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Suggested citation for this article: Otten JJ, Saelens BE, Kapphahn KI, Hekler EB, Buman MP, Goldstein BA, et al.
In 2011, San Francisco passed the first citywide ordinance to improve the nutritional standards of children’s meals sold at restaurants by preventing the giving away of free toys or other incentives with meals unless nutritional criteria were met. Both restaurant chains responded to the ordinance by selling toys separately from children’s meals, but neither changed their menus to meet ordinance-specified nutrition criteria. Although the changes at Chain A did not appear to be directly in response to the ordinance, the transition to a more healthful beverage and default side dish was consistent with the intent of the ordinance.
The marketing of unhealthful foods and beverages through toys and other incentives contributes to the development of unhealthy eating patterns and behaviors that lead to child obesity (1,2). Public health leaders have called for policy-driven strategies aimed at improving food environments and marketing practices (1,5,6).
The ordinance allows free toys or other incentives with foods, beverages, and meals that meet these criteria. The ordinance applied to all restaurants in San Francisco that sold children’s meals with toys or other incentives (n = 98). Research personnel were randomly assigned a set of restaurants and instructed to collect data at each location until they collected 10 surveys or 5 hours of data, whichever occurred first; restaurants where 10 surveys had been collected in less than 5 hours were revisited until 5 hours of data were accumulated. We used a street-intercept survey method to invite parents or caregivers to participate in the study, a method used in studies on menu-labeling legislation (18,19). A nutritional database was created for menu items available during each time point using data provided by corporate websites.
All analyses were conducted with R 3.1 [R Foundation for Statistical Computing, Vienna, Austria]. No children’s meals at either chain met the ordinance nutritional criteria at any time during the study.
This study examined the impact of the San Francisco Healthy Food Incentives Ordinance on restaurant response and child food and beverage orders in a natural experiment at global Chain A and B restaurants before and after ordinance enactment.
We found a significant decrease in calories per order for children purchasing children’s meals just before ordinance enactment. This study contributes to the limited research on the effects of public health policies aimed at improving restaurant food environments. This study illustrates two major findings: one, the wording of regulations and policies can have significant impacts on compliance, and two, more healthful default menu options can have a rapid and positive impact on the healthfulness of food and beverage purchases.
This project was supported by The Obesity Society Early-Career Research Grant awarded to Dr Otten and by Robert Wood Johnson Foundation grant no. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Study results underscore the importance of policy wording, support the concept that more healthful defaults may be a powerful approach for improving dietary intake, and suggest that public policies may contribute to positive restaurant changes.
On December 1, 2011, San Francisco, California, became the first US city to enact an ordinance prohibiting restaurants from giving away free toys or other incentives with children’s meals or with foods and beverages not meeting minimal nutritional criteria (Box) (7). The criteria were based on nutrient recommendations and standards for children provided by the Institute of Medicine of The National Academies and the US National School Lunch Standards (K–6) (9,10). The first US county-level ordinance of this type was implemented in Santa Clara County (no. We narrowed the sample to 2 global restaurant chains (Chain A [n = 19]; Chain B [n = 11]) that operated in San Francisco during the study period.
Because there were many ways a restaurant could comply with the ordinance and it was unknown how restaurants would comply, we tracked local changes in menus and restaurant practices by reviewing local press releases, by direct observation, and by test purchases by trained staff.

Parents or caregivers with children were approached as they entered the restaurant on foot and were offered a $5 restaurant gift card to complete a 10- to15-minute interviewer-administered survey after they completed their purchases. We excluded 101 surveys for the following reasons: survey was missing information on food orders or restaurant location (n = 58), food orders could not be verified (n = 14), or the children surveyed were older than 12, the parent or caregiver was younger than 18, or data on age were missing (n = 29). The main outcomes of interest were differences across time in mean energy content (kcal) per purchase for all children surveyed and for children ordering only children’s meals.
When restaurants began doing so, 88% of those in our sample purchasing children’s meals purchased the toy. However, changes at both chains during the study period affected the nutritional content of children’s meals. On July 31, 2011 (after pre-ordinance time point1 but before pre-ordinance time point 2), Chain B announced it would join the National Restaurant Association’s Kids LiveWell program (21). Both restaurant chains used the compliance strategy of offering toys for an additional 10 cents with the purchase of a children’s meal, and neither changed their menus to meet ordinance criteria (24).
This decrease appeared to result from menu changes at Chain A from a less healthful to a more healthful default side dish. Moreover, although Chain A menu changes may not have been caused by the ordinance, the transition to a more healthful default side dish and fat-free beverage option were consistent with the ordinance intent.
Otten, PhD, RD, Assistant Professor, University of Washington School of Public Health, Nutritional Sciences Program, Box 353410, Seattle, WA 98115.
A crisis in the marketplace: how food marketing contributes to childhood obesity and what can be done. Health code — setting nutritional standards for restaurant food sold accompanied by toys or other youth focused incentive items. Calorie labeling and food choices: a first look at the effects on low-income people in New York City. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. During the same year, these restaurants sold slightly more than 1 billion meals with toys to children aged 0 through 12 (3). Our target study population was parents or caregivers with children (aged 0–12 y) who were customers of the restaurants.
We tracked menus and restaurant practices at the national level by reviewing items in the news media and press releases, announcements, and menus posted on corporate websites. Data collection occurred only on weekends to reduce the potential effect of school being in or out of session.
Participants were informed that the research topic was child food purchases and were asked to provide their receipt; no mention was made of the ordinance at interview initiation. When data were unavailable, items were verified for existence, and nutritional information was often found in an announcement or press release. Outliers were verified for plausibility and validity by cross-checking with surveys; all were plausible and valid. In addition, Chain A started offering fat-free chocolate milk in lieu of 1% chocolate milk (as a beverage option, not a default; a reduction of 40 kcal and 3 g fat and addition of 20 mg sodium) (20).
As part of the program, Chain B announced that soda and french fries would no longer be default in children’s meals but that employees would verbally offer all beverage and side dish options (22). This compliance strategy did not significantly reduce the proportion of children receiving toys with children’s meals.

Although this ordinance applied to only a few restaurants in unincorporated areas of the county, research suggested it improved restaurant food environments and practices (12). We then excluded two Chain A restaurants because of lack of public space in which to conduct the street-intercept surveys. The study protocol was approved by the Stanford University institutional review board; parents and caregivers provided verbal consent. If an item could not be verified or adequate nutrition information found, we excluded the survey that mentioned the item. In test purchases during pre-ordinance time point 2, alternative beverages and side dishes were not offered and apple slices with caramel continued to be sold for an extra cost (which varied by location) compared with french fries. The horizontal line in the middle of each box indicates the median, and the top and bottom borders of the box mark the 75th and 25th percentiles, respectively. However, we found a significant decrease over time in calories, total fat, and sodium for side dishes and in total fat for beverages (due to a substitution of a nonfat beverage for a low-fat beverage). The restaurants were able to comply in this way because of ordinance language which prohibited only the giving away of free toys or other incentives with foods, beverages, and meals not meeting nutritional criteria (8). These results support research suggesting that more healthful default options may be a powerful approach for improving individual behavior (26). Limitations of the study include the use of self-reported data on food and beverages, height, weight, and other variables that are sensitive to bias (27). Another study found that children were significantly more likely to choose a more healthful meal among an array of healthful and less healthful meals when only more healthful meals were offered with a toy (13). However, in post-ordinance test purchases, Chain B employees offered beverage and side alternatives for children’s meals.
If details of a customization (eg, extra cheese, sauce, salad dressing, or beverage type) were not clear, we used average energy and nutrient values for all customization items in the same category. We also observed at post-ordinance and validated by reviewing corporate menus that Chain B stopped serving caramel sauce with its children’s apple slices (a reduction of 45 kcal, 1g fat, 5g sugar, and 35 mg sodium).
Although self-report of food and beverage purchases may introduce response bias, the use of receipts can introduce other inaccuracies or uncertainty.
The following variables were calculated for each item purchased and aggregated by order per person, including customizations: calories, fat, saturated fat, trans fat, sodium, sugar, fiber, and protein. To reduce bias, interviewers were trained to systematically collect food and beverage data, and collection was monitored weekly. As an a priori decision, we based data for orders on self-report from parents or caregivers rather than receipts because our pilot work at Santa Clara County fast food restaurants found that receipts were incorrect (eg, inaccurate sandwich types) or contained insufficient information (eg, type of sauce or beverage) in 50% of test purchases conducted by trained staff. The street-intercept method also may have introduced response bias; those willing to be surveyed may have differed from those not willing.
Buman, School of Nutrition and Health Promotion, Arizona State University, Phoenix, Arizona; Rebecca A. Finally, the data are limited to San Francisco, and the external validity of the findings is not known. To the best of our knowledge, these changes occurred in November 2011 near the end of pre-ordinance time point 2 and appeared to cause significant changes over time in the energy and nutrition values for the category Chain B side dish.
However, these changes were not large enough to affect the findings on Chain B orders for children’s meal only.

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