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SYSTEMATIC REVIEW

Community-Based Interventions in Prepared-Food Sources: A Systematic Review

Joel Gittelsohn, PhD; Seung Hee Lee-Kwan, PhD; Benjamin Batorsky, MPH

Suggested citation for this article: Gittelsohn J, Lee-Kwan SH, 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.

PEER REVIEWED

Abstract

Introduction
Food purchased from prepared-food sources has become a major part of the American diet and is linked to increased rates of chronic disease. Many interventions targeting prepared-food sources have been initiated with the goal of promoting healthful options. The objective of this study was to provide a systematic review of interventions in prepared-food sources in community settings.

Methods
We used PubMed and Google Scholar and identified 13 interventions that met these criteria: 1) focused on prepared-food sources in public community settings, 2) used an impact evaluation, 3) had written documentation, and 4) took place after 1990. We conducted interviews with intervention staff to obtain additional information. Reviewers extracted and reported data in table format to ensure comparability.

Results
Interventions mostly targeted an urban population, predominantly white, in a range of income levels. The most common framework used was social marketing theory. Most interventions used a nonexperimental design. All made use of signage and menu labeling to promote healthful food options. Several promoted more healthful cooking methods; only one introduced new healthful menu options. Levels of feasibility and sustainability were high; sales results showed increased purchasing of healthful options. Measures among consumers were limited but in many cases showed improved awareness and frequency of purchase of promoted foods.

Conclusion
Interventions in prepared-food sources show initial promising results at the store level. Future studies should focus on improved study designs, expanding intervention strategies beyond signage, and assessing impact among consumers.

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Introduction

Obesity is a multifactorial disease that has many contributing factors, including the food environment. Food environments in which energy-dense prepared foods (ready-to-eat foods that can be eaten outside the home or brought back or delivered to the home to eat) are readily available are associated with the increasing prevalence of obesity (1–3). As a consequence, environmental interventions may be more cost-effective, sustainable, and successful at reaching a large population than individual interventions (4). Today, Americans spend about half of their food dollars eating out (5,6) compared with 25% in 1955 (7). Americans are expected to spend $660.5 billion in 2013 on eating out, a 15-fold increase from 1970 (adjusted to current dollars) (7). The total energy intake per capita increased on average by 570 kcal between 1977–78 and 2003–06; this increase has been attributed to greater portion sizes and a greater frequency of eating out (8). Although prepared foods are generally more costly than foods prepared at home, people who have low incomes consume them at high rates (9–11). Prepared-food sources may be an important venue for efforts to reduce obesity and risks for other chronic diseases. In the past several decades, multiple interventions were conducted in venues that provide prepared foods. One review (12) showed that interventions had success in private prepared-food–source environments, such as worksite and college cafeterias. However, no systematic reviews examined prepared-food source interventions in public community settings such as carryout, fast-food, and sit-down restaurants, even though prepared-food sources are more numerous in public settings than in private settings, and low-income individuals may have little access to private settings, which may offer more healthful options. The objective of this study was to systematically review community-based interventions in prepared-food sources that aimed to increase access to and consumption of healthful foods.

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Methods

This systematic review was designed to identify interventions in public prepared-food sources; to present data on strategy, study design, evaluation, process indicators, and impact for each intervention identified; and to suggest next steps in research, practice, and policy. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which provide 27 checklist items that aim to standardize the structure of meta-analyses and ensure comprehensive reporting (13).

Data sources

From September 2011 through January 2013, we used PubMed and Google Scholar to search peer-reviewed journals and Google to search “gray” literature for articles on interventions in prepared-food sources. Gray literature included newsletters, published (but not peer-reviewed) articles, policy briefs or reports, published trial materials, and conference presentations. Search terms for each engine included the following: “restaurant intervention,” “nutrition AND intervention,” “fast-food AND intervention,” “prepared food intervention,” “point of purchase food,” “healthy food choices,” and “restaurant health food choices.”

Study selection

We initially identified 35 potential interventions. All identified food-source interventions were reviewed for inclusion according to the following criteria: 1) a focus on prepared-food sources in public community settings such as carryout, fast-food, and sit-down restaurants (although other intervention components could be included as part of the intervention); 2) a completed impact evaluation (eg, pre–post assessment, use of a comparison group, exposure assessment with or without a comparison group); 3) some form of written documentation (eg, peer-reviewed journal article, newsletter article, other published article, policy brief or report, published trial material, a project’s own website or conference presentation) that included a description of the implemented intervention and evaluation findings; and 4) an intervention start date after 1990. Of the original 35 interventions, 19 met these inclusion criteria.

For 4 of the 19 interventions, only website information was available, and because we were unable to obtain further information, these 4 were also excluded from our review. Of the 15 remaining, 2 interventions lacked information on study findings and were therefore excluded. These exclusions left 13 interventions for review, data extraction, and analysis.

Data extraction

The 2 primary reviewers (S.L.K., B.B.) independently extracted and analyzed data by reviewing all documents. The secondary reviewer (J.G.) developed the system for extracting data and coding variables. The secondary reviewer also resolved discrepancies noted by the 2 primary reviewers and identified and adjudicated other discrepancies that might affect reliability and analysis (Appendix).

Primary reviewers were instructed to extract data for each variable and to organize data using the intervention as the unit of analysis. We attempted to contact a representative of each intervention to obtain more information. Seven of 13 intervention managers or lead researchers participated in semistructured telephone interviews or e-mail communications (or both) designed to gather additional information needed to complete the data tables and to resolve any inconsistencies. One intervention (Baltimore Healthy Carryouts) was implemented by our team. After the interventions were reviewed, we summarized data in 3 tables: background and intervention approach, evaluation methods used, and study findings. Within each table, we grouped restaurants into 4 categories according to similar characteristics: specialty restaurants, chain restaurants, small local restaurants, and mixed types of restaurants (both local and chain) that did not share characteristics with other restaurants or whose characteristics were not well defined. The primary reviewers organized the information about each study into these tables. The secondary reviewer confirmed data accuracy by using initial review findings, e-mail correspondence, interview transcripts, and extraction and reporting guidelines.

We implemented previously used techniques (14) for analytic assessment of the selected interventions, such as identifying a standard set of quality criteria (eg, randomization and use of control groups) and reporting on the impact among prepared-food sources and consumers. Because of the heterogeneity of outcome data, which did not permit us to calculate summary estimates of impact, meta-analytic techniques were not used.

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Results

Of the 13 interventions (15–49) that met the inclusion criteria, 12 interventions (15–18,21,22,24–35,37–41,45–48) were described in peer-reviewed publications. Personal communications (e-mail correspondence, telephone interviews) (n = 11) (15–27,30,31,37–49), informal documentation (reports, intervention materials) (n = 5) (19,20,26,43,44,49), and websites (n = 5) (23,36,42,43,49) were also sources of information (Table 1a, 1b, 1c, 1d).

Target populations

Most interventions (n = 9) took place in urban settings; 3 interventions focused on mixed urban and rural populations, and one focused on rural settings. Interventions were conducted in various regions of the United States: 4 in the Northeast, 4 in the West, 2 in the Midwest, and 1 in the Southeast. Only 2 interventions took place outside the United States (Table 1a, 1b, 1c, 1d). The interventions targeted a range of consumer income levels: 3 interventions (Baltimore Healthy Carryouts [15–23], Steps to a Healthier Salinas [25,26], and Coeur en Santé [28,29] worked in low-income areas, Horgen and Brownell (27) worked in middle- to high-income areas, and the rest did not identify the income level of the targeted population. The race/ethnicity of consumers in the interventions was generally mixed: 5 populations were predominantly white; 1, Hispanic; 1, African American; 1, Korean; and 1, mixed; 4 interventions did not specify the race/ethnicity of the targeted population.

Behavior-change theory

Ten interventions explicitly stated the theoretical frameworks that guided their design (15–23,25–30,32–49). The theory most commonly identified was social marketing (n = 3), used by Winners Circle (47–49), TrEAT Yourself Well (30), and Baltimore Healthy Carryouts (15–23). No other theory was identified by more than 1 trial; however, an emphasis on changing the food environment was mentioned in Baltimore Healthy Carryouts (15–23), Horgen and Brownell (27), and Shape Up Somerville (32–36).

Intervention goals

Overall, the 13 interventions shared similar goals. All sought to promote more healthful menu items at prepared-food sources with the associated goal of increasing sales of these foods. Some interventions had additional goals. The larger goal of Shape Up Somerville (32–36) was to reduce childhood obesity, and their restaurant intervention (33) was viewed as an environmental component of that work. The additional goal of Baltimore Healthy Carryouts (15–23) was to assess the feasibility of a carryout intervention. Other projects stated that they sought to achieve their overall goals by specific means, such as menu labeling (Tandon et al [31] and Smart Menu program [37,38]) and price changes (Horgen and Brownell [27]).

Formative research

Three interventions (30,31,43) conducted no formative research before designing and implementing their program. Of the 10 that conducted formative research, 2 reported “informal” research (27,37,38), consisting mainly of literature reviews and discussions with a small number of stakeholders. The remaining 8 interventions did more extensive formative research, including qualitative (eg, focus groups, in-depth interviews) and quantitative (eg, surveys) data collection. Some interventions published separate reports on their formative research (15,18,21,22,25,28,41,45,46,49).

Intervention strategies

Food promotion

All interventions focused on identifying and promoting existing healthful food options at prepared-food sources as the primary intervention strategy. Five interventions identified specific nutritional criteria for a food to be considered healthful (Coeur en Santé [28,29], TrEAT Yourself Well [30], Tandon et al [31], Healthy Howard [43], and Healthy Restaurant [44]). Only 1 intervention (Baltimore Healthy Carryouts [15–23]) introduced new healthful options: lower-fat side dishes and grilled chicken. All interventions promoted healthful entrées, but 5 interventions also promoted healthful snacks and side dishes: for example, Winners Circle (47–49), Shape Up Somerville (32–36), Baltimore Healthy Carryouts (15–23).

Food preparation or portion size

Six interventions worked with restaurant owners and staff to develop more healthful recipes, usually by using lower-fat cooking methods (15–23,25,26,28,29,32–38,44–46). Two interventions, Shape Up Somerville (32–36) and the Smart Menu program (37,38), aimed to decrease the portion size of foods served.

Signage and menus

All 13 interventions used some form of signage to promote more healthful options. Most interventions (n = 10) used some form of menu labeling, usually a symbol to indicate more healthful choices. Baltimore Healthy Carryouts (15–23) redesigned carryout menus in low-income areas of Baltimore to emphasize more healthful choices. Other forms of signage included posters (n = 4) and menu inserts or tablemats (n = 4).

Pricing or cost reduction

Four interventions sought to reduce the consumers’ cost for the more healthful items. Steps to a Healthier Salinas (25,26) and TrEAT Yourself (30) included coupons or discount cards; Baltimore Healthy Carryouts (15–23) and Horgen and Brownell (27) implemented a price reduction. Baltimore Healthy Carryouts focused on price reductions for combination meals as a strategy (19,22).

Community promotion

Four interventions did not promote their programs outside the prepared-food sources or in the general community. Of the 7 interventions that promoted their programs widely, a variety of approaches were used, including newspaper advertisements (n = 5), promotion at community events (n = 3), and leaflets and newsletters (n = 3). These promotions were intended to increase awareness of the program and to direct consumers to prepared-food sources participating in the intervention.

Study design

Most interventions were nonexperimental interventions in which participation by the prepared-food sources was voluntary (n = 10). Two interventions had a quasi-experimental design: Shape up Somerville (32–36) and TrEAT Yourself Well (30). Baltimore Healthy Carryouts (15–23) used a true experimental design, with random assignment to treatment. Nearly half (n = 6) of the interventions (24,27,37–42,44–46) had pre–post assessment at the prepared-food source level with no comparison group (Table 2a, 2b, 2c, 2d).

Evaluation methods used and key findings

Feasibility and process evaluation of interventions

Most interventions (n = 8) collected information on feasibility. In general, this information was in the form of interviews and informal discussions with owners and managers of the prepared-food sources. These same 8 interventions also conducted some form of process evaluation (usually through store visits) to assess, for example, whether signage was displayed and healthful options were available.

Overall, the level of feasibility was moderate to high for intervention implementation (Table 3a, 3b, 3c, 3d). The level of acceptability was generally high among participating food-source owners. Menu labeling was particularly acceptable among multiple interventions. However, no trial assessed program acceptability among consumers.

Findings on process evaluation were more variable. Several interventions were public health interventions with open volunteer enrollment. Many of these interventions had low reach, when assessed by counting customers. We found that interventions had particular difficulty in recruiting restaurants, which was reflected in low reach among restaurants (37,38,47–49). One exception was Healthy Howard, which had moderate reach (43). At least 1 intervention (Shape Up Somerville [32–36]) experienced a decrease in participation over time, whereas others such as Healthy Howard (43) and Healthy Restaurant (44–46) experienced an increase. Only 2 interventions, Baltimore Healthy Carryouts (15–23) and the Healthy Options program (39–42), assessed fidelity; both demonstrated high fidelity. The level of acceptability was high among restaurant owners when the intervention was perceived as less burdensome (15–23,28,29,37–42) because of incentives such as free menu analyses, point-of-purchase materials, and media promotions.

Impact of interventions on prepared-food sources

Seven interventions assessed the impact of the intervention on prepared-food sources. Four of these 7 interventions (Baltimore Healthy Carryouts, Healthy Restaurant, Healthy Howard, and Shape Up Somerville) interviewed food-source owners to assess whether sales of healthful options increased. Four used data from food-source registers; 2 interventions collected sales receipts (Baltimore Healthy Carryouts [15–23] and Horgen and Brownell [27]). Three interventions — Healthy Howard (43), Healthy Restaurant (44–46), and Shape Up Somerville (32–36) — collected information other than sales data from the owner or manager of the prepared-food source, including information on nutrition awareness.

When sales were assessed, 5 interventions showed an increase in unit sales of promoted foods. Three interventions — Horgen and Brownell (27), Healthy Restaurant (44–46), and Baltimore Healthy Carryouts (15–23) — documented increases in total intervention-associated sales. This finding is best substantiated in Baltimore Healthy Carryouts (15–23), which also examined sales in a comparison group of prepared-food sources and demonstrated an increase in total revenue among the intervention group relative to the comparison group (17,20).

Impact of interventions on consumers

Eleven interventions collected information on the impact of the intervention on consumers (15–23,25–31,37–49). Six interventions collected data on psychosocial factors such as program awareness and nutrition knowledge (28–31,37–42,47–49). Seven interventions collected information on behavior, particularly food choices made at prepared-food sources and frequency of use of prepared-food sources (15–23,28–31,37–42,47–49).

Of the 6 interventions that reported an assessment of psychosocial factors among consumers, most (n = 4) found an increased awareness of the intervention and its goals. Of these, Coeur en Santé (29), TrEAT Yourself Well (30), and Healthy Restaurant (44–46) showed improvements in acceptability of healthful food among customers.

Among the 7 interventions that assessed the impact of the intervention on consumer food-related behaviors, only 5 interventions reported results. Four of the 5 interventions (Baltimore Healthy Carryouts [15–23], TrEAT Yourself Well [30], Smart Menu [37,38], and Winners Circle [47–49]) found an increase in the frequency of purchasing the more healthful food options promoted by the intervention.

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Discussion

This is the first systematic review of interventions in community-based prepared-food sources. Results are promising, showing that cost-effective methods (eg, labeling foods as healthful) may have a significant impact on prepared-food source sales and customer behavior. Most approaches centered on signage to promote existing healthful food choices. Several worked with kitchen staff to improve low-fat food preparation practices, and several conducted formal menu analyses to determine more healthful choices for promotion. These strategies, though resource intensive, show that it is important to engage prepared-food source staff in determining more healthful options.

Although interventions in prepared-food sources are increasingly being considered viable public health interventions, it is clear from this review that the evidence base for these interventions is deficient. Study designs tended to lack comparison groups, treatment conditions were not randomly assigned, and selection criteria were not readily apparent; these inadequacies cast doubt on the generalizability of findings.

Many of the interventions included in this review were not formal studies but rather certification or campaign programs operated by local health departments. These programs were voluntary, which may explain why they varied in levels of reach. Low reach may have been due to the actual burden placed on restaurant owners by the intervention or the lack of potential benefits perceived by them. Partnerships between local public health departments and academic institutions may help overcome some of these limitations through improved social marketing of program strategies and benefits. For example, local public health departments could initiate the intervention and manage recruitment while an academic institution partner conducts a full impact assessment, including psychosocial surveys and sales data collection.

We found no clear preference for a conceptual or behavior-change framework. A few interventions used social marketing approaches, but these interventions generally did not incorporate key social marketing components, such as formative research, audience segmentation, or targeting of messages (50). New frameworks for operationalizing prepared-food source interventions need to be developed; such frameworks should incorporate elements of theories on the food environment (51,52) and behavior change.

Although many interventions showed promising results, most lacked adequate measurement of the impact of the intervention on consumers. Of studies that examined consumer outcomes, most assessed only awareness of the health promotion campaign and food purchasing frequency. More sophisticated assessments — based on behavior-change theories — are needed to evaluate such outcomes as food purchasing patterns and dietary intake.

Almost half of the interventions lacked formal formative research — a major omission, especially considering that food environment research is an emerging area of public health programming. Formative research involves qualitative and quantitative data collection, which aids in program development (53–56); many interventions in our study would have benefited from this kind of preliminary research. In addition, most interventions focused only on promoting existing healthful options at prepared-food sources. Only 1 intervention sought to introduce new, more healthful foods. Interventions need to pay more attention to actively changing the food environment in prepared-food sources by increasing the availability of healthful food options.

Another approach worth exploring is price changes. Two interventions showed positive results by reducing food prices (Baltimore Health Carryouts [15–23] and Horgen and Brownell [27]). Ample evidence supports the use of price reduction as a means of promoting more healthful options among consumers (57–59). Moreover, research on pricing may support the hypothesis that the increased prevalence of obesity may be attributed to greater consumption of soda and chips that have artificially low prices because of government subsidies for corn and soybeans (4,60,61). If nonhealthful and healthful food prices were comparable, consumers might be more likely to purchase healthful foods. Baltimore Healthy Carryouts demonstrated that reducing the price of healthful foods not only increased sales of healthful foods but also increased total carryout revenue (17,20).

Our findings parallel in many ways the findings of recent interventions in small retail food stores (14). Both types of interventions focused on modifying the food environment and promoting healthful choices through point-of-purchase materials. A key difference, however, was that most research on small food stores has focused on food deserts in primarily low-income racial/ethnic minority populations. Only a few of the interventions in our study took place in low-income settings. More carefully evaluated interventions in food sources in low-income settings are needed. The high rates of obesity and other chronic diseases are related not only to the availability of healthful choices in retail food stores but also to access to healthful foods in prepared-food sources (15,62–64). Although a recent longitudinal study (63) showed mixed results on the relationship between the availability of grocery stores and diet-related outcomes, it demonstrated that the availability of fast food was related to fast food consumption in a low-income population. Low-income populations tend to rely on local prepared-food sources because they often work more than one job and do not have time to cook at home (65). One study found that during the 2007–09 recession, the middle quintile of households (the middle 20% of the income distribution) cut spending on food away from home by 20%, whereas the lowest quintile of households cut such spending by 12%, suggesting a greater reliance on food away from home among lower quintile households (66). Improving the availability of healthful food in prepared-food sources may be an effective way to promote dietary improvement in low-income settings.

This systematic review has some limitations. Many of the interventions reviewed were implemented by health departments that lacked the resources to conduct comprehensive evaluations and publish the findings in peer-reviewed publications. Thus, we included findings from the gray literature. Because of the wide variability in measures used and in impact assessments, we were not able to develop summary estimates or compare measures or impacts directly among interventions. These limitations emphasize the need for standardization of measures used by interventions and the need for further reviews that assess different strategies (14).

Our review lays the groundwork for further exploration of strategies to increase more healthful food options in community-based prepared-food sources. Many interventions showed that changing the prepared-food environment may improve sales and awareness of more healthful foods and improve purchasing and consumption behaviors. Interventions can be strengthened through comprehensive formative research and quantitative assessments of process and impacts. With these additions, future studies will be able to assess the relative effectiveness of different strategies and create standards of practice in prepared-food sources.

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Acknowledgments

This review was supported by a Commissioned Analysis grant from the Robert Wood Johnson Foundation’s Healthy Eating Research program. Dr Gittelsohn’s work in the study was supported in part by a research grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (no. U54HD070725), which is cofunded by the National Institute of Child Health and Human Development and the Office of Behavioral and Social Sciences Research at the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

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Author Information

Corresponding Author: Joel Gittelsohn, PhD, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Ste W2041A, Baltimore, MD 21205. Telephone: 410-955-3927. E-mail: jgittels@jhsph.edu.

Author Affiliations: Seung Hee Lee-Kwan, Benjamin Batorsky, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

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References

  1. French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health 2001;22:309–35. CrossRef PubMed
  2. Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR, Franco M. Fast-food consumption, diet quality, and neighborhood exposure to fast food: the Multi-Ethnic Study of Atherosclerosis. Am J Epidemiol 2009;170(1):29–36. CrossRef PubMed
  3. Jeffery RW, Baxter J, McGuire M, Linde J. Are fast food restaurants an environmental risk factor for obesity? Int J Behav Nutr Phys Act 2006;3:2. CrossRef PubMed
  4. Story M, Kaphingst KM, Robinson-O’Brien R, Glanz K. Creating healthy food and eating environments: policy and environmental approaches. Annu Rev Public Health 2008;29:253–72. CrossRef PubMed
  5. Stewart H, Blisard N, Jolliffe D. Let’s eat out: Americans weigh taste, convenience, and nutrition. Economic Information Bulletin. 2006. http://www.ers.usda.gov/media/860870/eib19.pdf. Accessed January 15, 2013.
  6. US Department of Agriculture. ERS/USDA Briefing Room — Food CPI and expenditures: Table 10 food away from home as a share of food expenditures. 2011. http://www.ers.usda.gov/briefing/cpifoodandexpenditures/data/Expenditures_tables/table10.htm. Accessed March 25, 2013.
  7. Riehle H, Grindy B, Altman M. Restaurant industry forecast. National Restaurant Association; 2013. http://www.restaurant.org/News-Research/Research/Forecast-2013. Accessed April 8, 2013.
  8. Duffey KJ, Popkin BM. Energy density, portion size, and eating occasions: contributions to increased energy intake in the United States, 1977–2006. PLoS Med 2011;8(6):e1001050. CrossRef PubMed
  9. Kant AK, Graubard BI. Eating out in America, 1987–2000: trends and nutritional correlates. Prev Med 2004;38(2):243–9. CrossRef PubMed
  10. Guthrie JF, Lin BH, Frazao E. Role of food prepared away from home in the American diet, 1977–78 versus 1994–96: changes and consequences. J Nutr Educ Behav 2002;34(3):140–50. CrossRef PubMed
  11. French SA, Harnack L, Jeffery R. Fast food restaurant use among women in the Pound of Prevention study: dietary, behavioral and demographic correlates. Int J Obes Relat Metab Diisord 2000;24(10):1353–9. CrossRef PubMed
  12. Seymour JD, Yaroch AL, Serdula M, Blanck HM, Khan LK. Impact of nutrition environmental interventions on point-of-purchase behavior in adults: a review. Prev Med 2004;39(Suppl 2):S108–36. CrossRef PubMed
  13. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009;6(7):e1000100. CrossRef PubMed
  14. Gittelsohn J, Rowan M, Gadhoke P. Interventions in small food stores to change the food environment, improve diet, and reduce risk of chronic disease. Prev Chronic Dis 2012;9:E59. PubMed
  15. Lee SH, Rowan M, Powell LM, Newman S, Klassen AC, Frick KD, et al. Characteristics of prepared food sources in low-income neighborhoods of Baltimore City. Ecol Food Nutr 2010;49(6):409–30. CrossRef PubMed
  16. Lee SH, Rowan MT, Dennisuk L, Klassen AC, Frick KD, Gittelsohn J. Pilot environmental intervention trial in carry-outs in low-income neighborhoods of Baltimore City. FASEB J 2011;25(973):2.
  17. Lee SH, Kim H, Yong R, Hamouda M, Shon J, Park JH, et al. Environmental intervention in carryouts increases sales of healthy menu items in low-income urban setting. FASEB J 2012;26(32):7.
  18. Lee SH, Hoffman VA, Bleich SN, Gittelsohn J. Frequency of visiting and food dollars spent at carryouts among low-income, urban African American adults. J Hunger Environ Nutr 2012;7(4):459–67. CrossRef
  19. Lee-Kwan SH, 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;13:638.
  20. Lee SH. Changing the food environment in Baltimore City: impact of an intervention to improve carry-outs in low-income neighborhoods [unpublished doctoral dissertation]. Baltimore (MD): Johns Hopkins University; 2012.
  21. Noormohamed A, Lee SH, Batorsky B, Jackson A, Newman S, Gittelsohn J. Factors influencing ordering practices at Baltimore City carryouts: qualitative research to inform an obesity prevention intervention. Ecol Food Nutr 2012;51(6):481–91. CrossRef PubMed
  22. Jeffries JK, Lee SH, Frick KD, Gittelsohn J. Preferences for healthy carryout meals in low-income neighborhoods of Baltimore City. Health Promot Pract 2013;14(2):293–300. CrossRef PubMed
  23. Baltimore Healthy Carryouts. Johns Hopkins University. http://healthystores.org/projects/baltimore-healthy-carryouts/. Accessed January 12, 2013.
  24. Eldridge AL, Snyder M, Faus N, Kotz K. Development and evaluation of a labeling program for low-fat foods in a discount department store foodservice area. J Nutr Educ 1997;29(3):159–61. CrossRef
  25. Hanni KD, Mendoza E, Snider J, Winkleby MA. A methodology for evaluating organizational change in community-based chronic disease interventions. Prev Chronic Dis 2007;4(4):A105. PubMed
  26. Hanni KD, Garcia E, Ellemberg C, Winkleby M. Targeting the taqueria: implementing healthy food options at Mexican American restaurants. Health Promot Pract 2009;10(2 Suppl):91S–9S. CrossRef PubMed
  27. Horgen KB, Brownell KD. Comparison of price change and health message interventions in promoting healthy food choices. Health Psychol 2002;21(5):505–12. CrossRef PubMed
  28. Paradis G, O’Loughlin J, Elliott M, Masson P, Renaud L, Sacks-Silver G, et al. Coeur en santé St-Henri — a heart health promotion programme in a low income, low education neighbourhood in Montreal, Canada: theoretical model and early field experience. J Epidemiol Community Health 1995;49(5):503–12. CrossRef PubMed
  29. Richard L, O’Loughlin J, Masson P, Devost S. Healthy menu intervention in restaurants in low-income neighbourhoods: a field experience. J Nutr Educ 1999;31(1):54–9. CrossRef
  30. Acharya RN, Patterson PM, Hill EP, Schmitz TG, Bohm E. An evaluation of the “TrEAT Yourself Well” restaurant nutrition campaign. Health Educ Behav 2006;33(3):309. CrossRef PubMed
  31. Tandon PS, Zhou C, Chan NL, Lozano P, Couch SC, Glanz K, et al. The impact of menu labeling on fast-food purchases for children and parents. Am J Prev Med 2011;41(4):434–8. CrossRef PubMed
  32. Economos CD, Irish-Hauser S. Community interventions: a brief overview and their application to the obesity epidemic. J Law Med Ethics 2007;35(1):131–7. CrossRef PubMed
  33. Economos CD, Folta SC, Goldberg J, Hudson D, Collins J, Baker Z, et al. A community-based restaurant initiative to increase availability of healthy menu options in Somerville, Massachusetts: Shape Up Somerville. Prev Chronic Dis 2009;6(3):A102. PubMed
  34. Economos CD, Curtatone JA. Shaping up Somerville: a community initiative in Massachusetts. Prev Med 2010;50(Suppl 1):S97–8. CrossRef PubMed
  35. Sliwa S, Goldberg JP, Clark V, Junot B, Nahar E, Nelson ME, et al. Using the community readiness model to select communities for a community-wide obesity prevention intervention. Prev Chronic Dis 2011;8(6):A150. PubMed
  36. Shape Up Somerville. Tufts University. http://www.nutrition.tufts.edu/index.php?q=research/shapeup-somerville. Accessed January 12 2013.
  37. Pulos E, Leng K. Evaluation of a voluntary menu-labeling program in full-service restaurants. Am J Public Health 2010;100(6):1035–9. CrossRef PubMed
  38. Britt JW, Frandsen K, Leng K, Evans D, Pulos E. Feasibility of voluntary menu labeling among locally owned restaurants. Health Promot Pract 2011;12(1):18–24. CrossRef PubMed
  39. 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;14(1):132–8. CrossRef PubMed
  40. Nothwehr F, Andsager J, Haines H. The Rural Restaurant Healthy Options Program: response of rural, local newspapers to a program press release. Health Promot Pract 2012.
  41. Nothwehr F, Snetselaar L, Dawson JD, Hradek C, Sepulveda M. Healthy option preferences of rural restaurant customers. Health Promot Pract 2010;11(6):828–36. CrossRef PubMed
  42. Toolkit materials for the Healthy Options Program. Prevention Research Center for Rural Health. Iowa City (IA): University of Iowa. http://cph.uiowa.edu/prc/IDPHtoolkit.html. Accessed January 14, 2013.
  43. Healthy Howard. Look for certified healthy restaurants. 2012. http://www.healthyhowardmd.org/healthy-howard/healthy-restaurants. Accessed April 18, 2012.
  44. Joung H. Effectiveness evaluation of Healthy Restaurant Program. Seoul National University School of Public Health and Management Center for Health Promotion; 2008. Report No: 07-26. http://research.hp.go.kr/hpResearch/rsrptTma.dia?method=detailView&RSR_IDX=575&mnid=021202000000&searchCount=0&searchLine=&page=13&outLine=10. Accessed October 10, 2012.
  45. Hong K, Joung H. Restaurateur’s willingness to participate in the Healthy Restaurant Program in Seoul. Korean J Nutr 2009;42(3):268-277. CrossRef
  46. Hong K, Gittelsohn J, Joung H. Determinants of customers’ intention to participate in a Korean restaurant health promotion program: an application of the theory of planned behavior. Health Promot Int 2010;25(2):174–82. CrossRef PubMed
  47. Molloy M. Practice notes: strategies in health education. Winner’s Circle Healthy Dining Program. Health Educ Behav 2002;29:406–8.
  48. Shovelin K, Molloy M, Yum D, Shirah K, Andersen K, Ezzell J, et al. Changing the environment in which consumers dine: the Winner’s Circle Healthy Dining Program. Preventing overweight and obesity: policy and environmental approaches. Conference proceedings from the 131st annual meeting of American Public Health Association. 2003 Nov 15–19; San Francisco, California. https://apha.confex.com/apha/131am/techprogram/paper_62943.htm. Accessed January 12, 2013.
  49. Winner’s circle FAQs. NC Prevention Partners. http://www.ncpreventionpartners.org/dnn/WhatWeDo/Programs/WinnersCircle/tabid/159/Default.aspx. Accessed January 12, 2013.
  50. Storey J, Saffitz G, Rimon J. Social marketing. In: Glanz K, Rimer BK, Viswanath K, editors. Health behavior and health education: theory, research and practice. 4th edition. San Fransisco (CA): Jossey-Bass; 2008. p. 435–61.
  51. Glanz K. Measuring food environments: a historical perspective. Am J Prev Med 2009;36(4, Suppl):S93–8. CrossRef PubMed
  52. Glanz K, Sallis JF, Saelens BE, Frank LD. Healthy nutrition environments: concepts and measures. Am J Health Promot 2005;19(5):330–3, ii. CrossRef PubMed
  53. Gittelsohn J, Steckler A, Johnson CC, Pratt C, Grieser M, Pickrel J, et al. Formative research in school and community-based health programs and studies: “state of the art” and the TAAG approach. Health Educ Behav 2006;33(1):25. CrossRef PubMed
  54. Gittelsohn J, Dyckman W, Tan ML, Boggs MK, Frick KD, Alfred J, et al. Development and implementation of a food store–based intervention to improve diet in the Republic of the Marshall Islands. Health Promot Pract 2006;7(4):396–405. CrossRef PubMed
  55. Gittelsohn J, Harris SB, Whitehead S, Wolever TMS, Hanley J, Barnie A, et al. Developing diabetes interventions in an Ojibwa-Cree community in northern Ontario: linking qualitative and quantitative data. Chronic Dis Can 1995;16(4):157–64.
  56. Strolla LO, Gans KM, Risica PM. Using qualitative and quantitative formative research to develop tailored nutrition intervention materials for a diverse low-income audience. Health Educ Res 2006;21(4):465. CrossRef PubMed
  57. Cummins S, Petticrew M, Higgins C, Findlay A, Sparks L. Large scale food retailing as an intervention for diet and health: quasi-experimental evaluation of a natural experiment. J Epidemiol Community Health 2005;59(12):1035–40. CrossRef PubMed
  58. Reger B, Wootan MG, Booth-Butterfield S. Using mass media to promote healthy eating: a community-based demonstration project. Prev Med 1999;29(5):414–21. CrossRef PubMed
  59. Gittelsohn J, Sharma S. Physical, consumer, and social aspects of measuring the food environment among diverse low-income populations. Am J Prev Med 2009;36(4, Suppl):S161–5. CrossRef PubMed
  60. Andreyeva T, Long MW, Brownell KD. The impact of food prices on consumption: a systematic review of research on the price elasticity of demand for food. Am J Public Health 2010;100(2):216–22. CrossRef PubMed
  61. Alston JM, Sumner DA, Vosti SA. Farm subsidies and obesity in the United States: national evidence and international comparisons. Food Policy 2008;33(6):470–9. CrossRef
  62. Neff RA, Palmer AM, McKenzie SE, Lawrence RS. Food systems and public health disparities. J Hunger Environ Nutr 2009;4(3-4):282–314. CrossRef PubMed
  63. Boone-Heinonen J, Gordon-Larsen P, Kiefe CI, Shikany JM, Lewis CE, Popkin BM. Fast food restaurants and food stores: longitudinal associations with diet in young to middle-aged adults: the CARDIA study. Arch Intern Med 2011;171(13):1162–70. CrossRef PubMed
  64. Richardson AS, Boone-Heinonen J, Popkin BM, Gordon-Larsen P. Neighborhood fast food restaurants and fast food consumption: a national study. BMC Public Health 2011;11(1):543. CrossRef PubMed
  65. Devine CM, Connors MM, Sobal J, Bisogni CA. Sandwiching it in: spillover of work onto food choices and family roles in low- and moderate-income urban households. Soc Sci Med 2003;56(3):617–30. CrossRef PubMed
  66. Kumcu A, Kaufman P. Food spending adjustments during recessionary times. US Department of Agriculture Economic Research Service. 2011. http://www.ers.usda.gov/amber-waves/2011-september/food-spending.aspx#.UVCJileNDKU. Accessed March 25, 2013.

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Tables

Return to your place in the textTable 1a. Key Components of Interventions on Community-based Prepared-Food Sources: Interventions Conducted in Specialty Restaurantsa
CharacteristicBaltimore Healthy Carryouts (15–23)Good for You (24)Steps to a Healthier Salinas (25,26)Horgen and Brownell 2002 (27)
Data sourcesPeer-reviewed articles; conference presentation; websitePeer-reviewed article; e-mail correspondencePeer-reviewed articles; interview; e-mail correspondence; intervention materialsPeer-reviewed article; interview
Target populationBaltimore; African American; low-income; urbanMinnesota; Target store customersSalinas, California; low-income; mostly Mexican AmericanNew Haven, Connecticut; delicatessen customers; mostly white, upper-middle class
Model/theorySocial cognitive theory; Social marketingNot specifiedSocioecological model; asset-based community developmentMatching model; health belief model
GoalsAwareness; availability; affordability; consumptionAwareness; consumptionAwareness; consumption; availabilityAwareness; consumption; affordability
Types of prepared-food sourcesCarryout restaurants serving mainly deep-fried foodsCafeteria in large general merchandise/department storeMexican-style restaurantsDelicatessen
Food targeted in interventionLow-fat, low-cholesterol entrées, sides, and beverages15 Low-fat items on menuHealthier preparations for dishes; replacement of lard with vegetable oil for cookingLow-fat meals and sides
Intervention strategies
SignageMenu board; menu labeling; point-of-purchase postersMenu labeling; point-of-purchase materials (table tents, tray liners)Point-of-purchase materials (logo on menu and signage)Price reduction messages; point-of purchase materials (signs, posters)
Increased availability of healthful foodsFresh fruits, yogurts, healthful sides, and grilled chicken sandwichNoneHealthful preparation strategies; fresh fruit juicesNone
PricingReduced-price combination mealsNoneCoupons (10% discount)20%–30% price reduction of low-fat items
Community componentsNoneNoneNoneNone
OtherNoneNoneHealthy Nutrition Tool kit; give-awaysNone
Formative researchSemi-structured interview with customers (N = 50) and owners (N = 12); focus groups, conjoint analysis (N = 50)Customer survey of interest in buying lower-fat foods at Target Food AvenueSurveys of local taquerias; work with owners to identify intervention strategiesInformal discussions with restaurant managers and staff

a Includes restaurants, such as carryouts, taquerias, and delicatessen cafés, that focused on specialty foods; it excludes chain fast-food restaurants.

 

Return to your place in the textTable 1b. Key Components of Interventions on Community-based Prepared-Food Sources: Interventions Conducted in Chain Restaurants
CharacteristicCoeur en Santé St-Henri (28,29)TrEAT Yourself Well (30)Tandon et al 2011 (31)
Data sourcesPeer-reviewed articlePeer-reviewed article; e-mail correspondencePeer-reviewed article; e-mail correspondence
Target populationMontreal; restaurant customers; low-incomeSan Diego area; restaurant customers; mostly whiteSeattle and San Diego; children aged 6–11 years and parents
Model/TheorySocial learning theoryTheory of reasoned action; social marketingNone specified
GoalAwareness; consumptionAwareness; consumptionAwareness; consumption
Types of prepared-food sourcesFast-food restaurant and family-style restaurant4 chain restaurantsChain restaurants
Food targeted in interventionLow-fat, high-fiber items on menusLow-fat menu items containing fruits and vegetablesChain restaurant foods
Intervention strategies
SignageMenu labelingPoint-of-purchase materials (table tents, posters)Menu labeling
Increased availability of healthful foodsRecipe modification to increase fiber or decrease fat NoneNone
PricingNoneDiscount cardsNone
Community componentsMedia (newspaper, telephone, leaflets)Community events and food tasting; media (television, magazines, newspaper)None
OtherNoneWait-staff incentivesNone
Formative researchCommunity informants identify popular restaurants; dietitian review of menu options via interviews with kitchen staff supervisor and suppliersNoneNone

 

Return to your place in the textTable 1c. Key Components of Interventions on Community-based Prepared-Food Sources: Interventions Conducted in Small Local Restaurantsa
CharacteristicShape Up Somerville (32–36)Smart Menu Program (37,38)The Healthy Options Program (39–42)
Data sourcesPeer-reviewed articles; websitePeer-reviewed articles; e-mail correspondencePeer-reviewed article; website; e-mail correspondence
Target populationSomerville, Massachusetts; restaurant customers; students in 1st–3rd gradeTacoma-Pierce County, Washington; restaurant customers; mostly whiteRural Iowa; mostly white
Model/TheoryCommunity-based participatory researchDiffusion of innovationsSocial cognitive theory
GoalAwareness; availabilityAwareness; consumptionAwareness; consumption
Types of prepared-food sourcesVarious participating restaurantsVarious participating locally owned restaurantsVarious locally owned restaurants
Food targeted in interventionsHalf-size portions; low-fat milk or waterMeal and dessert itemsLow-fat dressings, milk, meat, sides, breakfast items, desserts, whole-wheat bread
Intervention strategies
SignageMenu labeling; point-of-purchase materials (logo and signs, menu inserts)Menu labelingPoint-of-purchase materials (table placard, poster)
Increased availability of healthful foodsHalf-sized portions of entrées; fruit and vegetable side dishes; low-fat milk or waterEncouragement of addition of healthful items, preparations, smaller portion sizesNone
PricingNoneNoneNone
Community componentsImproved walkability and environmental policies; community advocates established; farmers market program; newspaper adsMedia (newsletters, newspapers, websites)Media (newspaper)
OtherNoneFree menu analysisNone
Formative researchMeetings, focus groups, and interviews with owners/managers; advisory council; approval criteria were refined with feedbacks from restaurant owners and managers; unable to complete 3 focus groups with restaurantsMenu labeling literature review; consulted food industry representative and health advisory group; no formal formative research phase.Pilot survey to indicate customer preferences; presented to owners

a Includes small, locally owned “mom-and-pop” establishments that include but are not limited to take-out and sit-down restaurants and restaurants that focused on specialty foods; it excludes chain restaurants.

 

Return to your place in the textTable 1d. Key Components of Interventions on Community-based Prepared-Food Sources: Interventions Conducted in Mixed Types of Restaurantsa
CharacteristicHealthy Howard Initiative (43)Healthy Restaurant Program (44–46)Winners Circle Healthy Dining Program (47–49)
Data sourcesInterview; website; printed materials; e-mail correspondencePeer-reviewed article; research report; interviewPeer-reviewed article; conference presentation; website; e-mail correspondence
Target populationHoward County, Maryland; restaurant customersSeoul, South Korea; restaurant customers65 North Carolina counties; mixed race/ethnicity
Model/theoryCommunity-based environmental change initiativeCommunity capacity analysisSocial marketing; community-based environmental-change initiative
GoalAwareness; consumptionAwareness; consumptionAwareness; consumption
Types of prepared-food sourcesVarious participating restaurantsVarious participating restaurantsVarious participating restaurants
Food targeted in interventionsHealthful entrées that meet nutritional criteriaHealthful menu items that meet nutritional criteriaMeals, side items, snacks and beverages good for “heart health”
Intervention strategies
SignageMenu labeling; point-of-purchase materials (window decal and certificate, nutrition sheets)Menu labeling; point-of-purchase materials (photos, menu boards, posters, logo on restaurant)Point-of-purchase materials (logo on menu, promoted items)
Increased availability of healthful foodsTrans fat-free; healthful menu optionsFoods that meet nutritional standardsNone
PricingDiscounts (planned, not yet implemented)NoneNone
Community componentsMedia (newspaper, magazine, websites); community eventsMedia (newspaper, website); community eventsMedia (billboards, television)
OtherComply with the “Clean Indoor Air Act”; pass food inspections; allergen labeling on menuNoneNutritional information in booklets or brochures in some locations
Formative researchNoneSurvey of customers and restaurant workers for information on how to design intervention; focus groups with restaurant workers; in-depth interviews with consumersPilot in 2 North Carolina counties; intercept interviews

a Includes restaurants (both local and chain) that did not share characteristics with other intervention restaurants or whose characteristics were not well defined.

 

Return to your place in the textTable 2a. Evaluation Methods Used by Interventions on Prepared-Food Sources, by Type of Intervention: Interventions Conducted in Specialty Restaurantsa
CharacteristicBaltimore Healthy Carryouts (15–23)Good for You (24)Steps to a Healthier Salinas (25,26)Horgen and Brownell 2002 (27)
Study designExperimental design; pre–post assessment (n = 8)Nonexperimental; pre–post sales analysis, broken down by quarter (n = 7)Nonexperimental; no pre–post assessment; intervention trial, voluntary participation; no comparison group (n = 16)Nonexperimental; pre–post assessment (n = 1)
Feasibility assessment measuresbInformal observation; staff reports; interviews with carryout owners or staffLaunched simultaneously in all Target Food Avenue restaurants; not assessed at individual store levelAssessments, discussion with health educatorsInformal visits, daily check-in
Process evaluation measurescDirect observationNoneSurveys with store owners; informal observationInformal visits, daily check-in
Prepared-food source impact measuresSalesSalesNoneSales
Consumer impact measuresdPurchasing; awareness; self-reported body mass indexNoneModified Behavioral Risk Factor Surveillance System Behavior

a Includes restaurants, such as carryouts, taquerias, and delicatessen cafés, that focused on specialty foods; it excludes chain fast-food restaurants.
b Feasibility assessment measures include acceptability, operability, and perceived sustainability.
c Process evaluation measures include dose, reach, and fidelity, which indicate how well the program was implemented according to plan.
d Consumer impact measures included psychosocial, behavioral, and health outcomes.

 

Return to your place in the textTable 2b. Evaluation Methods Used by Interventions on Prepared-Food Sources, by Type of Intervention: Interventions Conducted in Chain Restaurants
CharacteristicCoeur en Santé St-Henri (28,29)TrEAT Yourself Well (30)Tandon et al 2011 (31)
Study designNonexperimental; no pre–post assessment (n = 2)Quasi-experimental; no pre–post assessment; comparison regions (n = 4)Pre–post assessment; comparison counties
Feasibility assessment measuresaNoneNoneNone specified
Process evaluation measuresbNoneNoneNone specified
Prepared-food source impact measuresNoneNoneNone
Consumer impact measurescPurchasing; attitudesAwareness; attitudesAwareness; behavior (calories consumed)

a Feasibility assessment measures include acceptability, operability, and perceived sustainability.
b Process evaluation measures include dose, reach, and fidelity, which indicate how well the program was implemented according to plan.
c Consumer impact measures included psychosocial, behavioral, and health outcomes.

 

Return to your place in the textTable 2c. Evaluation Methods Used by Interventions on Prepared-Food Sources, by Type of Intervention: Interventions Conducted in Small Local Restaurantsa
CharacteristicShape Up Somerville (32–36)Smart Menu Program (37,38)The Healthy Options Program (39–42)
Study designQuasi-experimental; nonexperimental for restaurant portion of intervention; intervention trial, voluntary participation (n = 21)Nonexperimental; pre–post assessment; intervention trial, voluntary participation; no comparison group (n = 6)Nonexperimental; pre–post assessment (n = 4)
Feasibility assessment measuresbEnvironmental change assessment; owners’ compliance and perceived impactInterviews with restaurant owners or managersInterviews with owner and staff
Process evaluation measurescExtensive process evaluation; participation and adherence to intervention elementsObservation of nutrition information being postedNone
Prepared-food source impact measuresOwner survey (menu changes, sales, nutrition awareness)SalesSales
Consumer impact measuresdNone for restaurant intervention; assessment at child and household level (change in body mass index)Awareness; behaviorAwareness; behavior

a Includes small, locally owned “mom-and-pop” establishments that include but are not limited to take-out and sit-down restaurants and restaurants that focused on specialty foods; it excludes chain restaurants.
b Feasibility assessment measures include acceptability, operability, and perceived sustainability.
c Process evaluation measures include dose, reach, and fidelity, which indicate how well the program was implemented according to plan.
d Consumer impact measures included psychosocial, behavioral, and health outcomes.

 

Return to your place in the textTable 2d. Evaluation Methods Used by Interventions on Prepared-Food Sources, by Type of Intervention: Interventions Conducted in Mixed Types of Restaurantsa
CharacteristicHealthy Howard Initiative (43)Healthy Restaurant Program (44–46)Winners Circle Healthy Dining Program (47–49)
Study designNonexperimental design; intervention trial, voluntary participation; no comparison groupNonexperimental design; pre–post assessment; intervention trial, voluntary participation; no comparison groupNonexperimental; intervention trial, voluntary participation; cross-sectional survey of community awareness of program; no comparison group
Feasibility assessment measuresbRestaurant owner or manager survey; focus group; recipe analysisInterviews with chefs; survey of restaurant managers or staffSurvey of managers
Process evaluation measurescInformal observation, telephone communication; annual health inspection; recertification every 2 yearsAnnual menu analysis; annual observationTracked reach and dose using Winner’s Circle team reporting forms; menu review
Prepared-food source impact measuresRestaurant owner or manager survey (recall of sales)Restaurant owner surveyNone
Consumer impact measuresdPsychosocial, behavioral surveyAwareness; attitudesAwareness

a Includes restaurants (both local and chain) that did not share characteristics with other intervention restaurants or whose characteristics were not well defined.
b Feasibility assessment measures include acceptability, operability, and perceived sustainability.
c Process evaluation measures include dose, reach, and fidelity, which indicate how well the program was implemented according to plan.
d Consumer impact measures included psychosocial, behavioral, and health outcomes.

 

Return to your place in the textTable 3a. Feasibility, Process, and Impact Results of Interventions on Prepared-Food Sources: Interventions Conducted in Specialty Restaurantsa
CharacteristicBaltimore Healthy Carryouts (15–23)Good for You (24)Steps to a Healthier Salinas (25,26)Horgen and Brownell 2002 (27)
Feasibility and process resultsHigh acceptability and fidelity for Phase 1 and Phase 3; medium acceptability and operability for Phase 2; high dose receivedNot assessedMedium feasibility; medium reach to owners; moderate to high fidelity in terms of changes to menu itemsAssessed but results not reported
Prepared-food source impact resultsIncrease in sales of promoted itemsIncrease in sales of promoted itemsNot assessedIncrease in sales of promoted items, especially with price reductions
Consumer psychosocial impact resultsNot assessedNot assessedAssessed but results not reportedAssessed but results not reported because of low response rate
Consumer behavioral impact resultsIncreased purchasingNot assessedNot assessed Not assessed
Other resultsCommunity members’ positive response toward the interventionSeasonality of sales of some foods (salad, frozen yogurt)Mistrust of health educators by restaurant ownersHealth messages not very effective
SustainabilityLow implementation costSales of labeled foods remained highHigh sustainability: most signage still displayed 4 years laterWent out of business
Policy results, implicationsDisseminated citywide as a public market carryout strategy “Get Fresh Public Markets”Supports effectiveness of menu labelingConsidering permits based on healthful food offeringsSubsidies on healthful foods can increase sales

a Includes restaurants, such as carryouts, taquerias, and delicatessen cafés, that focused on specialty foods; it excludes chain fast-food restaurants.

 

Return to your place in the textTable 3b. Feasibility, Process, and Impact Results of Interventions on Prepared-Food Sources: Interventions Conducted in Chain Restaurants
CharacteristicCoeur en Santé St-Henri (28,29)TrEAT Yourself Well (30)Tandon et al 2011 (31)
Feasibility and process resultsHigh acceptability among owners and customersNot assessedNone
Prepared-food source impact resultsNot assessedNot assessedNone
Consumer psychosocial impact resultsAwareness of campaign; intentions to eat healthierHigh awareness; beliefs about healthful foodHigh awareness of nutrition information
Consumer behavioral impact resultsIncreased purchasing in family-style restaurant compared with fast-food restaurantIncreased purchasing of healthful foodsNo difference in mean calories consumed between or within groups
Other results25% of customers reported that they eat at the restaurant at least once a week; health and taste top 2 reasons for selecting healthful itemsDemographic variables had no effect on awarenessNo information
SustainabilityPermanent implementation of some healthful foodsNo informationNo information
Policy results and implicationsEvidence for feasibility of intervention in low-income settingModerate support for promotional campaigns as intervention strategyNone

 

Return to your place in the textTable 3c. Feasibility, Process, and Impact Results of Interventions on Prepared-Food Sources: Interventions Conducted in Small Local Restaurantsa
CharacteristicShape Up Somerville (32–36)Smart Menu Program (37,38)The Healthy Options Program (39–42)
Feasibility and process resultsLow acceptability; medium reachHigh acceptability; low feasibility; low reach; low operabilityModerate acceptability of promoted items; high fidelity; high feasibility
Prepared-food source impact results4/10 Restaurants changed menus; 6/10 reported customers ordering from Shape Up Somerville options; 7/10 believed beneficial to participate; 7/10 were more aware of nutrition; 4/10 thought customers were more aware of nutritionFewer average calories, lower levels of fat and sodium per entrée soldNo significant change in ordering
Consumer psychosocial impact resultsNot assessed at restaurant levelHigh level of awareness; no impact on knowledge reportedModerate awareness
Consumer behavioral impact resultsNot assessed at restaurant level20.4% of customers reported ordering lower calories, 16.5% lower fat1/3 of customers reported materials influenced ordering
Other resultsBody mass index among children reduced by 0.1005Higher entrée cost associated with more calories and fat consumed; consumers chose smaller, cheaper entréesNone
SustainabilityLow-medium: more than 50% of restaurants were noncompliant at follow-upMedium: resource-intensive intervention.High: materials stayed in place
Policy results, implicationsNeeded a stronger prepared-food source componentSuccess for calorie-labeling policyPossibilities for combination with other intervention strategies

a Includes small, locally owned “mom-and-pop” establishments that include but are not limited to take-out and sit-down restaurants and restaurants that focused on specialty foods; it excludes chain restaurants.

 

Return to your place in the textTable 3d. Feasibility, Process, and Impact Results of Interventions on Prepared-Food Sources: Interventions Conducted in Mixed Types of Restaurantsa
CharacteristicHealthy Howard Initiative (43)Healthy Restaurant Program (44–46)Winners Circle Healthy Dining Program (47–49)
Feasibility and process resultsModerate reach (currently on-going)Increasing reach; improved ratings of participating restaurantsHigh feasibility; medium-low reach
Prepared-food source impact resultsNot assessed (surveys not performed)Increase in sales of promoted items; sodium and fat in foods significantly decreasedNot assessed
Consumer psychosocial impact resultsAssessed but not reportedHigh customer acceptabilityLow awareness
Consumer behavioral impact resultsAssessed but not reportedNot assessedMedium use of label for food choice
Other resultsNoneNoneNone
SustainabilityLow implementation costHigh: 85/96 of restaurants are maintaining programLow-cost, easily implemented
Policy results, implicationsVoluntary programOrdinance for the Healthy Restaurant ProgramNo links with policy

a Includes restaurants (both local and chain) that did not share characteristics with other intervention restaurants or whose characteristics were not well defined.

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Return to your place in the textAppendix. Adjudication Chart for Study Review

TopicReviewer 1 long responseReviewer 1 short summary responseReviewer 2 long responseReviewer 2 short summary responseAdjudication (as it appears in the final table)
Project name     
Data sources     
Target population (ethnicity, age group, geographic location, etc.)     
Model/Theory     
Goal or Purpose of the trial (increase availability, increase sales, modify consumer diet, etc.)     
Food (foods that were the focus of the intervention)     
Intervention strategies: signage     
Intervention strategies: availability of healthy foods     
Intervention strategies: pricing or cost     
Intervention strategies: community components     
Intervention strategies: other     
Study design     
Formative research     
Feasibility assessment (acceptability, operability, perceived sustainability)     
Process evaluation (how well the program was implemented according to plan)     
Prepared-food source impact measures     
Consumer impact measures (psychosocial, behavioral, health outcomes)     
Feasibility and process results     
Prepared-food source impact results     
Consumer psychosocial Impact results     
Consumer behavioral impact results     
Other results     
Sustainability     
Policy results, implications     

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