Peters 2016a.

Methods	Design: ITS Timing: Retrospective Allocation to group: N/A (ITS without control group) Number of clusters or sites: 145 restaurants Number of individuals: N/A (the analysis is based on routinely‐collected sales data not linked to individual participants) Length of intervention: 6 years
Participants	General description of participants: Visitors to Walt Disney World quick‐service and table‐service restaurants located in the Walt Disney theme park in Orlando, USA Age: Children (age range 3 to 9 years) Inclusion criteria: N/A Exclusion criteria: N/A Recruitment: N/A Weight status at baseline: N/R SSB consumption at baseline: N/R (However, the study notes that prior to the start of the intervention, SSBs were the only beverage available as part of the kids' menus targeted by the intervention) Equity considerations: N/R
Interventions	Intervention: Change of the default beverage served with children's menus at chain restaurants. (Quote: "Beginning in October 2006, the Walt Disney Company changed the default side item and beverage offered with all complete kids’ lunch and dinner meals (including those offering healthy and classic entrées) served in its domestic US theme parks and resorts. Prior to this date, kids’ meals were served with french fries and a regular soft drink as the default side and beverage. Default choices were changed to servings of fruit (…) or vegetables (…) while beverage choices changed to low‐fat milk, water, or 100% juice (apple, orange, or fruit punch). Customers could substitute french fries or a soft drink upon request. In other words, they could opt out of the healthy side and beverage defaults. Pricing for kids’ meals with healthy defaults was the same as for meals with french fries and soft drink. Point‐of‐sale picture boards displaying the meals showed only the meal with the healthy default items, though all potential substitutes were listed on the menu board. (...) Menu changes were introduced without any substantial public relations campaign, avoiding a potentially negative consumer response if consumers perceived that healthy items may not taste as good or be as fun or if consumers perceived that the use of healthy defaults threatened their freedom, resulting in consumers intentionally opting out of the healthy defaults in order to counteract this perceived threat. This allowed consumers to become accustomed to the new offerings before the changes were deliberately brought to the public’s attention. (...) Prior to implementation of the healthy defaults, french fries and a soft drink were the only available options. (...) [T]herefore, the separate effects of offering healthy items as defaults from the effects of adding healthy items to the menu as opt‐in choices cannot be determined") Behavioural co‐intervention: None (Quote: "Menu changes were introduced without any substantial public relations campaign, avoiding a potentially negative consumer response if consumers perceived that healthy items may not taste as good or be as fun or if consumers perceived that the use of healthy defaults threatened their freedom, resulting in consumers intentionally opting out of the healthy defaults in order to counteract this perceived threat. This allowed consumers to become accustomed to the new offerings before the changes were deliberately brought to the public’s attention") Control: N/A (ITS without control group)
Outcomes	Measures of SSB intake: Share of customers accepting healthy beverage defaults as part of the kids' menus, assessed at baseline and at years 4, 5 and 6 post‐intervention with routinely‐collected sales data Measures of intake of alternatives to SSB: See above Anthropometric measures: N/R Adverse outcomes: The study does not report how data on adverse outcomes were collected, and if adverse outcomes were observed or not Other outcomes: None included in this review
Context and implementation	Setting: Restaurants Sector: Food service (private for profit) Country: USA Year(s) when implemented: 2006 ‐ 2012 Mode of implementation: Industry self‐regulation/voluntary industry action Level of implementation: Setting‐based intervention
Declarations	COI: "This work was supported by the Walt Disney Company and by the National Institutes of Health (grant no. DK48520). The Walt Disney Company and the National Institutes of Health had no role in the design, analysis, or writing of this article. Full disclosure: JH is a consultant for the Walt Disney Company and for McDonalds; KA is a consultant for the Walt Disney Company" Funding: See COI Trial registration: N/R Protocol availability: N/R
Notes	None
Risk of bias
Bias	Authors' judgement	Support for judgement
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Data for the first 3 years post‐intervention are missing, and data for the remaining years are described as "relatively complete" by the study authors. Study authors note that for the table‐service restaurants (TSR) in the sample, beverage purchase data was incomplete due to the way sales data were collected. Quotes: "Data were analyzed for three fiscal years for which Disney had relatively complete point‐of‐sale data at WDW. (…) At TSRs, Disney had incomplete data on beverage purchases because they are not always entered as individual sales (as are entrées) in this restaurant format. For example, TSRs offer water with all meals in addition to any other beverage, and these servings of water are not recorded with the beverage numbers. Because of this, the percentage of consumers who opted in to the healthy beverage option at TSR locations does not include consumers who consumed water as their beverage"
Blinding (performance and detection bias) Objective outcomes	Low risk	Participants were not blinded, but outcomes are objective, and outcome data were collected independently of the intervention and study. The study reports that "[m]enu changes were introduced without any substantial public relations campaign, avoiding a potentially negative consumer response if consumers perceived that healthy items may not taste as good or be as fun or if consumers perceived that the use of healthy defaults threatened their freedom, resulting in consumers intentionally opting out of the healthy defaults in order to counteract this perceived threat. This allowed consumers to become accustomed to the new offerings before the changes were deliberately brought to the public’s attention"
Selective reporting (reporting bias)	Unclear risk	It is not reported if the study was registered, if a protocol is available, or if analyses were prespecified. Data were provided by Walt Disney with the understanding that only certain outcomes are reported. This may have introduced bias. Quotes: "Disney did not have complete data for Disneyland, located in Anaheim, California; therefore, Disneyland is not part of this analysis. (…) Although raw sales data were provided for this analysis, access to these data was provided with the understanding that only the percentages of different kids’ meal items sold, as a function of the total meal items sold, would be published. Likewise, WDW [World Disney World] did not provide data for the number of children who visited the park for fiscal years 2010–12 or the absolute number of kids’ meal items sold during that period. Reporting percentages is not uncommon in the literature because of the proprietary nature of absolute numerical data for commercial businesses. In such cases where a company will not provide absolute numerical sales, the general convention has been to report differences in terms of percentages instead of as absolute numbers. Such an approach is common in health economics and psychology"
Independence of the intervention from other changes (performance bias)	Unclear risk	At baseline, no healthy beverages were offered. This implies that without the intervention (the introduction of healthy beverage defaults) the outcome (healthy beverage default acceptance rates) would have been zero. Quote: "Prior to implementation of the healthy defaults, french fries and a soft drink were the only available options. Therefore, these estimates compare the nutritional values based on 100% of individuals selecting french fries and soft drink defaults versus the percent of individuals in this sample who actually selected the healthy defaults once they were implemented." It is, however, possible that other developments occurring during the study period, such as increasing public awareness of health risks associated with SSB consumption, and secular trends towards healthier beverage choices, influenced the magnitude of the observed effects
Pre‐specification of the intervention effect (detection bias)	High risk	The intervention was implemented in October 2006, but no data are available for the first 3 years post‐intervention. That is, the point of intervention is not the point of analysis, and no prespecification of the shape of the intervention effect is reported
Intervention effects on data collection (detection bias)	Low risk	Data were collected routinely and independently of the intervention and the study. It is unlikely that the intervention affected data collection
Other bias	Low risk	No other concerns