Appendix Nutrition Environment Measures Study In

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AppendixNutrition Environment Measures Study in Restaurants(NEMS-R): Development and Evaluation(Saelens B, Glanz K, Sallis J, Frank L. Amer J Prev Med 2007)In this appendix, you will find the following: NEMS-R Measurement Forms (restaurant measures survey) NEMS-R Protocol (instructions on how to complete the survey) NEMS-R Rationale (explanation of the items in the survey)Using the Measures – and TrainingYou can obtain the NEMS-R tools, protocol and rationale here. There is no charge for using themeasures, but appropriate acknowledgment should be given. Also, we encourage you toconsider attending one of our NEMS trainings to receive hands-on practice and instruction on thetools. The training is free, but participants are responsible for travel costs. The studydemonstrated the tool to be reliable and supported its validity, but solid training on how tocomplete the tool is necessary to ensure reliability. The training workshops also provideguidance on identification of restaurants in a defined area, data analysis, quality assurance, andrelated issues. You can learn more about the NEMS trainings and training dates by visiting ourwebsite at www.sph.emory.edu/NEMS. Online training will be available in the future.ModificationsThe NEMS-R tool may be adapted or tailored to your project/research goals and to thecommunity/ies that you are assessing. However, if you decide to modify the measures, westrongly encourage you and others to pre-test it to make sure that the modifications work (i.e.,everyone understands and can properly complete them, and that the measures identify variationin what you’re examining). These modifications could consist simply of adding moretransportation items to the cover page, or more substantial changes such as adding a newmeasure to the restaurant tool. Do not be alarmed if it takes multiple attempts to arrive at themodifications that you ultimately use.It should be noted that since the study’s completion, an additional category of Fast Casual (FC)for restaurant classification was created beyond what was cited in the article. Also, an expandedsection on the children’s menu has been developed and is available upon request. Please sharewith us any modifications that you may decide to do, so we can share it with others.If you have any questions, please contact us at [email protected]: Glanz K, Clawson M, Young M, Carvalho M. Nutrition Environment MeasuresTraining Manual. Atlanta: Emory University, 2006. 2006 Rollins School of Public Health, Emory UniversityUsed with permission

NEMS-RMeasurement Forms

Nutrition Environment Measures Survey (NEMS)RESTAURANT MEASURES--DATA COLLECTION-Restaurant ID:--Date:Rater ID:Day/ YearCode #1) Type of Restaurant:2) Data Sources:/MonthSite Visit/ObservationyesTake-Away Menuno3) Site Visit Information:yesInternetnoyes4) Take-Away Menu Features:Take-away :yesnoComments:Interviewnoyes5) Internet Site Features:no6) Interview Information:NutritionInformationIdentification ofhealthier menuitemsyesnoMenuyesnoMenu tification ofhealthier menuitemsOther:yesnoyesnoComments (describe items above)Web site URLComments:Data Source(s):7) Hours of OpenSiteClosedMenuWebSaturdayOpenClosedB: 6:00 - 11:00amB: 6:00 - 11:00amB: 6:00 - 11:00amB: 6:00 - 11:00amL: 11:00 am - 3:00 pmL: 11:00 am - 3:00 pmL: 11:00 am - 3:00 pmL: 11:00 am - 3:00 pmD: 5:00 pm to CloseD: 5:00 pm to CloseD: 5:00 pm to CloseD: 5:00 pm to Close:AMPM:AM:PMAMPM:ORNumber of tables AMPMOpen 24 Hours (If 24-hr, leave Hours of Operation section blank)8) Access: Drive-thru windowyesComments:noParking onsiteyes9) Size of Restaurant:Seating capacity noComments:Page 16385533418

Nutrition Environment Measures Survey (NEMS)RESTAURANT MEASURES--DATA COLLECTIONRestaurant ID:---Date:/MonthRater ID:Site visit (Observation)Day/ YearSelect One10) Restaurant has a salad baryesnoyesnob. Do signs/table tents/displays highlight healthy menu options?yesnoc. Do signs/table tents/displays encourage healthy eating?yesnod. Do signs/table tents/displays encourage unhealthy eating?yesnoe. Do signs/table tents/displays encourage overeating (all-you-can-eat, super-size, jumbo, grande,supreme, king size, feast descriptors on menu or signage)?yesnof. Does this restaurant have a low-carb promotion?yesnog. Other?yesnoyesnob. Baked chipsyesnoa. Breadyesnob. 100% wheat or whole grain breadyesno14) 100% fruit juiceyesno15) 1% Low-fat, skim, or non-fat milkyesno11) Signage/Promotionsa. Is nutrition information posted near point-of-purchase, or available in a brochure?CommentsMenu Review/Site visit12)13)a. ChipsPage 26394533418

Nutrition Environment Measures Survey (NEMS)RESTAURANT MEASURES--DATA COLLECTIONRestaurant ID:---Date:Rater ID:Menu Review16) Main Dishes/Entrees:a. Total # Main Dishes/Entreesb. Healthy options/MonthSelect OneChoices (#)Day/ YearComments#yesno#yesno17) Main dish salads:a. Total # Main dish saladsb. Healthy options#yesno#yesnoc. Low-fat or fat free salad dressings#yesno18) Fruit (w/out added sugar)#yesno19) Non-fried vegetables (w/out added sauce)#yesno20) Diet sodayesno21) Other healthy or low calorie beverage?yesnoPage 38087533419

Nutrition Environment Measures Survey (NEMS)RESTAURANT MEASURES--DATA COLLECTIONRestaurant ID:---Date:/MonthRater ID:Day/ YearMenu Review/Site Visit22) Facilitators & SupportsSelect OneCommentsa. Nutrition information on menu (paper or posted menu)yesnob. Healthy entrees identified on menuyesnoc. Reduced-size portions offered on menuyesnostandardd. Menu notations that encourage healthy requestsyesnoe. Other?yesnoyesnoyesno23) Barriersa. Large portion sizes encouraged?Super-size items on menub. Menu notations that discourage special requests(e.g., No substitutions or charge for substitutions)Page 45026533419

Nutrition Environment Measures Survey (NEMS)RESTAURANT MEASURES--DATA COLLECTIONRestaurant ID:---Date:Rater ID:23) Barriers (Cont.)c. All-you-can-eat or "unlimited trips"/MonthSelect OneDay/ YearCommentsyesnod. Other?yesno24) Pricinga. Sum of individual items compared to combo mealb. Healthy entrees compared to regular onesc. Charge for shared entree?morelesssameNAmorelesssameNAyesnod. Smaller portion compared to regular portion(if 22c is No or Standard then mark N/A)e. Other?morelesssameNAmorelesssameNAPage 59776533415

Nutrition Environment Measures Study (NEMS)RESTAURANT MEASURES--DATA COLLECTIONRestaurant ID:---Date:Rater ID:Menu Review25) Kid's menu?/MonthSelect One/ YearCommentsyesnoDKa. Healthy choicesyesnoNAb. 100% fruit juiceyesnoNAc. MilkyesnoNAd. Other?yesnoNAPage 6Day97765334153825400024

NEMS-R Protocol

NUTRITION ENVIRONMENT MEASURES SURVEY (NEMS)RESTAURANT MEASURES SURVEY INSTRUCTIONSThese measures are designed to rate the nutrition environments of restaurants serving either lunch or dinner. They are not designed to ratespecialty shops such as coffee or ice cream shops, unless these shops serve lunch or dinner items (e.g., sandwiches). In addition, there areother establishments that may serve food that fall into an exclusions category (see below) and would not be rated. However, based on yoursurvey purposes, you may decide to set different exclusion criteria.ExclusionsEstablishments that are not open to the general public, or those where you have to pay a charge just to enter. Also, establishments wherefood is not the primary product (e.g., food counters at drugstores).Examples: schools churches convalescent homes bars, clubs, or places excluding children 18 and under movie theatres hospitalsstores not preparing food to order or consume immediately(bakery, dairy store, store that sells coffee beans, etc.)food counters within discount/superstores (e.g., Wal-Mart)workplace cafeteriasIn these protocol instructions, each section of the survey is shown, followed by instructions for completing that section. Refer to theRestaurant Data Collection Flowchart, which explains the suggested order for completing the survey components, if you have any questionson the data collection process.General Completion TipsRemember to follow the tips below to decrease the data cleaning time later.1. Write legibly.2. Check your work.3. Use the correct line/bubble.For Those Whose Forms will be ScannedThe surveys will be scanned on a machine that is very picky, so please remember to do the following:1. Darken your circles once you are sure of the answer.2. Press down when writing letters or numbers so they are legible and dark.3. Write your comments and notes on the lines provided.4. Do not cross through any individual items or sections.5. Erase any stray marks you make.1

COVER PAGE Record your Rater ID at the top of the page.Confirm that the category assigned to the restaurant (sit down-SD, fast casual-FC, fast food-FF, specialty, or other) during theenumeration process is correct and mark the appropriate bubble. See instructions below on restaurant classification. If it is incorrect, explain in the “Comments” section of the cover page and alert project coordinator when submitting the form. Continue with the assessment, unless it is not a restaurant.Record the date and start/end times for each data source as you complete the data collection.Classifying Restaurants:1. Sit-down Restaurants category (SD)This category includes traditional sit-down restaurants, and bars and pubs with full menus that are open to all ages.a. Sit-down Restaurant-Restaurant that offers full table service by wait staff, who take your order at the table.Examples: Applebee’s P.F. Chang's China Bistro - http://www.pfchangs.com/ Benihana - http://www.benihana.com/ Planet Hollywood - http://www.planethollywood.com/ Cheesecake Factory - http://www.cheesecakefactory.com/ Qdoba Mexican Grill - http://www.qdoba.com/ Chili's Grill & Bar - http://www.chilis.com/ Ruby Tuesday Denny's- http://www.dennys.com/ Sizzler - http://www.sizzler.com/home/home.html Don Pablo's TGI Friday's - http://www.tgifridays.com/ Golden Corral Thaicoon Hard Rock Cafe Todai Seafood Buffet - http://www.todai.com/ International House of Pancakes or IHOP Top Spice Olive Garden Touch of India Outback Steakhouse- http://www.outback.com/ Z' Tejas Southwestern Grill - http://www.ztejas.com/2

b. Bars/Pubs – A restaurant that sells a full range of alcoholic beverages, has a full menu and is open to all ages. These are to belisted under the Sit-down Restaurants heading.Examples: Brick Store Pub Maggie’s Neighborhood Bar & Grill Famous Pub and Sports Palace Taco Mac2. Fast Casual Restaurant (FC)A restaurant that is similar to fast-food in that it does not offer table service, but promises somewhat higher quality of food andatmosphere. (http://en.wikipedi.org/wiki/Fast casual restaurant) You may order and pay at a counter. Often food is brought to yourtable.Examples: Atlanta Bread Company Fuddruckers Baja Fresh Mama Fu’s Boston Market Moe’s Southwest Grill Café Express Panera Bread Company Chipotle Mexican Grill Pita Palace Fresh City Wingstop3. Fast Food Restaurants category (FF)This category includes fast food restaurants only. Fast food restaurants are characterized by minimal service and by food that issupplied quickly after ordering. Food purchased may or may not be eaten quickly as well. Food is commonly cooked in bulk inadvance and kept hot, or reheated to order.Fast Food restaurants usually meet at least one of the following criteria:A. A restaurant that is part of a fast food chain or franchise (see list) that ships standardized foodstuffs to the individualrestaurants from central locations.B. A restaurant that is located in a food court.C. A restaurant that is limited to take-out only.D. Lunch trucks, trailers, wagons, etc.3

More on Fast Food:Fast food is often highly processed and prepared in an industrial fashion, i.e., with standard ingredients and methodical cooking andproduction methods. It is served usually in cartons or bags in a rapid manner in order to minimize costs. Fast food outlets oftenprovide take-away or take-out food in addition to tables for eating-in. A drive-through allows food to be ordered and deliveredwithout leaving the car to further speed service.Fast food is often finger food that can be eaten quickly and without cutlery. Fast food often consists of fish and chips, sandwiches,pitas, hamburgers, breaded chicken, French fries, chicken nuggets, pizza or ice cream, although many fast food restaurants offer someother less easily consumed choices like chili, mashed potatoes, or salads. Chinese cuisine, although often served as take-away, is notalways considered fast food. (http://encyclopedia.thefreedictionary.com/Fast -food%20restaurant)Examples: Arby's http://www.arbys.com Panda Express http://www.pandaexpress.com/ Blimpie Pizza Hut Burger King Popeye's Fried Chicken http://www.popeyes.com/ Carl's Jr. http://www.carlsjr.com/ Quizno's Chick-fil-A http://www.chickfila.com Sbarro Dairy Queen (Brazier) Schlotzsky's http://www.cooldeli.com/ El Pollo Loco http://www.elpolloloco.com/ Sonic Drive-In http://www.sonicdrivein.com/ Jack in the Box Steak and Shake KFC Subway Sandwich Krystal http://www.krystalco.com/ Taco Bell Little Caesar's Tastee Freeze Long John Silver's Wendy's McDonald's Whataburger4

4. Specialty Shops categorya. Coffee/Pastry - This category includes restaurants where coffee and/or pastries are the main items sold.Examples: Caribou Coffee Dunkin’ Donuts Krispy Kreme Seattle’s Best CoffeeStarbucksb. Ice Cream -This category contains restaurants where ice cream or similar types of food such as smoothies, yogurt, etc. are themain items sold. The food is a single serving that is prepared for immediate consumption.Examples: Baskin Robbins Cold Stone Creamery Planet Smoothie Smoothie KingTCBY5. Other category – All other restaurants; we think that we captured all restaurant establishments, but in case we overlooked one,please use this category!5

ALL PAGESRestaurant ID: FF-F-FF-FFFDate: FF /FF /FFRater ID: FFRecord the following at the top of all pages of the form: Restaurant ID Today’s date Rater IDPAGE 1TYPE OF RESTAURANT:)1) Type of Restaurant: Code # FF1. Record code from Restaurant Code List for type of restaurant, basing it on the main category of cuisine served (e.g., if it is a Chinesevegetarian restaurant, code it as Chinese, not Vegetarian).6

NEMS Restaurant Code ListCode 5Type of RestaurantGeneral / Mixed / AmericanBurgersChickenSub SandwichesPizzaBagel / DeliSeafoodBBQSteakhouseCoffee ShopsIce Cream/Frozen Yogurt ShopsDonut ShopsBakery/Pastry ShopsBars/PubsAsian (mixed, nGreek, Middle EasternVegetarianOtherExamplesApplebees, Chili’s, TGI Friday, IHOP, Waffle HouseMcDonald’s, Wendy’s, HardeesKFC, Mrs. Winner’s, Chick-Fil-ASubway, Blimpie, QuiznosPizza Inn, Pizza Hut, Mellow MushroomEinstein’s, Bagel Palace DeliPappadeaux, Red LobsterDusty’s, Sonny’s BBQOutback Steakhouse, Ruth Chris’ Steakhouse, LonghornStarbuck’s, Seattle’s Best Coffee, Caribou CoffeeBaskin Robbins, TCBY, Cold Stone Creamery, Baskin-RobbinsKrispy Kreme, Dunkin’ DonutsMrs. Fields’ Cookies, CinnabonTaco Mac, ESPN ZoneMama Fu’s, Chopsticks, Top SpiceRed Pepper, The Golden Buddha, Panda ChineseThai Chili, ThaicoonEdo Steak House, Shogun, Fuji JapaneseChipotle, Pappasitos, Don PablosSbarro, Olive Garden, Romano’s Macaroni GrillPetite Auberge, Le MadeleineTouch of India, Himalayas Indian, HaveliAthens Restaurant, Kyma, Basil’s Mediterranean7

DATA SOURCES:2) Data sources:Site visit/Observation yes noTake-Away Menu yes no Internetyes no Interviewyes no2. Record all the data sources that you use in completing the data collection form for this restaurant.If you fill in "no" for any of the data sources, leave the corresponding data source in Items #3-6 blank and note the reason in comments. Forexample, if you are not able to complete the site visit for whatever reason, leave Item #3 (Site Visit) blank and note the reason (e.g., managerrefused).SITE FEATURES AND INFORMATION:3) Site Visit Information:4) Take-Away Menu Features:5) Internet Site Features:6) Interview Information:NutritionInformationIdentification ofhealthier menuitems yes noMenu yes noMenu options yes no yes noNutritionInformation yes noPricing yes no yes noTake-away Menu yes noNutritionInformation yes noOther: yes noOther: yes noIdentification ofhealthier menu items yes noOther:Other: yes noOther: yes noOther: yes noComments (describe items above):Comments:Comments:Web siteURL:Comments:3. Site Visit Information: Record whether you were able to obtain a take-away menu and/or nutrition information during your site visit. If thesite visit includes other nutrition-environment relevant information (e.g., a healthy eating brochure), mark “yes” next to “Other” and describein comments.4. Take-Away Menu Features: Record whether the take-away menu includes nutrition information or identification of healthier menu items. Ifthe menu includes other nutrition-environment relevant information (e.g., a statement encouraging healthy eating), mark “yes” next to“Other” and describe in comments.5. Internet Site Features: Record what type of information you found on the Internet about this restaurant. Also record the Web address(URL) or addresses where you found the information. If the website includes other nutrition-environment relevant information (e.g., anutrition calculator), mark “yes” next to “Other” and describe in comments.8

6. Interview Information: Record whether you used a formal sit-down interview to obtain menu options, pricing, or other information that youcould not get from the other data sources. Asking wait staff a few questions is not considered an interview.HOURS OF OPERATION:7) Hours of Operation:Sunday Open Closed B: 6:00 – 11:00 am L: 11:00 am – 3:00 pm D: 5:00 pm to CloseFF:FF AM PMThursday Open Closed B: 6:00 – 11:00 am L: 11:00 am – 3:00 pm D: 5:00 pm to CloseFF:FF AM PMData Source(s): Site Menu WebFriday Open ClosedSaturday Open Closed B: 6:00 – 11:00 am B: 6:00 – 11:00 am L: 11:00 am – 3:00 pm L: 11:00 am – 3:00 pm D: 5:00 pm to Close D: 5:00 pm to CloseFF:FF AM PMFF:FF AM PM Open 24 Hours (If 24-hr, leave Hours of Operation section blank)7. Hours of Operation Note: The hours listed beside breakfast (B), lunch (L), and dinner (D) are approximate times. For example, for a restaurant that is open 10:30am – 10:00 pm, mark L (Lunch) and D (Dinner), or even if the restaurant opens at 7:00 am instead of 6:00, mark B (Breakfast).During the site visit (or from another data source), record the following: Data source(s) Is the restaurant open or closed on the days indicated? If so, record whether it is open for breakfast (B), lunch (L), and/or dinner (D). If it serves brunch, mark as breakfast and lunch. Record the latest hour open, and mark am or pm. If the restaurant is open 24 hours, leave the rest of Section 7 blank.ACCESS:8) Access: Drive-thru windowParking onsite yes no yes noComments:8. Access Record whether there is a drive-thru window. If the restaurant offers the option of sitting in your car and a server comes out to take yourorder or bring you your food (e.g., such as Ruby Tuesday’s), this is NOT considered a drive-thru. Just note this in comments. Parking onsite9

Mark YES, if parking is available in a parking lot or structure/parking deck associated with the restaurant.It does not matter if the parking is paid, free, valet, or self-park.If there is only street parking (free or metered), answer NO to parking, as that is not associated with the restaurant.SIZE OF RESTAURANT:9) Size of Restaurant: Seating capacity OR Number of tables Comments:9. Size of Restaurant Record the seating capacity (from the fire department sign on the wall), or count the number of tables of any size, if you do not see thesign. Count both exterior and interior tables. Count the counter seating as one table and note the number of counter seats in comments. Note: If you use the seating capacity from the fire department sign, you will still need to count any exterior tables and note it incomments. If the restaurant is in a food court and has no tables, fill in seating capacity 0 and note in comments that the restaurant is in a food court.If the restaurant has its own tables, list the seating capacity, or count the tables and note in comments that there are also tables in the foodcourt.10

SITE VISIT (OBSERVATION) ITEMS 10-1110. SALAD BAR10) Restaurant has a salad bar yes noRecord whether the restaurant has a salad bar.11. SIGNAGE/PROMOTIONS11) Signage/Promotionsa. Is nutrition information posted near point-ofpurchase, or available in a brochure?b. Do signs/table tents/displays highlight healthy menuoptions?c. Do signs/table tents/displays encourage healthyeating?d. Do signs/table tents/displays encourage unhealthyeating?e. Do signs/table tents/displays encourage overeating(all-you-can-eat, super-size, jumbo, grande, supreme,king size, feast descriptors on menu or signage)?f. Does this restaurant have a low-carb promotion?g. Other? yes no yes no yes no yes no yes no yes yes no noRecord the following and describe the signage in comments. Please note that signage can be inside or outside the restaurant.a. Nutrition information near point of purchase Is nutrition information posted near point-of-purchase, or available in a brochure that is prominently displayed?b. Signs/table tents/displays highlight healthy menu options Signage may relate to nutritional value/type of food (grilled food, salads) Example: “Try a low-fat option—We feature salads made with fat-free dressing” Example: “Eat healthy: Try our Brown Rice”11

c. Signs/table tents/displays encourage healthy eating Signage that encourages making healthy choices Example: “Here’s to Eating Well” Example: “Fruits and Vegetables—the Smart Choice!”d. Signs/table tents/displays encourage unhealthy eating It can be related to nutritional value/type of food (promoting rich desserts and fried foods) or price (combo discounts) Example: “Try our cheesecake: Rich & creamy” Example: Posters featuring pictures of high-fat foods Example: Promotional signs or posters pushing combo discountse. Signs/table tents/displays encourage overeating Related to quantity Examples: All-you-can-eat, super-size, jumbo, grande, supreme, king size, feast descriptorsf. Low-carb promotion Is restaurant promoting low-carb menu items? Example: “The Low Carb Option” Example: Low-Carb Chopped Steakg. Other Note any other signage or displays that would influence food purchasing.12

MENU REVIEW/SITE VISIT ITEMS 12-15Items 12-15 are under the header Menu Review/Site Visit, because sometimes they are not listed on the menu and you may need to ask wait staffif they are available.12. CHIPS12) a. Chipsb. Baked chips yes no yes noRecord whether chips (fried) and baked chips are available (yes/no).Note: Baked chips must have 3 grams fat/serving. Baked Lays and Baked Tostitos meet this criterion; however, Baked Doritos donot.13. WHOLE GRAIN BREAD13) a. Breadb. 100% Whole wheat or whole grainbread yes yes no noRecord whether regular (enriched flour) and 100% whole wheat or whole grain bread are available (yes/no).14. 100% FRUIT JUICE14. 100% fruit juice yes noRecord whether 100% fruit juice is available (yes/no).15. 1% LOW-FAT, SKIM OR NON-FAT MILK15. 1% low-fat, skim, or non-fatmilk yes noRecord whether low-fat (1% or ½ %), skim or non-fat milk is available (yes/no).13

MENU REVIEW (#16-21)16. MAIN DISHES/ENTREES:16) Main Dishes/Entrees:a. Total # Main Dishes/Entrees.b. Healthy options yes no yes no# FFF# FF16a. Total number of main dishes/entrees Count the total number of main dishes and entrees on the menu. Include any entrees that are listed as specials that do not appear on themenu. If there are both lunch and dinner menu items listed on the same menu, do not count the entrees listed as “Lunch” items. Do notinclude main dish salads. Use the following guidelines:General rule of thumb: If an item is listed as a separate entrée, count it. Do not think too hard about it.Definition of an entrée-It must be distinctly different, either in ingredients, proportion of ingredients, or preparation methodandDiffer in ways OTHER THAN JUST SIZE/QUANTITY An example of different proportion of ingredients: A cheeseburger and a double cheeseburger have proportionately different ingredients,making one higher in percent fat than the other. Proportionally, a double cheeseburger is higher in percent fat than a cheeseburger, becauseit has a smaller percentage of bread, lettuce and tomato (lower fat ingredients) than meat and cheese (higher fat and saturated fatingredients). Thus, these would be two separate entrees. Count each type of entrée only once. If the entrée is offered in different sizes or in combination with another food, count it only once. Example: Baby Back Ribs (Count as one entrée)½ Rack Baby Back Ribs Example: FAJITAS (Count as 2 entrees, not 4)Steak: Seasoned Steak Grilled to PerfectionChicken: Grill and Marinated Chicken BreastCombo: Grilled and Marinated Chicken Breast with Seasoned SteakDouble: Your Choice of Chicken, Steak, or as a ComboIf the entrée is listed with an option of “chicken or beef” or similar choices, count each item as a separate entree. Example: Curries: Choice of Chicken, Beef, or Pork (Count as 12 entrees, not 4) 14

PanangMasamanRed CurryPineapple Curry If entrees are listed together in a section, but are distinctly different, count each one as an entrée. Example: (Count as 5 entrees, not 1)Blimpies Hot Subs—Grilled6 In: 3.99 6 In: Stacker: 5.19 12 In: 6.29 Buffalo Chicken Ultimate Club Beef, Turkey & Cheddar Pastrami Special Reuben If various preparation options, e.g., broiled, fried, or grilled, are available, count each preparation option as an entrée. Example: Farm-raised Catfish, grilled or breaded and pan-fried (Count as 2 entrées, not 1) If the same entrée is prepared with different sauces, count them as different entrées. Example: A dozen hot wings offered in BBQ, Honey Mustard or Lemon Pepper (count as 3 entrées, not 1) Example: Spaghetti with marinara sauce, meat sauce or Alfredo sauce (count as 3 entrées, not 1) If an entrée is listed twice in separate sections of the menu, count it twice. Soup is counted as an entrée if it is priced similar to other entrees. Do not count the following as main dishes: Sushi Dim Sum Tapas If a restaurant serves brunch items and there is no separate dinner menu, or if breakfast items are offered all day, count them as entrees. Count “build your own” as one item. Example: Build your own omelet (with choice of ingredients) (Count as 1 entrée)15

Example: Build your own pizza (Count as 1 entrée) If the restaurant features a buffet or smorgasbord for one price, count as one entrée. Note this in comments.16b. Healthy optionsIf calorie and fat information or a healthy symbol or notation (e.g., light fare, light, heart healthy, healthy) are provided, mark “yes”. If not,mark “no”. Then follow the steps below to count whether the options meet the NEMS definition of “healthy”.If nutrition information is available:1. Count the number of entrees (except burgers and sandwiches) that meet all three of the following criteria:a) 800 caloriesb) 30% of calories from fat (see % Fat Chart)c) If saturated fat data are available, then check to see if the items that meet the total fat criterion also have 10% of calories fromsaturated fat (see % Fat Chart).2. Count the number of a la carte burgers and sandwiches that meet all three of the following criteria:a) 650 caloriesb) 30% of calories from fat (see % Fat Chart)c) If saturated fat data are available, then check to see if the items that meet the total fat criterion also have 10% of calories fromsaturated fat (see % Fat Chart).3. Add the numbers of entrees, burgers, sandwiches meeting the criteria and record in #16b on data collection form.4. If a menu does not have any healthy options, write “0” in the # box.If nutrition information is not available:Record the number of entrees identified as “light fare,” “light,” “heart healthy,” “healthy,” sometimes designated with a small heart symbol.If a menu does not have any healthy options, write “0” in the # box.16

% FAT CHARTCount entrees and main dish salads with the following maximum amounts of calories and total fat (30% calories from fat) ashealthful choices. Look at the nutritional information listed by each entrée. Find where each entrée falls in the calorie range listed.Then, see if the grams of fat given for that range are equal to or less than the fat content of the entrée. If the fat grams in the entréeare greater than the chart, it is not counted as a healthy option.Calories 179180 - 209210 - 239240 - 269270 - 299300 - 329330 - 359360 - 389390 - 419420 - 449450 – 479480 - 509510 – 539540 - 569570 - 599600 – 629630 – 659660 – 689690 – 719720 – 749750 – 779780 – 800 grams of fat5 grams6 grams7 grams8 grams9 grams10 grams11 grams12 grams13 grams14 grams15 grams16 grams17 grams18 grams19 grams20 grams21 grams22 grams23 grams24 grams25 grams26 gramsIf saturated fat data are available, then items must also haveno more than 10% saturated fat calories to count as healthful.See chart below:Calories 149150 – 239240 – 319320 – 419420 – 499500 – 589 grams of saturated fat1 gram2 grams3 grams4 grams5 grams6 gramsRemember, burgers and sandwiches 650 calories590 – 689690 –769770 – 8007 grams8 grams9 grams17

17. MAIN DISH SALADS17) Main dish salads:a. Total # Main dish saladsb. Healthy optionsc. Low-fat or fat free salad dressings yes no yes no yes no# FF# FF# FF17a

Nutrition Environment Measures Study in Restaurants (NEMS-R): Development and Evaluation (Saelens B, Glanz K, Sallis J, Frank L. Amer J Prev Med 2007) . Wingstop 3. Fast Food Restaurants category (FF) This category includes fast food restaurants only. Fast food restaurants are characterized by minimal service and by food that is