2010 Model Practice Application (Public)

Creating and Marketing Healthier Meal Options at McDonald's Restaurants in Central Idaho

Central District Health Department

Food marketing has been shown to influence preferences for food and beverage choices. Unhealthy choices have led to an excess of kilo-calories and inadequate consumption of important nutrients, creating a population of Americans who are under-nourished and overweight or obese. McDonald’s of the Treasure Valley area and the Central District Health Department (CDHD) formed a strategic partnership to market healthy meal options and promote balanced, active lifestyles to Idaho McDonald’s customers. Education and awareness activities utilizing campaign menu boards and program materials are used to teach customers how to choose meal options which meet selected nutrition criteria. GOAL: Create meal options and a marketing campaign to help McDonald's of the Treasure Valley customers select healthier meal options. Objective 1: By July 2008, CDHD Public Health Nutritionist (PHN) will select existing McDonald's menu items to create 12 McDonald’s meal options to provide customers an opportunity to increase daily intake of nuts and seeds, whole grains, fruits and vegetables, and dairy servings. Each meal will contain no more than 30 percent total fat, 0.5 grams trans fat, 1500 milligrams sodium, and 700 calories. Objective 2: Marketing firm, Riester, will develop name, graphics, website, coupons, and marketing strategies to launch campaign in Fall 2008 at McDonald's of the Treasure Valley Restaurants. Objective 3: CDHD PHN will work with Boise State University (BSU) Community Nursing Professor and senior nursing students to observe McDonald's consumers before and after campaign launch and determine whether meal options were selected. Early pre and post observation survey of customers with children showed an increase in milk purchased after the launch. 1% lowfat chocolate milk was preferred. One restaurant manager noted that many more apple dippers were ordered and most do not use the low fat caramel dipping sauce. Another restaurant site revealed they sold more Southwest Chicken Salads than all other products during a weekday lunch period. The Good Fit Meals campaign is on-going and sustainable. Revisions were made in Happy Meals: no more than 35% total fat or 10% of total calories from saturated fat. CDHD PHN promotes campaign to health providers and the public. Good Fit Meals handouts and website are used by health teachers when reviewing nutrition and convenience foods. Good Fit Meals coupons are used at the Boise Women's Fitness Celebration, The Basic 5 Mile Run-Walk, and Be Outside events promoting healthier picnics. There is a national campaign to label calories and nutrition in restaurants. CDHD PHN has offered to assist with putting the meal options up on the reader boards. National McDonald's has hired a Registered Dietitian who reviews and evaluates promotional materials for Good Fit Meals. McDonald's of the Treasure Valley has grown from 27 to 34 restaurants since campaign launch.

The epidemic of obesity and overweight . . ." threatens the historic progress we have made in American's quality and years of healthy life" was written by Dr. Regina Benjamin in The Surgeon General's Vision for a Healthy and Fit Nation 2010. Increasing prevalence of chronic diseases: heart disease and stroke, pre-diabetes and type 2 diabetes, cancer, asthma, debilitating stress, and depression are linked to overweight and obesity. The burden of extra weight also impacts diseases such as arthritis, fibromyalgia, back pain, and many others. Nutritionists and other health advocates no longer focus just on defined diets and what individuals must give up; instead the priority is to select healthy foods and fitness to improve health and wellness. Whatever the source of food access: grocery stores, family table or home pantry, child care meals and snacks, school lunch and vending machines, worksite and vending machines and cafeterias, restaurants, travel food options; all consumers must learn how to select healthier food and appropriate portions. Increasing movement is also vital to the overweight and obesity epidemic. Although physical activity is annexed to decreasing caloric intake, physical fitness is vitally important to feeling good, having fun, and staying mobile, and it burns calories. All CDHD public health prevention programs include both messages: "Eat Smart and Play Hard"; Nutrition and Exercise Tips; Eat Less and Move More. The lives of many Americans are too physically easy. We have remote controls and wheels on our luggage. Elevators and escalators are attractive options near stairs behind closed doors. Parents create traffic jams driving children to school, even those who live close enough to walk or bike safely. The public health prevention message teaches fitting added movement and healthier behavior into the normal day. When an individual can safely walk or ride a bike, or walk to a bus, these are encouraged as healthier options than automobile transport. Poverty and food security is another issue in the overweight and obesity epidemic. Food availability and food quality adversely impact low income and minority populations. The built environment on the wrong side of the tracks may make physical activity unsafe and healthy foods harder to access. The practice being addressed in this application has been controversial to many health advocates. Teaching healthier choices where people already eat has often been lost to the argument that the poor will only choose the value menu, getting high fat and empty calories. All promotion attached to this practice includes information on nutrient rich foods. There is also a message to prepare foods at home whenever possible.Central District Health Department (CDHD) is one of seven local public health departments in Idaho. Each contracts with the Idaho Department of Health and Welfare to administer CDC funds for chronic disease prevention and awareness campaigns throughout the counties within the districts. Current CDC funding targets Diabetes Prevention and Awareness, Injury Prevention (with a state focus on fitness for seniors), Cancer Control, and Physical Activity and Nutrition (PAN). USDA funds support our WIC program. Cholesterol Screening has been continued for more than twenty years post CDC funding as a fee-for-service program. These community outreach areas put us in touch with groups of people whose chronic diseases are impacted by overweight and obesity. Our oldest health promotion program is cholesterol screening, which has always educated participants on the preventable risk factors of heart disease and promoted better nutrition and more physical activity. We encourage clients to share our evaluation and their scores with their physicians, PA’s, NP’s. WIC funding provided CDHD the opportunity for Public Health Nutritionists to train 25 pediatric and/or family practice office staffs how to utilize the CDC two to 20 years BMI forms. Advice about meas

Central District Health Department's (CDHD) role in this practice was to provide staff time for a public health nutritionist (PHN) to create healthy meal options from existing McDonald's menu choices. Graphics, campaign name, materials, coupons, website were created by the marketing firm, Riester with input and critique by CDHD PHN and CDHD public information officer (PIO). To support CDHD PHN with the nutrient rich foods campaign, franchise owners provided t-shirts, graphics display board, tablecloth, printed materials with nutrient breakdown, coupons, and incentive gifts for picnics: frisbees, cold carriers, fleece blankets. These have been used as prizes at Children in Nature/Be Outside events, March 4 into Nature youth events, weight loss campaigns sponsored by Humphrey's Diabetes Center for two years, Taft School Community Garden Open House, worksite wellness promotions, Wellness in the Rockies: Shaping A Healthy Future IV Conference, Treasure Valley Dietitian sponsored five mile walk/run during March, national nutrition month. McDonald's of the Treasure Valley preferred that CDHD release all news releases and either the PHN or PIO would handle media requests. Using these resources, CDHD PHN has spoken and displayed the campaign at the Idaho Hunger Forum, child care provider education, worksite wellness programs, and training partners to assist with evaluation, such as Boise State University senior nursing students and Girl Scouts and their leaders and parents. CDHD PHN and PIO have written and promoted articles which have appeared in magazines, newspapers, and on the CDHD website. Within Treasure Valley Restaurants, McDonald's franchise owners have provided employee education, window clings, table tents, display boards, tray liners, pamphlets, and coupons. The marketing firm Riester Kristen Armstrong, Olympic Cyclist and Idaho Dairy Council spokesperson was asked to help promote the meals to focus on the health benefits of low fat chocolate milk.

Through a trade show presentation, McDonald’s owners became aware of a “Smart Meal” program underway in Denver, Colorado McDonald’s Restaurants. CDHD was approached to approve nutrition criteria and create meal options for a local campaign to identify wholesome meal choices. CDHD PHN, formerly Coordinator of Treasure Valley Safe Kids, had previously worked with the franchise owners to host Child Car Seat Check Ups and also to provide free coupons for the Boise Bike Police to give kids "caught" wearing a bike helmet. CDHD PHN felt confident the proposed strategic partnership would benefit the community and the health department. McDonald’s utilized the USDA National Nutrient Database to evaluate products and publish nutritional values of menu items. Consistent products and portion sizes were maintained through education and supervision of owner/operators. Furthermore, McDonald’s had added several new healthy items to their menu. Combining items as meal options with established nutritional values was relatively easy and met the intended outcome of healthier meal options. CDHD PHN spent 40 hours of office time creating the meal options and working by phone and computer with the marketing firm, Riester, headquartered in Phoenix and Los Angeles. In-kind CDHD cost of development was $2,000. CDHD PHN precepted six BSU senior nursing students to develop a tool and collect pre and post-launch observation data. These 60 student hours are valued at $1500. Campaign name and artwork were completed late summer 2008. CDHD PHN presented the information as a poster for Shaping A Healthier Future IV Conference in Jackson Hole, Wyoming, interacting with health advocates who praised the artwork and verbalized future use of meal options at McDonald's Restaurants in their own locale. Many requested pdf versions to use as a teaching tool for their students/clients. CDHD in-kind cost $500.00. The project launch occurred the first week of October 2008. CDHD Public Information Officer (PIO) wrote a press release and distributed it to area print and broadcast media. Two television stations and one major newspaper covered the event. In-kind cost: $100. The Good Fit Meals campaign is on-going. Revisions were made in Happy Meals: no more than 35% total fat or 10% of total calories from saturated fat. CDHD PHN promotes campaign to health providers and the public. Estimate cost @ 6 hours per month: $4800. During the FY 2008 budgeting process, Russell Duke, CDHD Director, had petitioned the CDHD Board of Directors to allocate $30,000 of undesignated funds for Childhood Obesity Prevention. The CDHD Board has continued annual funding of $30,000 for FY2009 and FY2010. Although other projects have been created and completed with these funds, all staff time (including benefits and indirect) and travel costs related to Good Fit Meals have been covered by these funds. McDonald's of the Treasure Valley has paid for the marketing expertise of Riester and the development of artwork, brochures, signage, table tents, goodfitmeals.com, coupons, incentive prizes for health fairs and carnivals, sponsorship fees for local walks and events. They paid $200 to a local Girl Scout Troop to conduct a follow-up survey in summer 2009.

Partners meet and develop campaign timeline and components needed. Existing McDonald's resources are used to select meal options which meet pre-established nutrient requirements. Marketing firm Riester develops materials with critique and input of CDHD PHN and PIO and gains approvals from beverage providers and national McDonald's. PHN develops pre- and post-observation survey tools with input and approval of franchise owners. BSU students work with professor and PHN preceptor to understand methods of observation and adequate on-site notice of their presence to site managers. Survey results are analyzed and reported to franchise owners. Improvements are made in campaign materials management. The initial tasks were carried out within a six month time frame prior to campaign launch October 2008. Since the kick-off of Good Fit Meals was successful, and McDonald's of the Treasure Valley franchise owners have chosen to continue the program, improve materials, support events with coupons and incentive gifts, and ask CDHD PHN and PIO to take the lead with media coverage, it has become an on-going practice and partnership. There is a lot of public interaction with local health district staff and partners. The nutrient rich foods message and reducing overweight and obesity are more popular now in February 2010 than in October 2008. The U.S. Surgeon General and the First Lady, Michele Obama are wonderful national spokespersons to highlight improvements needed in nutritional intake and community gardening, moving more, limiting screen time, and the importance of family time and communication. Due to the success of Good Fit Meals and the community partnerships formed to improve the built environment, promote being outdoors, and support nutrient rich food choices, the CDHD Board has extended funds to work on the overweight/obesity issue.

McDonald's of the Treasure Valley franchise owners held an investor meeting in November 2009. PHN was invited to present. Survey results were reported by Riester. A committment was made to continue the Good Fit Meals campaign. The marketing firm Riester has been working with PHN and PIO to increase media contacts and a 2010 community event schedule has been developed. The CDHD FY 2010 budget has been revised and approved with funding maintained through June 2010 for the overweight and obesity prevention program. PHN will report current activities and outcomes to the CDHD Board on February 19, 2010. It is expected that the FY 2011 budget will support staff time for this issue. Modifications in the campaign will occur as nutrition science advances, additional wholesome products are added to the McDonald's menu, there are reductions in total fat, saturated fat, trans fat, and sodium content, calorie content on restaurant reader boards is mandated by law in Idaho and/or the United States. Ninety-eight percent of the Treasure Valley McDonald's are owned by one original family who developed them. The son and daughter each have young children and are actively involved in the business and supportive of promoting healthy choices. Community organizations support using the Good Fit Meals Campaign to promote nutrient rich food choices. CDHD and the franchise owners are proud of this partnership and hope it will go statewide and then national. If this occurs there will be new partners to support activities which promote making healthier food selections at McDonald's restaurants.

Create meal options and a marketing campaign to help McDonald's of the Treasure Valley customers select healthier meal options. Objective 1: By July 2008, CDHD Public Health Nutritionist (PHN) will select existing McDonald's menu items to create 12 McDonald’s meal options which provide customers an opportunity to increase daily intake of nuts and seeds, whole grains, fruits and vegetables, and dairy servings. Each meal will contain no more than 30 percent total fat, 0.5 grams trans fat, 1500 milligrams sodium, and 700 calories. CDHD PHN met in person with franchise owners and marketing staff from Riester to receive the Smart Meals flyer from Denver and discuss ways to improve the original practice. PHN was taught how to access the McDonald's "Bag-a-Meal" program and a timeline was created. PHN worked by e-mail, fax, and phone to complete meal option selections. Owners and marketing staff provided feedback. Beverages were selected and approval was needed from Dasani and the Idaho Dairy Council for their approval. During the process of option selection, the Bag-a-Meal site was updated due to the purchase of products with lower trans fat. This allowed for greater choice in entree items. Meal options were selected, reviewed, evaluated, and approved by the local franchise owners prior to July 2008. The "Smart Meals" name had been patented in Denver. Other names were considered and research was needed to collect and analyze before finding a suitable campaign name. Meals in grocery stores, such as Healthy Choice Meals, Smart Choice, and others could not be used to avoid patent infringement. Meal option data was collected and double checked for accuracy one time. Campaign name data was collected one time. All data results ended up at the National McDonald's Promotion office. The major lesson learned was that final approval took at least three months. Objective 1 was met and 12 meal options were developed and approved. This was an intermediate outcome. After initial launch, another meal was added and the nutritional requirements were changed to include a higher total fat allowance (35% of total calories) and lower saturated fat allowance (no more than 10%) for Happy Meals.Objective 2: Marketing firm, Riester, will develop name, graphics, website, coupons, and marketing strategies to launch campaign in Fall 2008 at McDonald's of the Treasure Valley Restaurants. As described under Objective 1, finding a campaign name was an unexpected Riester marketing effort. All initial campaign pieces were completed and ready for October 2008 launch.All campaign materials were developed in draft form and submitted to owners and CDHD PHN and PIO for comment, and then sent to National McDonald's. All correspondence was completed through e-mail and fax. Suggestions were made to change initial artwork, changes made, and input requested. This was a multi-step process.All creative campaign materials ended up at the National McDonald's Promotion office. Few changes were recommended.Objective 2 was met and the Good Fit Meals Campaign was launched in October 2008.Objective 3: CDHD PHN will work with Boise State University (BSU) Community Nursing Professor and senior nursing students to observe McDonald's consumers before and after campaign launch and determine whether meal options were selected.CDHD PHN created the pre and post observation survey with McDonald's input and approval. BSU students were trained and restaurant sites were selected. McDonald's owners notified site managers of student visits. Students observed and reported findings. Students completed pre and post observation forms. Original forms were collected and tallied by PHN. Students tallied their own data and included numbers in their final class project report. Pre observation survey was done individually by each of six students at six different selected restaurants. Post observation surveys were completed individually by six students returning to the same sites after the launch of Goo