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

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 with 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 nutrition 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 with existing expert and industry nutrition standards for meals and beverages. Main outcome measures: Measures included law characteristics, implementation characteristics, enforcement characteristics, definitions of key terms, and 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 the Cohen 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 nutrition standards policy. The nutrition 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’ influences on children's consumption. Future policies could use expert nutrition standards to inform the standards set for kids’ meals and specify supports for implementation.