Chamber of Commerce staff helped identify and invite restaurant owners and managers to a focus group to discuss the study. Chamber staff were invited to identify owners and managers from small and large locally owned restaurants as well as national fast food restaurants. A total of six attended, including one manager of a national fast food chain. Attendees appreciated the brief update given on the importance of regular consumption of high quality fats as an important component of a heart healthy diet, and while some were skeptical about customer interest in healthier restaurant food choices, supported efforts to inform their customers of healthy food items already on their menus. In addition, they agreed with plans for the study to distribute educational information at their restaurants and use coupons to promote healthful choices.

All licensed restaurants in the county, per the county health department listing, received a mailed invitation to take part in this study. This mailing described the purpose of the study and what would be required of restaurants that agreed to participate. Three expressed interest in participating (one fast-food chain restaurant and two independent restaurants) and comprised the sample for the pilot study. All served breakfast and lunch (one also served dinner), with the bulk of their business focused on lunch.

The overall goal of the intervention was to use local restaurants as a venue to provide patrons with evidence-informed information^9,11,32 on making healthful choices when dining out. In this regard, we included specific tips on menu choices at each restaurant to help customers choose food items with high quality fats (polyunsaturated and monounsaturated fats primarily from plant sources and fish), good carbohydrate quality (fruits, vegetables, and whole grains), or both. For example, many of the restaurants offered whole wheat buns or bread as an option and served chicken salad, so a heart healthy menu suggestion at these restaurants included chicken salad on whole wheat. Almost all restaurants had salads on the menu, so these were recommended with regular full fat salad dressing (made with vegetables oils) instead of low fat or not fat salad dressing (which typically includes high fructose corn syrup). At the participating Mexican restaurant, one of our recommendations was “Guacamole dip is made of avocados - a delicious heart healthy food.”

Intervention components included: 1) table tents with 10 healthy eating tips on one side, and more detailed information about a single tip on the other side, including a listing of relevant menu items for this tip (Table 1); 2) trifold pamphlets located at cash registers or in other prominent places that helped customers assess their individual dietary habits with linked tips to improve dietary choices, as appropriate; 3) a HHL window decal to alert customers to the restaurant’s participation in this study; and 4) coupons redeemed in exchange for customers purchasing healthy menu items (as outlined in Table 2). Though the dietary tips were developed before publication of the 2015 USDA dietary guidelines,²² they were highly concordant with these guidelines except for milk products. Whereas the guidelines recommend low fat milk products, our tip was to consume either low or regular fat milk products. This is consistent with the evolving literature that dietary saturated fat^24,33 may not be associated with CVD events, and with multiple observational studies suggesting full fat milk products do not increase the risk for CVD and that some full fat milk products may lower risk.^34–36 The table tents and brochure included a link to the HHL website, which provided more detailed information on dietary patterns associated with a reduced risk for CVD. Coupons were two sided, with the coupon value and suggested healthy eating options on one side, and a space for customers or restaurant staff to indicate which healthy options were selected (and the date) on the other side.

We used principles from the Socio-Ecological Model to build on individual level interventions which primed study participants to make healthier lifestyle choices in the broader restaurant environment. Constructs from social marketing informed intervention and materials development.³⁷ For example, the coupons involved the concept of exchange (trading off favored sweetened beverages for a lower cost meal).

The intervention was piloted over three months in fall 2013. Restaurants were asked to display a table tent on every table and make the tri-fold brochure available to patrons throughout the three month study; research staff provided replacement table tents and brochures as needed. Coupons were distributed to each of the three restaurants, HHL Lifestyle Study participants, CAC members, and several community groups to ensure a wide and diverse distribution.³⁷ Research staff collected the coupons received by restaurants each week, recorded the data available on each coupon, and submitted the coupons for monthly reimbursement to restaurants. Reimbursement to restaurants for redeemed coupons was provided by a local health promotion grant to the Lenoir County Cooperative Extension Center from the Kate B. Reynolds Charitable Trust. Coupons were tailored for each restaurant, and adapted slightly for the chain restaurant to comply with corporate requirements, but all restaurants were reimbursed the full cost of the coupon plus a small handling fee (as incentive to participate in the program). Coupons were valued at $2.50 - $5 depending on the restaurant. At the independent restaurants, participants received $2.50 off the price of a healthy menu item; at the chain restaurant, they received a menu item of about $5.00 in value when redeeming the coupon. Overall, twice as many coupons were distributed for the independent restaurants so that the total value of coupons was similar across all participating restaurants.

For the expanded program we again contacted all licensed restaurants in the county with a mailed invitation to take part in this study. Nine expressed interest in participating (five chain restaurants and four independent restaurants) and comprised the sample for the expanded study. All restaurants served lunch, with all but one serving breakfast; six of nine restaurants served dinner as well.

The intervention was adapted based on lessons learned during the pilot study. The expanded program, conducted September 2014 through January 2015, was five months long, and each month restaurants received table tents with two of the ten tips to highlight during the month so that over five months, all ten tips were covered. The table tents included quick response (QR) codes for customers to easily scan and link to more information on the HHL website. These tips were coordinated with a series of monthly articles in the local newspaper that provided additional information on the two tips for the month and listed the restaurants participating in the project. The topics, and order in which they were addressed in newspaper articles included: 1) Choose Nuts and Nut Butters Often; 2) How Healthy Fats are Part of a Heart Healthy Diet; 3) The Good and the Bad about Carbs and How They Fit into a Heart Healthy Diet; 4) Eggs, Chicken, Fish, Meat, and Dairy; and 5) Making Healthy Choices when Eating Out – Including Dessert. Restaurants continued to display and disseminate the trifold brochure, and project posters (instead of window decals) were provided to each restaurant for display in the window. Coupons were similar to the pilot coupons, although the value was increased from $2.50–$5 to $3.00–$5.50 depending on the restaurant; adaptations were again made to coupons for chain restaurants to accommodate corporate requirements. To increase customer uptake of the coupons, an average of 59 coupons per month were distributed to each restaurant (restaurants using the $3.00 coupons received about twice as many as those using the $5.50 coupons) and the managers were asked to disseminate the coupons as they saw fit (instead of dissemination of coupons by the research team).

Restaurant managers completed pre/post intervention interviews and written surveys to assess nutrition knowledge, perceived customer attitudes and preferences regarding healthy eating, perceived healthiness of current menu options, feasibility of the intervention, and successes/limitations of program components (table tents, brochures, coupons, and website). Data were collected after research staff obtained verbal consent from the managers to participate and no identifying information was obtained. During the interviews, research staff took notes on the managers’ responses; audio recording was not done. To solicit customer feedback on program components, about half way through both projects, trained research staff conducted customer intercept surveys (n=25 per restaurant) on a weekday during lunch at each of the restaurants. After reading a brief paragraph explaining the purpose of the study, customers agreed to participate by giving verbal consent. Participants were offered the choice of completing the survey on their own or to have study staff read the survey items and enter responses. Further, participants could complete the survey at their own table or at a table designated for study participants. As an incentive, participating customers were provided a program coupon to the restaurant for completing the survey. In addition, process evaluation measures were collected by trained research staff and included weekly observations of table tent and brochure availability, if the program poster was displayed, coupon counts, and coupon use information. The customer intercept surveys used in the pilot and expanded studies were identical, while the restaurant manager surveys were very similar.

Percentages are used to describe study findings from the surveys and process measures. Coupon data for pilot and expanded projects are presented separately because of slight variations to the coupon content and protocol. Qualitative results, including representative quotes from the managers, are also reported.

All managers were somewhat knowledgeable about health and nutrition information prior to participation, recognizing the importance of regular fruit and vegetable consumption as well as low sodium intake, but many initially believed low fat items were inherently healthy choices. Healthfulness of menu items was perceived by managers to be less important to customers than taste, presentation, and customer service.

At follow up, all but one manager said they would be likely to participate again. Representative quotes (in italics) from the managers follow.

“We appreciate being part of the study…”

“We are thankful for the investment in Lenoir County to assist in becoming more heart healthy”

“[Participating in the project] was easy!”

“Great program for all of us! Let’s see if the customers change their habits [when the program is over]”

One manager went beyond the required intervention components and posted information about the program on the restaurant’s Facebook page.

Managers believed table tents were generally well-received by their customers. However, they suggested improving their durability to withstand constant handling by customers and simplifying content to increase customer uptake of the message. Several managers suggested less text and more images in future iterations. The brochure’s appeal varied across restaurants, but one manager reported, “I was shocked by some of the folks who picked up a brochure! [I thought they had no interest in eating healthy].” Another manager suggested moving the brochure location from beside the cash register to customers’ eye level when ordering to increase brochure uptake.

Managers liked the coupons, and reported prompt reimbursement from the project. As one commented, “Coupons were easy – no hassle. [The research team] did the work – we just gave out coupons.” In the pilot study, there was a low (13%) redemption rate for coupons. Consequently, coupon dissemination was adapted during the expanded follow-up study, allowing managers to handle coupon distribution (offering coupons at the point of sale); the change resulted in a 39% coupon redemption rate during the expanded project (a three-fold increase over the pilot). Most managers agreed that the coupons (providing a discount for healthy foods) was the key to the project’s success; one manager suggested that even $1 off would encourage his customers to make healthier choices. Notably, none reported a negative economic impact of the intervention.

Managers also reported participation in this project increased their personal nutrition knowledge, especially in regards to healthy fat consumption. As one manager commented, “[I didn’t know] that fats and oils can be heart healthy!” Another manager reported surprise when he discovered, “…sugar is the most dangerous food,” and a third manager was pleasantly surprised by the number of items already on his menu that contained healthy components.

Of 1,564 coupons distributed, 207 (13 %) were redeemed during the three month pilot: 65 (31%) at Restaurant 1, 39 (19%) at Restaurant 2, 103 (50%) at Restaurant 3. Only 13 (6%) coupons were returned unmarked (i.e., research staff were unable to determine the healthy choices the customer selected). Among the 194 (94%) coupons with marked choices, the most popular selections were low sugar beverages (in part because most coupon users chose a beverage along with an entrée item), 147 (71%), followed by an entrée with a fruit/vegetable, 66 (32%), and a salad entrée, 63 (30%). A total of 66 (32%) HHL Lifestyle study members redeemed coupons; the rest of coupons redeemed were from those distributed to the broader community.

Of 2,650 coupons distributed, 1,037 (39%) were redeemed during the five month project (range for independent restaurants 33 to 264; range for fast food restaurants 61 to 119, with 2 months of coupon data not used because of data quality concerns). The most popular choices (Table 3) were a low sugar beverage (because most coupon users chose a beverage along with an entrée item), 550 (53%), followed by a whole grain bread, 469 (45%), and an entrée with a fruit/vegetable, 324 (31%).

A total of 300 customers completed intercept surveys during lunch, usually after they had purchased their meals. Among these respondents, 268 (89%) indicated they often eat lunch at this restaurant. Of the 150 interviewed at independent restaurants, 58 (39%) reported eating at the restaurant at least once per week; of the 150 interviewed at fast food restaurants, 66 (44%) reported eating at the restaurant at least once per week. Overall, 126 (42%) of those surveyed noticed the table tents; of those who did, 115 (91%) indicated the nutrition information was helpful and 91 (72%) reported the nutrition information would influence their restaurant purchasing habits in the future. A small percentage of customers, 23 (8%), requested a copy of the healthy lifestyle brochure with 17 (74%) reporting the information was helpful.

During the pilot intervention, only one person logged onto the website as a Lenoir County resident, and five logged on as residents of nearby counties. During the expanded intervention, the website averaged one new hit per day, but it is unknown how much of that traffic was due to the addition of QR codes to table tents versus other work related to the HHL Lifestyle program happening in the county.