According to our findings, nutrition information was not available for most combo meals offered targeting children. The few that did have information, the nutrition quality was not optimal according to U.S. nutrition standards . Furthermore, fast food chains are using toy giveaways that may promote less healthy combo meals to children. Comprehensive approaches are needed to improve access to healthy options within fast food restaurants and make these more desirable to children.
Marketing strategies found in our study (i.e., toy giveaways, time to delivery, price incentives, and health claims) are widely used by fast food chains [8, 21]. Basch et al.  found that these promoted reduced cost combo meals with high sugar, sodium, and fat content. Given that fast food combo meals with a poor nutritional content contribute to the increase of childhood obesity , restrictions are needed to ensure that nutrient quality of children’s fast food combo meals meet healthy guidelines. For instance, Guatemala could implement a policy that requires additional fruit and vegetable options for combo meal side dishes and low-fat milk as the first beverage alternative. To increase uptake, these could be offered as the default option rather than french fries and a soft drink. This would likely improve combo meal nutritional quality.
Fast food restaurants offer combo meals as an efficient and convenient way to purchase a meal. According to our findings, chains in Guatemala (and most likely elsewhere) offer meal items that are less expensive and served faster when they are purchased in a combo meal rather than separately. This suggests restaurants are using combo meals to offer more food for lower prices, promoting consumption and therefore higher energy intake.
Menu labeling is now being explored as a strategy to reduce calorie consumption. In 2008, the Board of Health of the New York City Department of Health and Mental Hygiene implemented regulations mandating chain restaurants to include calorie information on menus . Other U.S. cities and states have since tried to implement similar policies [24, 25], and the Patient Protection and Affordable Care Act (ACA) requires menu labeling at all restaurant chains with 20 or more locations nationally [26, 27]. Guatemalan fast food chains did not include calorie information on their menus and we found personnel were evasive when asked for nutrition information. Therefore, we were unable to obtain data for most of the combo meals we found. Mandatory menu labeling is a promising strategy providing consumers with knowledge  and improving the nutrient content of fast food combo meals since it could encourage restaurants to reformulate their products to offer healthier options. Rationale in favor of menu labeling is grounded in considerable evidence and unintended consequences are unlikely . The Guatemalan Ministry of Health should support policies requiring fast food chains to provide nutrition information at the point of sale and on menus in order to support the selection of healthier options. Furthermore, this information needs to be presented in a way that is easy to understand for consumers regardless of literacy level.
Consumption of nutrient poor foods, such as fast food combo meals, promoted by toy giveaways is likely one of the contributing factors to the observed increase in childhood obesity . Children’s combo meals found in our study included a toy and those that had nutrition information failed to meet nutrition standards proposed by the IOM and in California. Guatemala lacks regulation to improve the nutritional quality of children’s combo meals. However, restricting toy giveaways to children’s combo meals that meet established nutrition standards is likely to encourage healthier combo meal selections [8, 31].
Health claims create a “halo” effect over food, preventing consumers from seeking further nutrition information . Likewise, consumers also draw inferences about the nutritional quality of food with health claims on the package or combo meal . The food industry, however, is not the only industry using claims as a marketing strategy. The tobacco industry uses terms like “light” and “smooth” to give the impression that cigarettes are less harmful . Our results yield that most combo meals included in our study had health claims, even though they were all classified by our analysis as ‘less healthy’. Therefore, nutrient content or nutritional quality should be required in order to include health claims in children’s fast food combo meals to guarantee accuracy and avoid misleading marketing.
Our study has strengths and limitations. To the best of our knowledge this is the first study to document the prevalence, marketing strategies, and nutritional quality of children fast food combo meals in a LMIC. In addition, we surveyed local and international fast food chains. However, we only included children combo meals and therefore our findings are not generalizable to all combo meals available at fast food chains. In addition, we did not evaluate how these strategies influence purchasing decisions in Guatemala.