Sugar-sweetened beverages (SSBs) contribute significant excess sugar to the American diet (U.S. Department of Health and Human Services, 2015).Data show that nearly two-thirds of American youth drink an SSB on any given day (Russo et al., 2020). SSB consumption is associated with increased risk of obesity, other cardiometabolic diseases, and dental caries (Hu, 2013; Marshall, 2013; Xi et al., 2015). Children are particularly vulnerable to the obesogenic consequences of SSB consumption (Reilly & Kelly, 2011; Singh et al., 2008). With over a third of children eating fast food on a given day (Vikraman, Fryar, & Ogden, 2015) and higher SSB intake among children who eat out than those who eat at home (Powell & Nguyen, 2013), recent efforts to address childhood obesity have focused on the nutrition content of children’s menus in restaurants.

Although some restaurants have voluntarily committed to improving the nutrition content of their children’s menus or removing soda options for children (Moran et al., 2017), implementation of such voluntary standards is inconsistent, and studies on changes to the overall healthfulness of menus and access to SSBs over time have been mixed (Moran et al., 2017; Mueller et al., 2019; Soo et al., 2018).Several municipalities and three states have taken legislative action to assure improvements to the nutrition content of children’s meals offered at restaurants, through laws that require the default beverages in children’s meals be healthy beverages as opposed to SSBs (Center for Science in the Public Interest, 2019).

On June 25, 2019, Hawai‘i’s Act 138 was signed into law, making Hawai‘i the second of three states (along with California and Delaware) with a healthy default beverage (HDB) law. Hawai‘i’s HDB law stipulates that effective January 1, 2020, if a restaurant serves a children’s meal, the default beverage served with the meal should be plain, sparkling, or unsweetened water, unflavored low-fat or nonfat milk, a nondairy milk equivalent, or 100% or unsweetened, diluted juice (Relating to Healthy Beverages for Children, 2019). However, restaurants can offer alternative options, including SSBs, if requested.

HDB laws are based on findings that people will accept default options rather than ask for substitutes (Roberto & Kawachi, 2014). These laws nudge customers into healthier choices by making the healthy choice the easy choice (Ammerman et al., 2017; Matjasko et al., 2016). Studies of healthy default options indicate they have the potential to reduce children’s sugar and energy intake and shift norms toward consuming healthy beverages (Anzman-Frasca et al., 2015; Peters et al., 2016).

While HDB laws are an active policy area and improving children’s beverage options is a recommended action to reduce obesity (Institute of Medicine, 2012; Muth et al., 2019), the research base is limited due to the recency of these laws. Thus far, only one state and one city with HDB laws—California and Wilmington, Delaware—have reported any data about the impact of such laws. The California study found that restaurants increased their HDB offerings after the statewide law was passed, especially restaurants with voluntary HDB policies (Harpainter et al., 2020). However, the study was limited to quick-service restaurants (QSRs), not the full range of restaurants in a community that would be subject to an HDB law. The Wilmington study included both QSRs and full-service restaurants (FSRs), but it examined only 16 restaurants with children’s meals within the city limits and was conducted prior to the implementation of the statewide law, limiting its generalizability in understanding how to scale-up an HDB law statewide (Karpyn et al., 2020). Other studies have examined voluntary industry initiatives to improve the nutrition content of children’s menus in general (Moran et al., 2017; Peters et al., 2016), not laws regulating children’s meal beverages. These studies also only focused on changes in children’s menu offerings among limited restaurant types, such as a single restaurant chain over time (Anzman-Frasca et al., 2015; Wansink & Hanks, 2014) or only large national or regional chains (Moran et al., 2017; Mueller et al., 2019; Soo et al., 2018).

With many jurisdictions considering HDB laws, baseline data are urgently needed to understand characteristics of restaurants with children’s menus and meals and factors of variation in children’s meal beverage options. This will allow policy makers and advocates to evaluate the potential law impacts on all restaurant types in their jurisdictions and plan implementation strategies. It will also allow researchers to better understand the impact of HDB laws on children’s SSB consumption over time. The objectives of this cross-sectional observational study are, first, to document the landscape of restaurants offering children’s menus and meals in a statewide representative sample and, second, to examine the default beverages offered with children’s meals before a statewide HDB law’s implementation to inform future law language, implementation, and evaluation.

Methods

Study Sample

There is no database of restaurants that serve children’s meals in Hawai‘i that would indicate which restaurants would be subject to the HDB law. Therefore, sample development began with a list of all establishments with Hawaiʻi State Department of Health (HDOH) permits to prepare food. To be included in the sample, it needed to be plausible that the establishment could have a children’s meal. Figure 1 describes the sample selection, starting with 10,196 permitted establishments, which were searched via Google and coded by type. Excluded establishments were bars, manufacturers, caterers, food preparation centers, tour companies, school/worksite cafeterias, ice cream parlors, coffee shops, or lunch wagons, because the law would not apply to them. This search resulted in 2,131 eligible, operating establishments that were distributed statewide, with over half located in Honolulu County on O‘ahu, the most populated island. Insufficient time and personnel prohibited a full census sampling of establishments. Therefore, an 18% (N = 383) random sample was taken of all eligible establishments statewide, stratified by county in the same proportions found in the eligible establishments’ population. A 15% sample was initially planned, but to assure sufficient representation of neighbor island counties (i.e., Maui, Hawai‘i, Kaua‘i), the sample size was increased. When multiple locations of a restaurant chain were sampled, only one location was kept; the rest were replaced through random sampling to ensure only unique restaurants were sampled.

Data Collection

Restaurant menus were collected from November–December 2019, before the law’s effective date of January 1, 2020, using a methodology adapted from protocols used to assess children’s menus (DuBreck et al., 2018; Krukowski et al., 2011). Six trained researchers first reviewed official websites to determine if sampled restaurants had a menu or items that were specifically for children (hereafter referred to as a “children’s menu”) and then if they sold a children’s meal combination including a beverage (hereafter referred to as a “children’s meal”). Only official websites were reviewed because third-party websites, where customers order delivery or takeout, did not distinguish between the default and substitute beverages available. When an establishment had a children’s meal, the menu was downloaded (n = 37).

Next, all restaurants (n = 346) that did not have a confirmed children’s meal online were called. If the restaurant had a children’s meal, a copy of the menu was requested via email, text message, or fax. Restaurants that could not send their menu were visited. Additionally, locations with an online children’s meal were visited (n = 37) to validate that online and in-person meal options matched. There was 64.9% concordance between online and in-person options; thus, in-person menus were utilized for menu analysis.

Table 1: Characteristics of Restaurants With a Children’s Menu and Children’s Meal†

Restaurant Characteristics	Final Sample (N=383)	Children’s Menu (n=189)		Children’s Meal (n=64)^†
Restaurant Characteristics	Final Sample (N=383)	n (row %)	p-value	n (row %)	p-value
Restaurant service type			0.07		0.75
quick-service	114	48 (42.1%)		18 (15.8%)
full-service	269	141 (52.4%)		46 (17.1%)
Restaurant chain type			<0.001		<0.001
Not a chain	260	114 (43.8%)		27 (10.4%)
Local chain	60	29 (48.3%)		10 (16.7%)
National/international chain	63	46 (73.0%)		27 (42.9%)
Restaurant in a hotel			<0.001		0.50
No	333	151 (45.3%)		54 (16.2%)
Yes	50	38 (76.0%)		10 (20.0%)
County			<0.001		0.54
Honolulu County	214	88 (41.1%)		38 (17.8%)
Neighbor island counties	169	101 (59.8%)		26 (15.4%)

Note. Boldface indicates statistical significance. ^†Only children’s meals are subject to the HDB law.

Table 3. Children’s Beverages Offered by Restaurants With Children’s Meals (n = 64)

Children’s meal includes	n	%
Only compliant HDB^†options	2	3.1
At least 1 compliant HDB^†	8	12.5
Only non-SSB^‡ options	6	9.4
At least 1 type of non-SSB^‡ option	23	35.9
Any type of SSB	39	60.9
Free refills on SSBs for children^§	2	3.1
Unspecified “drink” or “beverage”	19	29.7
Specific types of beverages included
Juice, any^§	31	48.4
Juice, 100%^†^,^§	2	3.1
Juice, diluted without added sweeteners^†	4	6.3
“Juice,” not further specified	8	12.5
Juice, size specified as 8 oz or less	1	1.6
Milk, any^§	24	37.5
Milk, low-fat (1%) or nonfat^†^,^§	4	6.3
Milk, high fat (2% or whole)	2	3.1
Milk, flavored (any fat content)	6	9.4
“Milk” or “White Milk,” fat not specified	16	25.0
Milk, size specified 8 ounces or less	0	0.0
Nondairy milk equivalent^†	0	0.0
Water, plain^†	3	4.7
Water, sweetened or flavored	2	3.1
Soda or fountain drink targeted at children^§	31	48.4
“Soda” or brand name listed	16	25.0
“Fountain drink” or “soft drink” listed	15	23.4
Diet soda, specified	9	14.1
Sweetened tea or other SSB	5	7.8
Unsweetened tea	1	1.6
Sports or energy drinks	0	0.0
Age limit^§
No age limit listed	27	42.2
10 years and younger	13	20.3
12 years and younger	16	25.0
Other age limit	8	12.5

^†Compliant healthy default beverage (HDB) option per the law.

^‡Non-SSBs (sugar-sweetened beverages) include HDBs and unsweetened beverages not acceptable by the Hawai‘i HDB law (e.g., whole milk and reduced-fat milk).

^§Children’s Menu Assessment tool item.

Discussion

Results showed that among a statewide sample of diverse restaurants, all restaurant types had children’s menus and meals, not just large chain restaurants as examined by most of the previous studies (Harris et al., 2017; Moran et al., 2017; Mueller et al., 2019; Soo et al., 2018). However, national/international chains were much more likely than non-chains to have a children’s meal. This finding is important as a study examining purchases by U.S. households found families purchased more SSBs from national chain restaurants than other restaurant types (Moran et al., 2019).

This study also found that children’s meals inclusive of a drink were less common than children’s menus, which were offered by nearly half of the restaurants sampled, but are not subject to the law. This highlights a potential gap in the ability to reduce children’s access to SSBs. This study did not examine the beverages offered by restaurants with only children’s menus, as the objective was to examine the default beverages offered with children’s meals—the subject of the new legislation—prior to statewide implementation of the HDB law. However, Moran and colleagues (2017) examined changes in beverages on children’s menus between 2012 and 2015 and found that despite the decrease in sodas on children’s menus over time, beverage calories did not change and 80% of children’s menus still contained SSBs because sodas were often replaced by flavored milks. Additional legislation or efforts may be needed to target children’s menus, in addition to children’s meals, to impact children’s SSB access and consumption. However, it should be noted that children’s meals in Hawai‘i restaurants are more prevalent than reported, due to this study’s sampling methodology of including only one of each national/international chain’s numerous locations statewide (e.g., one of the 60 McDonald’s locations statewide). Thus, children’s meal HDB legislation, if implemented in chains, can have broad reach.

Prior to the law, just two (3.1%) restaurants offered only compliant HDBs, and few offered even one compliant HDB. In California’s study, 0–15.5% of QSRs offered only law-compliant HDBs (unflavored milk or water per California law), with higher rates among restaurants with voluntary beverage standards for children’s meals (Harpainter et al., 2020). The California authors also found that when the definition of HDBs was expanded to include unsweetened juice, as is allowed in Hawai‘i and Delaware, 4.4–65.2% of restaurants offered only HDBs. Lower rates found in this study could be due to the inclusion of FSRs, as 46 of the 64 children’s meals in this study were from FSRs. They could also be due to the inclusion of only one location to represent each chain restaurant, as opposed to multiple locations of the same fast food chain as used in the California study. Chain restaurants are able to quickly and cheaply develop compliant menus and menu boards that can be used in multiple locations.

Despite low HDB rates in this study, over a third of children’s meals included at least one non-SSB option. This is an improvement from a study among top-selling QSR chains that found increasing trends in non-SSB options bundled with children’s meals between 2004 and 2015 but that less than 20% of children’s meals included a non-SSB as a default option (Mueller et al., 2019). It is unclear if higher rates of non-SSB options in this study could be due to a continuation of trends, the inclusion of other restaurant types, or a difference in study methodology and context.

Low pre-law compliance was mostly attributable to the fact that SSBs were a default option for 60.9% of the children’s meals. This is a major public health concern, as SSBs provide calories with no nutritional value (Cantor et al., 2016; U.S. Department of Health and Human Services, 2015) and continue to be bundled with meals explicitly targeting young children (Anzman-Frasca et al., 2017). This corroborates other studies that have found that despite industry pledges to improve children’s beverage options, SSBs continue to be default options in many children’s meals (Harris et al., 2017; Mueller et al., 2019). It adds further evidence that HDB laws may be necessary to improve the healthfulness of children’s meal beverages and reduce children’s access to SSBs.

Lack of beverage specificity was another reason for low pre-law compliance. Almost 30% of restaurants just said a “drink” was included in the children’s meals, without specifying the type, and many did not specify the milk-fat or juice content. Lack of specificity may be a source of misclassification in this study. If restaurants served 100% juice but did not list it on their menus, they may have been compliant. Alternatively, if staff verbally offered options different from the menu options, restaurants may not have been compliant. Discrepancies between menu and verbal offerings of healthier beverage options for children have been found in other studies (Harpainter et al., 2020; Harris et al., 2017; Karpyn et al., 2020). Hawai‘i’s post-law evaluation study will need to examine if both the menu and the point-of-sale offerings are compliant to effectively understand HDB law impacts. Additionally, future policies may need to stipulate that HDBs should be offered both on menus and in point-of-sale offerings from cashiers.

Low pre-law compliance documented in this study also suggests additional efforts are needed to educate restaurants in Hawaiʻi to improve children’s meal compliance, considering pre-law data collection started four months after the law passed and was completed only weeks prior to the law going into effect. A recent study evaluating the implementation of Berkeley, California’s SSB tax recommends that laws have appropriate lead time between passage and effective dates and that early communication, outreach, and evaluation are needed in order to facilitate law implementation (Falbe et al., 2020). Jurisdictions considering HDB laws should plan implementation and evaluation efforts prior to law passage.

The much higher likelihood of having a children’s meal among national/international chains than non-chains may lend support for a national HDB regulation since there is considerable variation in what beverages are included under HDB laws across jurisdictions (Center for Science in the Public Interest, 2019), which can create challenges for restaurants. For example, one national chain in this study, with locations in both California and Hawai‘i, served milk that was compliant with California’s law, which allows unflavored milk of any fat content, but that was not compliant with Hawai‘i’s law, which only allows unflavored nonfat or low-fat milk. Cross-jurisdiction language may make menu development and ordering simpler for restaurants spanning multiple jurisdictions.

Finally, in a recent study, QSR and FSR executives reported that there is little incentive to modify children’s items as children’s menus are not revenue generating and are established based on ingredients already purchased by the restaurant to create main menu options (Anzman-Frasca et al., 2017).It is important to consider if HDB regulations will create cost burdens that could result in restaurants unbundling their beverages from their children’s meals or removing “children” from meal names to circumvent the laws, which a few restaurants did during data collection for this study. Although advocates recognize this potential outcome (ChangeLab Solutions, 2014; Karpyn et al., 2020), data are not yet available on how many restaurants choose to unbundle their children’s meals when faced with an HDB law, nor on the determining factors in that choice. Baseline data such as that collected in this study are critical for assessing HDB law impacts. Studies are also needed to understand the challenges restaurants face in offering HDBs, such as the role of third-party ordering websites, which have grown in popularity during the COVID-19 pandemic (Karpyn et al., 2020), and the drivers and consequences of restaurant decisions to unbundle their children’s meals, so that HDB law impacts can be fully assessed.

Limitations

This study examined some restaurant characteristics particularly relevant to Hawai‘i and other tourist destinations, such as hotel locations, thereby limiting the generalizability to all jurisdictions. However, the sample included restaurant types found in all communities, including 63 national/international chains and both QSRs and FSRs, resulting in broad relevance. Although random stratified sampling was used to obtain an unbiased representative sample, sampling may have missed restaurants that had compliant HDBs. This study followed practices used by other studies (DuBreck et al., 2018; Krukowski et al., 2011; Saelens et al., 2007), in assuming items were unhealthy unless menus specifically stated types of beverages stipulated as permissible in the law. However, this may have also resulted in undercounting of compliant restaurants, who may have offered an HDB, when they listed a “drink” on their menu. Related to this, because data collection was restricted to written menus, it cannot be generalized to verbal point-of-sale offerings. Additionally, due to the cross-sectional study design, the data only represent what was on the menus when the study was conducted.

Other limitations include the fact that this study did not assess restaurant managers’ awareness of the law. Because data collection occurred so close to the law’s effective date, it is likely that some restaurant managers were aware of the law and had already changed their children’s meal beverages in preparation for it. As previously stated, during data collection, a few restaurants did change their menus, but mostly to circumvent the law through unbundling. Assessing restaurant manager awareness may have aided in understanding if, and why, restaurants made changes to their menus at the time of data collection, but would likely not change the principal conclusion of this study that compliance was low prior to the law going into effect. Additionally, manager awareness was likely to be low at data collection because no efforts had been made to educate Hawai‘i restaurants on the upcoming law. The lack of education was due to the fact that the law did not stipulate implementation and enforcement guidelines but instead directed the HDOH to develop and adopt rules to implement the law, which are processes that take time to complete. Further, interviews with restaurant managers in Wilmington, Delaware, and in California 7–12 months after their HDB laws went into effect showed that between 0% and 29% of restaurant managers, respectively, were aware of the laws (Karpyn et al., 2020). That said, post-law data collection should assess restaurant managers’ law awareness.

Another limitation is that this study only examined children’s meals inclusive of a drink and did not examine the beverages offered by restaurants with general children’s menus that were not subject to the law. This limits the ability to draw conclusions about the types of beverages offered on children’s menus and what future regulations may be needed for children’s menus. Finally, although improved access to healthy options can increase the likelihood of purchasing them (Cantor et al., 2016), and customers are accepting of default options (Peters et al., 2016), this study did not capture purchasing or consumption behavior. Future studies are needed to determine if healthy options are being purchased and consumed by children, to understand how HDB laws impact children’s SSB consumption.

Conclusion

Despite these limitations, this study shows the baseline characteristics of restaurants with a children’s meal that would be subject to an HDB law, which can help inform future HDB law language and implementation to reduce children’s SSB consumption in other jurisdictions. It also shows that few restaurants are offering HDBs and most are offering SSBs, providing evidence that HDB laws, either nationally or in smaller U.S. jurisdictions, may be needed to improve the default beverage options included in children’s meals.

Corresponding Author:

Meghan D. McGurk, University of Hawai‘i at Mānoa, Office of Public Health Studies, 1960 East-West Road, Biomed D210, Honolulu, Hawai‘i 96822. mcgurkm@hawaii.edu. Phone: (808) 956-3401. Fax: (808) 956-3368

Tetine Sentell: https://orcid.org/0000-0003-3548-1281

Catherine M. Pirkle: https://orcid.org/0000-0002-1528-5438

Meghan D. McGurk https://orcid.org/0000-0003-0960-1147

Creative Commons License:

This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 International License (CC BY-NC 4.0).

Suggested citation (APA 7th edition): McGurk, M.D., Cacal, S.L.,Vu^,U., Sentell, T., Beckelman, T., Lee, J., Yang, A. & Pirkle, C.M. (2021). Baseline Assessment of Children’s Meals and Healthy Beverage Options Prior to a State-Level Healthy Default Beverage (HDB) Law. Journal of Healthy Eating and Active Living, 1(2), 53-63.

Author Contributions

Conceptualization, M.D.M, T.S., T.B., J.L., A.Y., and C.M.P; Methodology, M.D.M, S.C., U.V., and C.M.P.; Investigation, M.D.M, S.C., and U.V.; Data Curation, M.D.M, S.C., and U.V.; Formal Analysis, M.D.M.; Validation, M.D.M; Visualization, M.D.M; Project Administration, M.D.M.; Resources: M.D.M, S.C., and U.V.; Writing – Original Draft, M.D.M, S.C., T.S., and C.M.P.; Writing – Review & Editing, M.D.M., S.C., U.V., T.S., T.B., J.L., A.Y., and C.M.P.; Supervision: T.S. and C.M.P.; Funding Acquisition, T.S. and C.M.P.

Conflicts of Interest

No financial disclosures or conflicts of interest are reported by the authors of this paper.

Acknowledgments

This study was funded through a contract from the HDOH’s Chronic Disease Prevention and Health Promotion Division. The contents of this manuscript are the sole responsibility of the authors and do not necessarily reflect the official views of HDOH. The authors would like to acknowledge Katey Peck, Janiel Staana, Kelyse Dias, Roella Foronda, Sally Ancheta, and the Hawai‘i Public Health Institute for their assistance with data collection, and Katherine Inoue, Heidi Hansen-Smith, and Lance Ching for their contributions to the study design.

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Predictors	Children’s menu OR (95% CI)	Children’s meal OR (95% CI)
Restaurant service type
Quick-service	1 [ref]	1 [ref]
Full-Service	2.09 (1.26–3.47)**	1.57 (0.80–3.07)
Restaurant chain type
Not a chain	1 [ref]	1 [ref]
Local chain	1.99 (1.08–3.68)*	2.02 (0.89–4.580)
National/international chain	5.32 (2.75–10.29)***	7.57 (3.85–14.90)***
Restaurant in a hotel
No	1 [ref]	1 [ref]
Yes	3.77 (1.83–7.75)***	1.59 (0.69–3.66)
County
Honolulu County	1 [ref]	1 [ref]
Neighbor island counties	2.49 (1.58–3.92)***	0.94 (0.52–1.70)

Methods

Study Sample

Data Collection

Figure 1. Sample Selection Process

Measures

Statistical Analysis

Results