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BACKGROUND: In 2016, a voluntary National Healthy Food and Drink Policy was released to improve the healthiness of food and drinks for sale in New Zealand health sector organisations. The Policy aims to role model healthy eating and demonstrate commitment to health and well-being of hospital staff and visitors and the general public. This study aimed to understand the experiences of hospital food providers and public health dietitians/staff in implementing the Policy, and identify tools and resources needed to assist with the implementation. METHODS: A maximum variation purposive sampling strategy (based on a health district's population size and food outlet type) was used to recruit participants by email. Video conference or email semi-structured interviews included 15 open-ended questions that focused on awareness, understanding of, and attitudes towards the Policy; level of support received; perceived customer response; tools and resources needed to support implementation; and unintended or unforeseen consequences. Data was analysed using a reflexive thematic analysis approach. RESULTS: Twelve participants (eight food providers and four public health dietitians/staff) were interviewed; three from small (< 100,000 people), four from medium (100,000-300,000 people) and five from large (> 300,000 people) health districts. There was agreement that hospitals should role model healthy eating for the wider community. Three themes were identified relating to the implementation of the Policy: (1) Complexities of operating food outlets under a healthy food and drink policy in public health sector settings; (2) Adoption, implementation, and monitoring of the Policy as a series of incoherent ad-hoc actions; and (3) Policy is (currently) not achieving the desired impact. Concerns about increased food waste, loss of profits and an uneven playing field between food providers were related to the voluntary nature of the unsupported Policy. Three tools could enable implementation: a digital monitoring tool, a web-based database of compliant products, and customer communication materials. CONCLUSIONS: Adopting a single, mandatory Policy, provision of funding for implementation actions and supportive tools, and good communication with customers could facilitate implementation. Despite the relatively small sample size and views from only two stakeholder groups, strategies identified are relevant to policy makers, healthcare providers and public health professionals.

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BACKGROUND: The US Affordable Care Act (ACA) energy posting mandate requires restaurant chains to disclose information on the energy content of their food items. Assessments of the effect of menu energy labeling on dietary choices have reported inconsistent findings. OBJECTIVE: This study examines the impact of menu energy labeling on food items purchased by college students after the mandate was enacted nationally. STUDY DESIGN AND SETTING: Student food sales data from purchases made at three fast-food restaurants during the 2017/2018 and 2018/2019 academic years at a university campus were used for the analysis. The total sample included 1,662 students on the university meal plan; these students generated 145,295 food transactions at the restaurants over the study period. We utilized a difference-in-differences (DiD) empirical strategy, comparing changes in transaction-level energy purchases at two fast food restaurants (FFRB and FFRC - treatment groups) that posted energy information in the summer of 2018 with another fast food restaurant (FFRA - control group) that began posting energy information before the study period. RESULTS: We observed increases in the average energy content per transaction after implementing the menu labeling policy. The DiD estimates found an increase of 20.6 in the average calories of energy purchased per transaction at the treatment restaurants relative to the control restaurant. In the subgroup analyses, the DiD estimates indicate calories of energy increased: 18.7 for female students, 20.5 for male students, 23.5 for non-Hispanic Black students, 30.2 for students eligible for federal financial aid, and 19.9 for students not eligible for federal financial aid. CONCLUSION: The results suggest that the ACA energy menu labeling policy led to an increase in the energy content per transaction by students at a public university. This paper highlights the need for more research to better understand the determinants of food choice among college students.

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BACKGROUND: Food and beverage companies play a central role in shaping the healthfulness of food environments. METHODS: The BIA-Obesity tool was used to evaluate and benchmark the specificity, comprehensiveness and transparency of the food environment-related policies and commitments of leading food and beverage manufacturing and retailing companies in Canada. Policies and commitments related to the healthfulness of food environments within 6 action areas were assessed: 1) corporate nutrition strategy; 2) product (re)formulation; 3) nutrition information and labelling; 4) product and brand promotion; 5) product accessibility; and 6) disclosure of relationships with external organizations. Data were collected from publicly available sources, and companies were invited to supplement and validate information collected by the research team. Each company was then assigned a score out of 100 for each action area, and an overall BIA-Obesity score out of 100. RESULTS: Overall BIA-Obesity scores for manufacturers ranged from 18 to 75 out of 100 (median = 49), while scores for retailers ranged from 21 to 25 (median = 22). Scores were highest within the product (re)formulation (median = 60) followed by the corporate nutrition strategy (median = 59) domain for manufacturers, while retailers performed best within the corporate nutrition strategy (median = 53), followed by the disclosure of relationships with external organizations (median = 47) domain. Companies within both sectors performed worst within the product accessibility domain (medians = 8 and 0 for manufacturers and retailers, respectively). CONCLUSIONS: This study highlights important limitations to self-regulatory approaches of the food and beverage industry to improve the healthfulness of food environments. Although some companies had specific, comprehensive, and transparent policies and commitments to address the healthfulness of food environments in Canada, most fell short of recommended best-practice. Additional mandatory government policies and regulations may be warranted to effectively transform Canadian food environments to promote healthier diets and prevent related non-communicable diseases.

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Public procurement of food is crucial for ensuring proper nutrition and the provision of high-quality products in public institutions like schools and kindergartens. It should be seen as an investment in health promotion, particularly for young children. Notably, when no quality criteria are specified, the cheapest and often lowest-quality products are typically selected. This study analyzed 1126 public procurement orders processed by schools and kindergartens in Poland between November 2022 and March 2023, with a focus on cereal products and their derivatives. Of these orders, 197 met the inclusion criteria, yielding a total of 5084 cereal products for detailed analysis. The study assessed the quantities ordered and the quality characteristics specified in the procurement documents. The results revealed that the most commonly described criteria pertained to product composition, especially typical characteristics and the absence of additives. Sensorial characteristics such as consistency and color were also frequently specified, while sustainable public procurement criteria were mentioned the least, indicating their marginal importance in current procurement practices. This underscores the critical importance of establishing minimum standards for describing cereal products in terms of sensorial characteristics, composition, and sustainability. Such standards are essential for improving the quality of grain products supplied to public institutions and ensuring that these institutions actively contribute to promoting healthy eating habits among children.

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BACKGROUND: While the retail food environment has been well studied, research surrounding the university food environment is still emerging. Existing research suggests that university food environments can influence behavioral outcomes such as students' dietary choices, which may be maintained long-term. Despite a growing interest in assessing university food environments, there is no standardized tool for completing this task. How researchers define "healthy" when assessing university food environments needs to be clarified. This paper describes the protocol for systematically reviewing literature involving university food environment assessments. OBJECTIVE: This paper aimed to describe the protocol for a systematic review of the assessments of university food environments. The review will summarize previously used tools or methods and their implications. METHODS: Electronic databases, including PubMed (NLM), Cochrane Library (Wiley), Web of Science (Clarivate), APA PsycINFO (EBSCO), CINAHL (Cumulative Index to Nursing & Allied Health) Complete (EBSCO), ProQuest Nursing and Allied Health, and Google Scholar were searched for papers published between 2012 and 2022 using combinations of related medical subject headings terms and keywords. The electronic databases were supplemented by reviewing the reference list for all included papers and systematic reviews returned with our search results. The review will include all study types, including randomized controlled trials, observational studies, and other pre-post designs. Papers that examine at least 1 aspect of the university food environment, such as cafeterias, campus convenience stores, and vending machines, were considered for inclusion. A total of 2 reviewers will independently screen titles and abstracts, complete a full-text review, extract data, and perform a quality assessment of included papers, with a third reviewer resolving any conflicts. The Quality Assessment for Diverse Studies (QuADS) tool was used to determine the methodological quality of selected studies. A narrative and tabular summary of the findings were presented. There will not be a meta-analysis due to the methodological heterogeneity of the included papers. RESULTS: The initial queries of 4502 records have been executed, and papers have been screened for inclusion. Data extractions were completed in December 2023. The results of the review were accepted for publication in May 2024. The systematic review generated from this protocol will offer evidence for using different assessment tools to examine the campus food environment. CONCLUSIONS: This systematic review will summarize the tools and methods used to assess university food environments where many emerging adults spend a significant part of their young adult lives. The findings will highlight variations in practice and how "healthy" has been defined globally. This review will provide an understanding of this unique organizational food environment with implications for practice and policy. TRIAL REGISTRATION: PROSPERO CRD42023398073; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=398073. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54955.

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The change in policy that allowed Supplemental Nutrition Assistance Program recipients to redeem their benefits online during the coronavirus disease 2019 pandemic highlighted the potential role of nutrition education programs in facilitating the purchase of healthy, economical food online. The objective of this exploratory qualitative study was to understand the education provided by nutrition educators on online grocery shopping and educators' perspectives on education needs and ways that healthy purchases can be encouraged online. Interviews revealed topics that can be included in in-person education on online shopping, insights for online nutrition education, and promotion strategies for encouraging healthy purchases by low-income shoppers online.

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CONTEXT: International evidence shows that individuals from low socioeconomic positions (SEPs) consume a greater amount of salt than those from higher SEPs. This health inequality reflects a disproportionate effect of salt-reduction initiatives, and explains a higher prevalence of cardiovascular disease among the most vulnerable populations. Assessing this impact can help tailor implementation strategies in the future for the benefit of the whole population. OBJECTIVE: The aim was to systematically review the literature and assess the impact of salt-reduction initiatives on health and behavioral outcomes of adults by SEP. DATA SOURCES: The search strategy was conducted in 6 databases (CINAHL, Scopus, Embase, MEDLINE, PubMed, and Web of Science) using the terms sodium or salt, social class, policy, intervention or campaign. Peer-reviewed articles assessing salt-reduction interventions in adults reporting dietary or behavioral changes on salt consumption measurements by SEP were considered for inclusion. Articles in which salt intake data were not reported by SEP were excluded. DATA EXTRACTION: Two reviewers collected data independently using a predesigned electronic form. The AXIS and RoB 2 tools were used for critical appraisal. DATA ANALYSIS: Eight studies containing data from 111 548 adults were interpreted according to study design following a narrative synthesis approach. RESULTS: Salt-reduction initiatives are effective at reducing the intake of salt and sodium in adults. When reporting the impact of these initiatives, research outcomes are generally not evaluated by SEP, representing a question yet to be explored. CONCLUSION: A small number of articles that focused on the impact of salt-reduction interventions reported salt consumption measurements by SEP, indicating a critical gap in research. The limited evidence suggests potentially greater health benefits to be gained from the implementation of population-wide initiatives in adults of low SEP. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42021238055.

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Produce prescription programs (PPPs) are place-based interventions at the intersection of public health and local food advocacy. These programs have expanded significantly across the United States since 2010, particularly taking off in the state of West Virginia. This article draws on a 4-y institutional ethnography of PPP programs and associated policy. Although the possibilities of building support for improving community health alongside the livelihoods of small-scale producers is compelling, there exists an overall decontextualization from broader social and political determinants of health. This article concludes that although programs are able to meet some acute needs for program participants and provide income for small-scale producers, this decontextualization results from a lack of consideration of wider systems within policy and program construction, leading to missed opportunities for food system transformation.

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BACKGROUND: National food environment policies can contribute to the reduction of diet-related non-communicable diseases. Yet, their implementation in the Netherlands remains low. It has been hypothesized that the media can play a pivotal role in inducing spikes in policy attention, thereby shaping political action. The aim of this study was to examine the discourse on food policies in Dutch newspaper articles between 2000-2022, by analyzing arguments used by various actors. METHODS: A systematic search in Nexis Uni was used to identify newspaper articles that covered national-level Dutch food environment policies published in seven Dutch national newspapers between 2000-2022. Covered policies were classified into six domains including food composition, labeling, promotion, prices, provision and retail and into the four stages of the policy cycle; policy formulation, decision-making, implementation, and evaluation. A grey literature search was used to identify food policies implemented during 2000-2022. Descriptive statistics were used to summarize coverage of policies over time, policy type and policy stage. An interpretive content analysis was performed on a random subsample of the newspaper articles to determine the actors, viewpoints and arguments of the food policies. RESULTS: We identified 896 relevant newspaper articles. The coverage of food policies in newspapers was initially low but peaked in 2018/2021/2022. Through grey literature search we identified 6 food policies which were implemented or adjusted between 2000-2022. The majority of the newspaper articles reported on food pricing policies and were discussed in the policy formulation stage. Academics (mainly supportive) were the most and food industry (mostly opposing) the least cited actors. Supportive arguments highlighted health consequences, health inequalities and collective responsibility, whereas opposing arguments focused on unwanted governmental interference and ineffectiveness of policies. CONCLUSIONS: Dutch newspaper articles covering food policies represented a variety of actors and arguments, with individual versus collective responsibility for food choices playing a central role in the arguments. These insights may serve as a basis for further research into why certain arguments are used and their effect on policy attention and implementation.

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The double burden of malnutrition (DBM) is escalating in low- and middle-income countries (LMICs), including in Rwanda, most notably in urbanizing areas. The 2019-2020 Rwanda Demographic Health Survey (DHS) revealed that 33% of children under 5 years old are stunted while 42% of women in urban areas are overweight or obese. This coexistence has contributed to a surge in non-communicable diseases (NCDs), particularly in secondary cities. Using the World Health Organization's (WHOs) "double-duty action" (DDA) concept, this study aims to identify and evaluate interventions with double-duty potential in Rwanda's Rusizi and Rubavu districts and generate key recommendations for their improvement. A desk review of national policies pinpointed four programs with the greatest DDA potential: early childhood development (ECD) centers, the school feeding program, farmer field schools (FFS), and the provision of nutrition-sensitive direct support. In-person interviews with key stakeholders assessed the implementation of each program and a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was used to generate context-specific recommendations for their improvement. The main finding of this research is that Rwanda's potential to address the DBM can be improved across multiple sectors by implementing a few key changes: targeting beliefs surrounding nutrition, improving trainings for community educators, enhancing parent-particularly father-involvement, and engaging in close monitoring and follow-up. These findings offer actionable streps that governments and nutrition stakeholders can take to improve similar interventions in other rapidly urbanizing LMICs.

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Cardiovascular disease (CVD) is the leading cause of death in the U.S. and globally. Research demonstrates that diet is a leading contributor to the development of CVD, its prevention and management, and the overall promotion of cardiovascular health. This article describes the current state of the evidence, including research on the DASH and Mediterranean diets to promote cardiovascular health and prevent CVD. The article suggests approaches to implement evidence-based diets and federal dietary guidance to promote the adoption and integration of these interventions in both community and clinical settings. It highlights the current U.S. federal interest in "Food is Medicine" and its importance in addressing diet-related chronic diseases and promoting cardiovascular health.

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OBJECTIVE: To reveal students' experiences and perspectives related to Universal School Meals (USM) under the federal coronavirus disease 2019 waivers during school years 2021-22. DESIGN: Qualitative; 17 focus groups in June-July 2022. SETTING: Virtual; students from 9 California regions in public and charter schools. PARTICIPANTS: 67 students (n = 31 in high school, n = 36 in middle school) from a racially and economically diverse sample. PHENOMENON OF INTEREST: Students' perceived benefits and drawbacks of USM. ANALYSIS: Thematic analysis using an immersion-crystallization approach. RESULTS: Students appreciated USM for increasing school meals' accessibility, promoting food security by financially supporting families, reducing the stigma associated with school meals, simplifying the payment system, and enhancing school meals convenience. An increase in school meal participation was observed. However, concerns emerged regarding a perceived decline in food quality and quantity and increased food waste. CONCLUSIONS AND IMPLICATIONS: Universal School Meals showed promise in increasing access to meals, reducing food insecurity, stigma, and increasing participation. Addressing food quality, quantity, and waste concerns is critical for its sustained success. Policymakers need to advocate for the expansion and continuous refinement of USM, prioritizing stakeholder feedback. Ensuring adequate funding to balance meal quality and quantity while minimizing waste is essential for an adequate school meal policy.

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The objective of this study was to evaluate the quality of Brazilian school meals. Cross-sectional study that used 2785 daily menus, from 557 municipalities in the country, offered between 2022 and 2024, in elementary schools. For evaluation, the Quality Index for School Meal Menus Revised was used. It was observed that the majority of menus presented intermediate quality (70.74%) and the other categories presented similar frequencies. The groups of cereals and tubers; vegetables; and fruits were the most frequent, followed by legumes; red meat; and eggs, chicken and fish. Already ultra-processed; regional foods appeared on a quarter of the menus; dairy products; candy; processed foods; and time compatibility; socio-biodiversity foods and sweet regional preparations were less frequent. This study provides an overview of Brazilian school meals with a high frequency of fresh and minimally processed foods. However, it was also possible to observe the presence of foods that are not allowed in school meals.

El objetivo de este estudio fue evaluar la calidad de la alimentación escolar brasileña. Estudio transversal que utilizó 2785 menús diarios, de 557 municipios del país, ofrecidos entre 2022 y 2024, en escuelas primarias. Para la evaluación se utilizó el Índice de Calidad de Menús de Alimentación Escolar Revisado. Se observó que la mayoría de los menús presentaron calidad intermedia (70,74%) y las demás categorías presentaron frecuencias similares. Los grupos de cereales y tubérculos; hortalizas y verduras; y las frutas fueron las más frecuentes, seguidas de las legumbres; carne roja; y huevos y carne blanca. Ya ultraprocesados; los alimentos regionales aparecían en una cuarta parte de los menús; productos lácteos; dulce; alimentos procesados; y compatibilidad horaria; fueron menos frecuentes los alimentos de sociobiodiversidad y las preparaciones dulces regionales. Este estudio ofrece una visión general de la alimentación escolar brasileña con alta frecuencia de alimentos frescos y mínimamente procesados. Sin embargo, también fue posible observar la presencia de alimentos no permitidos en la alimentación escolar.

O objetivo foi avaliar a qualidade da alimentação escolar brasileira. Estudo transversal que utilizou 2785 cardápios diários, de 557 municípios do país, ofertados de 2022 a 2024. Para avaliação foi utilizado o Índice de Qualidade para Cardápios da Alimentação Escolar Revisado. Observou-se que a maioria dos cardápios apresentou qualidade intermediária (70,74%) e as demais categorias apresentaram frequências semelhantes. Os grupos de cereais e tubérculos; legumes e verduras; e frutas foram os mais frequentes, seguidos de  leguminosas; carnes vermelhas; e ovos aves e peixes. Já ultraprocessados; alimentos regionais apareceram em um quarto dos cardápios; laticínios; doces; alimentos processados; e compatibilidade de horário; alimentos da sociobiodiversidade e preparações regionais doces foram menos frequentes. Foi possível concluir a presença de alta frequência de alimentos in natura e minimamente processados. Contudo, também observou-se a presença de alimentos que não são permitidos na alimentação escolar.

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What constitutes an enabling environment for nutrition advocacy in low- and middle-income countries? While a sizeable body of scholarship considers the enabling environment for nutrition policy, we focus specifically on the necessary conditions for advocacy. We argue that three factors-voice, access, and ownership-provide a useful lens into the advocacy enabling environment. These are operationalized, respectively, as the space to articulate and frame policy positions, entry points to interact with policy decision makers, and the existence of committed decision makers rather than those responding to pressures from external actors. These three factors are explored vis-à-vis a comparative analysis of two federal democracies-India and Nigeria-that each have vibrant advocacy communities confronting persistent malnutrition. Drawing on more than 100 structured interviews with nutrition advocates, government actors, donors, and researchers in the two countries, we highlight the ways in which voice, access, and ownership interactively shape advocacy efforts. In doing so, we find that Nigeria has a less ideological approach to certain nutrition issues than in India but also perceived to be more beholden to external actors in defining its nutrition actions. Recent restrictions on freedom of speech and association shrunk the civic space in India but these were less problematic in Nigeria. In both countries, the multi-tiered, multi-party system offers many different points of access into the policy arena, with sometimes negative implications for coordination. Overall, the paper contributes more broadly to the literature on enabling environments by highlighting potential indicators to guide nutrition advocates in other settings.

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BACKGROUND: Comprehensive school-based programs applying the WHO Health Promoting School Model have the potential to initiate and sustain behavior change and impact health. However, since they often include intervention efforts on a school's policies, physical environment, curriculum, health care and involving parents and communities, they significantly 'intrude' on a complex system that is aimed primarily at education, not health promotion. More insights into and concrete strategies are therefore needed regarding their adoption, implementation, and sustainment processes to address the challenge to sustainable implementation of HPS initiatives in a primarily educational setting. This study consequently evaluates adoption, implementation and sustainment processes of Amsterdam's Jump-in healthy nutrition HPS intervention from a multi-stakeholder perspective. METHODS: We conducted semi-structured interviews and focus groups with all involved stakeholders (n = 131), i.e., Jump-in health promotion professionals (n = 5), school principals (n = 7), at-school Jump-in coordinators (n = 7), teachers (n = 20), parents (n = 50, 9 groups) and children (n = 42, 7 groups) from 10 primary schools that enrolled in Jump-in in the school year 2016-2017. Included schools had a higher prevalence of overweight and/or obesity than the Dutch average and they were all located in Amsterdam's low-SEP neighborhoods. Data were analyzed using a directed content analysis, in which the Determinants of Innovation Model was used for obtaining theory-based predetermined codes, supplemented with new codes emerging from the data. RESULTS: During intervention adoption, all stakeholders emphasized the importance of parental support, and accompanying workshops and promotional materials. Additionally, parents and teachers indicated that a shared responsibility for children's health and nuanced framing of health messages were important. During implementation, all stakeholders needed clear guidelines and support structures. Teachers and children highlighted the importance of peer influence, social norms, and uniform application of guidelines. School staff also found further tailoring of the intervention and dealing with financial constraints important. For long-term intervention sustainment, incorporating the intervention policies into the school statutes was crucial according to health promotion professionals. CONCLUSIONS: This qualitative evaluation provides valuable insights into factors influencing the adoption, implementation, and sustainment processes of dietary interventions, such as the importance of transparent and consistent intervention guidelines, clear communication regarding the rationale behind intervention guidelines, and, stakeholders' involvement in decision-making.

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ISSUE ADDRESSED: Food environments in early childhood, such as early childhood education and care services, influence the development of dietary patterns and behaviours that traverse into adulthood, where they affect health and longevity. Nutrition policies are mandatory in early childhood education and care services in Australia and can positively or negatively shape the food environment. However, the quality of such nutrition policies is unknown. This study aimed to evaluate the comprehensiveness and strength of nutrition policies of early childhood education and care services among services participating in a university-community alliance in South East Queensland. METHODS: Early childhood education and care services (n = 12) in Nerang, Queensland, Australia, participated in a cross-sectional study evaluating the comprehensiveness and strength of nutrition policies across four domains (Nutrition Education, Nutrition Standards, Promoting Healthy Eating and Communication and Evaluation) of the Wellness in Child Care Assessment Tool. RESULTS: Nutrition policies evaluated in this study had median total comprehensiveness scores of 55 (out of 100) and median total strength scores of 19 (out of 100). 'Nutrition Education' had the highest median scores for comprehensiveness (67 out of 100) and strength (33 out of 100), while 'Nutrition Standards' had the lowest comprehensiveness score (41 out of 100), and 'Communication and Evaluation' had the lowest strength score (0 out of 100). CONCLUSIONS: All services have a nutrition policy, but there are opportunities to enhance both the content and linguistic strength of statements within policies related to nutrition domains. SO WHAT?: There is a clear need to improve the comprehensiveness and strength of written statements in nutrition policies across all four domains, particularly 'Nutrition Standards' and 'Communication and Evaluation'.

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Food security is a concept with evolving definitions and meanings, shaped by contested knowledge and changing contexts. The way in which food security is understood by governments impacts how it is addressed in public policy. This research investigates the evolution of discourses and practices in Tasmanian food and nutrition policies from 1994 to 2023. Four foundational documents were analysed using qualitative document analysis, revealing persistent food insecurity issues over three decades. The analysis identified a duality in addressing the persistent policy challenges of nutrition-related health issues and food insecurity: the balancing act between advancing public health improvements and safeguarding Tasmania's economy. The research revealed that from 1994 to 2023, Tasmania's food and nutrition policies and strategies have been characterised by various transitions and tensions. Traditional approaches, predominantly emphasising food availability and, to a limited extent, access, have persisted for over thirty years. The transition towards a more contemporary approach to food security, incorporating dimensions of utilisation, stability, sustainability, and agency, has been markedly slow, indicating systemic inertia. This points to an opportunity for future policy evolution, to move towards a dynamic and comprehensive approach. Such an approach would move beyond the narrow focus of food availability to address the complex multi-dimensional nature of food security.

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Introduction: Ordering from kids' menus and children's restaurant consumption is associated with greater purchasing and intake, respectively, of sugar-sweetened beverages. In response, policymakers have enacted strategies to improve the healthfulness of kids' meal offerings. This study investigated restaurant kids' meal beverage offerings and compliance with an Illinois healthy beverage default act, effective from January 1, 2022. Methods: Using a pre-post intervention (Illinois)-comparison (Wisconsin) site research design, fast-food restaurant audit data were collected before and 1 year after the Illinois Healthy Beverage Default Act from 6 platforms: restaurant interior and drive-thru menu boards and websites/applications and 3 third-party ordering platforms (DoorDash, Uber Eats, and Grubhub). Analyses included 62-110 restaurants across platforms. Difference-in-differences-weighted logistic regression models with robust SEs, clustered on restaurants, were estimated to assess pre to 1-year postpolicy changes in overall compliance for each audit setting in Illinois relative to that in Wisconsin. Results: This study found no statistically significant (p<0.05) changes in the compliance of kids' meal beverage default offerings associated with the enactment of the Illinois Healthy Beverage Default Act in Illinois relative to that in Wisconsin at fast-food restaurants. There were some observed differences in results in the restaurants' physical locations versus online that are worth noting. That is, after the enactment of the Illinois Healthy Beverage Default Act, the results showed greater odds of fast-food restaurants exclusively offering healthy beverage defaults with kids' meals on restaurant interior (OR=1.83, 95% CI=0.93, 3.58) and drive-thru (OR=2.38, 95% CI=0.95, 5.96) menus, with weak statistical significance (p<0.10). However, the policy was not associated with either meaningful or statistically significant changes in healthy beverage default offerings on restaurant websites or third-party online ordering platforms. Conclusions: This study found limited evidence of changes in kids' meal beverage offerings attributable to the Illinois Healthy Beverage Default Act. Future investigations of communication channels that support awareness and implementation and the resources required for implementation and enforcement may provide insight that is key to improving compliance.

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OBJECTIVE: It is unknown how well menu labelling schemes that enforce the display of kilojoule (kJ) labelling at point-of-sale have been implemented on online food delivery (OFD) services in Australia. This study aimed to examine the prevalence of kJ labelling on the online menus of large food outlets with more than twenty locations in the state or fifty locations nationally. A secondary aim was to evaluate the nutritional quality of menu items on OFD from mid-sized outlets that have fewer locations than what is specified in the current scheme. DESIGN: Cross-sectional analysis. Prevalence of kJ labelling by large food outlets on OFD from August to September 2022 was examined. Proportion of discretionary ('junk food') items on menus from mid-sized outlets was assessed. SETTING: Forty-three unique large food outlets on company (e.g. MyMacca's) and third party OFD (Uber Eats, Menulog, Deliveroo) within Sydney, Australia. Ninety-two mid-sized food outlets were analysed. PARTICIPANTS: N/A. RESULTS: On company OFD apps, 35 % (7/23) had complete kJ labelling for each menu item. In comparison, only 4·8 % (2/42), 5·3 % (2/38) and 3·6 % (1/28) of large outlets on Uber Eats, Menulog and Deliveroo had complete kJ labelling at all locations, respectively. Over three-quarters, 76·3 % (345/452) of menu items from mid-sized outlets were classified as discretionary. CONCLUSIONS: Kilojoule labelling was absent or incomplete on a high proportion of online menus. Mid-sized outlets have abundant discretionary choices and yet escape criteria for mandatory menu labelling laws. Our findings show the need to further monitor the implementation of nutrition policies on OFD.

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