NEMS assessment tool and scoring

Between July and November 2013, the Nutrition Environment Measures Survey for Restaurants (NEMS-R) was used to assess restaurants and the Nutrition Environment Measures Survey for Stores (NEMS-S) was used to assess grocery and convenience stores [11, 20].

The NEMS-R was designed to assess the “relative healthfulness” of food and beverage options for main menus and children’s menus, and factors that may facilitate or challenge healthful eating. The assessment consists of a menu review, an observational restaurant visit, and interviews with restaurant staff. The instrument assesses the availability of entrees, main dish salads, side dishes (i.e., fruit without added sugar, non-fried vegetables without sauce or toppings, baked chips, whole grain bread) and beverages (i.e., diet soda, 100% fruit juice, and 1% or nonfat milk) that meet the criteria for being designated as “healthy.” Guidelines for “healthy” designation were determined by federal recommendations as established by the U.S. Food and Drug Administration, U.S. Department of Health and Human Services, and the U.S. Department of Agriculture [21]. In addition, the instrument includes measures of barriers and facilitators of healthful eating and a measure of pricing and signage related to promotion of healthier or less healthy foods. Restaurant scoring was based on 8 categories: 1) sources of information, 2) site visit information, 3) site visit menu review, 4) online menu review, 5) facilitators and support, 6) barriers, 7) pricing, and 8) children’s menu. The total possible composite score for food environment quality of NEMS-R was 72 points (range − 8 to 72), where greater points indicated availability of healthier options, promotion of healthier options for adults and children, and affordable pricing.

The NEMS-S was designed to assess the availability, price, and quality of 11 indicators of food categories and healthier options, which are noted in parenthesis: fruit (fresh), vegetables (fresh), milk (skim/low-fat), ground beef (lean), hot dogs (lean), frozen dinners (reduced-calorie), baked goods (low-fat), beverages (diet soda, 100% juice), bread (whole grain), chips (baked), and cereal (high fiber) [11, 20]. Measures for each indicator include availability of healthier options, with more points if additional varieties of the healthier option were available, if quality of produce was greater (acceptable/unacceptable based on over ripeness/bruising), and if price was lower for healthy items compared to non-healthy items. Lower prices for healthier items were scored positively while points were deducted for higher prices for healthy items. Scores for availability, quality, and price were summed up to generate a composite score of food environment quality ranging from − 8 to 62 with higher scores indicating greater availability of healthy options, higher quality food products, and affordable pricing. The maximum possible score was 34 points for availability, 22 points for price, and 6 points for quality.