New Style Menu 2:

A Restaurant Healthy Dining Program

A twelve-week restaurant healthy dining program, New Style Menu 2, was implemented by the Pennsylvania Department of Health from July 1, 2002 – June 30, 2004, through a grant agreement with the Erie Center on Health & Aging, Inc., an independent non-profit multi-service health organization in Erie, Pennsylvania. Funding was in the amount of $150,000, solely through the Centers for Disease Control and Prevention (CDC) Preventive Health and Health Services Block Grant. The project was an amendment to expand services by the Erie Center on Health & Aging under a prior grant agreement, beginning October 1999, to decrease dietary fat and increase fruit and vegetable consumption among residents of Erie and Crawford Counties. The restaurant dining program featured nine casual and fine dining restaurants throughout Erie County.

Starting Out

Erie Center on Health & Aging, through the original grant agreement, had implemented extensive community-wide educational campaigns to encourage residents to make the simple switch from whole and 2% milk to 1% or fat-free milk, and to increase consumption of fruits and vegetables, all with good results. These campaigns primarily addressed food purchasing and at-home food consumption patterns, but also promoted environmental and policy change in schools. The Department’s Heart Disease and Stroke Program Manager recognized the capacity of Erie Center staff for developing and implementing yet another environmental approach to healthy eating, a restaurant healthy dining project, building on their prior successes in the community. Restaurants were selected as the intervention venue, in recognition that although seventy-six percent (76%) of all food is eaten at home, the remaining 24% of all food is eaten away from home. Recently, health advocates have increased their focus on how to educate consumers where they purchase and consume food. An environment where low saturated fat and high fiber dietary options are available, whether at home or away, promotes the consumption of those foods, thereby fostering healthy eating behaviors. Good nutrition, along with physical activity, and no tobacco use, are recognized strategies for reducing risk for heart disease and stroke, our leading and third leading causes of death, respectively, among men and women in Pennsylvania.

Restaurants have, for years, responded to patron requests for customizations in menu items, whether due to calorie or special dietary concerns. Typical requests have been to “hold the sauce,” “serve salad dressings on the side,” or allow menu substitutions. This pattern has laid the groundwork for an expanded response by the restaurant industry to the increasing health concerns of consumers. According to the National Restaurant Association’s website article at www.restaurant.org/pressroom/market_solutions.cfm, there has been an increasing trend by restaurants across the nation to cater to health-conscious diners. Restaurants have and are developing special menu items for those watching their calorie, carbohydrate and/or fat intake, voluntarily providing nutritional information in brochures and on web sites, and establishing their own initiatives to assist consumers in living a healthy lifestyle. Given that most of these restaurant initiatives, described in the National Restaurant Association article, have occurred since late 2003, the Department’s project, begun in 2002, was on the cutting edge of this national trend. New Style Menu 2 was one of the first projects, nationally, to address dietary concerns among patrons at independent casual and fine dining restaurants, using a restaurant menu modification approach. New Style Menu 2 was also the first known project in the nation implemented by an independent restaurant group.

Health Agency Roles

The role of the Pennsylvania Department of Health was to provide ongoing technical assistance, and monitor progress and deliverables. In state fiscal year 2003 - 04, the Pennsylvania Department of Health amended the grant amendment with $32,719 in subsequently available funds for an expanded evaluation component. The Heart Disease and Stroke Program has had extensive experience in funding community health promotion and disease prevention programs, and was fortunate in being able to secure the needed funding from the Block Grant for the expanded evaluation component, so critically important in assessing the impact of the project.

New Style Menu 2 was a new twist on the small number of existing research projects found via a literature and Internet search by the Erie Center on Health & Aging, regarding nutritional information and menu labeling in casual and fine dining restaurants. Projects in Ontario, Vancouver, San Diego, and North Carolina used “healthy symbol” labels. Graham Kerr, internationally known chef and former Galloping Gourmet, developed a pilot in four independent fine dining restaurants in Spokane, Washington, entitled Menu 2, in conjunction with the Heart Institute of Spokane. Menu 2 featured nutritional information on all menu items on a separate menu. In that project, the Heart Institute provided the funding and dietitian time, and Chef Graham Kerr donated chef mentoring time to the participating restaurants. New Style Menu 2 was adapted from Menu 2. Graham Kerr’s endorsement of the Spokane project, and acknowledgement of Erie’s similar version, was quoted on the inside cover of the published New Style Menu 2 dining guide. Similarities and differences between the two projects are referenced as Attachment 1.

Timing of this July 2002 – June 2004 project preceded release in February 2003 of the Pennsylvania Nutrition and Physical Activity Plan to Prevent Obesity and Related Chronic Diseases (Plan), available on the Department’s website: www.health.state.pa.us. The plan provides strategies and activities necessary for community-based interventions, and focuses on the importance of policy and environmental change. It is only through a combined approach by individuals, communities, public, and private entities that environments and policies to support and promote active lifestyles and access to healthy food choices can occur, in order to impact large segments of the population simultaneously.

According to Pennsylvania’s Plan, policy change refers to "modifications to laws, regulations, formal and informal rules, as well as standards of practice. This includes fostering written and unwritten practices and incentives that provide new or enhanced supports for healthy behaviors and lead to changes in or to community and societal norms." Environmental change refers to "changes to physical and social environments that provide new or enhanced supports for healthy behaviors. An environmental change makes it easier for people to incorporate healthy behaviors as part of their daily routines. Changes in the environment can also include regular and consistent messages promoting health behaviors (labeling, signage, advertising, etc.).” New Style Menu 2 used an environmental change approach to answer the fundamental question: Would casual and fine dining restaurant patrons select from a modified heart healthy menu over the regular menu if calories, fat, fiber, and carbohydrate content of the modified menu items were displayed, and additional selections were offered to increase consumption of fruits and vegetables?

Related additional questions to be addressed through the Erie Center on Health & Aging project were 1) whether offering healthy menu items attract new guests to restaurants, 2) whether offering healthy menu items increase restaurant dollar sales, and 3) whether targeted marketing to fitness and weight loss facilities attract new guests to restaurants, increase restaurant dollar sales, and/or drive sales to the healthy menu items.

Although there appears to be an interest in healthy eating, as reflected by the popular media and the diet of the day, current available research in restaurant dining uncovered by the Erie Center on Health and Aging, indicates that many “healthy dining” promotions have not worked or at best have been modestly successful. Similarly, “heart healthy symbol” menu labeling has not caused those menu items to become a significant share of the total sales. Research does show that people want to enjoy themselves with good tasting food, and they want value for their paid dining experience, i.e., large portions. However, obesity rates are making healthy eating and dieting even hotter topics. Through this research project, the Department hoped to gain further insight into the degree to which health concerns motivate restaurant patronage and menu item selection.

Partnerships and Support

Central to the design of the Erie Center on Health & Aging project was collaboration with and among the project’s key partners: the Greater Erie Independent Restaurant Group, and nine area casual and fine dining restaurants, in the development of a modified second dinner menu for each participating restaurant. Menu offerings were adapted to make them more heart healthy, by removing the cheese, or using less fat in cooking, for example, and were analyzed by a registered dietitian, under contract with the Erie Center on Health & Aging. It was determined that the nutritional labeling on the 2^nd dinner menu would indicate calories, fat, fiber, and carbohydrates among appetizers, dinner salads, entrees, and side dishes, and that additional fruits and vegetables would be offered, along with modifications to food preparation and portion size. Patrons could compare the standard and modified menus, and order from either. The overall goal was to appeal to persons who are weight or health conscious, and dieters who want “the numbers.” The project targeted first, regular participants at fitness and weight loss facilities, and second, the general public. In keeping with Prochaska’s behavior change model, it was assumed that persons who have moved beyond contemplation to the action stage would be more health conscious, and therefore more receptive to the program.

The registered dietitian reviewed existing menus of the participating restaurants, and worked with the respective chefs to modify menu items, in keeping with taste and improved nutritional value, and management’s assessment of recipe appeal, potential sales, and profit. A faculty member from the Mercyhurst College Hotel Restaurant Institutional Management undergraduate program was contracted to provide technical assistance for analyzing sales and survey data. Project research and planning, implementation design, collaboration with restaurant management and staff, recipe analysis and final menu determination, printing of the New Style Menu 2 dining guide, and marketing the project, were the most time consuming aspects of the project, with actual implementation by the restaurants and evaluation occurring during the final three months of the grant period.

Key Events

Kick off for the restaurant project was on March 29, 2004, at one of the participating restaurants. The kick off event for 60 attendees was a press conference with speakers representing the Erie Center on Health & Aging, as well as Scott Simonsen, President, the Greater Erie Independent Restaurant Group; Rick Schenker, Erie County Executive; John Jesih, President, the USA Independent Restaurant Association; as well as Caryn Kadavy, renown Olympic figure skater and resident of Erie; and Star Campbell, the project’s registered dietitian. Graham Kerr’s endorsement of the Spokane Menu 2 project and acknowledgement of Erie’s similar version was read, and sample items from the nine restaurants were served.

During restaurant implementation, the participating restaurants were responsible for collecting specific data on a daily basis, including cover counts (number of guests), overall dollar sales, New Style Menu 2 item sales, and item sales from other items on the menu. In order to judge whether the New Style Menu 2 project was successful in attracting new customers to the participating restaurants, and generating additional sales from either the standard or New Style Menu 2, data would be compared to similar data from the same time period in 2003. The participating restaurants would track their respective data in two fashions. Six of the nine participating restaurants had point of sale computer systems, which automatically collected the data as the service staff member entered the customer’s order to be produced by the kitchen. Three of the nine participating restaurants used a manual pen and paper system for the input of orders and tracking of data. The restaurants tracking the data via computer were instructed to provide daily dollar sales data, daily guest counts, daily New Style Menu 2 item sales data, and daily menu item data.

After the 12-week intervention, patrons at the participating restaurants were asked to complete a Restaurant Customer Exit Survey to determine if they had ordered from the New Style Menu 2. A private survey company was utilized to conduct the customer exit survey, analyze the survey data, and report the results. Trained interview representatives from the survey company were positioned outside each restaurant at appointed times, during a selected weekend, and offered each guest leaving the restaurant the opportunity to participate in a survey of their experience with New Style Menu 2. Guests sat in sheltered locations right outside the restaurants to complete the paper survey, in direct response to requests by the restaurant managers who felt that completing surveys in the restaurants would be intrusive to the guests during their dining experience. Guests were not given any incentive to take part in the survey.

A pre and post-program survey was also constructed and administered to members of fitness and weight loss facilities throughout the Erie area to assess how marketing influenced survey participants to dine at any of the nine restaurants. The purpose of these surveys was to answer the question whether targeted marketing to members of fitness or weight loss facilities would attract new guests to the participating restaurants, drive dollar sales and entice purchase of New Style Menu 2 items. The hypothesis was that members of fitness and weight loss facilities would, after being exposed to the program through various promotional efforts, decide to dine at the participating restaurants versus other Erie area restaurants because of the healthy menu options.

Virtually all fitness and weight loss facilities in Erie County were selected to participate in the project, with a potential reach of approximately 9,000 persons. The methodology used in the administration of the fitness center surveys varied with the size and style of facility. Erie Center on Health & Aging developed partnerships with the 19 selected fitness and weight loss centers. Through these partnerships, surveys were distributed to facility members and completed during March 2004.

An extensive marketing plan was implemented over 12 weeks, including numerous presentations by staff of Erie Center on Health & Aging at the fitness and weight loss facilities, area worksites, civic and women’s clubs, and other organizations. The Erie Center on Health & Aging also distributed 100 posters, 2,500 flyers, and 5,000 dining guides, which detailed the adapted menu items for all participating restaurants. There was direct mail to 280 women’s and civic clubs, and 100 volunteer nurses at churches. Free print media coverage was provided in the form of six feature articles by the Erie Times News newspaper, and two articles by the Senior News monthly newspaper. Other free print media was provided through newsletters, such as the Erie Regional Chamber and Growth Partnership monthly magazine, the Pennsylvania Nutrition Education Network Newsletter, and Erie Center on Health & Aging’s senior newsletters. Paid television advertisements were aired 54 times on morning and evening local news through WICU-TV 12, NBC affiliate. Free television advertising was through ten advertising segments on Channels 24, 35, 6, and 2. Five free radio spots were on WLKK, WJET, and WQLN-radio. All of these avenues were in addition to the advertising at the restaurants, themselves. Each restaurant received clear acrylic stands to house the 5.5” X 8.5” Restaurant Dining Guides, the 8.5” X 11” color flyers, and the 18” X 22” color posters.

Obstacles

Despite outreach to several hundred thousand Erie County residents, and concurrent media attention to low-carbohydrate diets, obesity and restaurant dining, there were barriers to its success. Non-solicitation policies in place at several institutions prohibited promoting a business (the nine restaurants) that would profit from employee education provided. This impacted the educational reach to two major companies and a hospital very close to four of the restaurants; also, a public radio station, and two major weight loss groups. Other barriers were the inability of several fitness facilities to participate in surveys or other promotion because prominent fitness members had stake in competing restaurants, or the fitness or weight loss facility had an exclusive marketing agreement with another restaurant.

Other barriers included what was happening through other non-participating restaurants at the same time as New Style Menu 2’s implementation. Erie’s Twin’s Tavern, a local Erie independent establishment, widely promoted its menu items, tailored for low carbohydrate eating, in mid-March 2004. Ruby Tuesday’s national casual dining chain, with one prominent location in Erie, launched a menu modification project in May 2004. Their project included a second menu available at the table, listing calories, fat, and fiber of menu items, and low-carbohydrate labeling of other menu items in another section. It was marketed in the Erie Times News, along with reference to New Style Menu 2. Ruby Tuesday is the first known national chain to use the same four nutrition labeling information, and second national chain with a strong Erie presence, to launch programs within the three-month marketing launch of New Style Menu 2. Applebee’s chain launched its Weight Watchers menu in Erie in June 2004.

Outcomes

Fitness and weight loss facility members were targeted under the assumption that persons already health conscious and in the “action” stage would be most receptive to the program. Over 7,800 persons were reached at these sites. Results of the pre and post-program surveys were as follows:

Pre-Program Survey (Sample size: 378)

• 63.82% of persons had never eaten at any of the participating restaurants.
• 33.48% of persons had eaten at any of them occasionally; 2.38%, often; and .32% very often.
• Two factors influencing limited patronage at any of the participating restaurants were price and location. The participating restaurants, mostly casual dining but a few that are considered fine dining restaurants, have a higher price point than do the most frequented restaurants in the area, considered family dining restaurants. Also, whereas seven of the participating restaurants were located throughout the city of Erie, and two others were located in suburban communities outside of the city limits, more frequented family dining restaurants were located in heavily trafficked shopping areas within the city of Erie.

Post-Program Survey (Sample size: 107)

· 35.4% of persons who indicated that they ate at any of the participating restaurants during

the program period, chose a New Style Menu 2 selection. Hence, about one-third of the

survey respondents did report selecting an item from the modified menus.

• 94.5% of persons who ate at any of the participating restaurants during the program period and chose a New Style Menu 2 selection, would do so again. This speaks

to the participating restaurants’ success in the production of the New Style Menu 2 items.

Research studies have shown that food quality is one of the most important factors in a

customer choosing a restaurant after their first visit.

• 52% of persons who ate at one of the participating restaurants did so because of referral by friends, 15% because of the New Style Menu 2 promotion, 5% because of other advertisement, and 28% because of other unexplained reasons.

• 25% of people who ate at the participating restaurants during the program period were informed of the New Style Menu 2 options while at the restaurant.
• 17.4% of the fitness and weight loss center membership did not eat at a participating restaurant due to location; 13 % due to price; .5% due to perceived lack of healthy options; and 69% for other unexplained reasons.
• Age breakdown among respondents at fitness and weight loss centers was as follows:

18-24: 4%, 25-34: 4%; 35-44: 8%, 45-54: 42%, 55-64: 27%, and 65+: 15%.

• 56% of respondents first heard about New Style Menu 2 at a fitness or weight loss group; 10% through the newspaper, 3% through a friend; 0% through the radio, 1% through the television, 8% hadn’t heard about it, and 22% indicated other, with no explanation.

As noted above, the sample sizes for both pre and post-program surveys were small. The sample size for the Restaurant Customer Exit Survey was small (95), as well. Restaurant managers claimed that patronage was unusually limited during the selected weekend of the survey. But also, this points to the challenge of conducting restaurant research, using on-site survey methods. Only six of the nine participating restaurants allowed the interviewing process to take place, all during a three-hour peak dinner period on one selected weekend. The customer exit survey was a one-page questionnaire that asked patrons about their patronage frequency at the selected restaurant during 2004, how many times they chose from the second menu, whether they would order again from the adapted menu; whether they would recommend the adapted menu to a friend, what directed them to the restaurant during the time period, whether they were informed about the adapted menu options when in the restaurant, how they learned about New Style Menu 2; also, whether they currently attended a fitness or weight loss group, and, as an optional question, their age. Results from the Restaurant Customer Exit Surveys were as follows:

Restaurant Customer Exit Survey (Sample size: 95):

• 12% of persons reported ordering from the New Style Menu 2, however only 1 person ordered from it due to stated concerns about health.
• 32% of persons had heard of New Style Menu 2, even if they did not order from it.
• 0% of persons surveyed reported hearing about it at a fitness group or weight loss club, however 6 people reported hearing about it through newspaper or on radio, and 5 in television ads. Two heard about it through restaurant waiters or waitresses.
• 62% of persons said they would come back and order from New Style Menu 2 again; however, this was answered by 21 persons who did not order from the modified menu.
• 71% of people said they would recommend New Style Menu 2 to a friend.

The project met with significant problems in follow-through by the participating restaurants, where lack of data collection or release of information compromised certain components of the final assessment of the impact of the project. Only two of the nine participating restaurants provided any agreed upon sales data. One reported selling 10 entrees, the other, 40 entrees from the New Style Menu 2, with no other data collected during the three-month implementation phase of the project. Limited restaurant reporting of guest counts was widely found, as well. The results of the collected and analyzed data do not statistically indicate either way if the New Style Menu 2 project had an impact on dollar sales, menu item sales, or new guest numbers.

Would casual dining restaurant patrons select from a modified heart healthy menu over the regular menu if calories, fat, fiber, and carbohydrate content of the modified menu items were displayed, and additional selections were offered to increase consumption of fruits and vegetables? Self-reported data among restaurant patrons showed that 12% of the small sample size (11 people) did. Of these 11 respondents, 4 stated they selected the menu items because they were curious, 1 person stated the menu items were selected due to health or weight concerns, 1 person stated the menu item was selected due to appeal of the items, 1 person stated the menu items would be a change from the regularly selected items, and 1 person stated a “love for sushi.” The remaining 3 persons offered no reason.

Regarding the other questions posed by the Erie Center on Health & Aging, without proper data of restaurant guest counts and sales data, and, given the number of fitness and weight loss facility survey respondents who did not attend any of the participating restaurants during the program period, coupled with the price and location of the participating restaurants, results point to the unlikelihood that offering healthy menu items attract new guests to restaurants, increase restaurant dollar sales, or drive sales to these healthy menu items. Lack of statistically significant data also point to the ineffectiveness of targeting fitness and weight loss facilities in this project.

Enhancements and Modifications

The following are suggestions for future projects in increasing the likelihood of achieving statistically relevant answers to the questions posed in the hypothesis.

Improvement of menu analysis:

Menu item analysis was more complex, lengthy, and costly than anticipated, and different strategies should be developed to speed the process, such as recipes received in writing for analysis, with limited numbers of items to be analyzed.

Refinement of marketing techniques:

The targeted marketing to weight-conscious persons should be refined to determine if multiple approaches are needed and most effective for casual and fine dining patrons, including paid media, posters at restaurants, flyers, and educational presentations with the public. Marketing to fitness and weight loss facilities seems obvious to reach positive outcomes in sales, but further social marketing research must investigate the characteristics, motivations, and menu choices of patrons of casual and fine dining. They may attend for the dining experience and be willing to splurge, whether health-conscious, on a diet, or not. Low-cost and type of marketing must be matched to the characteristics of fitness and weight loss facilities.

Only work with 1 to 2 restaurants (one casual dining and one family dining):

From start to finish, this project was very labor and time intensive for the independent restaurant managers. This resulted in a waning of interest in the project as time went on. These people are very busy and have little time to make commitments to additional projects. As demonstrated in the Erie Center on Health & Aging project, attempting to coordinate such an endeavor with multiple restaurants is nearly impossible. Until research has advanced, securing the commitment of 1 to 2 restaurants, and a point person (not the owner or manager, but perhaps an employee compensated by the project team) within each restaurant will help a project team retrieve the data it needs for the statistical analysis and will help the restaurants realize the results from the project, as well as receive valuable information on how to best conduct these types of ventures on their own.

Given the survey response that price was a primary factor in why survey respondents from modestly priced fitness and weight loss facilities didn’t patronage any of the participating casual and fine dining restaurants during the program period, one recommendation is that future projects focus on matching independent restaurants with income of client. The family dining restaurants frequented by members of some fitness and weight loss facilities may be different than those frequented by members of high-end fitness and weight loss facilities, and thus, may generate greater response from such a project.

Define membership characteristics of fitness and weight loss facilities:

Similarly, it is recommended that future comparisons are made among fitness and weight loss facilities with clearly defined membership characteristics and committed managers and group leaders. Narrowing the focus would be appropriate to further understand their characteristics and dining preferences. One fitness or weight loss facility could be lower in price and the other cost more. By understanding fitness and weight loss facility membership, and by asking respondents in a pre-program survey why they chose their fitness or weight loss facility, it may shed light on why they choose restaurants, as well. This can help answer if it is truly the healthy menu options driving sales to the participating restaurants.

Bring all players on, early in the project:

All consultants, statisticians, dietitians, restaurant managers and staff, fitness and weight loss facility personnel should be brought on board at the beginning of the project. This will allow the team to meet early, discuss goals, strategies, and tactics for the project, and improve the likelihood that program participants will receive maximum benefit from the project.

Possible issues impacting the results of the Restaurant Customer Exit Survey:

Three main factors impacted the Customer Exit Survey portion of the project - lack of cooperation from the participating restaurants, lack of restaurant traffic, and lack of patron cooperation. Only 6 of the 9 participating restaurants took part in the customer exit survey. The remaining 3 restaurants communicated that either they didn’t know about the survey or they didn’t want the survey intruding on their guests. Each of the participating restaurants reported lower than average numbers of guests and dollar sales during the weekend of the customer exit survey. Had more restaurants participated, and had the restaurants experienced an average or above average number of guests during the survey weekend, the goal of 500 surveys may have been attained. As with all spontaneous person-to-person surveys, there is also a percentage of the population who will refuse to participate. The combination of these three factors may have affected the ability of the interviewers to gather enough responses to make the results statistically valid. Various methods of administration and use of incentives must also be explored for the survey, for patrons and for restaurant staff.

Possible issues impacting the results of the Fitness and Weight Loss Facility Member Survey:

The pre-program survey offered no opportunity for the participant to indicate why they may not have attended one of the participating restaurants during the year prior to the new menu program. Answer choices may have included location/price/perceived lack of healthy options/or another option. This information, coupled with information from the post-program survey, may have shed light on driving forces behind the survey participants’ restaurant selection. This may have helped answer the question as to whether offering healthy menu items attract new guests to restaurants.

As listed earlier, members from different fitness and weight loss facilities were surveyed in order to achieve information from different restaurant customer profiles. In the pre-program survey, an important question may have been why the survey participant chose to belong to their specific fitness or weight loss facility. Answer choices may have included location /price/available services/or another option. Correlating these answers with answers as to why the survey participants did not attend one of the participating restaurants before or during the program may have shed light on whether offering healthy menu items attract new guests to restaurants.

Tracking the number of surveys completed, pre-program, was another factor impacting the success of the fitness and weight loss facility survey. The goal was to have a majority of the pre-program survey participants also complete a survey, post-program. However, many of the pre-program participants could not be reached for the post-program survey. When contacting fitness and weight loss facility directors in an attempt to reach these participants, the response was that people had moved or were no longer members of the facility. This made it necessary to survey a population of members who had not participated in the pre-program survey. While still valuable information, having 500 people complete both pre-and-post-program surveys may have made program conclusions more reliable for future projects.

Possible issues impacting the results of the Sales Data Analysis:

Several issues impacted the results of the sales data analysis. These include data availability, data reliability, and data compilation. Each of these issues resulted from the restaurants’ lack of active participation in this component of the project. This lack of active participation included the following issues:

· Lack of planning and consistency in the tracking of relevant data (guest counts, dollar sales, menu item sales). Some restaurants were already tracking the requested project data for themselves. Others weren’t tracking such information, thereby making data collection tedious. Incomplete data yielded unreliable data to analyze. Also, restaurants had agreed to provide data to Erie Center on Health & Aging on a daily basis. The participating restaurants provided cumulative data instead, which hampered the style of analysis originally anticipated.

· Restaurant reluctance to provide dollar sales information. In order to answer the question whether the project had increased dollar sales for the participating restaurants, Erie Center on Health & Aging needed access to each restaurant’s sales data for the project period: April, May and June 2003 and 2004. When approached, all but two restaurants expressed reluctance to give Erie Center on Health & Aging the data, as it revealed the profitability of their operations, and thus, their financial success. Without this data, statistical analysis was impossible and the question whether the project had increased dollar sales for the participating restaurants will continue to be assumed at best.

· Restaurant contact persons’ energy for the project waned. As the overall project

continued to advance, the energy on the part of the restaurant contact persons continued

to fade. Several restaurant representatives expressed dismay over their not seeing the

results they had anticipated. Others merely didn’t return phone calls or refused to

provide data necessary for the project analysis, without explanation. Further research

must include how to determine and maximize capacity and resources of independent

restaurants to implement analysis, labeling, and marketing.

Lessons Learned

The Erie Center on Health & Aging experienced problems similar to those of other restaurant menu modification projects across the nation, with respect to restaurant staff record-keeping, disclosure of sales data, and patron completion of survey instruments. However, the Erie Center on Health & Aging did learn some important lessons that may help others embark on similar projects in the future, as summarized below:

1. Talk to national experts and evaluate what worked and what didn’t work so you can avoid mistakes and build on successes. Enlist the support of the project directors with national contacts and who are very willing to be helpful. Share your results among colleagues, and thank them.
2. Build trust with the public. Make sure public information is based on science and fact.
3. Remember that public/private partnerships can be extremely instrumental in effecting environmental and policy change. Relationship-building can be a very time consuming, endeavor, but every stakeholder is key to success.
4. Develop excellent working relationships with key media contacts. Media support is absolutely key to environmental change. Have your facts straight, and have press releases prepared in advance. Spend time to educate reporters, and say thank you.
5. Make it fun. People want to be part of an event. Public health isn’t glamorous work, you have to learn how to give people what they want, so they will do what they should.
6. Keep the message as simple as possible. The hardest part of behavior change is to take the first step. We have to sell the first step.

Conclusion

Although there were disappointments, on the whole, the project was successful. It undoubtedly raised awareness among restaurant patrons and the public, that heart healthy menu items can be simple adaptations of their fuller fat and higher calorie varieties. The project took a first step in fostering long-term behavior change among restaurant patrons, the public, and the participating restaurants, as well. This environmental change approach to healthy eating in restaurants resulted in sustained behavior change at several of the participating restaurants. At ten months, post project, six of the nine restaurants continue to make available the healthier adapted menu items from New Style Menu 2. Three of these restaurants will prepare adapted menu items upon customer request (based upon customer recollection of choices available from the dining guides previously received), two restaurants continue to provide the New Style Menu 2 dining guides along with the traditional menu, and one restaurant has re-written the regular menu to include some of the more popular or profitable second menu items. The fact that these practices have continued, lead the writer to assume that the restaurants benefited in some way by New Style Menu 2, and that perhaps, the problems encountered related more to inadequate or inappropriate survey and data collection instrument design and implementation.

Because the project did answer affirmatively, though with a very small survey sample, the fundamental question posed by the Pennsylvania Department of Health, and because six of the nine participating restaurants continue to offer heart healthy menu selections from the adapted menu, New Style Menu 2 was a successful environmental change approach to enhancing support for healthy behaviors, with some potential for improving cardiovascular health.

References

Treat Yourself Well restaurant nutrition research study, funded by California Dept. of Health Services (Esther Hill)

Eat Smart! Ontario, Canada Healthy Restaurant Program (Lisa Smedmore and staff)

Univ. of British Columbia, Vancouver, B.C. , Susan Barr, PHD, RDN, Professor of Nutrition, re: published 1997 report of "Fresh Choice" restaurant dining program of Vancouver

Allentown City Department of Health, Allentown, PA, Tina Amato, restaurant initiative

Dairy Farmers of Ontario, Zanat Reza re data on eating out and effects on milk consumption market analysis

Chain/ restaurant healthy items examples found, e.g., Isaac's Deli, Inc., Subway, Arby's, Eat 'n Park

“Menu 2” Spokane, Washington pilot project, created and endorsed by chef Graham Kerr

Margo Wootan, Center for Science in the Public Interest, Director of Nutrition Policy

“Winner’s Circle” North Carolina – Kate Shirah, State coordinator, and Kim Shovelin, Manager

Legal Seafoods, Boston-based New England seafood chain, nutrition labeling on table signs

William Patterson, local CEO and franchise owner of regional Burger King restaurants, northwestern Pennsylvania, regarding his billboard campaign in Erie, as a pilot to advertise the Weight Watchers points for several sandwiches.

Texas Department of Health, Chronic Disease Division

Vaheeda Prabhakher, Pennsylvania Department of Health 5 A Day Coordinator

National Restaurant Association, Sheila Cohn, staff nutritionist, regarding an update on the New Style Menu 2 project and requesting information on any other new projects being implemented nationally for nutrition labeling

Tomas Philipson, Food and Drug Administration, FDAObesity Working Group, regarding FDA Public Meeting on Obesity, Nov. 20, 2003, with hearings including restaurant menu nutrition labeling, "Exploring the Link between Weight Management and Food Labels and Packaging." Erie Center on Health & Aging provided background information on our current effort as well as other known efforts and contact information of projects for nutrition labeling at American and Canadian restaurants (non-industry-sponsored)

Council of Independent Restaurants of America, Philip Cook, regarding any other known independent restaurants or independent restaurant associations implementing nutrition analysis on menus

John Jesih, USA Independent Restaurant Association

Pennsylvania Restaurant Association, Mr. Pat Conway

Saint Vincent Health Center "Eat Hearty" Restaurant dining Program, developed and franchised; defunct since 1980s

American Heart Association, regional Pittsburgh office re past "heart healthy" labeling initiatives

Erie Times-News, Features Editor, regarding grant objectives, restaurant promotion through feature articles, food pages

STI Creative, marketing and public relations firm, for technical research regarding local restaurant marketing

Moore Research Services, Inc., Colleen Moore, telephone survey and other survey methods

Strategy Solutions, Inc., Amy Onest, focus group and other survey methods

Contact Information

Lila Darling, RD, LDN

Manager, Heart Disease and Stroke Program

Pennsylvania Department of Health

PO Box 90, Room 1011, Health & Welfare Building

Harrisburg, PA 17108

(717) 346-3978

(717) 772-0608 (fax)

ldarling@state.pa.us

Attachment.

Attachment 1

SIMILARITIES AND DIFFERENCES IN THE PILOT PROJECTS, SPOKANE & ERIE

Prepared by Erie Center on Health & Aging, Inc.

Menu2, Spokane Washington	New Style Menu 2, Erie Pennsylvania
Pilot at 4 fine dining restaurants	Pilot at 9 casual dining restaurants; 2 have “fine dining” in menu choices but don’t want labeled as such
4 restaurants modified their menus with Heart Institute dietitians to meet Menu2 requirements.	9 restaurants with no prior modifications; perceived "healthy" items were not significantly low calorie/low fat. No “heart healthy” symbols currently used
Goals/criteria: impact of a second menu with nutritional information, and choices. Minimum choice of 2 appetizers, 2 main entrees and 2 desserts that, when one is added from each category, do not exceed 1,000 calories or contain more than 39 grams of fat.	Goals/criteria: Same - impact of a second menu with nutritional information, and choices. Flexibility according to eating styles and/or diet. A focus on popular diets. Increasing opportunity to choose varied portion sizes, fruits, vegetables, side dishes; lowering refined carbs; 88% of entrees less than 500 cal; 54% less than 300 cal.; ave. 329 calories. 72 % of meals have less than 1,000 calories even with the highest calorie regular side dish + highest calorie appetizer + small soup from New Style Menu 2 34 grams of fat for ave. of entrees+appetizer +soup+side+salad
No labeling of "healthy;" focus on choice and nutritional facts	Same
Analyzed and written on second menu: Calories-Total fat(saturated fat)- carbohydrates Ex: 520-18(4)-25	Analyzed and written on menu: Calories, carbohydrates, fat, fiber
2 identical menus. All entrees analyzed for choices; smaller menus; less to analyze	2 menus, not identical, as 2^nd menu lists the modified or customizable items. Larger menus with 491 menu items and not feasible to analyze all; 36% of entrees analyzed; 29% entrees chosen for 2^nd menu (n=64); 184 choices of all items
Analyzed: appetizers, salad, soup, entrée, dessert	Analyzed: appetizers, salad, soup, entrée, sandwiches, plus side dishes
Time period: 4 weeks	Time period: 12 weeks
Menu presented: By request of diner, who read about it in newspaper or saw TV stories. Goal is to be offered by wait staff, after receiving first menu.	Menu presented: as an insert in the regular menu; or on the tables at one restaurant; not possible to sufficiently train large number of wait staff with high turnover
Dinner	Dinner; 2 restaurants serve lunch and use 2^nd menu at lunch and dinner
Evaluation: customer response cards	Evaluation: sales data where possible; Tracking of attendance by weight loss/fitness club members (sample); customer response survey (sample)
Marketing: low budget; relied on local newspaper articles; kick-off event	Marketing: low budget; will rely on local newspaper articles, ad spots on local radio station. Targeted marketing to fitness/weight loss clubs of printed restaurant guidebook with menus and nutrition analysis; kick-off event
Funded: Heart Institute of Spokane funded analysis and RD time, Chef Graham Kerr donated chef mentoring time.	Funded: Pennsylvania Dept. of Health, Cardiovascular Risk Division, via CDC block grant – 2 year extension to “Switch to 1% or Less” Milk and "5-A-Day" local campaigns (Cut the Fat, Erie)
Restaurants paid nothing	Restaurants did not pay towards analysis
Staff: dietitian at Heart Institute	Staff: Registered Dietitian consultant; program staff for relationships, logistics and marketing
10 year history with nutritionist/analyst. Heart Institute has had a restaurant program for 10 years…titled Lite ‘n Hearty.	No history with nutritionist/analyst

March 26, 2004