Baseline Assessment of Children’s Meals and Healthy Beverage Options Prior to a State-Level Healthy Default Beverage (HDB) Law
Black Girls Move


Healthy Default
Children’s Meals
Childhood Obesity


In January 2020, Hawai‘i became the second state with a healthy default beverage (HDB) law, requiring restaurants to offer HDBs with their children’s meals. This observational study presents baseline characteristics of restaurants with a children’s menu and meal, and describes pre-law beverage options to inform future HDB policy language, implementation, and evaluation. Between November and December 2019, data were collected from a statewide sample of unique restaurants (n=383) with health inspection permits. Restaurants were assessed separately for a children’s menu and meal using website reviews, telephone calls, and in-person visits. Meals were evaluated in February 2020 for pre-law beverage type and compliance. Logistic regression was used to estimate the likelihood of having a children’s menu and meal. Most of the restaurants were full-service (70.2%) and non-chains (67.9%). While 49.3% of restaurants had a children’s menu, only 16.7% had a meal. Significant predictors of having a children’s menu were being full-service (OR=2.09; p=0.004), national/international (OR=5.32; p<0.001) or local chains (OR=1.99; p=0.03), neighbor island (non-Honolulu) locations (OR=2.49; p<0.001), and hotel locations (OR=3.77; p<0.001). Only being a national/international chain significantly predicted having a children’s meal (OR=7.57; p<0.001). Although 35.9% of children’s meals offered a non-sugar-sweetened beverage (SSB) option, only 3.1% offered law-compliant beverages. Inclusion of an SSB default option (60.9%) and not specifying the type of default beverage were the predominant factors for pre-law non-compliance. Results support the need for HDB regulations, especially for national/international chains, which were most likely to have children’s meals, and provide data to inform policies in other jurisdictions.


Ammerman, A. S., Hartman, T., & DeMarco, M. M. (2017). Behavioral economics and the Supplemental Nutrition Assistance Program: American Journal of Preventive Medicine, 52(2), S145–S150.

Anzman-Frasca, S., Folta, S. C., Glenn, M. E., Jones-Mueller, A., Lynskey, V. M., Patel, A. A., Tse, L. L., & Lopez, N. V. (2017). Healthier children’s meals in restaurants: An exploratory study to inform approaches that are acceptable across stakeholders. Journal of Nutrition Education and Behavior, 49(4), 285-295.e1.

Anzman-Frasca, S., Mueller, M. P., Lynskey, V. M., Harelick, L., & Economos, C. D. (2015). Orders of healthier children’s items remain high more than two years after menu changes at a regional restaurant chain. Health Affairs, 34(11), 1885–1892.

Cantor, J., Breck, A., & Elbel, B. (2016). Correlates of sugar-sweetened beverages purchased for children at fast-food restaurants. American Journal of Public Health, 106(11), 2038–2041.

Center for Science in the Public Interest. (2019). State and local restaurant kids’ meal policies.

ChangeLab Solutions. (2014). Model healthy children’s meals ordinance.

DuBreck, C. M., Sadler, R. C., Arku, G., & Gilliland, J. A. (2018). Examining community and consumer food environments for children: An urban-suburban-rural comparison in Southwestern Ontario. Social Science & Medicine, 209, 33–42.

U.S. Census Bureau. (2017). North American Industry Classification System, United States, 2017.

Falbe, J., Grummon, A. H., Rojas, N., Ryan-Ibarra, S., Silver, L. D., & Madsen, K. A. (2020). Implementation of the first U.S. sugar-sweetened beverage tax in Berkeley, CA, 2015–2019. American Journal of Public Health, 110(9), 1429–1437.

Harpainter, P., Hewawitharana, S. C., Lee, D. L., Martin, A. C., Gosliner, W., Ritchie, L. D., & Woodward-Lopez, G. (2020). Voluntary kids’ meal beverage standards: Are they sufficient to ensure healthier restaurant practices and consumer choices? International Journal of Environmental Research and Public Health, 17(15), 5275.

Harris, J., Hyary, M., Seymour, N., & Choi, Y.-Y. (2017). Are fast-food restaurants keeping their promises to offer healthier kids’ meals? 30.

Hu, F. B. (2013). Resolved: There is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases: Sugar-sweetened beverages and risk of obesity. Obesity Reviews, 14(8), 606–619.

Institute of Medicine. (2012). Accelerating progress in obesity prevention: Solving the weight of the nation.

Karpyn, A., Ritchie, L., Harpainter, P., Lessard, L., Tsai, M., Atkins, J., McCallops, K., Tracy, T., Woodward-Lopez, G., & Gosliner, W. (2020). Assessing the implementation of kid’s meals healthy default beverage policies in the State of California and City of Wilmington, Del. Healthy Eating Research.

Krukowski, R. A., Eddings, K., & Smith West, D. (2011). The Children’s Menu Assessment: development, evaluation, and relevance of a tool for evaluating children’s menus. Journal of the American Dietetic Association, 111(6), 884–888.

Marshall, T. A. (2013). Preventing dental caries associated with sugar-sweetened beverages. The Journal of the American Dental Association, 144(10), 1148–1152.

Matjasko, J. L., Cawley, J. H., Baker-Goering, M. M., & Yokum, D. V. (2016). Applying behavioral economics to public health policy. American Journal of Preventive Medicine, 50(5 Suppl 1), S13–S19.

Moran, A. J., Block, J. P., Goshev, S. G., Bleich, S. N., & Roberto, C. A. (2017). Trends in nutrient content of children’s menu items in U.S. chain restaurants. American Journal of Preventive Medicine, 52(3), 284–291.

Moran, A. J., Subramanian, S. V., Rimm, E. B., & Bleich, S. N. (2019). Characteristics associated with household purchases of sugar-sweetened beverages in US restaurants. Obesity, 27(2), 339–348.

Mueller, M. P., Wilde, P., Folta, S. C., Anzman-Frasca, S., & Economos, C. D. (2019). Availability of healthier children’s menu items in the top selling quick service restaurant chains (2004–2015). American Journal of Public Health, 109(2), 267–269.

Muth, N. D., Dietz, W. H., Magge, S. N., Johnson, R. K. (2019). Public policies to reduce sugary drink consumption in children and adolescents. Pediatrics, 143(4).

Peters, J., Beck, J., Lande, J., Pan, Z., Cardel, M., Ayoob, K., & Hill, J. O. (2016). Using healthy defaults in Walt Disney World restaurants to improve nutritional choices. Journal of the Association for Consumer Research, 1(1), 92–103.

Powell, L. M., & Nguyen, B. T. (2013). Fast-food and full-service restaurant consumption among children and adolescents: Effect on energy, beverage, and nutrient intake. JAMA Pediatrics, 167(1), 14.

Reilly, J. J., & Kelly, J. (2011). Long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: Systematic review. International Journal of Obesity, 35(7), 891–898.

Relating to Healthy Beverages for Children, Pub. L. No. Act 138 (19), Hawai’i Revised Statutes Chapter 321 (2019).

Roberto, C. A., & Kawachi, I. (2014). Use of psychology and behavioral economics to promote healthy eating. American Journal of Preventive Medicine, 47(6), 832–837.

Russo, R. G., Northridge, M. E., Wu, B., & Yi, S. S. (2020). Characterizing sugar-sweetened beverage consumption for US children and adolescents by race/ethnicity. Journal of Racial and Ethnic Health Disparities.

Saelens, B. E., Glanz, K., Sallis, J. F., & Frank, L. D. (2007). Nutrition Environment Measures Study in Restaurants (NEMS-R) development and evaluation. American Journal of Preventive Medicine, 32(4), 273–281.

Singh, A. S., Mulder, C., Twisk, J. W. R., Mechelen, W. V., & Chinapaw, M. J. M. (2008). Tracking of childhood overweight into adulthood: A systematic review of the literature. Obesity Reviews, 9(5), 474–488.

Soo, J., Harris, J. L., Davison, K. K., Williams, D. R., & Roberto, C. A. (2018). Changes in the nutritional quality of fast-food items marketed at restaurants, 2010 v. 2013. Public Health Nutrition, 21(11), 2117–2127.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. (2015). 2015–2020 Dietary guidelines for Americans. 8th Edition.

Vikraman, S., Fryar, C.D., & Ogden C.L. (2015). Caloric intake from fast food among children and adolescents in the United States, 2011–2012. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.

Wansink, B., & Hanks, A. S. (2014). Calorie reductions and within-meal calorie compensation in children’s meal combos. Obesity, 22(3), 630–632.

Xi, B., Huang, Y., Reilly, K. H., Li, S., Zheng, R., Barrio-Lopez, M. T., Martinez-Gonzalez, M. A., & Zhou, D. (2015). Sugar-sweetened beverages and risk of hypertension and CVD: A dose–response meta-analysis. British Journal of Nutrition, 113(5), 709–717.

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Copyright (c) 2021 Array