*4.2. Comparisons of Findings to Previous Studies*

These findings are consistent with assessments of the fast-food supply in other countries including Australia, the US and Canada [26,28,29]. The Australian report on The State of the Fast-Food Supply in 2019 [26] concluded that most products were unhealthy, sold in oversized portions, and high in salt, sugar and harmful fats. The authors also commented on the lack of nutrition information with over half of Australian chains not providing sufficient data. In the United States, combination meals at chain restaurants were high in energy, sodium, saturated fat and sugar and most default options in meal combos exceeded national guidelines for calories and sodium [28]. In Canada, meals from fast-food chain restaurants were high in saturated fat, sodium and sugar [29]. An analysis of combo meals offered by quick-service restaurants in Australia [30] also found many combos provided more than 30% of an adult's average daily energy intake. An earlier analysis conducted in NZ reported mean serving size, energy per serving and sodium per serving [13]. While we cannot directly compare with the 2016 NZ data, we found that Burgers and Asian meals were still in the top three categories for energy per serving, and burgers and sandwiches/wraps were still in the top three for sodium content per serving.

Of particular concern were the high sodium levels of many products, with many exceeding the UK benchmarks and almost half the combos exceeding the daily recommended

maximum sodium intake. However, for every category where a benchmark existed, except for fries, there were also products that did not exceed that benchmark. This indicates that in most cases, it is possible to offer lower sodium options. There are no recent data to indicate the contribution of fast-food to New Zealanders' sodium intake. However, a survey conducted in 2012 indicates that New Zealanders consume considerably more sodium (3373 mg) [31] than the Suggested Dietary Target (SDT) for NZ adults of 2000 mg/day [24]. One NZ study estimated that the mean daily sodium intake from savory fast foods for regular fast-food consumers was 1229 mg/day [32]. Another NZ study estimated the percentage contribution of sodium from takeaway and restaurant foods at 887 mg/day, 26.3% of sodium sources in NZ diet [33] As fast food consumption is growing, this contribution is likely to be higher now.

While the fast-food industry has grown, it appears that it has done little to improve the overall healthiness of the fast-food supply despite the recommendations made by the Food Industry Taskforce convened by the Ministers of Health and Primary Industries in 2018 [18]. Eyles et al. 2018 [13] found moderate to large increases in product serving size, and energy and sodium per serving from 2012 to 2016. An Australian analysis [26] that looked at changes in categories, rather than individual products found there was little change in the healthiness of products between 2016 and 2019.

## *4.3. Strengths and Limitations*

A strength of this study is the systematic data collection from a large number of NZ fast-food chains, covering at least 60% of the fast-food sales [12], however data collection did not include small chains and independent retailers. Combination meals have not been assessed in NZ before and are useful to analyze as they provide the context of a meal when benchmarking against daily recommendations. As combination meals involve several options, the analysis of combo meals was carefully conducted; with two options analyzed for most combos: the healthiest (less energy and sugar) and the least healthy. There are also some important limitations to consider. Most NZ fast-food chains did not provide nutrition information on their products, so it was impossible to undertake a comprehensive analysis of the nutritional state of the national fast-food supply. Half of the chains that provided some nutrition information were international chains and half were national chains. However, of the six chains that did not provide any nutrition information about their products, five were international chains. There is also a chance that the products from chains that provided some nutrition information may have had a better nutrition profile in relation to products from chains that did not provide any information. This means that this study may have underestimated portion size and overestimated the healthiness of the fast-food supply. This study's data were not sales weighted and therefore do not reflect the healthiness of items by frequency of consumption, though our analysis does include the most commonly consumed fast foods (bread-based dishes, fries, non-alcoholic beverages, poultry) in New Zealand [22].
