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Out-of-home eating is increasing, but evidence about its healthiness is limited. The present systematic review and meta-analysis aimed to elucidate the effectiveness of full-service restaurant and canteen-based interventions in increasing the dietary intake, food availability, and food purchase of healthy meals. Studies from 2000–2020 were searched in Medline, Scopus, and Cochrane Library using the PRISMA checklist. A total of 35 randomized controlled trials (RCTs) and 6 non-RCTs were included in the systematic review and analyzed by outcome, intervention strategies, and settings (school, community, workplace). The meta-analysis included 16 RCTs (excluding non-RCTs for higher quality). For dietary intake, the included RCTs increased healthy foods (+0.20 servings/day; 0.12 to 0.29; p < 0.001) and decreased fat intake (−9.90 g/day; −12.61 to −7.19; p < 0.001), favoring the intervention group. For food availability, intervention schools reduced the risk of offering unhealthy menu items by 47% (RR 0.53; 0.34 to 0.85; p = 0.008). For food purchases, a systematic review showed that interventions could be partially effective in improving healthy foods. Lastly, restaurant- and canteen-based interventions improved the dietary intake of healthy foods, reduced fat intake, and increased the availability of healthy menus, mainly in schools. Higher-quality RCTs are needed to strengthen the results. Moreover, from our results, intervention strategy recommendations are provided.
- out-of-home eating
- menu choice
- restaurant-based interventions
- family
- food-service
- food behavior
- restaurant
- eating out
- systematic review
- meta-analysis
1. Introduction
The change in modern living due to urbanization and globalization [1] and the lack of sufficient free time to dedicate to home cooking have increased families’ consumption of daily meals out of the home [2]. Restaurants, schools, workplace canteens and food stores providing prepared meals are the preferred food services by both children and adult populations [3][4].
The change in modern living due to urbanization and globalization [1] and the lack of sufficient free time to dedicate to home cooking have increased families’ consumption of daily meals out of the home [2]. Restaurants, schools, workplace canteens and food stores providing prepared meals are the preferred food services by both children and adult populations [3,4].
Consequently, eating out of home is associated with a unhealthy diet [5] due to the lower consumption of fruits and vegetables [6]. Furthermore, comparisons of the nutritional profile of foods have shown that meals prepared out of the home are higher in energy density, fat and sodium and lower in calcium and fiber than foods prepared at home [7]. Thus, consumers of out-of-home meals may report important long-term health implications, such as obesity [8] and related chronic diseases [9]. In this regard, people are paying more attention to the healthiness of food when eating out of home [10], demanding higher-quality meals from food businesses that have the responsibility to provide them according to consumers’ necessities [11].
For instance, potential strategies for the promotion of healthier meals could be the improvement of the nutritional quality of food in terms of energy, fat and sodium [12], the reduction of portion sizes in meals [13] and the provision of nutritional labels [14]. The lack of nutritional information on menus, known as the consumer “nutritional knowledge gap”, could hinder people’s healthy eating intentions when they are eating out of home [15].
However, the literature on the most effective interventions to improve consumers’ diet when they are eating out of home is still scarce. Moreover, most nutrition interventions are set in fast-food and chain restaurants mainly placed in urban areas [16], leaving little evidence about independent restaurants and potential intervention strategies [17][18].
However, the literature on the most effective interventions to improve consumers’ diet when they are eating out of home is still scarce. Moreover, most nutrition interventions are set in fast-food and chain restaurants mainly placed in urban areas [16], leaving little evidence about independent restaurants and potential intervention strategies [17,18].
Another aspect is identifying suitable solutions for different population targets [19], such as children, adolescents and adults, and in different environments, such as restaurants [18], schools [20] and workplace canteens [21].
2. Interventions to Promote Healthy Meals in Full-Service Restaurants and Canteens
Eligible interventions were full-service restaurants and canteen-based interventions aimed at increasing dietary intake, food availability, and food purchases in different settings, such as schools, workplaces, and communities. The results from the present systematic review showed that restaurant- and canteen-based interventions are effective in improving healthy dietary intake and food availability, mainly in the school setting, with a beneficial impact on children. However, there is partial evidence for the improvement of food purchases, and more evidence is needed about workplaces and community settings as full-service restaurants. Moreover, when the meta-analysis was performed without considering non-RCT studies, the results were confirmed in dietary intake for increasing healthy food intake and in the reduction of fat intake.
Demonstrated effectiveness in increasing the intake of healthy food items (whole grains, dairy products and alternatives) and nutrients such as fiber [22][23][24][25][26][27][28][29][30][31][32][33][34] mainly in children, demonstrating that schools are a favorable environment for the promotion of healthy dietary intake. Furthermore, an increase in daily caloric intake occurred in favor of the CG [35][25][27][28][31][32][33], and effectiveness was observed for decreasing the consumption of other nutrients such as saturated fat and fat in the IG [36][24][25][32][33]. For food availability outcome, the intervention studies included in the meta-analysis were also demonstrated to be effective in reducing the risk, for the intervention schools, of offering unhealthy foods and beverages on canteen menus [37][38][39].
Demonstrated effectiveness in increasing the intake of healthy food items (whole grains, dairy products and alternatives) and nutrients such as fiber [27,43,50,51,52,55,56,58,59,63,64,67,69] mainly in children, demonstrating that schools are a favorable environment for the promotion of healthy dietary intake. Furthermore, an increase in daily caloric intake occurred in favor of the CG [44,51,55,56,63,64,67], and effectiveness was observed for decreasing the consumption of other nutrients such as saturated fat and fat in the IG [49,50,51,64,67]. For food availability outcome, the intervention studies included in the meta-analysis were also demonstrated to be effective in reducing the risk, for the intervention schools, of offering unhealthy foods and beverages on canteen menus [41,46,47].
For interventions in the dietary intake outcome category, the present results showed effectiveness mainly in school settings, which was the preferred setting for interventions targeting these outcomes. When targeting children, an important factor to be considered in nutrition interventions is food presentation in terms of color and smell, which should be appetized to trigger food selection and consumption. Thus, repeated exposure to healthier foods presented in attractive ways could help children become more accustomed to and consume it [40]. Focusing on adults, changing dietary habits to achieve a healthier lifestyle is made more difficult by the perceived barriers, such as: lack of cooking skills and willpower; time scarcity; the need to give up one’s favorite foods [41]; and social, cultural and economic conditions [42]. However, although the evidence about workplace settings is very limited in the present review, workplace interventions have the potential to change consumers’ dietary behavior through the working lifespan [43].
For interventions in the dietary intake outcome category, the present results showed effectiveness mainly in school settings, which was the preferred setting for interventions targeting these outcomes. When targeting children, an important factor to be considered in nutrition interventions is food presentation in terms of color and smell, which should be appetized to trigger food selection and consumption. Thus, repeated exposure to healthier foods presented in attractive ways could help children become more accustomed to and consume it [73]. Focusing on adults, changing dietary habits to achieve a healthier lifestyle is made more difficult by the perceived barriers, such as: lack of cooking skills and willpower; time scarcity; the need to give up one’s favorite foods [74]; and social, cultural and economic conditions [75]. However, although the evidence about workplace settings is very limited in the present review, workplace interventions have the potential to change consumers’ dietary behavior through the working lifespan [76].
Regarding the intervention strategies applied to improve dietary intake, the implementation of establishment-based interventions is different in the three evaluated settings. Specifically, the strategies that showed higher effectiveness in schools were the addition of healthier menu options combined with on-site support, training for the school canteen staff, performance monitoring and feedback reports (
Table 1). However, in the community setting, including after school programs and recreation centers, the provision of monetary incentives, rewards, and recognition for the participating food service are effective, while these methodologies are ineffective in schools.
4). However, in the community setting, including after school programs and recreation centers, the provision of monetary incentives, rewards, and recognition for the participating food service are effective, while these methodologies are ineffective in schools.
Table 14.
| Setting | Outcome Categories | ||
|---|---|---|---|
| Food Availability | Dietary Intake | Food Purchase | |
| School | The involvement of the students’ families, as a consumer-based strategy, together with the application of multiple establishment-based strategies, seemed to be effective in improving food availability in the school setting. | The application of consumer-based strategies together with the implementation of a menu with healthier options and limitation of the unhealthier ones, applied alone or in combination with other establishment-based strategies, seemed to be effective in improving dietary intake in the school setting. On the other hand, the provision of monetary incentives/rewards/recognition for the participating school canteen was not effective. | The application of consumer-based strategies together with the implementation of a menu with healthier options and limitation of the unhealthier ones, applied alone or in combination with other establishment-based strategies, seemed to be effective in improving food purchases in the school setting. |
| Community | No recommendation can be provided about both consumer- and establishment-based strategies. | The application of consumer-based strategies, together with establishment-based strategies such as the provision of monetary incentives/rewards/recognition for the participating restaurant or canteen, seemed to be effective in improving dietary intake in the community setting. | The application of multiple establishment-based strategies, including monetary incentives/rewards/recognition for the participating restaurant or canteen, seemed to be effective in improving food purchases in the community setting. |
| Workplace | Outcome not evaluated. | The application of consumer-based strategies together with the implementation of a menu with healthier options and limitation of the unhealthier ones, as an establishment-based strategy, seemed to be effective in improving dietary intake in the workplace setting; however more evidence is needed. | No recommendation can be provided about both consumer- and establishment-based strategies |
According to the interventions in the food availability outcome category, none of them were set in workplaces, and little evidence resulted in the community setting [44], whereas effectiveness was reported in the school setting [45][46][37][47][23][44][38][39][48][49]. In schools, regarding the intervention strategies applied for food availability outcomes, the involvement of the participants’ families, namely students and their parents in school-based interventions, through invitations to meetings, activities and the distribution of information letters, was the most effective consumer-based strategy [37][38][49]. Similarly, in a recent review focusing on family-based interventions to improve children’s diets, the family involvement strategy through the provision of information, advice and monitoring was also reported to be effective in improving the food environment of school canteens, demonstrating that parents are an important component when children are targeted [50].
According to the interventions in the food availability outcome category, none of them were set in workplaces, and little evidence resulted in the community setting [45], whereas effectiveness was reported in the school setting [38,39,41,42,43,45,46,47,48,72]. In schools, regarding the intervention strategies applied for food availability outcomes, the involvement of the participants’ families, namely students and their parents in school-based interventions, through invitations to meetings, activities and the distribution of information letters, was the most effective consumer-based strategy [41,46,72]. Similarly, in a recent review focusing on family-based interventions to improve children’s diets, the family involvement strategy through the provision of information, advice and monitoring was also reported to be effective in improving the food environment of school canteens, demonstrating that parents are an important component when children are targeted [78].
Children’s improvements in food availability are important because their adherence persists in adulthood, whereas unhealthy food availability reinforces children’s preference for nutrient-poor and ultra-processed foods [51]. The increase in healthy food availability in school settings is directly correlated with healthy food purchases, with the final aim of changing children’s dietary intake [52].
Children’s improvements in food availability are important because their adherence persists in adulthood, whereas unhealthy food availability reinforces children’s preference for nutrient-poor and ultra-processed foods [79]. The increase in healthy food availability in school settings is directly correlated with healthy food purchases, with the final aim of changing children’s dietary intake [80].
On the other hand, the implementation of healthier food availability in the community setting is more difficult due to the barriers stakeholders encounter, such as the lack of demand by customers and the increased cost associated with healthy fresh foods with a short shelf life [53][54][55], but financial support and resources such as guidelines and training from established associations could help achieve such improvements [53]. Thus, future interventions aimed at increasing the availability of healthier food options in community settings should also target an increase in consumers’ demands for healthy meals, as well as assure food services of the low risk of changes in their profits [56].
On the other hand, the implementation of healthier food availability in the community setting is more difficult due to the barriers stakeholders encounter, such as the lack of demand by customers and the increased cost associated with healthy fresh foods with a short shelf life [81,82,83], but financial support and resources such as guidelines and training from established associations could help achieve such improvements [81]. Thus, future interventions aimed at increasing the availability of healthier food options in community settings should also target an increase in consumers’ demands for healthy meals, as well as assure food services of the low risk of changes in their profits [84].
For the interventions in the food purchase outcome category, partial effectiveness was reported mainly in schools through the implementation of multiple consumer- and establishment-based strategies, including the involvement of participants’ families [57][22][58][38][59][60][61]; thus, family certainly has a good influence on children’s food selection [62].
For the interventions in the food purchase outcome category, partial effectiveness was reported mainly in schools through the implementation of multiple consumer- and establishment-based strategies, including the involvement of participants’ families [25,27,29,46,60,65,66]; thus, family certainly has a good influence on children’s food selection [85].
On the other hand, little evidence about effective strategies in community and workplace settings was apparent; however, in community settings such as restaurants and food stores, the provision of information and communication to consumers may not be enough to achieve behavior changes such as the selection of healthier food options [63][64], whereas multiple strategies targeting changes in the food environment could be fundamental for improving customers’ food purchases [44].
On the other hand, little evidence about effective strategies in community and workplace settings was apparent; however, in community settings such as restaurants and food stores, the provision of information and communication to consumers may not be enough to achieve behavior changes such as the selection of healthier food options [26,40], whereas multiple strategies targeting changes in the food environment could be fundamental for improving customers’ food purchases [45].
Moreover, effective consumer- and establishment-based strategies were derived from the included interventions to develop methodological recommendations, by outcome and setting, for the implementation of future restaurant and canteen-based interventions (
Table 1).
4).
The entry is from 10.3390/nu13041350
