Nutrition environment measures study in restaurants (NEMS-R) - Development and evaluation

Background: Americans are increasingly eating out, but nutrition environments in restaurants are poorly understood. An observational measure was developed to assess factors believed to contribute to food choices in restaurants, including availability of more healthy foods, facilitators and barriers to healthful eating, pricing, and signage/promotion of healthy and unhealthy foods. Methods: Inter-rater and test-retest reliability were assessed in 217 sit-down and fast-food restaurants in four neighborhoods in 2004 and 2005. Results: Inter-rater reliability was generally high, with most kappa values greater than 0.80 (range 0.27-0.97) and all percent-agreement values greater than 75% (77.6-99.5). Test-retest reliability was high, with most kappa values greater than 0.80 (0.46-1.0) and all percent-agreement values greater than 80% (80.4-100). There were several differences (p < 0.05) between nutrition environment variables in sit-down versus fast-food restaurants, although neither restaurant type was consistently more healthful. Fast-food restaurants had greater healthy entree and main-dish salad availability, but sit-down restaurants had a higher proportion of healthy main-dish salads and more healthy food and beverage items. Fast-food restaurants more often encouraged large portions, unhealthful eating, and overeating, and offered relative cost savings for combination meals, but were also more likely to provide nutrition information and highlight healthy options. Conclusions: Testing hypotheses about food environment influences on obesity and eating patterns requires psychometrically sound measurement of nutrition environments. This Nutrition Environment Measures Study restaurant assessment (NEMS-R) has evidence of reliability, and can discriminate restaurant types. The NEMS-R can be used in research and practice to characterize restaurant environments.