International Journal of Obesity (2000) 24, 13531359

2000 Macmillan Publishers Ltd All rights reserved 03070565/00 $15.00

www.nature.com/ijo

Fast food restaurant use among women in the

Pound of Prevention study: dietary, behavioral
and demographic correlates

SA French1*, L Harnack1 and RW Jeffery1

1
Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, MN 55454-1015, USA

OBJECTIVE: To examine demographic, behavioral and dietary correlates of frequency of fast food restaurant use in a
community-based sample of 891 adult women.
DESIGN: A survey was administered at baseline and 3 y later as part of a randomized, prospective intervention trial on
weight gain prevention.
SUBJECTS: Women (n 891) aged 20 45 y who enrolled in the Pound of Prevention study.
MEASUREMENTS: Frequency of fast food restaurant use, dietary intake, demographic and behavioral measures were
self-reported. Dietary intake was measured using the 60-item Block Food Frequency Questionnaire. Body weight and
height were directly measured.
RESULTS: Twenty-one percent of the sample reported eating  3 fast food meals per week. Frequency of fast food
restaurant use was associated with higher total energy intake, higher percentage fat energy, more frequent
consumption of hamburgers, French fries and soft drinks, and less frequent consumption of ber and fruit. Frequency
of fast food restaurant use was higher among younger women, those with lower income, non-White ethnicity, greater
body weight, lower dietary restraint, fewer low-fat eating behaviors, and greater television viewing. Over 3 y,
increases in frequency of fast food restaurant use were associated with increases in body weight, total energy
intake, percentage fat intake, intake of hamburgers, French fries and soft drinks, and with decreases in physical
activity, dietary restraint and low-fat eating behaviors. Intake of several other foods, including fruits and vegetables,
did not differ by frequency of fast food restaurant use.
CONCLUSION: Frequency of fast food restaurant use is associated with higher energy and fat intake and greater body
weight, and could be an important risk factor for excess weight gain in the population.
International Journal of Obesity (2000) 24, 13531359

Keywords: obesity; fast food; dietary intake; weight gain

Introduction contributing dietary behaviors is intake of fast food

High-fat diets are a public health issue
Although dietary fat intake, as a percentage of total
energy, has declined in the US population in recent
years, from 40% in 1977=1978 to 33% in 1994, levels
continue to be higher than the 30% recommended.1 3
The prevalence of high-fat diets in the US may have
contributed to the epidemic of obesity that currently
affects the US population.4,5 Currently, over 30%, or
58 million, Americans are overweight.6 In the most
recent decades, the prevalence of obesity has sharply
risen from 24.3% in 1960 to 33.3% in 1991.6 9
Dietary practices contributing to excessive fat intake
and overweight need to be identied so that public
health interventions targeted at modiable dietary
behaviors may be implemented. Among the potential
*Correspondence: SA French, Division of Epidemiology,
University of Minnesota, 1300 South Second Street, Suite 300,
Minneapolis, MN 55454-1015, USA.
E-mail: french@epi.umn.edu
Received 4 November 1999; revised 5 May 2000; accepted
12 June 2000
fare.
Fast food is a growing component of the American diet
`Fast food' has been dened as food purchased in self-
service or carry-out eating places without wait ser-
vice.10,11 Between 1970 and 1980, the number of fast
food outlets increased from 30,000 to 140,000, and
fast food sales increased by 300%.12 Although fast
food restaurants have diversied to include a much
broader range of foods, outlets focusing on hambur-
gers and French fries continue to be the industry
leaders in terms of sales volume.11 13
Since the early 1970s the frequency of fast food use
has dramatically increased. In the early 1970s, about
20% of the household food dollar was spent on food
away from home. By 1995, an estimated 40% of the
US household food dollar was spent on food away
from home.13 Although not all of the away-from-
home food purchases are from fast food restaurants,
fast food restaurants comprise an increasing share. For
example, in 1953, fast food comprised 4% of total
sales of food away from home, compared to 34% of
away-from-home food sales in 1997.11,13
 Fast food
SA French et al
1354
An early review of the impact of fast food on the
nutritional quality of the diet concluded that the
frequency of use of fast food restaurants was too
low to impact overall dietary quality.14 Twenty
years later, this may not be the case. Data from the
1994 1996 USDA Continuing Survey of Food
Intakes by Individuals show that 56% of US adults
report eating away from home on any given day; of
these, about 33% ate at a fast food outlet.11 Overall,
fast foods accounted for 14% of total energy intake in
1995.10 Thus, current data suggest that fast food may
play a signicant role in overall energy intake and
dietary quality.
Fast food is high in fat and energy
Concern has arisen over the nutritional quality of fast
food fare, especially since such a large proportion of
the population is exposed to fast food. Several studies
have shown that fast food meals generally provide
adequate nutrient density for protein, carbohydrates
and several vitamins, but are generally low in calcium,
vitamins C and A and ber, and are high in calories,
total fat, saturated fat, and cholesterol.10,14 17 For
example, the 1995 CSFII reported that meals eaten
out comprised 27% of eating occasions, but 34% of
total energy intake.10 To stay within recommended
guidelines, lower-fat food choices would be necessary
during other eating occasions that day.
Previous studies have focused on the fat and energy
derived from fast foods, but have not assessed the
broader impact fast food intake might have on total
dietary intake. This is an important issue if greater
consumption of fast food is associated with poor food
choices on other eating occasions. A recent study of
129 women found that, based on data from 7 day food
diaries, women who ate out six or more times per
week consumed more energy, fat and sodium, but
equal amounts of ber and calcium, compared to
women who ate out ve or fewer times per week.18
However, analyses of fat and micronutrients did not
adjust for total energy intake. Consumption of specic
foods was not examined by frequency of eating out.
Limited data are available on demographic factors
and almost no data are available on behavioral factors
associated with fast food use. Demographic factors
positively associated with fast food use include age,
being single or married without children, White eth-
nicity, and higher income.10,19 21 People in these
demographic groups may be at greater than average
risk of excessive fat and energy intake, given their
greater intake of fast foods. Behavioral information
would be useful to better characterize the overall
eating and physical activity patterns of those who
heavily rely on fast food and would inform the
development of more specic and targeted nutrition
interventions.
Our previous report showed that frequency of fast
food restaurant use was positively correlated with
total energy and fat intake in women both prospec-
International Journal of Obesity
tively and cross-sectionally.22 The present study
expands on these analyses by examining intake of a
broader range of specic foods and nutrients and by
examining associations over time between changes in
dietary intake and changes in frequency of fast food
restaurant use. These data will provide a broader,
more comprehensive picture of the impact that fast
food restaurant use may have on total dietary quality.
In addition, demographic and behavioral variables
related to fast food restaurant use will provide descrip-
tive information that may be useful for intervention
targeting and development.
Methods
Subjects and procedure
Data for the present report were obtained as part of
the Pound of Prevention study (POP).23 Recruitment,
intervention methods and study outcomes are fully
described elsewhere.23 POP was a 3 y intervention
trial to examine methods to prevent weight gain
among young adults of any body weight. Participants
were volunteers recruited from the community using
newspaper ads, radio public service announcements
and direct mail. In-person recruitment of low-income
women took place at community health clinics admin-
istering the Supplemental Food and Nutrition Program
(WIC). Nine-hundred and ninety-eight women (includ-
ing 404 low-income women, dened as annual house-
hold income  $25,000) and 228 men were recruited
and enrolled in the study. To be eligible, participants
had to be between 20 and 45 y, not currently pregnant
or pregnant within the past year, free from serious
disease, and willing to participate for 3 y.
Participants were randomized to a mail-based inter-
vention or to a no-contact control group. Intervention
consisted of monthly mailed newsletters with return
postcards and periodic opportunities to take part in
additional eating and exercise programs. Intervention
continued for 3 y with annual clinic visits to assess
body weight, dietary intake, and eating and exercise
behaviors. Data from women only are reported in the
present study due to the smaller number and greater
demographic homogeneity among male participants.
Women who did not become pregnant (n 106
became pregnant) and who had data at the third
annual follow-up were included in the present analysis
(n 891=998 women; 89.3%). The women averaged
35 y of age, and weighed 72.8 kg (160.6 lb;
s.d. 35.7), with an average BMI of 27.0 kg=m2
(s.d. 6.0). Forty-ve percent were currently married,
61% had one or more children, 86% were White
race=ethnicity, 46% had college degrees, and 60%
reported family yearly income of  $25,000.
Measures
The following measures were completed at baseline
and at each yearly clinic visit.

Fast food restaurant use. Frequency of fast food
restaurant use was estimated with the question `About
how many meals per week do you eat from fast food
restaurants?' Fast food restaurants were not dened
for participants.
Dietary intake. Habitual dietary intake during the
past year was estimated using the 60-item Block Food
Frequency Questionnaire (FFQ).24 The FFQ has been
validated in diverse populations, including women
and low-income populations.25 28 It should be noted
that food frequency dietary assessment instruments
underestimate food intake and are therefore most
useful for ranking individuals rather than estimating
absolute levels of energy or nutrient intakes.25 27
Dietary variables used in the present report include
total energy, percentage energy from fat, calcium,
ber and frequency of consumption of specic foods
of interest, including those that might be served at fast
food restaurants (eg hamburgers, French fries, soft
drinks). However, the source of the food is not
reported on the FFQ. It is not known, for example,
whether French fries reported were obtained in a fast
food restaurant or elsewhere. Total fruit servings and
total vegetable servings were examined because these
food groups are believed to be healthful and have been
targeted for increase by public health guidelines.
French fries were omitted from the aggregate measure
of vegetable servings because they were examined
separately as an example of a fast food. Milk con-
sumption was examined due to concerns about low
calcium intake among women, the reported low cal-
cium content of fast food, and the possibility that soft
drinks might be displacing milk among fast food
restaurant users.
Behavioral variables
Physical activity. Physical activity was measured
using an instrument adapted from Jacobs et al that
has been used in several large epidemiologic studies,
including those involving low-income populations.29
The questionnaire describes 13 physical activities (eg
running, racket sports, hiking, walking, swimming,
snow shoveling, gardening, etc). Respondents check
the average frequency per week that they did each of
the 13 activities for 20 min or greater duration during
the past year. A physical activity score was calculated
as the reported frequency per week for each activity
multiplied by its estimated intensity level in metabolic
equivalents (METS). These products were summed
across the 13 activities. Higher scores reect greater
physical activity levels (based on frequency and
intensity). As a measure of sedentary behavior, parti-
cipants reported the average number of hours per
week spent watching television.
Fast food
SA French et al
1355
Restrained eating. Restrained eating was measured
using the Cognitive Restraint subscale of Stunkard
and Messick's Three Factor Eating Questionnaire
(TFEQ-R).30 The TFEQ-R measures dietary restraint,
or the extent to which one engages in cognitive and
behavioral efforts to limit food intake. Items focus on
specic eating behaviors such as eating smaller por-
tions, keeping track of caloric intake and avoiding
specic foods. Higher scores indicate greater con-
scious control over eating or efforts to limit food
intake. The TFEQ-R is valid and reliable and identi-
es those who consume fewer calories in naturalistic
settings.30 32
Low-fat eating behaviors. The low fat eating beha-
viors scale measures the extent to which individuals
practice food preparation methods related to a low-fat
diet.33 This 18-item scale assesses ve theoretically
based dimensions of eating behavior and includes
behaviors such as eating bread without butter or
margarine, choosing low-fat dairy products, removing
skin from chicken, and using low-calorie salad dres-
sing. Higher scores indicate engaging in a greater
number or more frequent behaviors to limit fat
intake. The measure is valid, reliable and sensitive
to interventions targeting low-fat eating behaviors.33
Smoking. Smoking behavior was self-reported. Par-
ticipants were classied as current smokers if they
reported currently smoking cigarettes.
Body weight and height. Weight was measured in
light clothing without shoes on a calibrated balance
beam scale. Height was measured at baseline with a
wall-mounted ruler. Body mass index was computed
(BMI: weight (kg)=height (m)2).
Demographic variables
Demographic variables were self-reported and
included age in years, current marital status (married
vs not married), educational attainment ( high
school, some college,  college degree), income
(annual household income  $25,000 vs > $25,000),
ethnic identication (White vs non-White), employ-
ment status (employed full or part time vs not
employed), and number of children.
Statistical analysis
All analyses were conducted using SAS statistical
software.34 To examine cross-sectional associations
between frequency of fast food restaurant use and
demographic, behavioral and dietary variables, fre-
quency of fast food restaurant use was categorized
into terciles. PROC GLM was used for continuous
dependent variables in univariate analyses in which
International Journal of Obesity
 Fast food
SA French et al
1356
tercile of frequency of fast food restaurant use was the
independent variable. Chi-square analyses were used
for categorical variables. Total energy intake was
included as a covariate in analyses of dietary intake
variables.
Associations between changes in frequency of fast
food restaurant use and changes in dietary intake were
examined with PROC GLM in which the follow-up
value of the food group was used as the dependent
variable, and the baseline value was a covariate.
Change in frequency of fast food restaurant use was
examined by entering the baseline and follow-up
frequency of fast food restaurant use as independent
variables and interpreting the coefcient of the
follow-up frequency of fast food restaurant use vari-
able only. This approach is equivalent to a change
score analysis and is preferred for several reasons
described in detail by Cohen and Cohen.35 Long-
itudinal analyses were adjusted for demographic
co-variates and treatment group. P-values were
considered signicant at P < 0.05.
Results
Prevalence of fast food restaurant use and trends
over 3 y
Overall, 24% reported that they ate on average zero
times per week at fast food restaurants, while 39.2%
reported one visit per week, 15.7% reported two visits,
and 21.1% reported three or more visits to a fast food
restaurant on average per week. This distribution was
fairly consistent at each year of follow-up. At follow-
up three, 26.1% reported zero visits, 40.7% reported
one visit, 14% reported two visits, and 19.2% reported

Table 1 Cross-sectional associations at baselinea between frequency of fast food restaurant use and demographic, dietary and
behavioral variables among 891 women

Fast food frequency (tercile)

Low Medium High P

Number of subjects 214 349 328

Number of fast food meals per week 0 (0.1)a,b 1.0 (0.1)b 3.3 (0.1)c 0.01
Demographic variables
Age (y) 35.7 (0.4)a 35.0 (0.4)a,b 34.3 (0.4)b 0.04
Education (%)
 High school 14.0 16.3 13.1 0.24
Some college 35.1 39.5 43.6
 College degree 50.9 44.1 43.3
Low income (yearly; <$25,000) 32.7 41.3 43.1 0.04
Ethnicity (% White) 90.2 82.8 86.9 0.04
Employed (full or part time; %) 81.8 77.7 85.4 0.04
Married 50.5 47.0 39.6 0.03
Number of children 1.2 (0.1)a 1.6 (0.1)b 1.2 (0.1)a 0.01
Weight (kg) 69.1 (1.1)a 72.2 (0.9)b 76.0 (0.9)c 0.01
Body mass index (kg=m2) 25.4 (0.4)a 26.8 (0.3)b 28.2 (0.3)c 0.01
Behavioral variables
Restraint score 9.7 (0.3)a 8.6 (0.2)b 8.3 (0.2)b 0.01
Low-fat eating behaviors score 51.4 (0.7)a 49.5 (0.5)b 47.2 (0.5)c 0.01
Physical activity score 48.5 (2.1) 47.1 (1.7) 44.0 (1.7) 0.22
Television (h=day) 2.1 (0.2)a 2.4 (0.1)a 2.7 (0.1)b 0.02
Smoking (current) 15.4 22.1 19.0 0.15

Dietary variables
Total energy (kJ=day) 5668.3 (220.9)a 6770.8 (173.0)b 7391.6 (178.5)c 0.01
Percentage fat energy 32.8 (0.6)a 34.3 (0.4)b 35.0 (0.5)b 0.01
Fiber (gm=day)c 12.5 (0.4)a 10.9 (0.3)b 10.0 (0.3)b 0.01
Calcium (mg=day)c 899.9 (30.1) 902.2 (23.3) 841.7 (24.2) 0.15
Vegetables (servings=day)c 1.7 (0.1)a 1.6 (0.1)a 1.4 (0.1)b 0.01
Fruits (servings=day)c 1.1 (0.1)a 1.1 (0.1)a 0.8 (0.1)b 0.01
Hamburgers (servings=day)c 0.12 (0.02)a 0.15 (0.02)a 0.25 (0.02)b 0.01
French fries (servings=day)c 0.19 (0.03)a 0.14 (0.03)a 0.31 (0.03)b 0.01
Soft drinks (servings=day)c 0.58 (0.1)a 0.78 (0.1)a 1.08 (0.1)b 0.01
Milk (whole, 2% or skim) (servings=day)c 0.99 (0.1) 1.13 (0.1) 1.04 (0.1) 0.31
Fried chicken (servings=day)c 0.13 (0.02) 0.07 (0.02) 0.10 (0.02) 0.11
Other chicken (servings=day)c 0.33 (0.03) 0.27 (0.02) 0.28 (0.02) 0.26
Fried sh (servings=day)c 0.05 (0.01) 0.05 (0.01) 0.05 (0.01) 0.27
Other sh (servings=day)c 0.10 (0.02) 0.07 (0.01) 0.08 (0.01) 0.47
Beef (servings=day)c 0.10 (0.01) 0.09 (0.01) 0.13 (0.01) 0.06
Bacon (servings=day)c 0.08 (0.01) 0.07 (0.01) 0.10 (0.01) 0.19
Sausage (servings=day)c 0.06 (0.02) 0.05 (0.01) 0.08 (0.01) 0.49
Eggs (servings=day)c 0.16 (0.02) 0.17 (0.02) 0.15 (0.02) 0.85
a
Means (standard errors) or percentages.
b
Means with different superscripts differ signicantly (P < 0.05) by post hoc comparison.
c
Adjusted for total energy intake by analysis of covariance.

International Journal of Obesity

 Fast food
SA French et al
1357
three or more visits, on average, per week, to a fast use reported consuming on average 1.8 hamburgers,
food restaurant. There were no signicant differences 2.2 servings of French fries, and 7.6 soft drinks per
between treatment and control groups on baseline week, compared to 0.8 hamburgers, 1.3 servings of
frequency of fast food restaurant use (mean 1.5 French fries, and 4.1 soft drinks per week among low
visits per week vs 1.7 visits per week, respectively, users of fast food restaurants. Intake of fried chicken,
P < 0.15). The correlation between number of weekly other chicken, fried sh, other sh, beef, bacon,
fast food restaurant visits at baseline and at follow-up sausage and eggs did not differ by frequency of fast
three was r 0.57 (P < 0.0001). Of those in the food restaurant use.
lowest tercile of fast food restaurant use at baseline,
62.9% remained in the lowest tercile at follow-up,
while 8.7% moved into the highest tercile of fast food Changes in fast food intake and changes in dietary and
restaurant use. Similarly, 61% of those in the highest behavioral variables
tercile of fast food restaurant use remained in the Table 2 shows associations between changes in fast
highest tercile at the follow-up, while 8.8% moved food restaurant use frequency and changes in dietary
into the lowest tercile. Twenty-seven percent and behavioral variables over 3 y. Increases in fre-
decreased their fast food restaurant visits by one or quency of fast food restaurant use were associated
more meals per week, while 26.4% increased their fast with increases in total energy intake, percentage
food restaurant visits by one or more meals per week. energy from fat, servings of hamburgers, French
fries and soft drinks, and body weight. On average,
an increase of one fast food meal per week was
Cross-sectional demographic, behavioral and dietary associated with an increase of 234.4 kJ=day (56 kcal=
correlates of fast food restaurant use day), an increase of 0.6% in fat energy=day, and a
Cross-sectional associations between frequency of fast weight gain of 0.72 kg (1.6 lb) over 3 y above the
food restaurant use and demographic, behavioral and average weight gain over the 3 y period (average
dietary variables are shown in Table 1. More frequent weight gain was 1.68 kg (3.7 lb)).21
fast food restaurant use was signicantly associated Increases in frequency of fast food restaurant use
with younger age, being unmarried, lower income, were associated with decreases in vegetable servings
non-White ethnicity, heavier body weight and higher per day, but changes in frequency of fast food restau-
BMI. Those in the highest tercile of frequency of fast rant use were unrelated to changes in intake of fruit,
food restaurant use were more likely to be employed, ber and milk. Changes in frequency of fast food
but also had the largest percentage of women with low
incomes. Those falling in the middle tercile of fre-
quency of fast food restaurant use were least likely to Table 2 Associations between changes in frequency of fast
be White and had a greater number of children than food restaurant use and changes in dietary intake over 3 y
those in the lowest or highest tercile of frequency of among 891 womena
fast food restaurant use. B (SE) P
Measures of restrained eating and low-fat eating
Change in:
behaviors were inversely related to frequency of fast Total energy (kJ=day) 237.22 (74.45) 0.01
food restaurant use. Associations were linear, with Percent fat energy 0.56 (0.21) 0.01
women in the lowest frequency of fast food restaurant Fiber (g=day) 7 0.22 (0.18) 0.22
Calcium (mg=day) 7 11.18 (12.61) 0.38
use tercile reporting the highest restrained eating Vegetables (servings=day) 7 0.09 (0.03) 0.01
scores and the highest low fat eating behaviors Fruit (servings=day) 7 0.03 (0.02) 0.15
scores. Television viewing was highest in the highest Hamburgers (servings=day) 0.04 (0.01) 0.01
French fries (servings=day) 0.06 (0.01) 0.01
frequency of fast food restaurant use tercile and Soft drinks (servings=day) 0.10 (0.03) 0.01
lowest in the lowest frequency of fast food restaurant Weight (kg) 0.72 (0.20) 0.01
use tercile. Smoking and physical activity were Restraint score 7 0.27 (0.10) 0.01
unrelated to frequency of fast food restaurant use. Low-fat eating behaviors score 7 1.14 (0.18) 0.01
Physical activity score 7 1.92 (0.76) 0.01
Total energy intake and percentage fat energy were Television viewing (h=day) 7 0.04 (0.04) 0.28
positively associated with frequency of fast food Bacon (servings=day) 0.01 (0.01) 0.01
restaurant use (Table 1). By contrast, intake of health- Sausage (servings=day) 0.01 (0.01) 0.01
Eggs (servings=day) 0.004 (0.01) 0.46
ful foods and nutrients was inversely associated with
Milk (whole, 2% or skim) (servings=day) 7 0.01 (0.03) 0.69
frequency of fast food restaurant use. Those in the
Fried sh (servings=day) 0.001 (0.01) 0.57
highest tercile of fast food restaurant frequency con- Other sh (servings=day) 7 0.008 (0.01) 0.05
sumed signicantly less ber and fewer servings per Fried chicken (servings=day) 0.009 (0.01) 0.01
day of vegetables and fruits. However, total calcium Other chicken (servings=day) 7 0.002 (0.01) 0.78
Beef (servings=day) 0.007 (0.01) 0.03
and milk intake did not differ by fast food restaurant
frequency. Fast food restaurant use frequency was a
Regression coefcient (standard error). Regression coefcients
positively associated with hamburger, French fries adjusted for baseline value of frequency of fast food restaurant
use and baseline value of dependent variable; demographic
and soft drinks consumption. For example, those in variables (marital status, ethnicity, income, age, body weight)
the highest tercile of frequency of fast food restaurant and treatment group.

International Journal of Obesity

 Fast food
SA French et al
1358
restaurant use were associated with changes in several
other dietary variables, but associations were weak.
Changes in behavioral variables reecting attention to
healthy eating (restraint scores, low-fat eating beha-
viors score), and physical activity, were inversely
associated with changes in frequency of fast food
restaurant use. Changes in television viewing time
were not associated with changes in frequency of fast
food restaurant use. There were no signicant differ-
ences between treatment and control groups in change
in frequency of fast food restaurant use (P < 0.15).
Discussion
The purpose of this study was to describe the pre-
valence of fast food restaurant use and its demo-
graphic, dietary and behavioral correlates in a
diverse sample of adult women. Frequency of fast
food restaurant use was cross-sectionally and prospec-
tively associated with higher fat and energy intake,
greater body weight, more frequent intake of hambur-
gers, French fries and soft drinks, less frequent intake
of vegetables, less restrained eating, and fewer low-fat
eating behaviors. Frequency of fast food restaurant
use was cross-sectionally positively associated with
television viewing and prospectively inversely
associated with leisure time physical activity.
These data have several potential implications.
First, although the mean frequency of fast food
restaurant use was low, about 37% of the sample
visited fast food restaurants two or more times per
week. Increases in the frequency of fast food restau-
rant use were associated with increases in body weight
over a 3 y period. The average weight gain was 1.7 kg
over 3 y. Women in the highest tercile of fast food
restaurant use gained an additional 0.72 kg more than
women in the lowest tercile of fast food restaurant use
during the 3 y study period. This nding suggests that
frequent fast food restaurant use could be a risk factor
for excess weight gain over time.
Second, fruit and vegetable intake was lower
among more frequent fast food restaurant users, sug-
gesting either displacement by other foods, or else a
lack of choosing fruits and vegetables at other eating
occasions. It is questionable whether fruits and vege-
tables would be selected if offered on the menu at fast
food restaurants. Low-fat menu items have not sold
well at fast food restaurants, thus the reasons for low
intake could be lack of interest or motivation or lack
of perceived taste, rather than lack of availability or
displacement by other foods.19,36,37
Third, frequent fast food restaurant use was not
associated with lower milk consumption or total
calcium intake. Perhaps milk consumption occurs
primarily at breakfast, while fast food meals are
primarily concentrated at lunch and dinner.38
However, data from at least one national study suggest
International Journal of Obesity
an inverse association between soft drink consumption
and calcium or milk intake, at least in some
population subgroups.39,40
Finally, frequent fast food restaurant use was high-
est prospectively and cross-sectionally, among those
who were less concerned about restricting food intake
or engaging in low fat eating behaviors and prospec-
tively, among those who were less physically active.
Together, these ndings suggest that frequent fast
food restaurant users may be less concerned with
their eating and exercise behaviors more broadly,
including the quality of their diets and their physical
activity levels.
The current epidemic of obesity is caused largely
by an environment that discourages physical activity
and encourages the overconsumption of food energy.4
Environmental inuences are variables that increase
the behaviors that contribute to creating a postive
energy balance.4 Environmental variables include
the availability, convenience and low price of fast
foods, the pervasive inuence of television advertising
for fast foods,41,42 and the high population exposure to
both television and fast food restaurants. In fact, the
largest fast food restaurant in the US recently part-
nered with a well-known television manufacturer to
give away free television sets in their restaurants.43
Behaviors include leisure time physical activity,
sedentary behaviors such as television viewing, and
dietary intake. Thus, fast food use is one of a cluster of
inter-related behaviors that may contribute to excess
weight gain and obesity. The independent contribution
of each behavior and their potential interactions on
body weight change over time warrant additional
research attention.
Community-based nutrition interventions promot-
ing healthful eating behaviors may need to incorporate
specic components addressing fast food consumption
and its potential impact of overall dietary intake.
Frequent fast food restaurant users might also be
targeted for intervention around increasing fruit and
vegetable intake and decreasing fat intake at other
eating occasions during the day.
References
1 US Department of Health and Human Services. Healthy
People 2000: National Health promotion and disease preven-
tion objective. US Department of Health and Human Services,
Public Health Service: Washington DC, 1988.
2 McDowell MA, Briefel RR, Alaimo R, Bischof AM, Caugh-
man CR, Carroll MD, Loria CM, Johnson CL. Energy and
macronutrient intakes of persons ages 2 months and over in
the United States: Third National Health and Nutrition Exam-
ination Survey, Phase 1, 1988 91. Advance Data From Vital
and Health Statistics, no. 255, National Center for Health
Statistics: Hyattsville, MD, 1994.
3 Borrud L, Wilkinson-Enns C, Mickle S. What we eat: USDA
surveys food consumption changes. CNI 1997; 18: 4 5.
4 Hill J, Peters J. Environmental contributions to the obesity
epidemic. Science 1998; 280: 1371 1374.

5 Shah M, Jeffery R. Is obesity due to overeating and inactivity,
or to a defective metabolic rate: a review. Ann Behav Med
1991; 13: 73 81.
6 Kruczmarski RJ, Flegal KM, Campbell SM, Johnson CL.
Increasing prevalence of overweight among US adults: the
National Health and Nutrition Examination Surveys, 1960
1991. JAMA 1994; 272: 205 211.
7 Flegal KM, Harlan WR, Landis JR. Secular trends in body
mass index and skinfold thickness with socioeconomic factors
in young adult women. Am J Clin Nutr 1988; 48: 535 543.
8 Flegal KM, Harlan WR, Landis JR. Secular trends in body
mass index and skinfold thickness with socioeconomic factors
in young adult men. Am J Clin Nutr 1998; 48: 544 551.
9 Shah M, Hannan PJ, Jeffery RW. Secular trend in body mass
index in the adult population of three communities from the
upper mid-western part of the USA: the Minnesota Heart
Health Program. Int J Obes 1991; 15: 499 503.
10 Biing-Hwan L, Frazao E. Nutritional quality of foods at and
away from home. Food review. US Government Printing
Ofce, Food and Rural Economics Division, Economics
Research Service, USDA 1997, pp 33 40.
11 USDA continuing survey of food intakes by individuals,
1994 1996. US Department of Agriculture, Economic
Research Service: Washington DC, 1997.
12 Sheridan M, McPherrin E. Fast food and the American diet.
American Council of Science and Health: New York, 1983.
13 Putnam J, Allshouse J. Food consumption, prices, and expen-
ditures, 1996, SB-928. US Department of Agriculture, Eco-
nomic Research Service: Washington, DC, April 1996.
14 Shannon BM, Parks SC. Fast foods: a perspective on their
nutritional impact. JADA 1980; 76: 242 247.
15 Guenther PM, Ricart G. Effects of eating at food service
establishments on the nutritional quality of women's diets. Top
Clin Nutr 1989; 4: 41 45.
16 Haines PS, Popkin BM, Guilkey DK. Methods of patterning
eating behaviors of American women. J Nutr Educ 1990; 22:
124 132.
17 Greecher CP, Shannon B. Impact of fast food meals on
nutrient intake of two groups. JADA 1977; 70: 368 372.
18 Eck-Clemens LH, Slawson DL, Klesges RC. The effect of
eating out on quality of diet in premenopausal women. JADA
1999; 99: 442 444.
19 Schwenk NE. Trends in food and alcohol consumption away
from home. Family Econ Nutr Rev 1995; 8: 30 40.
20 Ries CP, Kline K, Weaver SO. Impact of commercial eating
on nutrient adequacy. JADA 1987; 87: 463 468.
21 Consumer Reports. Where's the beef? Consumer Reports 1984
July: 367 373.
22 Jeffery RW, French SA. Epidemic obesity in the US: are fast
foods contributing? Am J Public Health 1998; 88: 277 280.
23 Jeffery RW, French SA. Prevention of weight gain in adults:
the Pound of Prevention Study. Am J Public Health 1999; 89:
747 751.
24 Block G, Hartman AM, Dresser CM, Carroll MD, Gannon J,
Gardener L. A data-based approach to diet questionnaire
design and testing. Am J Epidemiol 1986; 124: 453 469.
25 Mares-Perlman JA, Klein BE, Klein R, Ritter LL, Fisher MR,
Freudenheim JL. A diet history questionnaire ranks nutrient
intakes in middle-aged and older men and women similarly to
multiple food records. J Nutr 1993; 123: 489 501.
Fast food
SA French et al
1359
26 Block G, Woods M, Potosky A, Clifford C. Validation of a
self-administered diet history questionnaire using multiple diet
records. J Clin Epidemiol 1990; 43: 1327 1335.
27 Block G, Thompson FE, Hartman AM, Larkin FA, Guire KE.
Comparison of two dietary questionnaires validated against
multiple dietary records collected during a 1-year period.
JADA 1992; 92: 686 693.
28 Coates RJ, Eley JW, Block G, Gunter EW, Sowell Al, Gross-
man C, Greenberg RS. An evaluation of a food frequency
questionnaire for assesing dietary intake of specic carote-
noids and vitamin E among low-income black women. Am J
Epidemiol 1991; 134: 658 371.
29 Jacobs DR, Hahn LP, Haskell WL, Pirie P, Sidney S. Validity
and reliability of short physical activity history: CARDIA and
the Minnesota Heart Health Program. J Cardiopulmon Rehab
1989; 9: 448 459.
30 Stunkard AJ, Messick S. The three factor eating questionnaire
to measure dietary restraint, disinhibition, and hunger.
J Psychosom Res 1985; 29: 71 83.
31 Laessle RG, Tuschl RJ, Kotthaus BC, Pirke KM. A compar-
ison of the validity of three scales for the assessment of dietary
restraint. J Abnorm Psychol 1989; 98: 504 507.
32 Tuschl RJ, Platte P, Laessle RG, Stichler W, Pirke KM.
Energy expenditure and everyday eating behavior in healthy
young women. Am J Clin Nutr 1990; 52: 81 86.
33 Kristal AR, White E, Shattuck AL, Curry S, Anderson GL,
Fowler A, Urban N. Long-term maintenance of a low-fat diet:
durability of fat-related dietary habits in the Women's Health
Trial. JADA 1992; 92: 553 559.
34 SAS Institute Inc. SAS=STAT software: changes and enhance-
ments through release 6.12. SAS Institute: Cary, NC, 1997.
35 Cohen J, Cohen P. Applied Multiple Regression=Correlation
Analysis for the Behavioral Sciences. Erlbaum: Hillsdale, NJ,
1975, pp 72 73, 413 423.
36 Consumer Reports. Fast food for fat-watchers. Consumer Rep
1993; September: 574 578.
37 Kramer L. Taco Bell `lightens up' on Border Lights. Taco Bell
amends its Border Lights menu and launches Lighten Up.
Nation's Restaurant News 1996; 30: 1.
38 Jekanowski M. Causes and consequences of fast food sales
growth. USDA=ERS Food Rev 1999; 22: 11 16.
39 Liquid candy: how soft drinks are harming American's health.
Center for Science in the Public Interest: Washington, DC,
1998.
40 Harnack L, Stang J, Story M. Soft drink consumption among
US children and adolescents: nutritional consequences. JADA
1999; 99: 436 441.
41 Story M, Faulkner P. The prime time diet: a content analysis
of eating behavior and food messages in television program
content and commercials. Am J Pub Health 1990; 80:
738 740.
42 Kotz K, Story M. Food advertisements during children's
Saturday morning television programming: are they
consistent with dietary recommendations? JADA 1994; 94:
1296 1300.
43 Zenith teams with McDonald's in Monopoly promo. Brand-
week 2000; 41: 90 (Article A61408896).
International Journal of Obesity