A Natural Experiment to Evaluate Changes in Kids' Meal Beverages in Fast-Food Restaurants Following a Healthy Default Policy, 2019-2022.

Background: Jurisdictions have implemented "healthy beverage policies" requiring restaurants to make lower-sugar beverages the default option listed on kids' menus to improve the nutrition of restaurant offerings for children.

Objective: The aim of this study was to compare changes in beverage offerings in kids' meals written on menu boards within chain restaurants before and after policy implementation in intervention and comparison communities.

Design: This was a quasi-experimental study with comparison using photograph and audit observations at restaurants from October 2019 to June 2022.

Participants/setting: Forty-three restaurants in 3 fast-food chains serving kids' meals with a beverage that did not make lower-sugar beverages the default option at baseline in 2 intervention communities (New York, New York, and Philadelphia, Pennsylvania) and 1 comparison community (Newark, New Jersey) were included.

Intervention: Policies that require only healthier beverages as default options are written on kids' meal menus.

Main outcome measures: Beverage options listed in the kids' meal on the menu board were allowable under healthy beverage policies.

Statistical analyses performed: Descriptive and repeated measures analyses were performed for difference in primary outcome from baseline to follow-up overall and by policy status.

Results: At follow-up, 39 locations (91%), including 8 (89%) in the comparison area with no healthy default policy, listed only beverages allowable as defaults under healthy beverage policies (P < .001 vs baseline, all locations). From baseline to follow-up, 2 chains changed the beverages listed with the kids' meal to align with the healthy default policies in all but 1 location, and 1 chain made no menu changes (P < .001). No statistically significant differences in menu changes were observed between intervention and comparison areas.

Conclusions: After healthy beverage policies were enacted in 2 of 3 communities, most locations in 2 restaurant chains listed only allowable beverages regardless of location outside of cities where the policies were in place. Regional implementation in response to new local healthy default policies may result in broader accessibility of healthier children's beverage options.