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Texas Nutrition Environment Assessment (TxNEA-R) Tool Strategies

Effective Strategies for Making Healthy Choices Easier When Eating Out

Children and adults regularly eat out, and these food and beverage choices affect their health and businesses in the community. The following strategies have been effective in helping customers make healthy choices when eating out and helping foodservice operators improve their business. Public health practitioners and foodservice operators can use the following information to make an informed decision when working together to make healthy choices easier in a variety of foodservice settings. 

Foods prepared away from home are higher in sodium compared to foods prepared at home (1). This resource describes strategies to reduce sodium in prepared foods:  Restaurant Guide: Cut the Sodium but Keep the Flavor.

  1. Healthy Carry-Outs
  2. Healthy messaging and price decrease
  3. Promoting Healthy Options
  4. Healthy Options Program
  5. SmartMenu Program
  6. Smart Choices Healthy
  7. Chinese Take-Out Initiative
  8. Point-of-Purchase Health Messaging 

1. Healthy Carry-Outs (2, 3)

Healthy Carry-Outs menu with healthy items labeled.

Setting
Carry-outs in low-income areas of Baltimore, Maryland

Description

Phase 1: Menu revision & labeling

  • Identified healthier items using a nutrition standard and green leaf symbol
  • Promoted 3 healthier options with a photo on the menu
  • Placed point-of-purchase posters that promoted healthier options placed throughout the carry-outs

Phase 2: Healthy sides and beverages

  • Added healthy sides and beverages
  • Provided initial stock to remove risk from restaurant owner
  • Placed POP posters with healthy sides and beverages

Phase 3: Affordable healthy combo meals

  • Made new reduced-price combos with new healthy entrée
  • Conducted taste tests with customers on new entrees
  • Provided subsidies to owners in case of a decrease in profit

    Point-of-purchase posters showed affordable healthy combo meals

Outcomes

  • Total revenue was significantly greater in all phases compared to the control group.
  • Total units sold was the same between intervention and comparison carry-outs.
  • The number of customers increased by 36.8% in the intervention carry-outs compared to 1.2% increase in control carry-outs.
  • Customers said they purchased specific foods because of a photo on a menu board (65.3%) or because of menu labeling (42.6%).  
  • Menu boards and labels were seen by 100% and 84.2% of customers, respectively.
  • Posters were seen 55%, 35%, and 55% of the time.

Keys to Success

  • Developing rapport with carry-out owners was very important.
  • Phases started with little obligation from owners. 
  • Maintaining communication with owners and incorporating their ideas for intervention strategy development and enhanced commitment was very important. 

Resources

This Process evaluation report includes implementation steps and suggestions for improvement.

Photos


2. Healthy messaging and price decreases  (4)

Setting

Deli-style restaurant in a business district with substantial base of repeat customers 

Description

Phase 1: Price decrease only
Phase 2: Health-message intervention
Phase 3: Combination health-message and price decrease interventions

  • Gain-framed and loss-framed messages on posters using target items (Ex: “Healthy eating increases physical and mental well-being. The Mill offers these and other healthy choices.”)
  • Decrease prices of healthy items by 20-30%
  • Advertised price decreases on chalkboard menu and board at entry

Outcomes:

Compared to control items, the number of healthier items sold were significantly higher and increased during the promotion, pricing, and combo specials.  

Keys to Success:

The price decrease and combination of health-message and pricing interventions produced the strongest increase in the number sold.


3. Promoting Healthy Options (5)

TXNEA image- Catering Menu

Setting

Family-style chain restaurants in Northern California

Description:

  • Placed red hearts on menus next to low-fat and low-cholesterol items
  • Sign below menu board explained that entrees with heart symbol were low in fat and cholesterol.
  • Displayed tip sheets displayed next to cashier which had more information about heart labels and more nutrition tips to make the entire meal low in fat and cholesterol.

Outcome

  • The proportion of targeted entrees sold significantly increased in 2 restaurants. 
  • No change in proportion of targeted entrees sold in other 2 restaurants.
  • ~1/4 of patrons selected a heart healthy entrée. Heart labels were well understood. 

Keys to Success

  • Women and patrons over 50 were more likely to engage in the intervention.
  • Monitor appropriate use of labels to make sure only the healthier items are labeled.

Resources:

¡Por Vida! is a similar intervention in Texas.


4.  Healthy Options Program (6)

Healthy Options Program menu of healthy options

Setting

Owner-operated full-service restaurants in rural Iowa 

Description

  • Plastic signs at tables listed healthy options and ways orders could be adjusted (ex: smaller portion, bake/broil meat, toppings on side).
  • Laminated sign-in entryway or front window stating, “Ask about our healthy menu options.”
  • Local newspaper press release Owners voluntarily added healthier options after positive customer feedback. 

Outcome

  • 34% of customers who noticed the signs said that it affected their order.
  • Owners reported no concerns that the program would cause financial losses.
  • Customers appreciated the program. 

Keys to Success

Those who were trying to lose weight, change fat intake, or change salt intake were more likely to say that seeing the signs changed their order.

Resources

Healthy Options Program Toolkit



5. SmartMenu Program (7, 8)

SmartMenu Program item labeled with nutrition information

Setting

Local restaurants in Pierce County, Washington

Description

  • Restaurant recipes were analyzed and restaurants agreed to post nutrition information on new menus.
  • Some restaurants made changes to their menus by adding healthy options, substituting recipe ingredients, and reducing portion sizes. New menu items were reanalyzed.
  • After the menu labeling, entrees had an average decrease of 15 calories, 1.5 grams of fat, and 45 mg sodium.
  • Health Department provided free promotion: ads in community newsletters, local newspapers, and on their website. Provided plaque, window clings, pens, and buttons to each restaurant.

Outcome

  • 20% of customers chose an entrée lower in calories because of seeing the nutrition information.
  • 33% of customers used nutrition information to change any behavior, including choosing an entrée lower in fat (16%), calories (20%), carbohydrates (9%), sodium (8%), and sharing or not finishing a meal (6%).
  • 71% of customers noticed the menu labeling.

Keys to Success

  • Customers 45 years old and younger were more likely to notice the nutrition information.
  • Men and women were equally likely to notice the nutrition information.

Resources

Description of SmartMenu Implementation (See Strategies on pp. 19-22)



6. Smart Choices (9)

Smart Choices concession stand menu

Setting

Concession stand of large high school in Muscatine, Iowa 

Description

  • Introduced and prominently displayed new healthier foods.
  • Priced new items based on lowest profitable price. Increased price of candy bars.
  • Modified foods to decrease saturated fat and trans fat. Replaced coconut oil with canola oil for popcorn. Replaced nacho cheese sauce with a trans-fat free sauce. 

Outcome

  • Increased average sales per varsity football game by 4%
  • Combined profit margin of nachos and popcorn increased from $1.19 to $1.28 (7.6% increase). 
  • Modified items generated 25.5% of yearly revenue. New healthier items accounted for 9.5% of yearly revenue.
  • Average profit margin was $1.01 for standard items and $.78 for healthier new items.
  • Student overall satisfaction stayed the same. Increased parent overall satisfaction.
  • Increased student satisfaction with healthy foods offered. 

Keys to Success

Research was done as a partnership between the parent booster organization and a research team from a public university.

Resources:

Eight Steps Implementation Guide


7.  Healthy Chinese Take-Out Initiative (10)

Healthy-Chinese-TakeOut-Initiative-image

Setting

Chinese take-out restaurants in high-poverty areas with large African American and Hispanic populations in Philadelphia, Pennsylvania

Description

  • Reduced the amount of sauce by half
  • Used standardized measuring tool for sauces
  • Used low sodium ingredients Used fresh vs. canned produce
  • Used non-salt ingredients to add flavor (garlic, ginger, chiles, etc.)
  • Avoided using table salt while cooking Distributed soy sauce packets on request only
  • Reduced the sodium by 20% for two most common dishes

Outcome

  • Over 90% of customers said they would purchase the dish after the taste test.
  • 52% of chefs/owners said it was easy to make low-salt changes.
  • 37% of chefs/owners agree and 39% were neutral with the statement that customers respond favorably to low-salt changes.
  • Overall taste for each of the 3 modified dishes ranged from 4.36 to 4.73 out of 5.

Keys to Success

  • There are over 400 Chinese take-out restaurants in Philadelphia. Offered 2 rounds of trainings with the Culinary Institute of America on 3 different days that worked for owners.
  • Trainings and materials were offered in Chinese. For some owners this was the first type of formal training they received.

Resources

Salt Reduction Resources
Pictures and videos of training and intervention
Restaurant Guide: Cut the Sodium but Keep the Flavor


8. Point-of-Purchase Health Messaging (11)

Menu insert with entree salads

Setting:

Café-style restaurant in small town in the Netherlands

Description:

  • Dinner menus included a plastic sheet with special offer of entrée salads.
  • Description of salads were supplemented by reminder messages like, “low in calories,” “calorie-conscious,” and “Are you watching your weight?” 

Outcome:

  • Chronic and current dieters increased choices for low-calorie foods; other customers were unaffected.
  • Almost half of dieters made a healthy menu choice when the reminder messages were used.


References 

  1. Mancino L, Todd J, Guthrie J, Lin B. How Food Away From Home Affects Children's Diet Quality.https://www.ers.usda.gov/webdocs/publications/err104/8129_err104_reportsummary_1_.pdf. U.S. Dept. of Agriculture, Econ. Res. Serv.; 2010. Report No.: 104.
  2. Lee-Kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, et al. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health. 2013 08;13(1):1-9.
  3. Lee-Kwan S, Bleich SN, Kim H, Colantuoni E, Gittelsohn J. Environmental Intervention in Carryout Restaurants Increases Sales of Healthy Menu Items in a Low-Income Urban Setting. Am J Health Promot. 2015 07/20;29(6):357-64.
  4. Horgen KB, Brownell KD. Comparison of price change and health message interventions in promoting healthy food choices. Health Psychol. 2002 09;21(5):505-12.
  5. Albright CL, Flora JA, Fortmann SP. Restaurant menu labeling: impact of nutrition information on entree sales and patron attitudes. Health Educ Q. 1990 90;17(2):157-67.
  6. Nothwehr FK, Snetselaar L, Dawson J, Schultz U. Promoting healthy choices in non-chain restaurants: effects of a simple cue to customers. Health Promot Pract. 2013 01;14(1):132-8.
  7. Pulos E, Leng K. Evaluation of a voluntary menu-labeling program in full-service restaurants. Am J Public Health. 2010 06;100(6):1035-9.
  8. Britt JW, Frandsen K, Leng K, Evans D, Pulos E. Feasibility of voluntary menu labeling among locally owned restaurants. Health Promot Pract. 2011 01;12(1):18-24.
  9. Laroche HH, Ford C, Hansen K, Cai X, Just DR, Hanks AS, et al. Concession stand makeovers: a pilot study of offering healthy foods at high school concession stands. J Public Health (Oxf). 2015 03;37(1):116-24.
  10. Ma GX, Shive S, Zhang Y, Aquilante J, Tan Y, Zhao M, et al. Knowledge, Perceptions, and Behaviors Related to Salt Use Among Philadelphia Chinese Take-Out Restaurant Owners and Chefs. Health Promotion Practice. 2014 09;15(5):638-45.
  11. Papies EK, Veling H. Healthy dining. Subtle diet reminders at the point of purchase increase low-calorie food choices among both chronic and current dieters. Appetite. 2013 02;61:1-7.

    The following literature reviews were used to identify evidence-based interventions: 
  • Valdivia Espino JN, Guerrero N, Rhoads N, Simon N, Escaron AL, Meinen A, et al. Community-Based Restaurant Interventions to Promote Healthy Eating: A Systematic Review. Prev Chronic Dis 2015; 12:140455. DOI: http://dx.doi.org/10.5888/pcd12.140455
  • Gittelsohn J, Lee-Kwan S, Batorsky B. Community-Based Interventions in Prepared Food Sources: A Systematic Review. Prev Chronic Dis 2013;10:130073. DOI: http://dx.doi.org/10.5888/pcd10.130073


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Last updated August 15, 2018