likely to order a
healthier meal compared to children in the control condition (OR=3.19,
95% CI: 1.89-5.40). The children ordering the healthier meal options
were also significantly more likely to be female (OR=1.19, 95% CI:
1.14-3.17). Children aged 6 years were more likely to order the
healthier meal options than children aged 9-12 years when adjusting for
condition. In addition, a significant two-way interaction between
condition and gender ([X.sup.2]=4.33, p=0.038) was observed: although
girls in the intervention condition were more likely to choose the
healthier meal options than girls in the control condition, boys had an
even greater odds of selecting healthier meals in the intervention
condition than girls. Analyses were conducted to test the effect of
study week by intervention and control conditions. There was a
significant effect by week, however when study week was entered as a
covariate in the main regression model, the pattern of findings did not
change.
DISCUSSION
To our knowledge, this is the first experimental study to examine
the impact of toy premiums on children's fast-food meal choices in
Canada. The findings indicate that children are more likely to order
healthier fast-food options if a toy is only provided with healthier
options. In the current study, children were three times more likely to
order the healthier meal options when toys were not offered with meals
that failed to meet nutritional criteria.
Pairing toys with healthier meal options had a stronger effect on
boys compared to girls. Boys were less likely to order healthier meal
options than girls in the control condition, consistent with some
research indicating that boys like fatty and sugary foods more than
girls and that among adults, males are less likely than females to
consider the nutritional content of foods they consume. (26,27) The
findings also suggest that the toys provided in the current study may
have been more appealing to boys than girls. The toys accompanying the
meals were the same toys offered by McDonalds[R] for that particular
week. Differences in the proportion of children who selected the
healthier meal across intervention weeks suggest that the influence of
toy premiums to shift eating habits may depend upon the intrinsic appeal
of the particular toy, which may differ across gender.
The results also suggest that children age 6 years were more likely
to order the healthier meal than children ages 9-12 years. This is
consistent with previous research stating that the diet quality of
children tends to decline as they approach adolescence. (26,27) An
alternative explanation specific to this study is that parents discussed
meal options with children prior to camp and younger children were more
apt to obey parents' requests for them to order a healthier meal
option whereas older children did not obey parents' requests.
Strengths and limitations
The sample consisted of children aged 6-12 years attending a YMCA
summer camp in the Waterloo Region. This convenience sample of children
does not constitute a representative sample and information about the
ethnicity/race of the children was not collected; however, children
attending the YMCA day camp are drawn from a cross-section of
socio-economic strata and ethnic groups within Cambridge, Ontario.
The overall response rate was 64% (proportion of children invited
to participate who completed the study). Estimates may be biased by
systematic differences between respondents and non-respondents. In
addition, participants in the intervention condition tended to be older
than participants in the control condition. However, regression models
were adjusted for age when testing the effect of condition. Given that
the results suggest toys are less likely to influence the food choices
of older children compared to younger children, the data in this
analysis may underestimate the effect of toys on children's food
choices.
Last, although parents were presented with study information and
children may have been instructed by parents to choose the healthier
meal option, ultimately the children's meal choices were made
without parents being present. Future research should examine the impact
of toy premiums on children's fast-food meal choices when parents
are present when food is ordered, which may be more consistent with how
these decisions are made in practice.
Implications
Reducing the marketing to children of foods and beverages high in
fat, sugar and sodium is one of three key priorities identified by the
Federal, Provincial and Territorial Framework for Action to Promote
Healthy Weights. (28) The current study contributes to the evidence base
on food marketing and highlights a potentially effective policy measure
for promoting healthier eating. Two California counties are the first
jurisdictions in the world to implement such a measure and to regulate
toy premiums for the purpose of promoting healthier diets. Future
research should examine the impact of this policy on actual food sales
and consumption.
McDonald's[R] restaurants in Canada and the US recently
announced nationwide changes to children's Happy Meals[R]. Starting
in the fall of 2011, McDonald's[R] Canada began testing Happy
Meals[R] with a default option that includes a small serving of 1% milk
fat yogurt and a smaller serving of French fries, in addition to the
drink and entree already offered. (29) Overall, the new default Happy
Meal[R] in Canada will contain fewer than 500 calories, whereas the
previous Happy Meals[R] contained more than 570 calories. (29) In the
US, McDonald's[R] announced plans to add a half-order of apple
slices and reduce the French fry serving to a half-order as the default
option for all Happy Meals[R] starting in January 2012. (29) Customers
in the US will be able to request all fries or all apples if desired.
The impact of these changes on meal selection and consumption is
unknown.
Received: January 3, 2012
Accepted: April 28, 2012
REFERENCES
(1.) Tremblay M, Shields M, Laviolette M, Craig C, Janssen I,
Gorber S. Fitness of Canadian children and youth: Results from the
2007-2009 Canadian Health Measures Survey. Health Rep 2010;21(1):1-15.
(2.) Ball G, McCargar L. Childhood obesity in Canada: A review of
prevalence estimates and risk factors for cardiovascular diseases and
type 2 diabetes. Can J Appl Physiol 2003;28:117-40.
(3.) Franks P, Hanson R, Knowler W, Sievers M, Bennett P, Looker H.
Childhood obesity, other cardiovascular risk factors, and premature
death. N Engl J Med 2010;462(6):485-93.
(4.) Bowman S, Gortmaker S, Ebbeling C, Pereira M, Ludwig D.
Effects of fast-food consumption on energy intake and diet quality among
children in a national household survey. Pediatrics 2004;113:112-18.
(5.) Kant A, Graubard B. Eating out in America, 1987-2000: Trends
and nutritional correlates. Prev Med 2004;38(2):243-49.
(6.) French S, Story M, Jeffery R. Environmental influences on
eating and physical activity. Annu Rev Public Health 2001;22:309-35.
(7.) Satia J, Galanko J, Siega-Riz A. Eating at fast-food
restaurants is associated with dietary intake, demographic, psychosocial
and behavioral factors among African Americans in North Carolina. Public
Health Nutr 2004;7:1089-96.
(8.) Schmidt M, Affenito S, Striegel-Moore R, Khoury P, Barton B,
Crawford P, et al. Fast-food intake and diet quality in black and white
girls: The National Heart, Lung, and Blood Institute Growth and Health
Study. Arch Pediatr Adolesc Med 2005;159(7):626-31.
(9.) O'Donnell S, Hoerr S, Mendoza J, Goh E. Nutrient quality
of fast-food kids meals. Am J Clin Nutr 2008;88:1388-95.
(10.) Kraak V, Pelletier D. The influence of commercialism on the
food purchasing behaviour of children and teenage youth. Fam Economics
Nutr Rev 1998;11:31-41.
(11.) Brownell K, Horgen K. Food Fight: The Inside Story of the
Food Industry, America's Obesity Crisis, and What We Can Do About
It. Chicago, IL: Contemporary Books, 2004.
(12.) Scholsser E. Fast Food Nation: The Dark Side of the All
American Meal. New York, NY: HarperCollins, 2001.
(13.) Federal Trade Commission. Marketing food to children and
adolescents: A review of industry expenditures, activities and
self-regulation, 2008. Available at:
http://www.ftc.gov/os/2008/07/P064504foodmktingreport.pdf (Accessed
November 4, 2011).
(14.) Dietitians of Canada. Advertising of food and beverages to
children: Position of Dietitians of Canada, December 2010. Available at:
http://www.dietitians.ca/Downloadable-Content/Public/Advertising-
to-Children-position-paper.aspx (Accessed November 4, 2011).
(15.) Santa Clara County Board of Supervisors. An ordinance of the
board of supervisors of the county of Santa Clara adding chapter XXII of
division A18 to the County of Santa Clara ordinance code relating to
toys and other incentives with restaurant food. Available at:
http://www.sccgov.org/keyboard/attachments/BOS%20Agenda/
2010/April%2027,%202010/202926863/TMPKey-board203046978.pdf (Accessed
November 4, 2011).
(16.) San Francisco Committee/Board of Supervisors. Ordinance
amending Article 8 of the San Francisco Health Code by adding Sections
471.1 through 471.8, to set nutritional standards for restaurant food
sold accompanied by toys or other youth focused incentive items.
Available at: http://www.sfbos.org/ftp/uploadedfiles/bdsupvrs/
committees/materials/lu092710_101096.pdf (Accessed November 4, 2011).
(17.) Bernstein S. Fast-food industry is quietly defeating Happy
Meal bans. Available at:
http://articles.latimes.com/2011/may/18/business/la-fi-happy-
mealbacklash-20110518 (Accessed November 4, 2011).
(18.) Elliott C. Assessing "fun foods": Nutritional
content and analysis of supermarket foods targeted at children. Obes Rev
2008;9(4):368-77.
(19.) Harris J, Pomeranz J, Lobstein T, Brownell K. A crisis in the
marketplace: How food marketing contributes to childhood obesity and
what can be done. Annu Rev Public Health 2009a;30:211-25.
(20.) Harris J, Schwartz M, Brownell K. Marketing foods to children
and adolescents: Licensed characters and other promotions on packaged
foods in the supermarket. Public Health Nutr 2009b;13(3):409-17.
(21.) Kovacic W, Harbour J, Leibowitz J, Rosch J. Marketing Food to
Children and Adolescents: A Review of Industry Expenditures, Activities,
and Self-Regulation. Washington, DC: FTC, 2008.
(22.) Institute of Medicine. Food Marketing to Children and Youth:
Threat or Opportunity? Washington, DC: The National Academies Press,
2006.
(23.) McAlister A, Cornwell T. Collectible toys as marketing tools:
Understanding preschool children's responses to foods. J Public
Policy Marketing 2011;doi: 10.1509/jppm.10.0197
(24.) Plain hamburger bun McDonald's. Available at:
http://www.livestrong.com/thedailyplate/nutrition-
calories/food/mcdonalds/plain-hamburger-bun/ (Accessed November 4,
2011).
(25.) 100% Wonder Whole Wheat Wraps. Available at:
http://www.livestrong.com/thedailyplate/nutrition-
calories/food/wonder-bread/10025-whole-wheatwraps/ (Accessed November 4,
2011).
(26.) Golley R, Hendrie G, McNaughton S. Scores on the dietary
guidelines index for children and adolescents are associated with
nutrient intake and socioeconomic position. J Nutr 2011;141:1340-47.
(27.) Rasmussen M, Krolner R, Klepp K, Lytle L, Brug J, Bere E, Due
P. Determinants of fruit and vegetable consumption among children and
adolescents: A review of the literature. Part I: Quantitative studies.
Int J Behav Nutr Phys Act 2006;3(22).
(28.) Public Health Agency of Canada. Curbing childhood obesity:
Federal, Provincial and Territorial framework for action to promote
healthy weights. Available at:
http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/framework-cadre/pdf/ccofw-eng.pdf (Accessed November 4, 2011).
(29.) CTV News. McDonald's Happy Meals changing in US, Canada.
Available at: http://www.ctv.ca/CTVNews/Health/20110726/mcdonalds-apples-happymeal-110726/C (Accessed November 4, 2011).
Erin P. Hobin, PhD, [1] David G. Hammond, PhD, [1] Samantha Daniel,
BA, [1] Rhona M. Hanning, PhD, [1] Steve R. Manske, EdD [2]
Author Affiliations
[1]. School of Public Health and Health Systems, University of
Waterloo, Waterloo, ON
[2]. Propel Centre for Population Health Impact, University of
Waterloo, Waterloo, ON
Correspondence: David Hammond, School of Public Health and Health
Systems, University of Waterloo, 200 University Ave West, Waterloo, ON
N2L 3G1, Tel: 519-888-4567, ext. 36462, E-mail: dhammond@uwaterloo.ca
Acknowledgements of Sources of Support: We would like to thank the
Chaplin Family YMCA of Cambridge for their support of this study. This
research was supported by a grant from the Propel Centre for Population
Health Impact at the University of Waterloo, a Post-doctoral Fellowship
Award funded by the Heart and Stroke Foundation of Canada and the
CIHR/Training Grant in Population Intervention for Chronic Disease
Prevention: A Pan-Canadian Program (Hobin, Grant #: 53893), a Canadian
Institutes of Health Research New Investigator Award (Hammond), and a
Canadian Cancer Society Research Institute Junior Investigator Research
Award (Hammond).
Conflict of Interest: None to declare.
"McDonald's" and "Happy Meal" are
registered trademarks of the McDonald's Corporation.
"Coke" is a registered trademark of The Coca-Cola Company.
Table 1. Characteristics of Participants by Experimental
Condition
Experimental Conditions
Control Intervention Chi-square by
n = 167 n = 170 Condition
% (n) % (n)
Gender Male 51.3 (78) 48.7 (74) [X.sup.2] = 0.3, p = 0.558
Female 48.1 (89) 51.9 (96)
Age 6 58.2 (32) 41.8 (23) [X.sup.2] = 15.0, p = 0.020
7 44.4 (24) 55.6 (30)
8 62.5 (35) 37.5 (21)
9 45.0 (27) 55.0 (33)
10 54.8 (34) 45.2 (28)
11 29.0 (11) 71.1 (27)
12 35.3 (6) 64.7 (11)
Table 2. Odds Ratios for Characteristics Associated With
Choosing Healthier Meal Options Among Children
Ages 6 to 12
Odds Ratio * 95% CI p-value
Gender Male 1.00 Ref.
Female 1.90 1.14-3.17 0.01
Age 6 1.00 Ref.
7 0.45 0.20-1.03 0.06
8 0.62 0.27-1.39 0.24
9 0.27 0.11-0.64 0.003
10 0.31 0.13-0.72 0.007
11 0.28 0.11-0.73 0.01
12 0.19 0.05-0.79 0.02
Condition Control 1.00 Ref.
Intervention 3.19 1.89-5.40 <0.0001
CI = confidence interval.
* Adjusted odds ratio.
Figure 1. Proportion of children who chose healthier meal
options by study condition (n=337)
Control Intervention
Overall 19.4% 39.5%
Boys 10.1% 37.3%
Girls 27.5% 41.2%
Note: Table made from bar graph.
