Excess sodium intake can lead to increased blood pressure.1 High blood pressure is a major risk factor for heart disease and stroke, both of which are leading causes of death in the United States.2 The average amount of sodium consumed by Americans is considerably higher than the Dietary Guidelines for Americans recommendations and is primarily from processed and restaurant foods.3 During 2007-2008, restaurant foods contributed nearly a quarter of the sodium consumed (24.8%) in the American diet.3 Recent national attention to sodium in foods has resulted in some large restaurant chains committing to reduce sodium in menu items.4,5
Restaurants are either independent or part of a restaurant chain. Independent restaurants are not associated with national or regional names, and the owners of these restaurants are usually involved in the day-to-day operations of their facility and often make menu decisions.6 For both chain and independent restaurants, considerations for menu development or revisions may include patron needs and desires, staff skills, capacity of the kitchen facility, availability and costs of ingredients, and nutrient content of the foods bought and prepared.7 Substantial amounts of sodium may already be part of the food items purchased by the restaurant from distributors (eg, breaded chicken breast, soup base), or salt may be added to food items as an ingredient. Because of their smaller sizes, independent restaurants may have limited resources, both in terms of money to purchase food and buying power when sourcing food (negotiations based on the quantity of products needed), but may have more decision-making authority over what is served and how foods are prepared.
Smaller, independent restaurants present an opportunity for collaboration with public health to facilitate sodium-reduction efforts. Local health departments often have existing relationships with independent restaurant owners by virtue of the health department's food safety inspectors and can provide restaurants with the expertise and tools for nutrition analysis, request nutritional information from vendors, and compare products. Local health departments can also promote the restaurants they are working with through advertisements in local publications, such as newspapers and newsletters, and the health department's Web site.
Given the potential effect that local health departments and independent restaurants can have on efforts to reduce sodium intake, a pilot program using the Restaurant Assessment Tool and Evaluation (RATE) was implemented by the Schenectady County Health Department (SCHD) staff in New York. Building upon their existing infrastructure, the SCHD staff engaged independent restaurant owners by using a facilitated discussion tool (RATE) to assess their sodium-related practices and motivation to change menu items, cooking techniques, and ingredients. The goal of the pilot program was to assess efforts to reduce sodium in independent restaurants and measure changes over time within, not between, each participating restaurant. Although not an initial goal of the pilot, an unintended benefit of the RATE was that it allowed the SCHD staff to develop relationships with restaurant owners and to provide coordinated technical assistance to facilitate sodium reduction in participating restaurants.
This article describes the development, implementation, and findings for the use of a facilitated assessment tool that successfully assisted independent restaurant owners in Schenectady County, New York, to voluntarily implement sodium-reduction practices. Other positive outcomes resulting from the pilot and suggestions for furthering sodium-reduction strategies in the local community are also provided.
Methods
The SCHD staff searched for a validated instrument to use to measure sodium-related practices in small, independent restaurants. Without one, the SCHD staff drew upon their expertise as public health practitioners to devise a new instrument-RATE, which consisted of 46 questions evaluating menu items, cooking techniques, and products purchased by the restaurant owner (see Supplementary Digital Content available at http://links.lww.com/JPHMP/A39). The tool was generally modeled after the Centers for Disease Control and Prevention's CHANGE (Community Health Assessment and Group Evaluation) tool, an assessment and action planning tool for school, health care, work site, and community settings.8 The New York State Department of Health Institutional Review Board reviewed this project and found that it was exempt from institutional review board review because the project was focused on implementation of public health strategies and did not meet the definition of human subjects research.
The RATE was specifically designed to assess independent restaurants, and questions were organized to assess 3 categories: menu items (eg, portion sizes, fruit and vegetable offerings; see Supplementary Digital Content available at http://links.lww.com/JPHMP/A42), cooking techniques (eg, reducing salt, measuring salt, or making sauces from scratch; see Supplementary Digital Content available at http://links.lww.com/JPHMP/A41), and products (eg, using lower-sodium ingredients or products; see Supplementary Digital Content available at http://links.lww.com/JPHMP/A43). Each question was scored on a Likert-type scale with responses ranging from "never" (1 point) to "all of the time" (5 points); a score of 5 was the most beneficial to reducing sodium, and 1 was the least. A not applicable category was also included to help account for differences among restaurant types (see Supplementary Digital Content available at http://links.lww.com/JPHMP/A40). Questions were structured the same way so that positive responses (ie, practices that the restaurant reported using to reduce sodium) received higher scores and negative responses (ie, practices to reduce sodium that the restaurant reported not using, or not using all of the time) received lower scores. Points were tallied and translated into percentages for a maximum score of 100% in each category. Changes in score were compared with each restaurant over time to assess change in sodium-reduction practices.
The SCHD staff worked closely with the county's Environmental Health Department to identify potential participating restaurants and make the initial phone contact with them. The Environmental Health Department is responsible for food safety inspections of all food service establishments in the county. The Environmental Health director made an initial introduction with 16 potential restaurants, and the SCHD staff reached out to these restaurants to determine their interest in participating in the voluntary pilot program. Incentives, such as advertising and promotional materials, were discussed with the first 5 of 16 restaurants recruited but were declined. The restaurant owners reported wanting to participate because of a desire to accommodate the dietary needs and preferences of their customers, not because of incentives. Because of this, incentives were not offered to any other restaurants recruited to participate.
Twelve restaurants agreed to participate in the pilot. The restaurants served a variety of fare-Greek-American, barbeque, West Indian, Moroccan, Mexican, or Tavern-style foods-and their seating capacity ranged from 50 to 200 people.
Initial assessment
Each participating restaurant took part in an initial assessment conducted by the SCHD staff that lasted 45 to 60 minutes. The assessment included a facilitated discussion to provide background on the RATE and its components (Table). The initial assessment was conducted by 2 to 3 SCHD staff members to compare the consistency of scoring. Although no formal reliability analysis was completed, scoring was generally consistent among different raters. The restaurant owners were asked to respond to questions in each of the 3 categories, and on the basis of the responses, a score was generated for the menu, cooking techniques, and products. For each question that did not receive the maximum score of 5, the SCHD staff asked the restaurant owners whether they would consider making a change, and their response was noted on the RATE. The restaurant owners were allowed to provide open-ended responses when they could not decide on a numerical response. While the RATE was in development, the open-ended responses allowed the SCHD staff to gather additional information in order to refine the questions.
During the assessment, the SCHD staff also provided technical assistance by answering questions about strategies that could be used to reduce sodium and making suggestions for the restaurant owners to consider. The restaurant owners were provided an evaluation feedback summary via either mail or during a face-to-face visit approximately 6 to 8 weeks after the assessments. The feedback summary (Figure) provided specific suggestions about strategies that could be implemented to reduce sodium, noted current practices that were strengths, and included notations made during the initial interview about the restaurant owners' willingness to reduce sodium in each category.
After initial assessments of 5 participating restaurants, the SCHD staff met to discuss their experiences using the RATE and impressions about whether the questions could be further refined to reflect the particular environment of an independent restaurant. From these discussions, the team revised the RATE by rephrasing questions to ensure clarity and consistency throughout the assessment and reordering questions to facilitate flow of discussion. Although changes were made in the RATE, the assessment remained essentially the same in content. The revised RATE was used with the remaining 7 restaurants for the initial assessment. After these assessments, the team made additional revisions to improve the RATE.
Follow-up assessment
The follow-up occurred 6 months after the initial assessment and analyzed changes that occurred during that time. The restaurant owners again responded to the RATE questions, and a new score was generated on the basis of relevant changes that were reported. Reported changes in sodium-reduction practices related to the menu (eg, whether a greater amount of lower-sodium items were offered), cooking techniques (eg, whether cooking practices were modified such as reducing or eliminating added salt or soup base from a recipe), and the type of products purchased by the restaurant (eg, the purchase of more lower-sodium products by the restaurant) were compared between baseline and follow-up to assess changes to reported practices. Scores were then compared with each restaurant's initial assessment to determine the percent change in that category. In addition, the SCHD staff conducted a count of all entree and side items on participating restaurants' menus. Any entree or side item affected by the reported changes was counted and divided by the total number of entrees or side items to determine the total percentage of the menu affected by the reported changes. An evaluation feedback form was again provided by the SCHD staff after the completion of the follow-up visit. The SCHD staff used the second evaluation feedback form as an opportunity to provide technical assistance to the restaurant owners, explaining the strengths of the sodium-reduction strategies being used and how additional changes could be implemented. The second feedback report showed a numeric score from each of the 2 RATE assessments and a calculated difference between the scores. Because the RATE had been revised, however, the scores provided a general impression of improvement rather than a precise count.
The RATE was strengthened by the provision of technical assistance by the SCHD staff to the restaurant owners about sodium-reduction practices. To interfere as little as possible with restaurant owners' businesses, the SCHD staff made the restaurant owners aware that technical assistance could be provided at any point by contacting staff. Formal opportunities for technical assistance were built in during the initial and follow-up assessments and through the initial and follow-up evaluation feedback forms. In addition, informal technical assistance was provided through phone calls and intermediate check-in visits that occurred approximately once every 3 months. These opportunities allowed the restaurant owners to ask questions and for the SCHD staff to provide information on products, analyze recipes, provide sodium content, and offer suggestions for sodium-reduction strategies.
Results
Of the 16 independent restaurants initially contacted about participation in the pilot program, 12 participated in the RATE. The primary reason that a restaurant declined participation was time constraints. Twelve restaurants completed initial assessments, and 11 restaurants participated in a follow-up assessment conducted approximately 6 months after the initial assessment. One restaurant from the initial assessment was not included in a second assessment at the discretion of the SCHD staff because the restaurant reported having already implemented the recommended sodium-reduction strategies during the initial assessment. After receiving feedback from the SCHD staff regarding the initial assessments, most restaurant owners reported a willingness to improve in areas where they scored lower than the maximum score of 5 during the initial assessment. Of the items that the restaurant owners were willing to consider changing, the follow-up assessment found that the majority of changes were made to the menu and cooking techniques categories. Although the restaurant owners reported willingness to make changes to the product category, only small changes were reported at follow-up compared with the number of possible product changes listed.
All 11 restaurants showed improvement in the cooking category; 9 improved in the menu category; and 7 improved in the product category (data not shown). Common strategies that were used to reduce sodium included the following: (a) reducing the salt or soup base in a recipe; (b) reformulation of a recipe by using a lower-sodium product with regular products (eg, lower-sodium and regular tomato sauce combined); and (c) offering more healthful side items, such as salads, fruit, and cooked vegetables. Menu analysis conducted by the SCHD staff suggested that reported sodium-reduction strategies might have affected approximately 25% of the restaurant menu items (menu items affected by reported changes were counted and divided by the total number of items to determine the total percentage of the menu impacted for each restaurant).
The restaurant owners reported a lack of time to read information, develop a sodium-reduction plan, and implement strategies on their own as barriers to reducing sodium. They indicated that a facilitated discussion with health department staff appealed to them and provided momentum to make sodium-reduction changes. The SCHD staff found that the RATE provided a useful structure to facilitate discussions between the SCHD staff and independent restaurant owners and to track changes made by the restaurants to their sodium-related practices. The RATE process also provided the restaurant owners with new information about sodium in food and potential sodium-reduction strategies. For example, some participants expressed surprise when learning about the common sources of sodium such as bread. The tool also offered a convenient way to provide suggested strategies for improving sodium reduction.
An unintended result of the RATE was that it allowed for the SCHD staff to routinely provide technical assistance and share expertise with the restaurant owners by providing nutrition assessments and other assistance. During the pilot, the SCHD staff educated the restaurant owners about ways to obtain nutritional information from their food distributors. In turn, the restaurant owners reported contacting their distributors for nutritional information to compare different products. The SCHD staff believed that this ongoing exchange of information and their support of the restaurant owners further strengthened the existing relationships.
The restaurant owners reported that changes in menu and cooking technique categories were feasible to implement, typically without incurring increased costs. However, the restaurant owners reported that changes in the product category were more difficult to achieve and sustain because of flavor profile concerns, cost concerns, and lack of availability of lower-sodium products in the current commercial food market. Many lower-sodium products were reported as being available only by special order. The restaurant owners reported that lower-sodium products often did not have the same flavor profile as the product currently being used. Keeping the flavor profile consistent to meet their customers' flavor expectations was reported as more important to the restaurant owners than the cost of the product.
Discussion
The RATE helps demonstrate that independent restaurant owners can be motivated to reduce the level of sodium in the foods they serve and can be amenable to a facilitated tool to assess changes in sodium-reduction practices over time. The RATE assisted in providing an opportunity for health department staff and restaurant owners to develop personal relationships through ongoing discussions and technical assistance. Such relationships may have provided additional support for sodium reduction in the restaurants. In the process of conducting the RATE, the SCHD staff asked restaurant owners about their willingness to implement changes and recorded their intentions. This aspect of the RATE may have provided further motivation to the restaurant owners who understood that a follow-up assessment would be conducted at a future time.
The restaurant owners reported concern that consumers would equate lower salt with poorer taste. Because of this perception, restaurants did not advertise that they were lowering the sodium content in the menu items; however, they reported little to no adverse customer response to the changes they implemented. This finding indicates that reducing sodium does not necessarily result in negative consumer reactions and may support consumer acceptance of lower-sodium menu offerings. An unanticipated benefit that may have resulted from the pilot program was increased offerings of salads, vegetables, and fruits as side dishes.
During the pilot, several restaurant owners reported that they talked with their distributors about lower-sodium products and noted that many lower-sodium products are not offered in the larger sizes needed for commercial kitchens. In addition, the lack of a universal measuring standard makes it difficult to compare the nutrient content of similar products and choose lower-sodium options, such as deli turkey labeled in ounces compared with deli turkey labeled per 100 g. Some restaurant owners also considered strategies to strengthen purchasing power and increase demand, such as combining purchase orders with multiple restaurants. Changes by manufacturers and distributors to increase the availability of lower-sodium items in larger sizes may facilitate the purchase and use of these products by smaller, independent restaurants.
One limitation of this project is that the restaurant owners involved in this pilot were volunteers based on recommendations from environmental health inspectors. These restaurant owners may have had interest in increasing the nutrition profile of menu items even before the pilot program was initiated. This selection bias might diminish the impact and usability of the tool if used in restaurants where owners are not motivated to offer nutritious options.
Limitations of the RATE itself include its lack of reliability and validity testing. However, both the restaurant owners and the SCHD staff found the RATE to be useful in facilitating productive discussions and motivating positive change. Although staff time was required to administer the assessment, compile results, and provide feedback to restaurant owners, the SCHD staff reported that the time spent with restaurant owners increased their understanding of the independent restaurant environment and strengthened their relationships with restaurant owners.
The RATE is also limited by its design as a self-reported measure that could under- or overestimate the changes in sodium-reduction practices. During the pilot test, some of the questions in the tool were refined to improve clarity, but RATE questions still might not adequately capture and quantify reductions in sodium. For example, one question asked during both the initial and follow-up assessments was, "To what extent does the restaurant measure salt while cooking?" Measuring salt, however, does not indicate whether the restaurant actually reduced their use of added salt. In addition, each question was weighted the same on the 5-point scale, a scale that does not reflect that some changes may have a greater effect than others on sodium reduction. Finally, the restaurant owners were reluctant to share sales data, making it difficult for the SCHD staff to gauge how menu changes might be related to changes in purchasing decisions by the customer.
Despite its limitations, the RATE may be useful for other jurisdictions exploring ways to work with independent restaurants. A potential option to further leverage the benefits of the RATE would be to use it with established organizations, such as restaurant buying cooperatives. It may also be useful as a tool in food safety courses or other educational applications, where an organized set of questions and strategies can influence the perceptions and practices of those who select, prepare, and serve food. As part of a public health strategy to reduce the negative aspects of excess sodium intake, a multilevel approach may hold the greatest potential for positive change. The use of RATE assisted with motivating independent restaurant owners to change their practices and be part of such positive change.
Conclusion
Independent restaurants have the opportunity to lower sodium in food. A facilitated assessment, such as the RATE, can provide a useful platform for independent restaurant owners and public health practitioners to discuss and encourage sodium reduction through changes in menu offerings, cooking techniques, and purchasing and product availability. The RATE process also provides opportunities to build and strengthen relationships between public health practitioners and independent restaurant owners, which may help sustain the positive changes made. Independent restaurant owners can contribute to an improved nutritional environment by offering lower-sodium items. Systems-level changes that impact food formulations and distribution systems to improve accessibility of lower-sodium ingredients can support restaurants and may have the potential for even broader impacts on restaurant chains and food service operations.
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