State and Local Healthy Kids’ Meal Laws in the United States: A Review and Content Analysis

Abstract

Background.

To address unhealthy restaurant food intake among children, localities and states are passing healthy restaurant kids’ meal laws. However, there is limited knowledge of what these policies require and how they compare to expert and industry nutrition standards.

Objectives.

The aim of this study was to develop a research instrument to evaluate healthy kids’ meal laws and assess their alignment with expert and industry nutritional standards.

Design.

The study team conducted a content analysis of healthy kids’ meal laws passed between January 2010 and August 2020 in the United States. Using a structured codebook, two researchers abstracted policy elements and implementation language from laws, regulations, fiscal notes, and policy notes. Nutritional criteria for kids’ beverages and meals were compared to existing expert and industry nutrition standards for meals and beverages.

Main outcome measures.

Measures included 1) law characteristics, 2) implementation characteristics, 3) enforcement characteristics, 4) definitions of key terms, and 5) nutritional requirements for meals and default beverage options and alignment with expert and industry nutrition standards.

Statistical analyses performed.

Interrater reliability of the coding tool was estimated using Cohen’s kappa statistic, and researchers calculated descriptive statistics of policy elements.

Results.

Twenty laws were identified. Eighteen were healthy default beverage policies, two were toy restriction policies, and one was a nutritional standards policy. The nutritional standards, default beverage offerings, and implementation characteristics varied by location. No law met the expert nutrition standards for kids’ meals or beverages.

Conclusions.

The variations in policy specifications may influence how restaurants implement the policies, and, consequently, the policies’ impacts on children’s consumption. Future policies could use expert nutrition standards to inform the standards set for kids’ meals and specify supports for implementation.

INTRODUCTION

Over the past three decades, kids’ restaurant food intake has increased dramatically.^1–3 In the United States (US), more than one in three kids eat fast-food on any given day, and fast-food comprises 13.8% of kids’ daily energy intake.⁴ Among young kids, fast-food consumption is associated with excess weight gain^5,6 and poorer diet quality, including higher daily intake of calories, added sugars, and sugary drinks.^1,7

One reason fast-food consumption is associated with weight gain and poorer diet quality is that most restaurants offer unhealthy items on kids’ menus. In 2013, the Center for Science in the Public Interest (CSPI) examined menu offerings from the top 50 restaurant chains and found that 97% of kids’ meal combinations did not meet the National Alliance for Nutrition and Activity’s Model Local School Wellness Policies on Physical Activity and Nutrition.^8,9 Approximately 86% of kids’ meal combinations contained excess calories (>430 calories), 66% contained excess sodium (>1200 mg), and 55% contained excess saturated fat (>10% of calories from saturated fat), compared to what nutrition experts recommend.⁸ Additionally, kids’ meals often include a sugary drink like soda. In 2019, CSPI found that 61% of the top 50 restaurant chains and 83% of the top 200 restaurant chains that offered a kids’ menu included sugary drinks as the default, or automatic, beverage option.¹⁰

Within the past decade, the restaurant industry has made voluntary commitments to improve the nutritional quality of kids’ meals.¹¹ In 2011, the National Restaurant Association (NRA), the largest restaurant industry trade association, launched their Kids Live Well (KLW) program, which set nutrition standards for kids’ entrees and sides, expanding to include beverages in 2019. Additionally, several restaurant chains made voluntary changes to increase the healthfulness of their kids’ meals.¹² For example, Jack-in-the-Box dropped toys from their kids’ meals and replaced french fries with options like fresh apples.¹³ While such voluntary commitments are promising, researchers found that chain restaurants that made public commitments to improve the nutritional composition of kids’ meals made no significant changes compared to restaurants that had not made these commitments.¹⁴ Therefore, despite fast-food intake being one crucial modifiable risk factor for childhood obesity,⁵ voluntary initiatives to improve the nutritional quality of kids’ meals have not led to widespread, meaningful change.¹⁵

To address unhealthy restaurant food intake among children, cities, counties, and states are passing healthy kids’ meal policies. These policies aim to improve the nutritional quality of restaurant kids’ meals by setting nutritional standards for meals or meal components. For example, some policies require that restaurants offer only healthy beverages, such as water or milk, as the default beverage options in kids’ meals. Other policies require kids’ meals sold with a toy to meet nutritional standards.

This research seeks to understand how states and localities use policy to improve child nutrition in the restaurant setting. First, the study team identified all healthy kids’ meal policies passed between January 2010 and August 2020. Second, the study team developed a coding instrument to evaluate healthy kids’ meal policies. Third, the study team summarized key provisions of this legislation, including nutritional standards, beverage options, and enforcement mechanisms. Fourth, the study team compared the nutritional standards for beverages and meals in healthy kids’ meal legislation to expert and industry nutrition guidelines. Understanding the policy landscape is important for explaining why these policies’ effects on dietary behaviors may differ across jurisdictions and for informing future advocacy and policy development.

METHODS

This study used a modified legal mapping approach to identify all jurisdictions in the US with healthy kids’ meal policies passed into law between January 2010 and August 2020. Healthy kids’ meal policies were defined as laws that targeted the nutritional quality of restaurant kids’ meals and could address kids’ meals using one or more of at least three provisions. The first was a healthy default beverage provision, which requires restaurants to offer only healthy beverages (e.g., water or low-fat milk) as the default option in kids’ meals. The second was a nutritional standards provision, which requires that kids’ meals meet certain nutrient thresholds (e.g., limits on sodium) or food group requirements (e.g., minimum number of servings of fruits and vegetables). The third was a toy restriction provision, which requires restaurants to meet certain nutrient thresholds to offer toys or giveaways with kids’ meals.

Identifying Healthy Kids’ Meal Policies

Relevant policies were identified using several sources. First, a list of healthy kids’ meal policies was obtained from CSPI, a national nutrition advocacy organization.¹⁶ Second, legal and policy databases, including Westlaw¹⁷; Legiscan¹⁸; National Conference of State Legislatures¹⁹; the Healthy Food Policy Project database²⁰; the World Cancer Research Fund International’s NOURISHING database²¹; the Growing Food Connections database²²; the Rudd Center for Food Policy Legislation database²³; and the Center for Public Health Law Research Law Atlas at Temple University database²⁴ were searched and cross-referenced. Finally, each state legislature’s website was searched along with a Google search for a healthy kids’ meal law in each state. The phrases “children’s meals,” “kids’ meal policies,” “default beverage,” and “toys” were used for search queries in the databases, and the search string “kids meal policies AND (default beverage OR toys) AND [state name]” was used in Google searches. If the search results listed specific cities or counties, the same search was repeated but with the county or city name instead of the state. Policies were included if they were adopted as of August 2020 and applied only to kids’ menus and meals. A list of the 20 laws identified was shared with five advocates and experts who work in child nutrition policy to ensure its completeness. No additional policies were identified after review. The full text of each law and supporting documents (i.e., regulations, fiscal notes, policy notes, and technical support documents) were collected from government websites when publicly available. Regulations were defined as the accompanying rules written by the agency responsible for implementing the law. Fiscal notes were defined as short reports that provide an estimate of a bill’s fiscal impact on the State, local governments, and small businesses, whereas policy notes described the current state of the law and provided background analysis of the law. Jurisdictions with documents that were not publicly available were acquired directly from government officials (n=8) per the direct request of one researcher.

Measure Development: The Healthy Kids’ Meal Policy Assessment Tool

Step 1: Identification of Policy Elements

To identify the policy components of the various healthy kids’ meal laws, one researcher read the full text of all policy documents and identified key elements of healthy kids’ meal laws. These measures were organized under five domains: 1) law characteristics, such as effective dates and jurisdiction; 2) implementation characteristics, such as communication of the policy to the community; 3) enforcement characteristics, such as penalties for noncompliance; 4) definitions of key terms, such as “children’s menu” or “default beverage”; and 5) nutritional requirements for meals and default beverage options. A 130-item structured coding instrument was created to capture and describe the content of healthy kids’ meal policies. Measures were dichotomous to capture the presence of characteristics (e.g., “Is water allowed?”) or open-ended to capture specific information that could not be captured in a yes/no format (e.g., “What is the anticipated impact of this policy on revenues?”). The study team reviewed the coding instrument for completeness and updated it accordingly. The operationalization of the measures in each domain is defined in Supplementary Figure 1.

Step 2: Coding Policy Text

Two trained graduate student researchers piloted the coding instrument on a sample of four policies that included each type of kids’ meal policy and type of jurisdiction. Inter-rater agreement was calculated for each item using Cohen’s kappa statistic, which ranges in value from −1 to 1.²⁵ Items with poor agreement (κ < 0.60, n=23) were discussed among the study team and additional clarification for the item definitions was added to the final codebook.

Once the coding instrument was finalized, two researchers independently reviewed each law and associated documents. Data were abstracted using Qualtrics²⁶, an electronic data collection tool. Open-ended responses were analyzed in-depth, coded, and organized into themes when appropriate. Discrepancies between coders were discussed and resolved among the study team. If no consensus was reached, experts in healthy kids’ meal policies were consulted as needed to resolve any discrepancies.

Step 3: Comparing Food and/or Beverage Specifications with Expert and Industry Nutrition Standards

The 2019 Healthy Eating Research (HER) Beverage Consumption Guidelines in Early Childhood²⁷ were used to assess the extent to which healthy kids’ beverage policies aligned with expert nutrition standards. To meet the expert standards, beverages on the kids’ menu must be: 1) water (plain, unsweetened, and unflavored), 2) plain nonfat or low-fat (1%) milk, 3) plain soy milk, 4) 100% juice in a package size of 6 fl oz or less, or 5) 100% juice combined with water or sparkling water in a package size of 6 fl oz or less. The study team decided that the recommendation of only plain nonfat or low-fat (1%) milk for 2-to-5-year-olds was consistent with HER recommendations given that kids’ meals are packaged and marketed by restaurants for children ages 2 to 11.²⁸ The NRA’s KLW voluntary criteria²⁹ were used to assess the extent to which policies met industry standards. To meet the industry standards, beverages on the kids’ menu must be: 1) water (plain, carbonated, or flavored) with no added natural or artificial sweeteners, 2) plain or flavored nonfat or low-fat (1%) milk in a package size of 8 fl oz or less, 3) plain or flavored non-dairy milk alternatives of equivalent nutritional value to milk in a package size of 8 fl oz or less, 4) 100% juice with no added natural or artificial sweeteners in a package size of 8 fl oz or less, or 5) 100% juice combined with water or sparkling water with no added natural or artificial sweeteners in a package size of 8 fl oz or less (Supplementary Figure 2).

The US Department of Agriculture (USDA) National School Lunch Program (NSLP) standards for kids (K-5^th grade)³⁰ were used to assess the extent to which kids’ meal policies met expert nutrition standards. To meet expert standards, kids’ meals must include: 1) less than 650 calories, 2) no more than 935 mg sodium, and 3) less than 10% of calories from saturated fat. Additionally, the meal must include at least one-half cup of fruits and/or vegetables and at least two of five other meal components: at least one-half cup of fruits, three-fourths cup of vegetables, 1-oz of meat/ meat alternate, one cup of fluid milk, and at least half of the grains offered must be whole grain-rich (≥51% whole grain). The NRA’s KLW voluntary criteria were used to assess the extent to which policies met industry standards. To meet the industry standards, kids’ meals must include no more than: 1) 550 calories, 2) 700 mg sodium, 3) 10% of calories from saturated fat, and 4) 15 g of added sugars. Additionally, the meal must include at least two of the four components: one-half cup of fruits and/or vegetables, 1 cup of nonfat or low-fat dairy, at least 1-oz of meat or meat alternate, and at least half of the grains offered must be whole grain-rich (≥50% whole grain).

Statistical Analyses

Inter-rater agreement was calculated for each item using Cohen’s kappa statistic to assess consensus among the coders. In addition, the number and proportion of laws containing each policy component and meeting expert and industry nutrition standards were calculated using Stata version 15 (College Station, TX).³¹ This study was deemed not human subjects research by the Johns Hopkins University Bloomberg School of Public Health Institutional Review Board under federal regulation 45 46.101 (b) CFR.

RESULTS

A total of 20 healthy kids’ meal laws within nine states were identified.^32–51 Eighteen laws contained provisions for healthy default beverages, two laws contained provisions for toy restrictions, and one law contained provisions for nutritional standards. Louisville’s law included a healthy default beverage provision and a nutritional standards provision (Supplementary Tables 1 and 2).

Psychometric Properties of the Coding Instrument

Interrater agreement analyses of the coding instrument suggested that the instrument was adequately reliable, with kappa values of 0.61 or higher (Supplementary Figure 3).

General Characteristics

Fourteen laws (70%) were passed at the city level (Table 3). Three laws (15%) were passed at the state level, and of these, only California included preemptive language. Most jurisdictions were led by a Democratic local executive (71%) or state governor (75%) at the time of passage. Seven laws (35%) passed unanimously. Nine laws (45%) included a purpose statement, such as supporting the health of children (56%), promoting healthy lifestyles and habits in children (33%), combatting childhood obesity (33%), providing healthy meal options (11%), and supporting parents’ efforts to feed their children nutritious foods (11%). Half (50%) of the codified bills had a fiscal note attached, and all fiscal notes reported no impact on revenue or expenditures or negligible costs to administer the new law. Enactment dates ranged from May 11, 2010 to July 29, 2020, and effective dates ranged from August 11, 2010 to January 29, 2021.

Table 3.

Descriptive characteristics of healthy kids’ meal laws enacted in the United States from January 2010 through August 2020 (N=20^a)

Variable	Overall N (%)	Default Beverage (N=18) N (%)	Nutritional Standards (N=1) N (%)	Toy Restriction (N=2) N (%)
Jurisdictionb
City	14 (70)	14 (78)	1 (100)	0 (0)
County	3 (15)	1 (6)	0 (0)	2 (100)
State	3 (15)	3 (17)	0 (0)	0 (0)
Political affiliation of state governor
Democrat	15 (75)	15 (83)	0 (0)	0 (0)
Republican	5 (25)	3 (17)	1 (100)	2 (100)
Other	0 (0)	0 (0)	0 (0)	0 (0)
Political affiliation of local executivec
Democrat	12 (71)	10 (67)	1 (100)	2 (100)
Republican	1 (6)	1 (7)	0 (0)	0 (0)
Other	4 (24)	4 (26)	0 (0)	0 (0)
Political affiliation of bill sponsor
Democrat	15 (75)	13 (72)	1 (100)	2 (100)
Nonpartisan	1 (5)	1 (6)	0 (0)	0 (0)
Unable to determine	4 (20)	4 (22)	0 (0)	0 (0)
Decision-making bodyd
State Health Dept	3 (15)	3 (17)	0 (0)	0 (0)
Local Board of Supervisors	3 (15)	1 (6)	0 (0)	2 (100)
City Health Dept	5 (25)	5 (28)	0 (0)	0 (0)
City Council	4 (20)	4 (22)	0 (0)	0 (0)
City Board of Health	2 (10)	2 (11)	1 (100)	0 (0)
City Dept of Licenses & Inspections	1 (5)	1 (6)	0 (0)	0 (0)
City Health Initiative	1 (5)	1 (6)	0 (0)	0 (0)
City Housing & Human Services	1 (5)	1 (6)	0 (0)	0 (0)
Preemptive language usede,f	1 (33)	1 (33)	0 (0)	0 (0)
Unanimous passage	7 (35)	7 (39)	0 (0)	0 (0)
Time from enactment to effective date
Less than 1 month	2 (10)	2 (11)	0 (0)	0 (0)
1 month	5 (25)	5 (28)	0 (0)	0 (0)
3 months	6 (30)	5 (28)	1 (100)	1 (50)
5 months	1 (5)	1 (6)	0 (0)	0 (0)
6 months	3 (15)	3 (17)	0 (0)	0 (0)
12 months	3 (15)	2 (11)	0 (0)	1 (50)
Fiscal note attached to billg	10 (50)	9 (50)	0 (0)	1 (50)
Policy note attached to billh	2 (10)	2 (11)	0 (0)	0 (0)

^aA bill may have more than one provision (e.g., a healthy default beverage provision and a nutritional standards provision).

^bOrdinances in San Francisco were passed at both the city and county levels. Here, the ordinance is counted only as a county-level bill because the legislation encompasses the city as well.

^cThe denominator only consists of local bills (n=17) at the city and county level who may have a local executive such as a city mayor or county executive.

^dThe decision-making body consists of the group or agency responsible for the rule-making portion of the policy.

^eThe denominator only consists of statutes (n=3) where state preemption may affect local laws.

^f“Preemptive language” refers to legislative language at the state level that nullifies or limits the scope of a municipal ordinance or authority.

^gA fiscal note is a note attached to the legislative bill for review and is defined as short reports that provide an estimate of a bill’s fiscal impact on the State, local governments, and small businesses.

^hA policy note is a note attached to the legislative bill for review and is defined as short reports that describe the current state of the law and provide background analysis of the law.

Implementation and Enforcement Provisions

Seventeen laws (85%) specified penalties for violations, with eight laws (40%) imposing a maximum fine of $500 (Table 4). In most cases (70%), the state or local health department is responsible for monitoring and enforcing the law. Twelve laws (60%) are enforced via restaurant inspections. Ten laws (50%) detailed a plan for communication of the policy to the community once passed. Only three laws (15%) specified that educational outreach and/or technical assistance must be provided to restaurants in the community. All policies affect restaurants as defined by their jurisdiction’s respective code; Santa Clara County’s policies apply only to restaurants located in the county’s unincorporated areas.⁵²

Table 4.

Implementation and enforcement characteristics of healthy kids’ meal laws enacted in the United States from January 2010 through August 2020 (N=20)

Variable	Laws, N (%)
Monitoring & enforcement agency
State Health Dept	3 (15)
Local Health Dept	11 (55)
City Manager	2 (10)
City Attorney	1 (5)
City Health Initiative	1 (5)
City Administrative Services Dept	1 (5)
City Dept of Licenses & Inspections	1 (5)
Enforcement method
Inspections	12 (60)
Self-certification	6 (30)
Self-reporting, customer-reporting	1 (5)
Pending rulemaking	1 (5)
Maximum violation fines
No fine	2 (10)
$50	1 (5)
$100	2 (10)
$200	2 (10)
$250	1 (5)
$500	8 (40)
$1,000	3 (15)
Pending rulemaking	1 (5)
Restaurants and community must be notified of policy adoptiona	10 (50)
Education or technical assistance must be provided to restaurants and community	3 (15)
Only applies to unincorporated regions of a jurisdictionb	2 (10)
Healthy default beverage and nutritional standards provisions (N=18)
Kids’ meal is defined as a
Combination of food and beverage that is prepared by and offered for purchase at a food service establishment as a unit at a single price intended to be consumed by children	3 (17)
Combination of food and beverage primarily intended for consumption by children sold at a single unit price	15 (83)
Kids’ meals exclude foods pre-packaged elsewhere	2 (11)
Kids’ meals must be listed on the menu or menu board	1 (6)
Default beverages are defined as any beverage	14 (78)
Automatically included or offered as part of a kids’ meal, absent a specific request by the purchaser of the children’s meal for an alternative beverage	12 (67)
Automatically included as part of a kids’ meal, absent a specific request by the purchaser of the children’s meal for an alternative beverage	2 (11)
Only default beverages can be offered on the menu or menu board	5 (28)
Only default beverages can be offered on advertisements of kids’ meals	1 (6)
Only default beverages can be offered on online menus or ordering platforms	0 (0)
Substitute beverage can be requested at no cost	16 (89)
Toy restriction provision (N=2)
Meal is defined as a combination of single food items and/or beverages offered together for a single price	2 (100)
Incentives include food incentives	1 (50)
Mandates a restaurant can give away a “free” incentive if the kids’ meal meets minimum nutrition standards	1 (50)

^aDecision-making body or monitoring/enforcement agency is listed as responsible for notifying the community and restaurant of the policy adoption such as posting the policy in a distinct number of conspicuous places for the public.

^bAn unincorporated region is a geographic area with a common social identity that is not governed by a local municipal corporation.

All healthy default beverage laws defined “children’s meals,” with most (83%) defining these meals as a combination of food and beverage primarily intended for consumption by children sold at a single unit price (Supplementary Table 5). Only New York City expanded the definition to include any food items alongside words like “child” or “kiddie”; a cartoon, puzzle, or game; accompanied with a toy or kids’ game; or with a maximum age (as set by the restaurant).³⁶ Only Wilmington and Baltimore excluded pre-packaged food items from kids’ meals (e.g., sandwiches prepared in a facility other than the restaurant).^37,40 Both toy restriction laws defined “meals” as a combination of food and/or beverages offered together for a single price.

Fourteen (78%) of the healthy default beverage laws defined “default beverage” as any beverage that is automatically included or offered as part of a kids’ meal, absent a specific request by the purchaser of the kids’ meal for an alternative beverage. Five laws (28%) stated that default beverages, but not other beverages, could be listed/displayed on kids’ menus and/or menu boards, and one law (6%) stated that default beverages, but not other beverages, could be listed/displayed on an advertisement. All laws allowed alternative beverages to be provided upon customer request, but only 16 laws (89%) explicitly allowed a substitution at no charge. New York City’s was the only policy to define a “menu” or “menu board” – a printed list of the names or images of food items and the primary writing of a covered establishment from which a customer makes an order selection.³⁶ No state or locality explicitly addressed whether the law applied to online menus or online ordering.

Santa Clara County and San Francisco included different wording to implement their toy restriction laws. The San Francisco law prohibited restaurants from giving away a “free” incentive item with the purchase of a meal unless the meal met specific nutrition requirements.⁵⁰ However, the Santa Clara County law did not include the word “free” and prohibited restaurants from offering a toy or incentive item with the purchase of a single food item or meal unless that food item or meal met specific nutrition requirements.⁵¹

Alignment of Healthy Default Beverage Provision and Nutritional Standards Provision with Nutritional Guidelines

All 18 healthy default beverage laws allowed for plain, flavored, or sparkling water with no added sweeteners and nonfat or low-fat (1%) milk. Thirteen laws (72%) allowed for both whole or 2% milk and flavored milk. Seventeen laws (94%) allowed for non-dairy milk alternatives. Four laws (22%) required the non-dairy milk alternative to be nutritionally equivalent to milk or soy milk. Ten laws (56%) allowed for 100% fruit or vegetable juice. Eight laws (44%) allowed 100% juice mixed with water. One law (6%) specified that any low-calorie beverage, which was defined as any drink with fewer than 25 kcal/8-oz serving and no artificial sweeteners (Table 6), could be considered a healthy default option. None of the healthy default beverage laws met the 2019 HER Beverage Consumption Guidelines in Early Childhood, and only two (11%) met the industry standards for default beverage options.

Table 6.

Default beverage options permitted by healthy kids’ meal laws enacted in the United States from January 2010 through August 2020 (N=18)

Default Beverage Options	Laws, N (%)
Water	18 (100)
Flavored water	18 (100)
Sparkling water	18 (100)
Contains caloric sweeteners	0 (0)
Contains non-caloric sweeteners	0 (0)
Contains artificial colors/flavors	18 (100)
Milk	18 (100)
Nonfat milk	18 (100)
Low-fat or 1% milk	18 (100)
Whole or 2% milk	13 (72)
Flavored milk	13 (72)
Caloric sweeteners	12 (67)
Non-caloric sweeteners	12 (67)
Artificial colors/flavors	13 (72)
Non-dairy milk alternative	17 (94)
Flavored non-dairy milk alternative	12 (67)
Caloric sweeteners	12 (67)
Non-caloric sweeteners	12 (67)
Artificial colors/flavors	12 (67)
Nutritionally equivalent to milk	4 (22)
100% Juice	10 (56)
Fruit juice	10 (56)
Vegetable juice	6 (33)
Juice combined with water	8 (44)
Caloric sweeteners	1 (6)
Non-caloric sweeteners	1 (6)
Artificial colors/flavors	9 (50)
Low calorie beverage a	1 (6)
Meets expert nutrition standards b	0 (0)
Water	0 (0)
Milk	1 (6)
Nondairy alternative	2 (11)
100% Juice	1 (6)
Meets industry nutrition standards c	2 (11)
Water	18 (100)
Milk	5 (28)
Nondairy alternative	4 (22)
100% Juice	9 (50)

^aDefined as any beverage with fewer than 25 kcals/8 oz.

^bLott M, Callahan E, Duffy EW, Story M, Daniels S. Healthy Beverage Consumption in Early Childhood: Recommendations from Key National Health and Nutrition Organizations. 2019.

^cNational Restaurant Association’s Kids Live Well 2019. Accessed September 1, 2020, https://restaurant.org/manage-my-restaurant/food-nutrition/kidslivewell.

None of the nutritional standards laws or toy restriction laws met the standards from the NSLP or industry (Table 7). The laws of Santa Clara County and San Francisco included similar specifications for nutrients but offered few, if any, specifications for food groups. Louisville’s law covered multiple food components to be included in the kids’ meal but required fewer servings than the expert standards and did not cover specific nutrients.

Table 7.

Comparison of nutrient standards specified by healthy kids’ meal laws (N=3) enacted in the United States from January 2010 through August 2020 to expert and industry nutrition guidelines for meals

Nutrient/Food Group	Guidelines		Nutrient Standards of Healthy Kids’ Meal Laws (N=3)
	NSLPa Meal Standards	NRA’s KLWb Kids’ Meal Standards	Santa Clara Countyc Standards	San Franciscod Standards	Louisvillee Standards
Overview	Lunch meals for kids in grades K-5 must adhere to the guidelines below.	Kids’ meals must adhere to the guidelines below.	The Santa Clara County toy restriction prohibits restaurants in the unincorporated parts of the county from giving away toys and other incentives, such as games, trading cards, admission tickets, or other consumer products (physical or digital), with any foods, beverages, or meals that exceed any of the nutrient criteria below.	The San Francisco toy restriction prohibits restaurants from distributing any free toy, game, trading card, admission ticket, or any other consumer product, whether digital or physical, with kids’ meals or with foods and beverages unless they meet the nutrient requirements below.	The Louisville nutrition requirements and healthy default beverage law mandates that restaurants that provide kids’ meals are required to provide at least one healthy default beverage option and at least one of the menu options listed below.
Calories	550–650 kcals	550 kcals or less	Meals: 485 kcals Single food items: 200 kcals Beverages: 120 kcals	Meals: Less than 600 kcals	--
Sodium	935 mg or less	700 mg or less	Meals: 600 mg Single food items: 480 mg	Meals: Less than 640 mg	--
Total fat	--	--	Meals: 35% of total kcals from fatf Single food items: 35% of total kcals from fat Beverages: 35% of total kcals from fat	Meals: Less than 35% of total kcals from fatf Single food items: Less than 35% of total kcals from fat Beverages: Less than 35% of total kcals from fat	--
Saturated fat	Less than 10% of kcals	10% or less of kcals	Meals: 10% of total kcals from saturated fatf Single food items: 10% of total kcals from saturated fat	Meals: Less than 10% of total kcals from saturated fatsf	--
Trans fat	0% of kcals	0% of kcals	Meals: 0.5 g of trans fat Single food items: 0.5 g of trans fat	Meals: Less than 0.5 g of trans fats	--
Added sugars	--	15 g or less	Meals: 10% of kcals from added caloric sweeteners Single food items: 10% of kcals from added caloric sweeteners Beverages: 10% of kcals from added caloric sweeteners	--	--
Fruits	½ cup	At least ½ cup	--	Meals: ½ cup or more of fruit	Meals: At least ¼ cup of unfried fruit
Vegetables	¾ cup	At least ½ cup	--	Meals: ¾ cup or more of vegetables	Meals: At least ¼ cup of unfried vegetables, excluding white potatoes
Non/low-fat dairy g	--	At least 1 cup	--	--	--
Whole grains	½ of all grains offered must be at least 51% whole grain	½ of all grains offered must be at least 50% whole grain	--	--	A whole grain product that contains not less than 51% by weight in whole grain ingredients, or list whole grain as the first ingredient
Meat/Meat alternates	At least 1 oz (not to exceed 10 oz)	At least 1 oz	--	--	A lean protein, defined as a food containing less than 10 g of fat, 4.5 g or less of saturated fat and less than 95 mg of cholesterol/100 g and per labeled serving
Milk g	1 cup	--	--	--	--
Additives: Caffeine, Sweeteners	--	--	Beverages: No caffeine or added non-nutritive sweeteners	Single food items: Less than 10% of kcals from added caloric sweeteners Beverages: Less than 10% of kcals from added caloric sweeteners	--
Meets NSLP standards Under OVSh, students must select: At least ½ cup of fruits and/or vegetables AND At least 2 of 5 food components: ½ cup serving of fruits ¾ cup serving of vegetable 1-oz serving of meats/meat alternates 1-oz serving of grains 1 cup serving of milk			No, did not meet the standards for food components required because it failed to include any food components.	No, did not meet the standards for certain food components because it failed to include specifications for whole grains and meat/meat alternates, thereby, making it impossible to select at least 3 distinct food components.	No, did not meet the standards for calories, sodium, saturated fat, trans fat, and some food components because it either did not include them or served less than the recommended serving sizes.
Meets NRA’s KLW voluntary criteria			No, did not meet the standards for added sugars and food components because it failed to include them.	No, did not meet the standards for meal calories, added sugars, and certain food components such as non-fat/low-fat dairy, whole grains, and meat/meat alternates.	No, did not meet the standards for calories, sodium, saturated fat, trans fat, added sugars, and some food components because it either did not include them or served less than the recommended serving sizes.

^aUS Department of Agriculture Food and Nutrition Service. Final rule: Nutrition standards in the National School Lunch and School Breakfast programs. 77 Federal Register 4088–4167. 2012. Codifed at 7 CFR §210. Accessed September 1, 2020, https://www.federalregister.gov/documents/2012/01/26/2012-1010/nutrition-standards-in-the-national-school-lunch-and-school-breakfast-programs.

^bNational Restaurant Association’s (NRA) Kids Live Well (KLW) 2019. Accessed September 1, 2020, https://restaurant.org/manage-my-restaurant/food-nutrition/kidslivewell.

^cAn Ordinance of the Board of Supervisors of the County of Santa Clara Adding Chapter XXII of Division A18 to the County of Santa Clara Ordinance Code Relating to Toys and Other Incentives with Restaurant Food. May 11, 2010. Available at https://bit.ly/3BA5lEx. Accessed August 1, 2020.

^dOrdinance Amending Article 8 of the San Francisco Health Code by Adding Sections 471.1 through 471.9, to Set Nutritional Standards for Restaurant Food Sold Accompanied by Toys or Other Youth Focused Incentive Items. November 23, 2010. Available at https://bit.ly/3BvInhH. Accessed August 1, 2020.

^eAn Ordinance Amending Chapter 118 of the Louisville Metro Code of Ordinances Regarding Establishing the Nutrition Requirements and Default Beverages Offered with Children’s Meals (as Amended). June 7, 2018. Available at https://bit.ly/2WHZQ7J. Accessed August 1, 2020.

^fExcept for fat contained in nuts, seeds, peanut butter, or other nut butters, or an individually served or packaged egg or individually served or packaged low-fat or reduced fat cheese.

^gThis was not evaluated as part of the nutrition standards because it has been evaluated using beverage standards - evaluated separately in Table 3.

^hUS Department of Agriculture Food and Nutrition Service. Updated offer vs serve guidance for the NSLP and SBP beginning SY2015–16. Published December 24, 2015. Accessed August 16, 2021, https://www.fns.usda.gov/updated-offer-vs-serve-guidancenslp-and-sbp-beginning-sy2015-16.

DISCUSSION

This study systematically identified and compared policy elements of all healthy kids’ meal laws in the US and compared these policies against expert and industry nutrition standards. This research filled an important gap in knowledge because there is limited understanding of these variations in policies. This research showed that as of August 2020, 20 jurisdictions had enacted healthy kids’ meal laws. Most of the healthy kids’ meal laws were passed at the local level under Democratic leadership and enforced by local and state health departments via restaurant inspections with violation fines for noncompliance. There was variation in the implementation provisions, particularly regarding requirements for educational outreach and technical assistance to restaurants, descriptions of key policy elements, and nutritional requirements for kids’ beverages and meals. No laws fully aligned with expert beverage or nutrition standards, and only two laws aligned with industry beverage standards.

While nearly all laws included a definition of kids’ meals, there was variation in this definition, which beverages can be offered as a healthy default, and how the default is to be implemented. Understanding these variations in policy language is important because restaurants can choose to comply with the letter of the law but not necessarily the spirit of the law, as was seen in San Francisco where restaurants were able to bypass its policy by charging a small fee for incentive items that came with kids’ meals due to the policy language used.^52,53 Another example is that if a kids’ meal is defined as a combination (package) of food and beverage items, restaurants that offer food and beverage components for sale separately may not be obligated to comply with the beverage or nutrition standards. Additionally, no policy addressed kids’ meals or their nutritional standards in online menus or ordering and delivery platforms. Given the recent increase in revenue and users of online food delivery options during the COVID-19 pandemic, future policies could look to include specifications for these types of online food sources.⁵⁴

Few policies included provisions that required educational outreach or technical assistance to help restaurants implement the law. This gap is concerning given early findings from Ritchie and colleagues, which found limited awareness of an existing healthy default beverage policy in their jurisdictions among restaurant managers (29% in California and 0% in Wilmington), and found that most managers were interested in receiving implementation support.⁵⁵ Previous evidence suggests that lack of awareness of policy changes among those responsible for execution can inhibit implementation and compliance, potentially diminishing the policy’s impact.⁵⁶ Policies may be strengthened by specification of the types and sources of outreach to restaurants to support implementation. For instance, Cleveland states in their policy that “…the Director of Public Health or a designee shall make available educational material regarding the nutritional and health reasons to limit a child’s consumption of sugared beverages.”³²

None of the nutrition standards specified in the laws met expert nutrition standards for kids’ beverages and meals. No healthy default beverage laws met the expert nutrition guidelines because they allowed the wrong types of beverages (e.g., whole milk) and the wrong sizes of beverages (e.g., juice size larger than 6 fl oz). The healthy default beverage laws of Hawaii and New York City did meet the industry standards for healthy beverage options. The remaining 16 healthy default beverage laws did not meet the industry nutrition guidelines in their entirety due to the allowance of whole milk, nondairy alternatives that are not nutritionally equivalent to milk, and juice sizes larger than the 8 fl oz. Most healthy default beverage laws allowed for the wrong types of beverages (e.g., 17 laws included the whole milk and/or flavored milk) and the wrong sizes of beverages (e.g., 17 laws included juice sizes that were larger than 6 fl oz or 40 calories). Flavored milk includes caloric sweeteners²⁷ and can include added sodium, artificial colors, and artificial flavors, all of which have adverse effects on kids’ health.²⁴ Similarly, frequent consumption of 100% juice in sizes greater than 6 fl oz/day may lead to excess weight gain in kids.⁵⁷ The beverage industry has pushed for a size limit of 8 fl oz for juice and milk, arguing that this size is “readily available in the restaurant channel” compared to the proposed 6 fl oz.⁵⁸ Recently, the NRA updated its KLW industry guidelines to better align with expert nutrition standards, though these revised guidelines allow for higher sodium levels and specify fewer vegetable servings. Potentially, if more healthy kids’ meals policies were to specify smaller size limits based on expert nutrition standards, it is possible that the juice industry would adjust its products to align with these mandates.

This study has strengths and limitations. Given the lack of a systematic online research tool to identify local laws, it is possible that some city and/or county laws may have been missed in the data collection process. However, experts in child nutrition with knowledge of healthy kids’ meal policies were engaged throughout the data collection and analysis process to help identify relevant legislation and reduce this risk. Although the overall inter-rater agreement was moderate, the use of two independent coders and the reconciliation process used helped to ensure greater consistency and accuracy of data gathered. Additionally, this study focused on the content of the laws and supporting documents but did not examine how these policies were being implemented in the real world or whether restaurants were complying with the policy. Consequently, there is a need for more research to understand how these policies are implemented across jurisdictions. Finally, further research could empirically determine which elements of the laws and the implementation strategies used to support compliance are most effective at increasing the offering and selection of healthy default beverages in place of sugary drinks.

CONCLUSION

This study identified and classified the content of and nutrition standards used in healthy kids’ meal policies in the US as of August 2020. The findings have implications for how future policies are crafted and implemented. Healthy kids’ meal policies are intended to create healthier options in restaurants for kids, but no policies included in this review fully aligned with expert nutrition recommendations. Future policies aligned with recognized expert nutrition standards may have a greater potential to impact the overall healthfulness of kids’ meals served in restaurants while legislative provisions to support awareness and implementation may be strengthened to foster compliance. The findings from this study can inform how jurisdictions design future healthy kids’ meal policies.

RESEARCH SNAPSHOT.

• Research Question: What are the key characteristics of healthy kids’ meal policies in the United States, and how do they align with expert and industry nutrition standards?

• Key Findings: There was substantial variation across policies in terms of their nutritional and beverage offerings and implementation. No policy was aligned with expert nutrition standards. Alignment with expert nutrition standards would have the greatest potential to impact the overall healthfulness of kids’ meals and their beverages.