Progress Evaluation for the Restaurant Industry Assessed by a Voluntary Marketing-Mix and Choice-Architecture Framework That Offers Strategies to Nudge American Customers toward Healthy Food Environments, 2006-2017

Position statement on nutrition therapy for overweight and obesity: nutrition department of the Brazilian association for the study of obesity and metabolic syndrome (ABESO-2022)

Obesity is a chronic disease resulting from multifactorial causes mainly related to lifestyle (sedentary lifestyle, inadequate eating habits) and to other conditions such as genetic, hereditary, psychological, cultural, and ethnic factors. The weight loss process is slow and complex, and involves lifestyle changes with an emphasis on nutritional therapy, physical activity practice, psychological interventions, and pharmacological or surgical treatment. Because the management of obesity is a long-term process, it is essential that the nutritional treatment contributes to the maintenance of the individual's global health. The main diet-related causes associated with excess weight are the high consumption of ultraprocessed foods, which are high in fats, sugars, and have high energy density; increased portion sizes; and low intake of fruits, vegetables, and grains. In addition, some situations negatively interfere with the weight loss process, such as fad diets that involve the belief in superfoods, the use of teas and phytotherapics, or even the avoidance of certain food groups, as has currently been the case for foods that are sources of carbohydrates. Individuals with obesity are often exposed to fad diets and, on a recurring basis, adhere to proposals with promises of quick solutions, which are not supported by the scientific literature. The adoption of a dietary pattern combining foods such as grains, lean meats, low-fat dairy, fruits, and vegetables, associated with an energy deficit, is the nutritional treatment recommended by the main international guidelines. Moreover, an emphasis on behavioral aspects including motivational interviewing and the encouragement for the individual to develop skills will contribute to achieve and maintain a healthy weight. Therefore, this Position Statement was prepared based on the analysis of the main randomized controlled studies and meta-analyses that tested different nutrition interventions for weight loss. Topics in the frontier of knowledge such as gut microbiota, inflammation, and nutritional genomics, as well as the processes involved in weight regain, were included in this document. This Position Statement was prepared by the Nutrition Department of the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO), with the collaboration of dietitians from research and clinical fields with an emphasis on strategies for weight loss.

Fast-Food Optimal Defaults Reduce Calories Ordered, as Well as Dietary Autonomy: A Scenario-Based Experiment

BACKGROUND

Low-calorie menu items as optimal defaults may encourage healthier choices when people eat out. Limited research has studied default effects from the restauranteurs' perspective, as well as the public health perspective.

OBJECTIVE

To examine the effects of optimal defaults on calories ordered, dietary autonomy, and visit intention in the context of a fast-food drive-through.

DESIGN

Between-subjects randomized scenario-based experiment.

PARTICIPANTS/SETTING

In all, 377 adults who lived in the United States were recruited through a crowdsourcing platform in July 2020.

INTERVENTION

Participants were asked to visualize ordering a combo meal in a fast-food drive-through. They were randomly assigned to order from 1 of 3 menu boards: (1) menu items available for combos by customer choice, (2) combos that included traditional high-calorie default items, or (3) combos that included low-calorie optimal defaults.

MAIN OUTCOME MEASURES

Differences in calories ordered among groups, dietary autonomy, and restaurant visit intention.

ANALYSIS

Statistical tests included multiple regression, Kruskal-Wallis, χ², and 1-way analysis of variance. Covariates such as education and sex were tested in regression models as potential confounders.

RESULTS

Compared with the choice combo meals, optimal combo meals reduced calories ordered by consumers (-337 kcal, standard error = 19, P < .001), while traditional combos increased them (+132 kcal, standard error = 20, P < .001). No significant difference was found in visit intention. Dietary autonomy was affected by the optimal defaults (P = .025), even in participants with high health concern. Conversely, the traditional combo's effect on dietary autonomy was moderated by health concern (B = -0.26, P = .023), with only individuals with very high levels of health concern perceiving less autonomy.

CONCLUSIONS

Optimal defaults provided a robust reduction in calories ordered but had implications for dietary autonomy.

Visual Cues and Optimal Defaults in Fast-Food Combo Meals Benefit Health-Concerned Consumers-A Randomized Scenario-Based Experiment

BACKGROUND

The use of low-calorie menu items as optimal defaults and visual cues may nudge consumers to healthier choices at restaurants. However, little is known regarding their effects on emotions and behavioral intentions, particularly among people with different levels of health concern.

OBJECTIVE

Evaluate optimal defaults and visual cues' effect on anticipated pleasure and order intention depending upon consumers' health concern level.

DESIGN

Between-subjects randomized scenario-based experiment.

PARTICIPANTS/SETTING

In all, 636 US adults recruited through an online crowdsourcing platform in July 2020.

INTERVENTION

Participants saw 1 of 6 menu boards in a fast-food drive-through simulation. Half the menu boards included meal photos with (1) menu items to be arranged as a combo by choice (ie, create-your-own combo); (2) traditional combos that included high-calorie default items; or (3) optimal combos that included low-calorie default items. The remaining 3 boards were identical without photos.

MAIN OUTCOME MEASURES

Anticipated pleasure, order intention, and health concern were evaluated with 7-point Likert scales.

ANALYSIS

Statistical tests included multiple regression, Kruskal-Wallis, χ², and analysis of variance. Education and sex were tested as potential confounders.

RESULTS

Optimal combos negatively affected anticipated pleasure (P = .003) and order intention (P < .001) compared with choice combos. Order intention reduction was the same for traditional and optimal combos (P = .128). The presence of photos changed order intention for optimal combos but varied by consumer's health concern level. When health concern was lower, photos decreased the likelihood of ordering the optimal combos (B = -3.06, P = .001), but when health concern was higher, photos enhanced ordering intention compared with the choice group (B = 0.60, P = .001). The photos did not affect anticipated pleasure for any level of health concern.

CONCLUSIONS

The adverse effect of optimal defaults and how visual cues may reduce their negative effect should be considered in menu design.

Use of artificial intelligence to enable dark nudges by transnational food and beverage companies: analysis of company documents

OBJECTIVE

To describe the use of artificial intelligence (AI)-enabled dark nudges by leading global food and beverage companies to influence consumer behaviour.

DESIGN

The five most recent annual reports (ranging from 2014-2018 or 2015-2019, depending on the company) and websites from 12 of the leading companies in the global food and beverage industry were reviewed to identify uses of AI and emerging technologies to influence consumer behaviour. Uses of AI and emerging technologies were categorised according to the Typology of Interventions in Proximal Physical Micro-Environments (TIPPME) framework, a tool for categorising and describing nudge-type behaviour change interventions (which has also previously been used to describe dark nudge-type approaches used by the alcohol industry).

SETTING

Not applicable.

PARTICIPANTS

12 leading companies in the global food and beverage industry.

RESULTS

Text was extracted from 56 documents from 11 companies. AI-enabled dark nudges used by food and beverage companies included those that altered products and objects' availability (e.g., social listening to inform product development), position (e.g., decision technology and facial recognition to manipulate the position of products on menu boards), functionality (e.g., decision technology to prompt further purchases based on current selections) and presentation (e.g., augmented or virtual reality to deliver engaging and immersive marketing).

CONCLUSIONS

Public health practitioners and policymakers must understand and engage with these technologies and tactics if they are to counter industry promotion of products harmful to health, particularly as investment by the industry in AI and other emerging technologies suggests their use will continue to grow.

Examining demographic characteristics and food access indicators from the location of vegan soul food restaurants in the south

Objective: There have been a number of soul food restaurants serving exclusively vegan meals opening up across the country to appeal to African Americans and others interested in eating healthier soul foods. This study determined the number of restaurants serving vegan soul foods in the South and identified the locations of these restaurants in order to understand the characteristics of the surrounding communities that they serve.Design: Two reviewers identified restaurants using standardized search criteria for menu items in the 16 states (and the District of Columbia) that are categorized as being in the South from the Census Bureau. Mean percentage of African Americans, poverty rates, and obesity rates by county where restaurants were located were collected via census data. Restaurants were classified as being in or out of a food desert zone using the United States Department of Agriculture's (USDA) food atlas map (0.5- and 1.0-mile radius). T-tests were conducted to test for differences in the census data between the restaurants that were considered to be in and out of a food desert zone.Results: Overall, 45 restaurants met the inclusion criteria. Counties where restaurants were located had a mean African American population of 36.5 ± 18.5%, mean poverty rate of 15.5 ± 3.85% and mean obesity rate of 26.8 ± 4.8%. More than one third (n = 18, 40.0%) of the restaurants were considered to be in a food desert zone. There were no significant differences in the mean population, obesity, and poverty rates between restaurants classified in a food desert zone and restaurants not located in a food desert zone.Conclusion: A significant number of restaurants were classified in food desert zones, implying their potential to provide healthier meals by serving vegan soul foods to residents in the surrounding neighborhoods. Future work should assess how these restaurants might influence healthier eating habits in their communities.

Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews

The aim of this systematic review of reviews was to synthesise the evidence on factors influencing the implementation, sustainability and scalability of food retail interventions to improve the healthiness of food purchased by consumers. A search strategy to identify reviews published up until June 2020 was applied to four databases. The Risk of Bias in Systematic Review tool was used. Review findings were synthesised narratively using the socio-ecological model. A total of 25 reviews met the inclusion criteria. A number of factors influenced implementation; these included retailers' and consumers' knowledge and preferences regarding healthy food; establishing trust and relationships; perceived consumer demand for healthy food; profitability; store infrastructure; organizational support, including resources; and enabling policies that promote health. Few reviews reported on factors influencing sustainability or scalability of the interventions. While there is a large and rapidly growing body of evidence on factors influencing implementation of interventions, more work is needed to identify factors associated with their sustainability and scalability. These findings can be used to develop implementation strategies that consider the multiple levels of influence (individual, intrapersonal and environmental) to better support implementation of healthy food retail interventions.

Limited implementation of California's Healthy Default Beverage law for children's meals sold online

OBJECTIVE

To reduce children's sugar-sweetened beverage intake, California's Healthy-By-Default Beverage law (SB1192) mandates only unflavoured dairy/non-dairy milk or water be the default drinks with restaurant children's meals. The objective of this study is to examine consistency with this law for meals sold through online platforms from restaurants in low-income California neighbourhoods.

DESIGN

This observational, cross-sectional study examines beverage availability, upcharges (additional cost) and presentation of beverage options consistent with SB1192 (using four increasingly restrictive criteria) within a random sample of quick-service restaurants (QSR) in Supplemental Nutrition Assistance Program Education eligible census tracts selling children's meals online from November 2020 to April 2021.

SETTING

Low-income California neighbourhoods (n 226 census tracts).

PARTICIPANTS

QSR that sold children's meals online via a restaurant-specific platform, DoorDash, GrubHub and/or UberEats (n 631 observations from 254 QSR).

RESULTS

Seventy percent of observations offered water; 63 % offered unflavoured milk. Among all beverages, water was most likely to have an upcharge; among observations offering water (n 445), 41 % had an upcharge (average $0·51). Among observations offering unflavoured milk (n 396), 11 % had an upcharge (average $0·38). No observations upcharged for soda (regular or diet). Implementation consistency with SB1192 ranged from 40·5 % (using the least restrictive criteria) to 5·6 % (most restrictive) of observations.

CONCLUSIONS

Based on observations from restaurant websites and three of the most popular online ordering platforms, most California QSR located in low-income neighbourhoods are not offering children's meal beverages consistent with the state's Healthy-By-Default Beverage law. As the popularity of online ordering increases, further work to ensure restaurants offering healthy default beverages with children's meals sold online is necessary.

Post-Secondary Food Service Manager Perspectives on Fruit and Vegetable Nudging Strategies: Qualitative Study

BACKGROUND

Changing the choice architecture in post-secondary food service contexts to "nudge" customers to choose more fruits and vegetables (FV) shows promise in intervention studies to date. If such approaches are to become more widely adopted, they must be feasible and acceptable to food service managers. Among possible early adopters, managers of food services in post-secondary education institutions may have unique insights on implementation of such approaches, as they have dual mandates to support student health and maintain profitability.

OBJECTIVE

The goal of this exploratory study was to examine current knowledge, practice, facilitators, and barriers to uptake of nudge strategies promoting FV in a sample of post-secondary food service managers.

METHODS

A qualitative telephone interview study was undertaken with food service managers across Canada (n = 10 institutions), recruited from a national professional organization. One or more representatives from each institution completed the interview. Interviews were audio-recorded, transcribed, and underwent framework descriptive and interpretative content analysis in NVivo (QSR International). Münscher's Taxonomy of Choice Architecture and the Ottawa Model for Research Use guided development and analysis.

RESULTS

Managers from 9 universities and 1 technical college participated. Local context, governance, and resources varied widely. Eight of 10 institutions used some form of FV nudging as part of their marketing and health promotion, most commonly to reduce the effort associated with choosing FV. Nudging strategies aimed at increasing the range and composition of FV offerings, providing a social reference (opinion leaders) for choosing FV, and changing consequences with loyalty cards were also common. Other nudging strategies were used infrequently. Cost, operational ease of implementation, and students' privacy and choices were critical issues in adoption.

CONCLUSIONS

The results can inform development and testing of locally adapted nudge interventions. It is critical that managers be involved from the outset of any planned academic implementation study.

Policy Progress in Reducing Sodium in the American Diet, 2010–2019

Most Americans consume dietary sodium exceeding age-specific government-recommended targets of 1,500–2,300 mg/day per person. The majority (71%) of US dietary sodium comes from restaurant and packaged foods. Excess sodium intake contributes to hypertension and cardiovascular disease, which is the leading cause of death in the United States. This review summarizes evidence for policy progress to reduce sodium in the US food supply and the American diet. We provide a historical overview of US sodium-reduction policy (1969–2010), then examine progress toward implementing the 2010 National Academy of Medicine (NAM) sodium report's recommendations (2010–2019). Results suggest that the US Food and Drug Administration made no progress in setting mandatory sodium-reduction standards, industry made some progress in meeting voluntary targets, and other stakeholders made some progress on sodium-reduction actions. Insights from countries that have significantly reduced population sodium intake offer strategies to accelerate US progress toward implementing the NAM sodium-reduction recommendations in the future.

Effects of Menu Labeling Policies on Transnational Restaurant Chains to Promote a Healthy Diet: A Scoping Review to Inform Policy and Research

There is insufficient evidence that restaurant menu labeling policies are cost-effective strategies to reduce obesity and diet-related non-communicable diseases (NCDs). Evidence suggests that menu labeling has a modest effect on calories purchased and consumed. No review has been published on the effect of menu labeling policies on transnational restaurant chains globally. This study conducted a two-step scoping review to map and describe the effect of restaurant menu labeling policies on menu reformulation. First, we identified national, state, and municipal menu labeling policies in countries from global databases. Second, we searched four databases (i.e., PubMed, CINHAL/EBSCO, Web of Science, and Google Scholar) for peer-reviewed studies and gray-literature sources in English and Spanish (2000–2020). Step 1 identified three voluntary and eight mandatory menu labeling policies primarily for energy disclosures for 11 upper-middle and high-income countries, but none for low- or middle-income countries. Step 2 identified 15 of 577 studies that met the inclusion criteria. The analysis showed reductions in energy for newly introduced menu items only in the United States. We suggest actions for governments, civil society organizations, and the restaurant businesses to develop, implement, and evaluate comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.

Quality of Meals Consumed by US Adults at Full-Service and Fast-Food Restaurants, 2003-2016: Persistent Low Quality and Widening Disparities

BACKGROUND

Meals from full-service restaurants (FS) and fast-food restaurants (FF) are an integral part of US diets, but current levels and trends in consumption, healthfulness, and related sociodemographic disparities are not well characterized.

OBJECTIVES

We aimed to assess patterns and nutritional quality (using validated American Heart Association [AHA] diet scores) of FS and FF meals consumed by US adults.

METHODS

Serial cross-sectional investigation utilizing 24-h dietary recalls in survey-weighted, nationally representative samples of 35,015 adults aged ≥20 y from 7 NHANES cycles, 2003-2016.

RESULTS

Between 2003 and 2016, American adults consumed ∼21 percent of energyfrom restaurants (FS: 8.5% in 2003-2004, 9.5% in 2015-2016, P-trend = 0.38; FF: 10.5%; 13.4%, P-trend = 0.31). Over this period, more FF meals were eaten for breakfast (from 4.4% to 7.6% of all breakfasts, P-trend <0.001), with no changes for lunch (15.2% to 15.3%) or dinner (14.6% to 14.4%). In 2015-2016, diet quality of both FS and FF were low, with mean AHA diet scores of 31.6 and 27.6 (out of 80). Between 2003 and 2016, diet quality of FF meals improved slightly, (the percentage with poor quality went from 74.6% to 69.8%; and with intermediate quality, from 25.4% to 30.2%; P-trend <0.001 each). Proportions of FS meals of poor (∼50%) and intermediate (∼50%) quality were stable over time, with <0.1% of consumed FS or FF meals meeting ideal quality. Disparities in FS meal quality persisted by race/ethnicity, obesity status, and education and worsened by income; whereas disparities in FF meal quality persisted by age, sex, and obesity status and worsened by race/ethnicity, education, and income.

CONCLUSIONS

Between 2003 and 2016, FF and FS meals provided 1 in 5 calories for US adults. Modest improvements occurred in nutritional quality of FF, but not FS, meals consumed, and the average quality for both remained low with persistent or widening disparities. These findings highlight the need for strategies to improve the nutritional quality of US restaurant meals.

An accountability evaluation for the International Food & Beverage Alliance's Global Policy on Marketing Communications to Children to reduce obesity: A narrative review to inform policy

United Nations (UN) organizations have urged governments to restrict the marketing of unhealthy food and nonalcoholic beverage products to children. This study conducted an accountability evaluation for the International Food & Beverage Alliance's (IFBA's) Global Policy on Marketing Communications to Children (Global Policy) compared with UN and other best-practice recommendations. We used the National Academy of Medicine's LEAD (ie, locate, evaluate, assemble evidence to inform decisions) framework to identify evidence (January 2004 to October 2018). We assigned a progress score (ie, none, limited, some, extensive) for five accountability steps. No progress was made to appoint an empowered body to evaluate IFBA's Global Policy. IFBA and the Access to Nutrition Foundation made some progress to take and share the account. Diverse actors made no progress to hold IFBA to account for nonadherence or to strengthen accountability structures for future compliance. IFBA could strengthen its Global Policy to align with best practices. UN organizations and other stakeholders should encourage IFBA firms to restrict the marketing of unhealthy foods and beverages to reduce children's obesity risk. This evaluation is relevant to all firms and industry associations that market products to children that undermine their diet and health.

BIA-Obesity (Business Impact Assessment-Obesity and population-level nutrition): A tool and process to assess food company policies and commitments related to obesity prevention and population nutrition at the national level

Addressing obesity and improving the diets of populations requires a comprehensive societal response. The need for broad-based action has led to a focus on accountability of the key factors that influence food environments, including the food and beverage industry. This paper describes the Business Impact Assessment-Obesity and population-level nutrition (BIA-Obesity) tool and process for benchmarking food and beverage company policies and practices related to obesity and population-level nutrition at the national level. The methods for BIA-Obesity draw largely from relevant components of the Access to Nutrition Index (ATNI), with specific assessment criteria developed for food and nonalcoholic beverage manufacturers, supermarkets, and chain restaurants, based on international recommendations and evidence of best practices related to each sector. The process for implementing the BIA-Obesity tool involves independent civil society organisations selecting the most prominent food and beverage companies in each country, engaging with the companies to understand their policies and practices, and assessing each company's policies and practices across six domains. The domains include: "corporate strategy," "product formulation," "nutrition labelling," "product and brand promotion," "product accessibility," and "relationships with other organisations." Assessment of company policies is based on their level of transparency, comprehensiveness, and specificity, with reference to best practice.

Investigating business outcomes of healthy food retail strategies: A systematic scoping review

Large changes to food retail settings are required to improve population diet. However, limited research has comprehensively considered the business implications of healthy food retail strategies for food retailers. We performed a systematic scoping review to identify types of business outcomes that have been reported in healthy food retail strategy evaluations. Peer-reviewed and grey literature were searched. We identified qualitative or quantitative real-world food or beverage retail strategies designed to improve the healthiness of the consumer nutrition environment (eg, changes to the "marketing mix" of product, price, promotion, and/or placement). Eligible studies reported store- or chain-level outcomes for measures of commercial viability, retailer perspectives, customer perspectives, and/or community outcomes. 11 682 titles and abstracts were screened with 107 studies included for review from 15 countries. Overall item sales, revenue, store patronage, and customer level of satisfaction with strategy were the most frequently examined outcomes. There was a large heterogeneity in outcome measures reported and in favourability for retailers of outcomes across studies. We recommend more consistent reporting of business outcomes and increased development and use of validated and reliable measurement tools. This may help generate more robust research evidence to aid retailers and policymakers to select feasible and sustainable healthy food retail strategies to benefit population health within and across countries.

Progress Evaluation for Transnational Restaurant Chains to Reformulate Products and Standardize Portions to Meet Healthy Dietary Guidelines and Reduce Obesity and Non-Communicable Disease Risks, 2000-2018: A Scoping and Systematic Review to Inform Policy

Transnational restaurant chains sell food and beverage products in 75 to 139 countries worldwide linked to obesity and non-communicable diseases (NCDs). This study examined whether transnational restaurant chains reformulated products and standardized portions aligned with healthy dietary guidelines and criteria. Firstly, we describe the transnational restaurant industry structure and eating trends. Secondly, we summarize results from a scoping review of healthy dietary guidelines for restaurants. Thirdly, we describe a systematic review of five electronic databases (2000-2018) to identify studies on nutrient profile and portion size changes made by transnational restaurants over 18 years. We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, identified 179 records, and included 50 studies conducted in 30 countries across six regions. The scoping review found a few expert-recommended targets for restaurants to improve offerings, but no internationally accepted standard for portions or serving sizes. The systematic review results showed no standardized assessment methods or metrics to evaluate transnational chain restaurants' practices to improve menu offerings. There was wide variation within and across countries, regions, firms, and chains to reduce energy, saturated and trans fats, sodium, and standardized portions. These results may inform future research and encourage transnational chain restaurants to offer healthy product profiles and standardized portions to reduce obesity and NCD risks worldwide.

Assessing the Importance of Health in Choosing a Restaurant: An Empirical Study from Romania

In the context of a spectacular growth of the Romanian restaurant market, it has become a necessity for managers to analyze the decision-making process related to restaurant selection toward obtaining a competitive advantage, which can be achieved through better segmentation and adequate targeting. The main objectives involved the identification of the main factors that influence restaurant selection by evaluating the role that health concerns play in this process and identifying consumers’ restaurant profiles. A survey was conducted using face-to-face interviews as the contact method, in order to identify the main factors considered important for consumers in the city of Cluj-Napoca in the decision-making process related to restaurant selection. Principal component analysis (PCA) was conducted to group the attributes. The non-hierarchical cluster analysis through the use of the k-means method was used to define different groups within the sample and identify common features. Results suggest that the analyzed restaurant market is dominated by three segments of consumers, of which the largest is represented by “health seekers”: a group of young women with medium and low incomes. As such, the possibility of consuming healthy meals within a restaurant is the most important factor for them during the decision-making process for restaurant selection. The present study has important managerial implications. Restaurant managers should admit that this process represents the starting point in designing restaurant concepts, as this type of information is fundamental for management decisions. On the other hand, the study offers important information regarding consumer perception of food, which has recently changed significantly, especially in the segment of young consumers to whom health is very important.

Evaluation of a Healthy Chinese Take-Out Sodium-Reduction Initiative in Philadelphia Low-Income Communities and Neighborhoods

OBJECTIVES

Sodium reduction in restaurant foods is important because 77% of sodium in the United States is consumed by eating prepared and restaurant foods. We evaluated a sodium-reduction intervention, Healthy Chinese Take-Out Initiative, among Chinese take-out restaurants in low-income neighborhoods in Philadelphia, Pennsylvania. Our objectives were to (1) analyze changes in the sodium content of food samples and (2) collect data on changes in chefs' and owners' knowledge about the health risks of sodium overconsumption, perceptions of the need for sodium reduction, self-efficacy for lowering sodium use, and perceptions of training needs for sodium-reduction strategies.

METHODS

The initiative trained chefs from 206 Chinese take-out restaurants on strategies to reduce sodium in prepared dishes. We analyzed changes in the sodium content of the 3 most frequently ordered dishes-shrimp and broccoli, chicken lo mein, and General Tso's chicken-from baseline (July-September 2012) to 36 months after baseline (July-September 2015) among 40 restaurants. We conducted a survey to examine the changes in chefs' and owners' knowledge, perceptions, and self-efficacy of sodium reduction. We used multilevel analysis and repeated-measures analysis of variance to examine effects of the intervention on various outcomes.

RESULTS

We found significant reductions in the sodium content of all 3 dishes 36 months after a low-sodium cooking training intervention (coefficients range, -1.06 to -1.69, P < .001 for all). Mean knowledge (range, 9.2-11.1), perceptions (range, 4.6-6.0), and self-efficacy (range, 4.2-5.9) ( P < .001 for all) of sodium reduction improved significantly from baseline (August 2012) to posttraining (also August 2012), but perceptions of the need for sodium reduction and self-efficacy for lowering sodium use returned to baseline levels 36 months later (August 2015).

CONCLUSIONS

The intervention was a useful population health approach that led to engaging restaurants in sodium-reduction practices. Local public health agencies and professionals could partner with independent restaurants to introduce environmental changes that can affect population health on a broad scale, particularly for vulnerable populations.