Reinventing health promotion for healthy default beverage laws in the face of COVID-19

COVID-19 impacts on restaurants

The COVID-19 pandemic has transformed the way people socialize, work, and eat. Restaurants, the focus of HDB laws, have been particularly challenged by virus containment measures. In Hawai‘i, an emergency proclamation required physical distancing and ordered people to stay home, halting all ‘non-essential’ business, and deeming only restaurants ‘that prepare food for consumption off-premises’ as ‘essential’ (8). Fast-food restaurants that already prepared food for drive-through or carry-out continued operations, while other restaurant types sought to change practices or closed. Restaurants remaining open needed to modify employee procedures to prevent viral spread. Additionally, restaurants without online platforms needed to develop websites or engage third-party services (e.g., Uber Eats) to facilitate take-out and delivery, which increased in demand with stay-at-home orders.

Economic shutdowns have resulted in major declines in restaurants’ customer numbers and revenues (9). High unemployment rates (10) have eliminated many customers’ disposable incomes and exposure concerns kept customers home even when they could afford to eat out. To reopen, restaurants had to navigate new restrictions and address customer concerns about the safety of dining out (11). Current guidelines require six feet between tables (12), which, for many restaurants, has resulted in reduced seating capacity and lost revenue. Although third-party services have facilitated business, they include substantial fees, affecting restaurants’ already diminished profits (13). COVID-19 impacts on restaurants will require adaptations to HDB law implementation and enforcement.

COVID-19 impacts on healthy eating

As in many locations, the perceived high cost of healthy foods was already a barrier to healthy eating (14). Many with low incomes also have household food insecurity, defined as reduced ability to access quality foods or food generally, due to limited funds and other factors (15). The economic repercussions of COVID-19 containment efforts have exacerbated these preexisting challenges with eating healthfully. Panicked hoarding left grocery shelves devoid of low-cost items, and foods typically donated to food banks were stockpiled, creating donation shortages (16). Additionally, ‘essential business’ definitions unintentionally favored fast-food restaurants, who already offered carry-out and drive-through services. Consequently, access to fast-food restaurants, with their high-calorie, low-cost foods, has remained high, especially in low-income and racially/ethnically diverse communities, which have higher fast-food density than other communities (17). At a time when healthful eating can be challenging for many, and chronic diseases magnify COVID-19 effects (18), promoting healthful food environments and default options is critical.

Health promotion and HDB law challenges

New restaurant practices and reduced revenues resulting from COVID-19 have raised logistic challenges for HDB implementation and enforcement, predominantly around increased ordering from websites, apps, and third-party services, and restaurant decisions to comply with the law. Compliance guidelines indicate that all in-store and online menus need to list an HDB. However, online menus do not always accurately reflect what is offered inside restaurants (19). Also, the law allows restaurants to offer alternative beverages, but indicates that restaurants must first offer healthy options, and wait for a request before offering unhealthy options. Restaurants with self-ordering kiosks have complied with this regulation by creating layers of choices. Customers are presented with HDB options first, and must click forward to see additional options. Third-party services do not have layers; they indicate all beverage options for children’s meals simultaneously, which effectively circumvents the law.

It is unclear if third-party services fall under the scope of HDB laws, as these services are not offering the children’s meals; they are only facilitating ordering or delivery. Additionally, during the pandemic, restaurants have complained that some third-party services are establishing unauthorized websites with inaccurate information (13), which makes HDB law enforcement challenging. HDB laws need to clarify if third-party services are under their purview and how enforcement will be handled.

Prior to COVID-19, restaurant executives reported reticence to change children’s items because children’s meals were not high revenue sources (20). One study found that a regional restaurant chain successfully added healthy default options to their children’s menus without losing revenue; however, this was done through increasing meal prices (21). This may be unappealing to restaurants during an economic recession. Also, before the pandemic, it was recognized that restaurants might unbundle their children’s meals, selling beverages and entrées separately, to avoid the law. Restaurants’ decisions to comply with the law are more complex post-COVID-19. HDB implementation will be most effective if done in partnership with restaurants to reduce impacts on profits.

Health promotion efforts generally will also be challenged by the pandemic. Local governments are facing significant budget shortfalls, which will impact funding for health and social services (22). Globally, public health and healthcare resources for chronic disease have been directed toward addressing the immediate infectious disease crisis, which is anticipated to exacerbate chronic disease (23). Additionally, the economic recession has differentially impacted low-wage workers and people of color (24), populations that already faced higher rates of chronic disease and food insecurity prior to the pandemic (25). Health and economic disparities are also likely to increase post-COVID-19.

Health promotion opportunities

Despite these challenges, COVID-19 has created several unanticipated opportunities for reducing SSB consumption and promoting healthy eating. Reopening guidance recommends restaurants assign a staff member to fill beverages at the self-service beverage station (26) or discontinue their use altogether to mitigate viral spread (12). These changes would make refilling SSBs onerous and could reduce consumption. Guidelines also recommend technology be a part of restaurants’ recovery toolkits (27). As electronic menus, tableside app-ordering, and self-order kiosks replace paper menus and staff contact, guidance for online content and prompts will be needed to ensure compliance in virtual domains. However, if technology is standardized, it could improve how HDBs are offered at the point-of-sale by mitigating discrepancies between written menus and staff’s verbal offerings (19).

The global economic recession resulting from the pandemic has also opened a policy window for SSB fees, which can lower SSB consumption while generating revenue for governments to support vulnerable communities most impacted by COVID-19. For example, San Francisco, California, has used US$1.65m of their SSB fee revenues to ensure fresh produce is accessible to those facing food insecurity during the pandemic (28) and Seattle, Washington, has allocated a portion of their fee proceeds to fund a grocery voucher program for low-income families (29). This crisis has created a unique opportunity for Hawai‘i and governments globally to garner support for an SSB fee to both reduce SSB consumption and to invest in programs that reduce chronic disease and health disparities.

COVID-19 may create other health promotion opportunities. In recent years, health has been a priority for many US consumers (30); some in the restaurant industry predict this trend will continue after the pandemic (31). If restaurant and beverage industries are interested in capturing the healthy eating market, there may be opportunities for government–business partnerships to promote healthy eating (32). Public health practitioners could collaborate with local businesses to develop and promote low-sugar beverages or healthy grab-and-go meal options. The public’s focus on health due to COVID-19 could also aid health promotion and behavior change efforts. Media campaigns may gain traction if messages about the importance of losing weight, and managing and preventing diabetes and heart disease are framed around reducing the risk of negative outcomes from COVID-19. Recognizing the necessity in highlighting this connection, US health departments have already started pivoting their chronic disease messaging in conjunction with COVID-19 (33). In the austere post-COVID-19 times, it will be critical to continue to capitalize on synergistic opportunities and use creative solutions to promote health and healthful eating.

Conclusion

The COVID-19 pandemic has created significant challenges for HDB implementation and enforcement, and healthy eating in general, while highlighting the importance of policies that improve access to healthy foods to prevent and manage chronic disease. Understanding the new landscape created by COVID-19 can lead to improved design and implementation of HDB laws, and to novel opportunities to promote healthy food environments.