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The US Chain Restaurant Industry Must Transform Its Business Model to Market Healthy Menu Items to Americans to Reduce Obesity and Chronic Disease Risks.

Over the past decade, the US chain restaurant industry has been identified as a business vector for poor diet quality, obesity, and noncommunicable disease risks among American adults (1, 2). Americans love eating out at fast-food restaurant (FFR), fast-casual restaurant (FCR), and full-service restaurant (FSR) chains; independent eateries; and upscale fine-dining restaurants. The National Restaurant Association’s (NRA’s) projected sales were $863 billion US dollars in 2019, representing half (51%) of Americans’ out-of-home food dollar spending (3). The industry boasts that most American customers dine out with friends and family because it is better than cooking at home and cleaning up (3). Two-thirds of Americans prefer to eat restaurant foods that offer flavors they cannot replicate at home, and 4 of 10 adults say restaurants are “an essential part of their lifestyle” (3). In this issue of the Journal, Liu et al. (4) examined trends in the nutrient quality of meals consumed by US adults at FFR and FSR chains from 2003 to 2016, and socioeconomic disparities among adults who ate at these chains. The novelty of this study is that the investigators conducted serial crosssectional analyses of 24-h dietary recalls based on 7 NHANES cycles with representative samples of >35,000 adults. They used the American Heart Association’s (AHA’s) diet score to assess the FFR and FSR meal quality aligned with the AHA’s 2020 strategic impact dietary goals. The AHA has set the ambitious goal to improve the cardiovascular health of all Americans by 20% and reduce deaths from cardiovascular diseases and stroke by 20% by 2020 (5). The AHA dietary pattern score is similar to the USDA’s Healthy Eating Index 2015, both of which examine foods and nutrients according to the Dietary Guidelines for Americans 2015–2020 (DGA). The AHA diet score includes 5 components for fruits and vegetables, fish or shellfish, whole grains, sodium, and sugary beverages and a secondary score for nuts/seeds/legumes, processed meat, and saturated fat (4). Liu et al. found that American adults consume about onefifth (21%) of their energy from chain restaurants. They also examined the proportion of meals consumed at FFR and FSR chains, ranging from a poor diet quality score (<20 out of