title: Nutritional quality and marketing strategies of fast food children's combo meals in Guatemala.
abstract: BACKGROUND
  Overweight and obesity prevalence in children is now on the rise in low/middle-income countries, including Guatemala. Fast food consumption is a recognized contributing factor to this rise. Fast food restaurants use health claims, toy giveaways, price incentives and fast service to promote children's combo meals. This study sought to assess the use of toy giveaways, time to delivery and price incentives as marketing strategies in fast food chain restaurants in Guatemala. In addition, we sought to compare nutritional quality of combo meals with and without health claims.
  
  
  METHODS
  We visited one restaurant from each of the 8 major fast food chains in Guatemala and purchased all children's combo meals to assess the prevalence of toy giveaways, health claims, and difference in delivery time and price between the combo meal and each meal item purchased separately. Each item was then classified as "healthy" or "less healthy" using the UK Nutrition Profile Model. Nutrition information was collected on-site, from the restaurant website, or by calling the customer service phone number.
  
  
  RESULTS
  We found 114 combo meals, 21 (18.4%) of which were children's combo meals. Five (24%) had nutrition information, all were classified by our analysis as "less healthy", and three had a health claim. On average, combo meals were US$1.93 less expensive than purchasing children's meal items individually (p= 0.01). Time to delivery was 1.44 min faster for combo meals compared to purchasing meal items individually (p= 0.19).
  
  
  CONCLUSIONS
  Children's fast food combo meals in Guatemala were promoted using several marketing strategies that encourage consumption, including offering toy giveaways and price incentives. In addition, nutrition information is lacking in fast food chain restaurants. Public health advocates in Guatemala should consider a comprehensive approach to encourage healthier choices within fast food restaurants including policies that require fruit and vegetable options for meal side dishes, accessible and easy to read nutrition information, and restrict the use of toy giveaways.
authors.affiliation: Cardiovascular Surgery Unit of Guatemala, 6a Ave 8-71 zona 10, Clinica #3, Ala Sur, Guatemala, 01011 Guatemala ; Center for the Prevention of Chronic Diseases, Instituto de Nutrición de Centro America y Panama, Guatemala, Guatemala.
authors.forename: Sofia
authors.initials: S
authors.lastname: Mazariegos
authors.affiliation: Cardiovascular Surgery Unit of Guatemala, 6a Ave 8-71 zona 10, Clinica #3, Ala Sur, Guatemala, 01011 Guatemala ; Center for the Prevention of Chronic Diseases, Instituto de Nutrición de Centro America y Panama, Guatemala, Guatemala.
authors.forename: Violeta
authors.initials: V
authors.lastname: Chacón
authors.affiliation: School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada.
authors.forename: Adam
authors.initials: A
authors.lastname: Cole
authors.affiliation: Cardiovascular Surgery Unit of Guatemala, 6a Ave 8-71 zona 10, Clinica #3, Ala Sur, Guatemala, 01011 Guatemala ; Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, USA.
authors.forename: Joaquin
authors.initials: J
authors.lastname: Barnoya
keywords: Children; Fast food; Low/middle-income countries; Obesity