Many fast food restaurants have been working overtime to make sure their menus are stocked with healthy choices. McDonald’s has added an array of salads, apple slices, grilled sandwiches and other low-calorie fare. And Subway has staked its reputation on providing a complete menu of healthy choices.
But, do aggressively advertised and available healthy food options actually lead people to make better choices? That was the question posed by veteran obesity researcher Lenard Lesser, MD, MSHS, a Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2009-2012). “Our study did not focus on menus and what the restaurants offered. We wanted to look at outcomes. We wanted to find out what young people were actually ordering,” he said.
“I’ve been interested in the marketing environment and how that affects the food purchases people make,” explained Lesser, a family physician at the Palo Alto Medical Foundation, whose previous work focused on obesity linked to billboard advertising. “We wanted to find out if advertising healthy food encouraged people to eat fewer calories.”
Testing the Healthy Options Effect
To get answers, Lesser and his team partnered with the Carson, CA.-based organization Youth Family Schools and Community Partnership In Action to create a community-based-participatory-research project incorporating the opinions of teens and young adults.
“The kids and their parents contributed ideas about study design and data collection methods,” Lesser said. “We asked ninety-seven 12- to 21-year-olds to purchase a meal at Subway on one day and at McDonald’s on another day. They used their own money and appeared to have a meal budget of about $5.” There was some sensitivity to price at Subway because the meals cost close to $6. They cost only $4 at McDonald’s.
The teens chose Subway as their local healthy choice, but their decision was also backed by the Nutrition Environment Measures Survey for Restaurants (NEMS-R). The 25-question survey counts the number of healthy options available in a restaurant as well as environmental factors such as signs that promote healthy eating, combo-meal deals, pricing, and choices for side items. Subway’s NEMS score is 41. McDonald’s comes in at 22 (63 is the highest and most positive score).
When in Subway, people may experience a sort of halo effect,” Lenard Lesser, MD
The teens were allowed to select their own main menu items and sides. Lesser and his team then determined the mean nutrition content for the meals purchased at each restaurant. The results were published in the article “Adolescent Purchasing Behavior at McDonald’s and Subway,” published online in the May 6 Journal of Adolescent Health.
“After determining the mean nutritional content of the meals selected, we found no statistical difference between the calories in the meals selected at the two restaurants, though there were other small differences,” Lesser said.
At McDonald’s, the teens ate 1,038 calories a meal. At Subway, they ate 955 calories per meal. There were 45 grams of fat in the McDonald’s meal and 42 grams of fat in the Subway meal. The Subway meal also had a whopping 2,149 mg of sodium (the recommended amount for a full day’s food intake is 2,300). The McDonald’s meal had 1,829 mg of sodium. But that meal made up for the relatively lower amount of salt by packing 54 grams of sugar (recommended daily intake is about 25-35 grams). Subway did a little better with 36 grams of sugar.
Beware the Halo Effect
The take-home message, Lesser advised, is that even when healthy foods are available, we must order our meals with caution and common sense. “Research on adults has shown that when in Subway, people may experience a sort of halo effect. They underestimate the amount of calories they consume because they assume all of the food is healthy.”
Lesser’s research, which was supported by the Robert Wood Johnson Foundation, did reveal subtle differences in the teen’s food ordering patterns that indicate where calories could have been saved.
“At Subway, the teens got more calories from the main dish. At McDonald’s, the extra calories primarily came from the side dishes, such as fries and large drinks,” Lesser said. “The teens ate more vegetables [the menu offers tomato, cucumbers, onions, peppers] at Subway and less sugar, but far more sodium. That salt may come from the processed meats.”
To get a healthier fast food fix, Lesser recommends:
- Slim the sides: “At McDonald’s, eliminate the sugary drinks and French fries,” he advised. “Study participants ate significantly more carbohydrates at McDonald’s and less protein.”
- Lose like Jared: “At Subway, opt for the six-inch sub, rather the foot-long. If the foot-long combo price is tempting, split it with someone. Also ask for half the meat and twice the veggies on your sandwich,” Lesser said. That last step should reduce the salt.
- Ignore the advertising: “Subway is trying to draw people in with healthy options, but on the day we were there, the featured sub was the meatball marinara—white bread and red meat.”
“If you put all of these results together, it is not clear that Subway is healthier than McDonald’s,” Lesser said. “Offering healthy choices and advertising them widely is fine, but until we have policies or initiatives that improve the outcomes of eating healthy foods, we will not succeed in solving the crisis of poor eating.”