In the UK, it has been reported that 20 % of children and 27 % of adults eat out at least once every week⁽¹⁾. In the USA, it is stated that 36 % of children aged 2–19 years eat at a fast food restaurant on a typical day⁽²⁾. Eating in restaurants has now become a regular occurrence rather than an occasional treat^{(Reference Seguin, Aggarwal and Vermeylen3,Reference Paddock, Warde and Whillans4)} . Given that the incidence of overweight and obesity is still rising^(5,6) and levels of obesity disproportionally affect children living in deprived areas^(6,7) , we need to consider the way unhealthy foods are promoted and how we can facilitate parents to make healthy choices for their children including when eating out of the home.

In the linked paper, Dunn and colleagues^{(Reference Dunn, Vercammen and Frelier8)} consider the Nutrition Composition of Children’s Meals in twenty-six large US Chain Restaurants. The authors highlight that not only do restaurants frequently sell unhealthy individual menu items, but they are also often bundled into combinations such as a meal deal that include a main dish, a side order or a dessert and a beverage at a discounted price. Even when healthier sides and beverages are available, they are rarely included as the default meal deal. This paper investigated and found that when the default meals advertised were compared with the minimum and maximum versions that can be chosen, nutrient values differed significantly. For example, they found default meals on average contained 584 kcal, whereas the minimum option was 400 kcal and the maximum was 792 kcal; similar patterns were seen for fat, salt and sugar. Some items in particular were found to have a salient effect; substituting a beverage for a low energy version or water could reduce energy intakes by on average 100 kcal and sugar by 20 g, and substituting side orders such as French fries resulted in the greatest reductions in fat and salt. They proposed that restaurants could repackage their meal deals by simply substituting healthier items that in most cases, the restaurants already offered; a simple strategy requiring neither reformulation nor investment. Thus, they showed that realistic modifications can significantly alter a meals’ nutrient composition and that relatively straightforward changes to beverages and side dishes had the potential to reduce energy, fat, salt and sugar, paving the way for healthier items to be the default options. This confirms the findings from one of our own studies^{(Reference Young, Coppinger and Reeves9)} that highlighted the extent to which additional courses and drinks in default meal deals offered on children’s menus in restaurants substantially contributed to the energy content of a meal in the UK and Ireland. In particular, by choosing the meal deal option, often seen as more convenient and sometimes, but not always, cheaper, parents are perhaps unknowingly ordering meals that have higher levels of energy, fat, salt and sugar.

Marketing practices, that often include a toy^{(Reference Webley10)}, can persuade increased consumption by using meal bundling and default meals to override individual decisions that encourage customers to buy items together that they may not have chosen if each item were listed separately^{(Reference Cohen and Lesser11)}. Bundling may also give the perceived impression of better value for money^{(Reference Henry and Borzekowski12,Reference Sharpe and Staelin13)} . Furthermore in some restaurants, the sheer number of options to choose from can make selecting the healthier choice more complicated than it should be^{(Reference Henry and Borzekowski12)}. Bundling and meal deals also provide a perception norm^{(Reference Harris and Thomas14)} and give the notion that the constituent items complement each other^{(Reference Sharpe and Staelin13)}. This includes desserts and drinks that when included in a meal deal are more likely to be ordered and consumed^{(Reference Loeb, Radnitz and Keller15)}. Thus, bundles increase the purchase of calories which naturally leads to greater consumption^{(Reference Fisher, Roll and Birch16)}.

Given that customers often revert to the default menus^{(Reference Loeb, Radnitz and Keller15)}, simple substitutions have the potential to improve the nutrient composition of meals on children’s menus in restaurants. There are other studies that have measured the effectiveness of substituting items in different meal deals^{(Reference Cantor, Breck and Elbel17,Reference Anzman-Frasca, Dawes and Silwa18)} . Similarly to the Dunn et al.’s^{(Reference Dunn, Vercammen and Frelier8)} findings, an Australian study found that choosing water rather than a sugar-sweetened beverage could significantly reduce the amount of energy consumed. An American cross-sectional study of 483 restaurant receipts showed that 60 % of beverages purchased were sugar-sweetened, and uncoupling sugary beverages from a meal deal could reduce energy and sugar intakes, since in this study, meals with a non-sugar-sweetened beverage had on average 179 kcal less than meals with a sugar-sweetened beverage^{(Reference Cantor, Breck and Elbel17)}. Thus, it would appear that eliminating a sugar-sweetened beverage offers the easiest way to reduce energy and sugar from a fast food meal. This highlights that a simple move, such as restaurants offering tap water as default, could have a significant effect^{(7,Reference Brindal, Mohr and Wilson19)} . Simple modifications or optimal defaults can nudge choices in a positive direction^{(Reference Loeb, Radnitz and Keller15)}. Bundled meals have been reported as being popular with parents as long as they could choose the individual items that were included^{(Reference Henry and Borzekowski12,Reference Anzman-Frasca, Folta and Glenn20)} . One qualitative study revealed that parents thought healthier defaults could facilitate ordering and in their view ‘help other parents’^{(Reference Henry and Borzekowski12)}. Modifications to children’s menus to make them healthier, for example, increasing fruit and vegetable dishes, providing water and the removal of automatic defaults for fries and sugar-sweetened beverages, can result in healthier offerings without removing choice or reducing revenue, so restaurants can remain competitive^{(Reference Anzman-Frasa, Mueller and Silwa21)}.

In addition to bundling, children’s menus are often reported as generally lacking in variety^{(Reference Young, Coppinger and Reeves9)} and Hay^{(Reference Hay22)} raised the question why do kid’s menus in the UK always have chicken nuggets? A study in Germany also noted that the range of dishes on offer for children is severely restricted and in need of improvement^{(Reference Schneider, Hilger-Kolb and Lisa23)}. Of course, children are not limited to only choosing from food from the children’s menus and can choose from the main restaurant menu; some restaurants may not even have a children’s menu. However, an American study showed that 63 % of parents do choose from the children’s menu and this was higher in children under the age of 10 years^{(Reference Anzman-Frasca, Folta and Glenn20)}. Clearly, restaurants could consider designing their children’s menus to include some variety and make the healthy choice the easiest choice^{(Reference Henry and Borzekowski12)}; however, the full impact of such measures on child health has yet to be explored.

As reported in the linked paper by Dunn and colleagues^{(Reference Dunn, Vercammen and Frelier8)}, in the USA, some states have taken legislative action to ensure restaurants provide healthy beverages with children’s meals as default; however, less emphasis has been given to other parts of the menu. In the UK, the 2016 sugar levy was a positive step to help improve the quality of beverages on offer; however, it is evident that there is still more work to be done on the menus in many chain restaurants^{(Reference Young, Coppinger and Reeves9,Reference Reeves, Wake and Zick24,Reference Goffe, Rushton and White25)} . The second chapter of the UK Childhood Obesity: a plan for action⁽²⁶⁾ included proposals for several food environment interventions such as restrictions on unhealthy food advertising and greater support for using planning regulations to improve local food environments. An energy reduction programme also challenged all food and drink companies, including restaurants and takeaways, to reduce energy by 20 % in a range of everyday foods consumed by children by 2024 with additional recommendations to introduce legislation for consistent energy labelling in the out-of-home sector. More recently, the Chief Medical Officer’s independent report on child obesity⁽⁷⁾ stated a number of recommendations including fiscal measures to favour healthier options such as energy caps on food and drink sold outside the home, nutrition labelling and free drinking water to be available for all customers in on-site premises. Emphasising that there is a clear need to consider the role of the food environment and the nutritional value of food and beverages consumed outside the home in relation to childhood obesity.

These studies show that there is a trend for families and young children to eat increasingly frequently outside of the home. This is not to say that families should not enjoy an occasional treat; however, we need to recognise that if opting to eat out on a more regular basis, then the nutritional content of the food served in restaurants can make significant contributions to the overall diet. Changing the occasional restaurant meal to a healthier one may not have a great impact on obesity risk^{(Reference Mazidi and Speakman27)}; however, it should be easier to eat out healthily and be possible, even sustainable, to eat in restaurants as part of an overall healthy diet^{(Reference Brindal, Mohr and Wilson19,Reference Gorski and Roberto28)} . Furthermore, it is recognised that children’s menus in restaurants are just one component of the complex problem that is obesity, and thus only an innovative and multifaceted approach^{(Reference Kaur and Briggs29,Reference Economos30)} that includes policy changes^{(Reference Frieden, Dietz and Collins31)}, transformation of the food supply^{(Reference Jebb32,Reference Branca, Laertey and Oenema33)} as well as changes to the environment will solve.