2. Development and Findings

The goal of this scoping review was to examine the engagement of a wide range of restaurants in strategies or innovations to facilitate healthier eating, calling attention to independent as well as corporate or chain restaurants. Expanding beyond investigator-initiated research sources, and specifically with the inclusion of media and gray literature sources, this review provides insights from the perspective of the restaurant—a research gap in the existing academic literature as noted in pasts reviews ^[17]. Our assessment of real-world practices suggests that restaurants are responding to the increased customer demand for healthier offerings ^[18] and that this response varies according to restaurant type and who initiates the change.

Changes initiated by restaurants, mostly in corporate-owned restaurants, sought to increase the availability of healthier offerings, in general. Investigator-initiated changes and those in independently owned restaurants were mostly environmental in nature, notably the promotion of available healthier choices. This may be due to these changes being driven mostly by investigators seeking to work with healthful offerings already offered (rather than telling restaurants what foods to offer). While our review does not provide confirmation on the rationale behind this difference, this may be potentially due to investigators seeking to lower the risk of participation for the restaurants or the tangible and intangible costs involved in creating new dishes. This trend concurs with past reviews focusing on community-based restaurants, where the point of sale promotion and provision of information was the more salient intervention, compared with the increase in healthier offerings ^[8]. Compared with independently-owned restaurants, corporate restaurants have more resources to develop and test new offerings, respond to perceived consumer trends or avoid alienating the healthy eater in the party ^[19]. Independently owned restaurants often cater to a smaller customer base and operate under much narrower profit margins that can limit the experimentation with new offerings unless it is driven by an intrinsic motivation to innovate. Future research can best be used to explore these differences, examining the innovation processes driving innovation in restaurants, examining in greater detail these processes while accounting for restaurant type, such as corporate vs. independently owned, as well as categorizing establishments by price-point and target clientele. This information will provide public health practitioners more information from the business perspective, highlighting leverage points when seeking to collaborate with restaurants in future interventions.

While the changes in offerings may be encouraging, less reporting was found when examining the increase of specific health-promoting foods, as in the case of fruits, vegetables, whole grains, and salads. The innovations or changes in regards to offerings demonstrated the restaurant response to food trends, including changes made in concordance to diet “fads”, as in the case of low carb or high protein offerings, which respond to popular diets as in the case of the Atkins diet or Keto diets, among others ^[20], and in concordance with concerns over environmental sustainability and additives in the food supply, where restaurants were seeking to promote plant-based diets, as well as dishes made with local foods or additive-free (“clean”) offerings ^[21][22].

The analysis revealed four factors that were found to influence restaurants’ ability to engage in healthy eating promotion strategies: perceptions regarding customer demand, expectations concerning revenue, views concerning community health, and food sourcing. Perceptions concerning demand and profitability were salient as both motivation and barrier, demonstrating the potentially subjective and context-dependent nature of this important factor. Glanz et al. conducted a study on menu planning where they documented the reluctance to increase healthier offerings if consumer demand is low, as these offerings can also risk spoilage and may need additional labor in preparation ^[19]. The sourcing of fresh ingredients, as in the case of fruits and vegetables, can also be inconsistent, further increasing the risk for these healthier offerings, which may not be viewed as profitable in the first place. At the same time, our findings concerning reported outcomes reveal that engagement in health-promoting strategies can be good for business, given the reported increase in profit, consumer acceptance, and business visibility. While our examination of outcomes was not systematic and limited to what was reported in the source, this finding concurs with Blake et al. scoping review of the effect of health-promoting strategies on business outcomes, where 45% of sources reported favorable business outcomes and only 15% were unfavorable (34% classified as “neutral”). These included retailer satisfaction, perceived customer satisfaction, and those influencing profit (i.e., Amount spent by transaction) ^[17]. Public health research articles focused mostly on consumer-related outcomes, including acceptability and purchasing behaviors. In concordance with Blake et al., outcomes were not well reported in terms of revenue or profit, especially in public health intervention studies ^[17]. These were mostly assessed relying on restaurant-provided sales data, presenting logistical barriers for researchers to obtain.

Aside from business outcomes, our findings revealed the importance placed on community health—a factor that may also be subjective and highly personal. While restaurants may be nudged to engage in healthy eating promotion strategies, by policy mandate or an investigator-led effort, the success and sustainability of such strategies will depend on the value restaurant owners place on health and whether owners perceive restaurants have a role in improving health in their communities. Lack of interest was an important barrier in sources describing investigator-led strategies, underscoring the importance of ownership and engagement when working with restaurant stakeholders. Creating the change needed cannot be sustainably done by public health interventionist plea or imposition.

Our examination of sources describing healthy restaurant business models reveals potential case studies for future research where we see a confluence of key motivations, resulting in healthy restaurant environments. These restaurants are the result of a recognition of healthful offerings as profitable, meeting perceived market demand, while also being driven to improve community health. Our examination of these restaurants was facilitated by the inclusion of gray literature, as these were not featured as part of academic intervention studies. Moving forward, building on this approach, future research can continue to examine healthy restaurant business models, gather potential lessons learned for other restaurants wishing to undertake changes to follow, and document these as success stories that can help model desired behaviors for other restaurants in the future.

3. Conclusions

This scoping review contributes to food environment research by going beyond more commonplace disciplinary boundaries used in other review studies focused on public health research articles. Our review demonstrated that most of the evidence to date was found in the real world and not in academic, peer-reviewed sources. We were able to bring forth practice-based evidence, showcasing the business perspective, as an important consideration when seeking to change food environments. This approach can be considered in future work seeking to understand system dynamics shaping food environments and persisting diet-related disparities, pushing researchers to engage in interdisciplinary and intersectoral collaborations to assess and learn from real-world practices. Our approach also allowed us to examine key differences by restaurant type, underscoring the importance of tailored approaches when seeking to address independently owned versus corporate restaurants. The former is in need of incentives-based approaches, such as subsidies or tax incentives, to create healthful changes.

The engagement of restaurants in healthy eating promoting strategies and innovations demonstrates the growing recognition of demand and need for these innovations ^[18]. This is further evidenced by restaurants designed with healthy eating in mind, as found in the subsample of records regarding these restaurants ^{[23][24][25][26][27][28][29][30][31][32][33][34][35][36][37]}. At the same time, these strategies, particularly those involving changes in offerings, do not seem as widely adopted in independently owned restaurants compared to corporate ones. More work is needed to create incentives that facilitate such changes, potentially including policy interventions that support these restaurants, while recognizing their important role in local communities and needs as businesses. The COVID-19 pandemic has highlighted the fragility of the restaurant industry ^[38], but also the adaptability of the sector when faced with the need to innovate. More research is needed to examine whether the innovations examined in this study will continue to cater to healthy eaters, or if these efforts will be halted given business-related concerns, issues with the food supplies, or the uncertainty of regulations targeting the industry, in response to the pandemic.