Since the COVID-19 pandemic began, almost all discussion of restaurant-related health has centered on one topic: how to protect diners and staff from the virus. But another health issue has been largely overlooked: how restaurants compromise Americans' health by selling fare that is high in caloric density, fat, added sugars, and sodium, but low in essential fiber. And during a pandemic where obesity and other pre-existing health conditions have been risk factors for severe disease, this discussion couldn't be more relevant.
It's common knowledge that fast food sold by chains such as McDonald's, Burger King, Wendy's, and the like has a poor nutritional profile. But the appetizers, entrees, and desserts sold at full-service restaurants aren't much better.
That was made clear in a Friedman School of Nutrition published last year. It showed that about 70% of meals at fast-food restaurants were of "poor quality" and just 30% were even of "intermediate" quality. At full-service restaurants, 47% of meals were of intermediate quality and 52% were poor quality.
Perhaps most striking, fewer than 0.1% of meals consumed at these restaurants met the American Heart Association's definition of "ideal quality," which are meals high in fruits, vegetables, whole grains, legumes and low in processed meats, sugar-sweetened beverages, saturated fat, and sodium.
Franchise outlets -- fast food and otherwise -- have tried to bring some balance to their menu offerings. Burger King, for example, offers a . But more common are offerings -- like a bacon and pretzel triple cheeseburger sold by Wendy's -- that are high in calories, saturated fat, cholesterol, and sodium.
Beyond the Nutritional Profile
Another area of concern is portion sizes at restaurants. While the Cheesecake Factory's may seem like an outlier, that the average serving of a hamburger and french fries at a restaurant today is about three times larger than it was in the 1950s.
Similarly, the authors of a analyzed menu items at 10 popular fast-food chains in the U.S. spanning from 1986 to 2016. They found calorie counts and portion sizes (in grams) of entrée items had increased 12% and 25%, respectively; desserts had increased 46% and 37%, respectively; and the calorie counts of side orders had increased 21%.
This double dose of large portions and unhealthy food has contributed to the U.S. adult obesity rate rising from to . The weight gain is particularly worrying given that obesity and related conditions, such as diabetes and high blood pressure, have been associated with an increased risk of COVID-19 complications and mortality.
The Evolving Dining Landscape
The rising obesity rates come against the backdrop of two major changes across the U.S. dining landscape.
The first is the dramatic expansion of access to food options outside the home. From 1977 to 2012, the number of food establishments in the U.S. , according to the U.S. Department of Agriculture. More recently, the number of "quick service" establishments rose from about .
The impact of increased restaurant density was demonstrated by the authors of a . They showed a strong connection between a rising obesity rate and a per capita increase in the number of restaurants in a state.
The second change in the dining landscape is that people are eating out much more than they used to. In 1962, food consumed away from home of Americans' total food budget. By 2017, that had risen to .
These trends, coupled with the troubling nutritional profile of food offered by restaurants, are one explanation for the poor state of the average American diet. Most and don't consume the recommended daily amounts of fruits, vegetables, whole grains, and legumes, while consuming higher-than-recommended amounts of added sugar, sodium, and processed meats.
These dietary patterns are correlated with adverse health outcomes. In 2012, more than 45% of U.S. adult deaths from diabetes, heart disease, and stroke were associated with a suboptimal diet, according to a . That diet is defined as low in fruits, vegetables, and whole grains, and high in sodium, processed meats, and sugar-sweetened beverages.
What Needs to Change?
There are no easy answers for getting Americans to develop healthier nutritional habits, but one step is eating out less frequently and cooking healthy food at home more often. Researchers at Johns Hopkins University when people do their own cooking, they consume 12% less sugar, 6% fewer calories, and 6% less fat.
With delivery services making restaurant meals more accessible than ever, there is a pressing need for all food establishments to improve the health profile of their menu items. That means more offerings that are low in fat and sodium and high in nutritional density. It also means smaller portions.
COVID-19 has shown the vulnerabilities of those facing diet-related health challenges. Restaurants should take the lead in helping Americans overcome those challenges and, in the process, help them realize better health.
is the Clinic Director at the Barnard Medical Center, a clinical instructor in medicine at the George Washington University School of Medicine, and author of Simply Plant Based. is editor of the , a senior fellow at Dartmouth's Tuck School of Business, and a former White House speechwriter.