PUBLICATIONS and TOOLS
- National Prevention Strategy is Released
- The Effect of Food and Beverage Prices on Children's Weights
- APHA Releases Transportation and Health Toolkit
- Industry Role in Child Obesity Less Prominent on TV
- Fast-Food Outlets Near Schools May Not Be Making Teens Fat
- Teens keep Chugging Soda Despite Health Risks, Says Study
- Child Obesity Study Finds Parents Need the Training
- Lenient Fathers Are More Likely to Influence Childhood Obesity
CHILDHOOD OBESITY NEWS
- First Lady Targets Healthy Habits for Toddler Set
- L.A. School District Bans Chocolate Milks
- Schools Set to Weigh in on Fitness
- Breastfeeding Initiative is Part of Let's Move! in Indian Country
- Jack in the Box Yanks Toys from Kids' Meals
June 28, 2011, HealthDay
Strategies to encourage physical activity, healthy eating and good sleep habits are needed to reduce high rates of obesity among infants, toddlers and preschoolers in the United States, says an Institute of Medicine report released June 23.
Limiting children's TV time is a key recommendation.
Rates of excess weight and obesity among U.S. children ages 2 to 5 have doubled since the 1980s. About 10 percent of children from infancy up to age 2 years and a little more than 20 percent of children ages 2 to 5 are overweight or obese, the report said.
"Contrary to the common perception that chubby babies are healthy babies and will naturally outgrow their baby fat, excess weight tends to persist," report committee chair Leann Birch, professor of human development and director in the Center for Childhood Obesity Research at Pennsylvania State University, said in an institute news release.
"This is a national concern because weight-related conditions such as diabetes and high blood pressure once occurred almost exclusively in adults but are now occurring at rising rates among teens and young adults," Birch said.
"Child care providers, health professionals, and policymakers can be helpful partners to parents in reducing obesity risk by creating healthy environments and implementing positive practices during the crucial early years of development," she added.
Tackling only one factor will not solve the problem of obesity among infants, toddlers and preschoolers. The issue requires a wide-ranging approach that includes identifying when young children are overweight, increasing physical activity, encouraging healthy eating, and making sure children get enough sleep, the report said.
- Limiting young children's television and other media use,
- Requiring child-care providers to promote healthy sleeping practices,
- Educating parents about age-appropriate sleep times and good sleep habits,
- Requiring child-care providers to provide opportunities and environments that encourage physical activity,
- Increasing efforts to promote breast-feeding,
- Requiring child-care facilities and preschools to follow the meal patterns established by the U.S. Child and Adult Care Food Program.
The report recommendations are aimed at policymakers and health-care and child-care providers, but these professionals can educate and support parents in establishing health habits in the home, too, the report authors said.
PUBLICATIONS and TOOLS
National Prevention Strategy is Released
On June 16 members of the National Prevention, Health Promotion, and Public Health Council released the National Prevention and Health Promotion Strategy, a comprehensive plan aimed at increasing the number of Americans who are healthy at every stage of life. Mandated by the Affordable Care Act, the strategy includes actions that public and private partners can take to help Americans stay healthy and fit and improve our nation's prosperity. The strategy outlines four strategic directions: Healthy and Safe Community Environments; Clinical and Community Preventive Services; Empowered People; and Elimination of Health Disparities. The strategy contains multiple indicators on healthy eating and physical activity, including measuring the proportion of children who are obese.
The Effect of Food and Beverage Prices on Children's Weights
One factor that may be important in explaining rising childhood obesity is food prices. This report explores the effect of food prices on children's Body Mass Index (BMI) using data from the Early Childhood Longitudinal Study, Kindergarten Class of 1998-99 (ECLS-K) and the Quarterly Food-at-Home Price Database. On average, higher prices for soda, 100 percent juices, starchy vegetables, and sweet snacks are associated with lower BMIs among children. In addition, lower prices for dark green vegetables and lowfat milk are associated with reduced BMI. The effect of subsidizing healthy food may be just as large as raising prices of less healthy foods.
APHA Releases Transportation and Health Toolkit
The American Public Health Association (APHA) has developed a health and transportation toolkit, which aims to bridge the communications gap between public health and transportation. There is growing concern about the impact of transportation policies on public health; areas of overlap such as improving the built environment for more active transportation opportunities have been a core tenant in the holistic approach to combating childhood obesity.
Industry Role in Child Obesity Less Prominent on TV
June 21, 2011, Reuters
By Frederik Joelving
Television coverage of childhood obesity is less likely than print media to focus on the role of the food and beverage industry, according to a new report in the journal Pediatrics.
On the other hand, TV networks more often mention solutions on the personal level, like exercising and eating healthy foods.
That is concerning, researchers say, because spotlighting individual ways to combat obesity instead of focusing on underlying societal issues can pull the public's attention away from needed changes.
"If we think the answer to solving the problem is all about individuals changing their behavior, then there is no role for policy changes," said Colleen Barry of Johns Hopkins Bloomberg School of Public Health in Baltimore, who worked on the study.
According to the U.S. Centers for Disease Control and Prevention, childhood obesity has more than tripled over the past three decades, reaching close to 20 percent in 2008. With her colleagues, Barry analyzed a sample of 806 of the news stories that ran in U.S. magazines and newspapers and on TV networks between 2000 and 2009.
The team found that nearly all stories mentioned some sort of solution to the obesity problem. About two-thirds of TV news stories mentioned diet or exercise changes, while newspapers did so 52 percent of the time and magazines 58 percent of the time.
By contrast, TV networks mentioned system-level solutions -- like creating playgrounds or making sure that healthy foods are available in poor neighborhoods -- less frequently than print media.
Specifically, networks pointed to potential changes in the food and beverage industry only 18 percent of the time, compared to more than 30 percent in newspapers and magazines.
Barry said the reasons for this are unclear, but said industry ads on TV might play a role.
"TV news relies more heavily on advertising dollars from the food and beverage industry, so I think that could provide some influence," she told Reuters Health.
According to data from the Nielsen Company, about 15 percent of ads on TV were paid for by the food industry in 2008, compared to only two percent of the ads in newspapers. Another possible explanation for the different coverage is that systems-based solutions may be too abstract and therefore harder to address in a visual medium, Barry said. The researchers also found that childhood obesity coverage had dropped markedly since 2007, although the extra weight is still plaguing our society.
"It's a serious public health problem, and despite efforts to change people's behavior, childhood obesity shows no signs of abating," Barry said.
Fast-Food Outlets Near Schools May Not Be Making Teens Fat
June 16, 2011, U.S. News & World Report
By Alan Mozes
If a new survey of high school teens in Maine is any indication, locating fast-food outlets near schools may not actually affect students' chances of being overweight.
The survey polled more than 550 students in grades 9 through 12 at 11 schools throughout the state. On the one hand, it revealed that most teens in the state are indeed consumers of fast-food staples such as burgers, fries, pizza and soft drinks. But it also indicated that the pull toward unhealthful food among these teens appears to be a function of generally bad dietary habits and poor nutritional knowledge, rather than the location of fast-food outlets.
"Our hypothesis was that the so-called 'built environment' -- what a person's environment around them might be -- would have an influence on the [teens'] diet and obesity rate," explained study co-author Janet Whatley Blum, an associate professor in the department of exercise, health and sports science at the University of Southern Maine. "But in terms of their school environment, we did not find that," she said.
"We think the reason for that is that the availability of unhealthy foods is basically ubiquitous," Blum noted. "So while the students said they do go and buy it around their schools, they also said that they also get that same food from home and from local stores near their home. So whether or not fast-food places are near to their schools really doesn't change the overall situation."
Blum and her colleagues report their findings in the July/August issue of the Journal of Nutrition Education and Behavior.
The investigators found that about 25 percent of the students were either overweight or obese, and slightly less than 2 percent were underweight. Half of the students said they drank soda at least once a week, and one in 10 said they drank it every day. About two-thirds said they'd been to an outlet that served burgers and fries in the past month, and half had been to a pizza restaurant.
Fast-food outlets were located within about a half-mile of eight of the 11 schools, according to the survey, and 10 schools had stores nearby that sold soft drinks.
However, the researchers' statistical analysis found no correlation between a risk for being overweight and the proximity of fast-food restaurants to the teens' respective schools.
"This finding suggests that maybe we should be doing more to educate kids as to the impact of unhealthful food," Blum said.
Lona Sandon, a registered dietitian and assistant professor of clinical nutrition at the University of Texas Southwestern Medical Center at Dallas, said that the findings were "surprising, yet not surprising."
"Knowledge is power," Sandon said. "Offering the knowledge of what foods are health-promoting and beneficial is certainly the first place to start. But behavior based on knowledge and the built environment both impact food choices. The question is, what has the biggest impact?
"In this case, they're saying the built environment around these teens is less impactful than what the children know about nutrition, and also less impactful perhaps than what's going on in the home," she said.
The home environment, Sandon stressed, plays a critical role.
"Past research has looked at what students bring to school when they bring their own lunch, and it's actually often less nutritious than if they ate a school lunch, which means that what's going on in the home is often worse in terms of giving kids a sense of what to do in terms of making healthy food decisions," she said. "And that might explain these findings."
Sandon suggested that "if we focus on informing kids as to how best to think about what they're eating, that may be a more impactful way to affect their decisions than trying to change the built environment around them."
Teens keep Chugging Soda Despite Health Risks, Says Study
June 16, 2011, CBS News
By Ryan Jaslow
A new study says that an alarming number of teens continue to consume soda and other sugary soft drinks every day, despite the fact that such behavior may contribute to childhood obesity and diabetes.
A survey of 11,000 high school students found one in four teens drink soda every day. And when other sugary drinks like Gatorade are counted, the figure is closer to two-thirds of students drinking a sugary beverage daily. The findings were published in the June 17 issue of Morbidity and Mortality Weekly Report.
The numbers are actually lower than previous estimates. Earlier research in the 1990s and early 2000s showed more than three-quarters of teens were drinking a sugary beverage each day. That means more teens are now drinking water, milk, and fruit juices.
"We were very pleased to see that," said the study's lead author, Nancy Bener, a health scientist at the Centers for Disease Control and Prevention.
But one-quarter of high school students is still too high of a number, because consumption of sugary drinks is considered a major public health problem. Soda consumption has been linked to the U.S. explosion in childhood obesity, where 17 percent of Americans age 2 to 19 are obese, according to the CDC.
A study of Massachusetts schoolchildren found that for each additional sweet drink per day, the odds of obesity increased 60 percent. Many schools stopped selling soda or artificial juice to students in light of those findings, but experts think that's not enough.
"Getting them out of the schools doesn't solve the problem completely because a lot of these drinks are consumed in the home," Bener said.
And obesity is far from the only health risk soda has been linked with.
A 2010 study in the journal, Diabetes Care, found daily soda drinkers were 25 percent more likely to develop type 2 diabetes. Also phosphoric acid, a main ingredient in soda, has been linked to bone loss in those getting more of the chemical than calcium, according to WebMD. Too much caffeine has also been associated with bone loss, in addition to insomnia, high blood pressure and headaches.
And the diet stuff isn't much better. A 2011 study found daily diet soda drinkers were at a 61 percent higher risk for stroke and heart attack, Medscape reported.
How will researchers stop this trend?
The authors said its "Critical to involve families, the media, and other institutions that interact with adolescents to increase their awareness of possible detrimental health effects and discourage their consumption of sugar-sweetened beverages."
Child Obesity Study Finds Parents Need the Training
June 19, 2011, Times Live
By Taschica Pillay
Training the parents of obese children to adopt a healthy lifestyle is likely to have a positive effect on their children's weight.
So says a study published in the International Journal of Obesity.
The parents of 98 overweight or obese children, aged from 7 to 13, were signed up for training to help their children attain a healthy weight. Parents were randomly assigned to either a treatment group or a waiting-list control group. In the treatment group, each session addressed a theme associated with childhood obesity, including parental control, exercise and eating behavior.
The purpose was not purely to present information, but to teach parents to think of alternatives and possible solutions themselves.
The study found that children's weight decreased significantly in the treatment group. However, there was no change in weight in the waiting-list control group. There was also no significant relapse at follow-up - after three months - in the treatment group.
Durban clinical psychologist Sherona Rawat said obesity stemmed from eating disorders, medical conditions, and behavioral and environmental effects.
"Does the mother have any hang-ups in relation to eating, how does she manage attachment and showing affection? "A lot of moms show attachment and affection in the form of feeding the child," said Rawat.
She said through advertising, children are bombarded with junk food and fizzy drinks. "Children want to be a part of that because it's socialization."
Rawat found children sometimes ate fast food, not because they liked the taste "but are attracted by the adverts and hype".
There was also a lack of physical activities because of television.
"Children snack while watching TV. Social and cultural aspects play a big role and need to be modified, as well as the home environment and the parent-child relationship."
Dietician Priya Seetal said successful weight loss could only be attained by weekly weigh-ins, physical activity, eating breakfast daily and consistent eating habits.
Lenient Fathers Are More Likely to Influence Childhood Obesity
Jun 15, 2011, KBTX
Lenient fathers are more likely than mothers to influence childhood obesity because they allow their kids to eat at fast-food restaurants frequently, according to a new study published in the Journal of Nutrition Education and Behavior.
"Dads who think that dinner time is a special family time certainly do not see a fast-food restaurant as an appropriate place for that special family time, so this means that his kids are spending less time in those places. Dads who have no trouble eating food in a fast-food restaurant are going to be more likely to have kids who do so," said Dr. Alex McIntosh, AgriLife Research sociologist.
Researchers at Texas A&M University conducted a 15-month study to examine parents' use of time and how that impacted meal choices and the choice between fast-food and full-service restaurants. The researchers also asked children in these families to keep a record of what they ate and whether it was at home or out.
"To our surprise, it was father's time spent at fast-food restaurants-not mother's time spent there-that was associated with kids' time spent in a fast-food place." McIntosh said, noting fathers also need to know more about nutritional content of fast food in order to raise healthy, well-adjusted children.
They also found mothers who are neglectful and those who are highly committed to their work were more likely to allow their kids to eat at fast-food restaurants.
The current study seems to affirm one that appeared in the December 2010 issue of the Journal of Epidemiology and Community Health, which noted parents need to be better empowered to be good role models and help their children eat healthy diets.
CHILDHOOD OBESITY NEWS
First Lady Targets Healthy Habits for Toddler Set
June 8, 2011, Associated Press
By Nancy Benac
Michelle Obama dropped in on lunch and circle time at a Washington child care center on June 8 and used the occasion to announce a new national initiative to encourage child care centers to promote healthy eating and exercise habits starting with the littlest Americans.
The first lady watched as toddlers ate a healthy lunch of fish, fruit and salad greens, did the bunny hop with youngsters in a P.E. class and clapped along with singing time at CentroNia, a bilingual child care center that stresses just the kinds of healthy practices that Mrs. Obama is trying to encourage.
The first lady said instilling good health habits through child care centers and home-based care can be "a real building block for an entire generation of healthy kids." She noted that more than half of obese children first become overweight before they reach their second birthday.
Mrs. Obama announced that 1,600 child care centers nationwide already have committed to standards that promote healthy eating, exercise and limited time in front of TV, computer and other screens. And she released a checklist that parents and child care centers can use to make sure they're hitting the right notes.
The first lady said child care centers run by the Defense Department, the General Services Administration and Bright Horizons, a private company that manages child care centers for many corporations, hospitals, universities and government agencies, all had signed on to the program.
She was joined by Health and Human Services Secretary Kathleen Sebelius and Gen. James Cartwright, vice chairman of the Joint Chiefs of Staff. Cartwright recalled that when his children were young, military child care centers were sometimes "just a corner of a hangar" without clear standards. Some 200,000 children use military child care centers daily.
The first lady's Let's Move child care checklist stresses five principles:
- Provide one to two hours of physical activity daily.
- No screen time for children under 2. Limit screen time for older children to no more than 30 minutes per week during child care, and ensure children have no more than one to two hours of quality screen time per day overall.
- Serve fruits and vegetables at every meal, eat family-style when possible and no fried foods.
- Provide access to water throughout the day, and do not serve sugary drinks.
- Support mothers who want to breast-feed by providing mother's milk to infants and welcoming mothers who want to breast-feed their children during the child-care day.
L.A. School District Bans Chocolate Milk
June 15, 2011, USA Today
The Los Angeles Unified School District is taking a stand against child obesity, becoming the nation's largest school system to stop serving sugar-laden flavored milk. The school board on June 14 voted to eliminate chocolate and strawberry milk from schools as of July 1.
LAUSD joins a growing number of school districts nationwide, including in the District of Columbia, Boulder Valley, Colorado, and Berkeley, California that serve only plain milk because of the added sugar contained in flavored versions.
The proposal by Superintendent John Deasy came after popular British TV chef Jamie Oliver criticized the district in recent months for serving flavored milks, saying they contain the sugar equivalent of a candy bar.
In one stunt on his ABC show "Food Revolution," he filled a school bus with sand to represent the amount of added sugar LAUSD students consume in a year through flavored milk.
Some board members were rankled by the perception that the district was caving in to Oliver, who unsuccessfully lobbied the district to be allowed to film in local schools.
"I really don't understand why we're letting a TV chef dictate our policy," said board member Tamar Galatzan, who noted that many health advocates including the American Heart Association say the nutritional benefits of flavored milk outweigh the harm of added sugar.
Some advocates say that milk consumption drops when children are not offered the option of chocolate and other flavors.
She noted the district serves fruit juices containing 27 to 29 grams of sugar per serving, more than the amount of sugar in flavored milk — 20 grams in 8 ounces of fat-free chocolate milk and 27 grams in fat-free strawberry.
Galatzan was the lone dissenter on the board.
The board's decision was applauded by several proponents in the audience.
"Thirty percent of our kids are obese or are on track to diabetes," said Jennie Cook of Food for Lunch, a coalition advocating nutritious school food. She has been pushing the district to eliminate flavored milk for the past year. "This is a social justice issue."
Emily Ventura, a researcher with the University of Southern California's Childhood Research Center, noted that a number of experts did not recommend flavored milk as a healthy choice. She said 6,000 LAUSD parents had signed a petition to eliminate flavored milk from the district.
Some school districts have opted for a middle road, using natural sweeteners like cane sugar, beet sugar and Truvia to sweeten milks instead of high-fructose corn syrup based flavorings.
But others say children should learn to drink plain milk.
LAUSD has about 688,000 students, second only to the New York City Department of Education.
Schools Set to Weigh in on Fitness
June 09, 2011, Boston Globe
By Chelsea Conaboy
Two of every five children in Boston's public schools weigh more than they should. But 30 percent of the district's schools offer no physical education classes.
Now, school administrators are promising to do more to bridge the gap between what is needed and what is available to address a health problem that has been declared a national crisis.
The district yesterday announced that it will hire more physical education teachers so that 106 schools can offer PE. This year, only 94 of the district's 134 schools offered those classes.
In the past year, the district received $4.6 million, primarily from the US Department of Education and the Centers for Disease Control and Prevention, to address student fitness and nutrition.
"If you want to improve academics of students, you also have to look at their health, because healthy children are better able to learn,'' said Jill Carter, executive director of the district's Health and Wellness Department. "We're dealing with achievement gaps that sort of overlap or are in some way affected by health disparities."
The district's finding that 40 percent of students are overweight or obese came from physical assessments students receive every three years in school.
State law requires that students in every grade be taught physical education but does not specify how much. That loophole means many students never dribble a ball during the school day. A CDC survey found that 73 percent of Boston high school students do not get the recommended one hour of activity per day — at school or at home.
Under the new plan, called Healthy Connections, the district will change the fitness curriculum. Four instructors were hired this year to travel to schools and instruct teachers how to make gym class a better workout. A traditional baseball game, for example, would be replaced in elementary and middle school by "all-run'' baseball, in which one person bats, but all team members run. They keep running until the team in the field knocks down a series of cones.
Because space is an issue at many schools — about half have no gymnasium, Carter said — the district is training "wellness champions'' at each school who will look for ways to help get youngsters moving at recess, for example. Healthy Connections also aims to make food at school events more nutritious and to reduce tobacco use.
Improving student health has been a major focus of the district since about 2006, said Carter. She was the only district employee focused on wellness about a year ago and now oversees a staff of 15 people.
Breastfeeding Initiative is Part of Let's Move! in Indian Country
June 22, 2011, Native American Times
By Dianne Dawson
Indian Health Service (IHS) Director Yvette Roubideaux, M.D., M.P.H., announced in June the official IHS launch of the Baby-Friendly Hospital Initiative at the Northern Navajo Medical Center in Shiprock, NM. This breastfeeding initiative is designed to create a healthy start on life and prevent childhood obesity. It is part of the Let's Move! in Indian Country (LMIC) initiative, which is part of first lady Michelle Obama's Let's Move! initiative. The LMIC brings together federal agencies, communities, nonprofits, corporate partners and tribes with the goal of ending the epidemic of childhood obesity in Indian Country within a generation.
"Our goal for the IHS Baby-Friendly Hospital Initiative is to certify 14 federal IHS obstetric facilities as baby-friendly hospitals by 2012 and to encourage 12 tribal obstetric facilities to adopt this initiative," said Dr. Roubideaux. "This initiative is a quality improvement process to improve breastfeeding rates through new maternity care and infant feeding practices. By promoting breastfeeding, the IHS will reduce current and future medical problems and decrease health care costs."
A baby-friendly hospital is one that supports breastfeeding and offers breastfeeding mothers the information, confidence and skills needed to start and continue breastfeeding their babies. Breastfeeding is critical for both baby and mother as it supports infant growth and development, and it protects both the infant's and the mother's health.
"We are truly honored to host the launch of the IHS Baby-Friendly Hospital Initiative," said Dr. Chris Percy, Director of Community Health Services at Northern Navajo Medical Center. "We have seen firsthand the benefits of breastfeeding in reducing the number of visits to our emergency room or acute care clinic for babies with diarrhea, ear infections, and pneumonia."
"At the Northern Navajo Medical Center, we honor breastfeeding mothers and work closely with the Navajo Nation Breastfeeding Coalition to promote and support the wisdom of this traditional practice," said Fannessa Comer, Northern Navajo Medical Center CEO. "We are pleased to join in launching the Baby-Friendly Hospital Initiative and to becoming baby-friendly certified."
The Baby-Friendly Hospital Initiative is a series of maternity care practices that were created in 1991 by the United Nations Children's Fund and World Health Organization as the gold standard for significantly increasing breastfeeding initiation and duration rates. In the 20 years since the initiative started, more than 200,000 hospitals in 156 countries have joined the program. The program offers ten steps to successful breastfeeding that enable facilities and communities to support women who breastfeed. Hospitals that demonstrate adherence to these steps receive the designation of "baby friendly."
Invited speakers at the Northern Navajo Medical Center launch event included Fannessa Comer; Navajo Nation Vice President Rex Lee Jim; Dr. Susan Karol, IHS Chief Medical Officer; representatives from the Navajo Nation Breastfeeding Coalition and Just Move It program; as well as local women and families who have shared their personal stories about breastfeeding.
Jack in the Box Yanks Toys from Kids' Meals
Jun 21, 2011, Reuters
By Mary Slosson
Ronald McDonald is having a midlife crisis.
Fast-food chain Jack in the Box has pulled toys from its kids' meals, a spokesman told Reuters on June 21.
The move, which managers at Los Angeles outlets said took effect on June 16, comes as fast-food companies are under pressure to stop using toys to market children's meals that are high in calories, sugar, fat and salt.
Lawmakers in San Francisco and nearby Santa Clara County have passed laws that will require kids' meals to meet certain nutritional standards before they can be sold with toys.
"While we've been aware of efforts to ban the inclusion of toys in kids' meals, that did not drive our decision," Jack in the Box spokesman Brian Luscomb said.
"Our advertising and promotions have focused exclusively on the frequent fast-food customer, not children," added Randy Carmical, also a Jack in the Box spokesman.
Carmical said the San Diego-based company has been more focused on the food in its meals for children, such as grilled cheese sandwiches or grilled chicken strips. The company pulled toys from the meals when it began offering parents the option of substituting sliced apples with caramel sauce as an alternative to French fries, he said. "We believe that providing these kinds of options is more appealing to a parent than packaging a toy with lower-quality fare," Carmical said.
The Jack in the Box decision won praise from organizations and advocates critical of the fast-food industry.
"It's terrific that Jack in the Box has taken this step," said Margo Wootan, nutrition policy director at the Center for Science in the Public Interest. "It's really a monumental step that I hope their competitors will emulate." CSPI in December sued McDonald's Corp, the world's largest hamburger chain, to stop it from using Happy Meal toys to lure children into its restaurants.
Consumer and health advocates are using the announcement to put pressure on McDonalds, Burger King, Taco Bell and other fast food chains that still include toys in kids' meals.
Lobbyists for fast-food companies are fighting anti-obesity laws by asking U.S. state legislators to remove restaurant marketing from local governments' regulatory menu.
Toy giveaways make up more than half of the marketing expenditures in the fast-food industry, according to Wootan, with $360 million spent annually to put toys in kids meals. Jack in the Box has about 2,200 restaurants across the United States, where it is the fifth-largest hamburger chain.