Abstract

Food environments influence food consumption and population health. This study sought to establish the outstanding themes in recent scientific literature about healthy eating and restaurants. Studies about the topic published from 2011 to 2016 in seven recognized databases were reviewed systematically. From 999 titles, 20 articles were selected. Content analysis through an inductive method by two independent investigators was performed using Nvivo 10.0. Three dominant subjects were identified: Food supply modifications, promotion of healthy choices and barriers against healthy eating promotion. The findings describe research opportunities in the area, particularly in the Latin American context. It is necessary to make interventions that result in healthy food environments given the impact on collective health.

Food services; Collective feeding; Restaurants; Healthy lifestyle (DeCS

Introduction

Nowadays a large proportion of the population regularly consumes meals away fromhome¹1. Mikkelsen BE. Images of foodscapes: Introduction to foodscape studies and their application in the study of healthy eating out-of-home environments. Perspect Public Health 2011; 131(5):209-216.. In fact, in countries such as the United States (U.S.), individuals spend half of every dollar on out-of-home food²2. American Institute for Cancer Research. Americans Spending Half of Every Dollar Going out to Eat. Pagina 1/1 [Internet] [citado 2016 Dic 15] Disponible en: http://www.aicr.org/cancer-research-update/2016/02_10/cru_Americans_Spending_Half_of_Every_Dollar_Going_Out_to_Eat.html?referrer=https://www.google.com.co/.
http://www.aicr.org/cancer-research-upda... . In comparison, in 2009 the Brazilian population spent a third of its food budget at food establishments, while in 2002 they only spent24%³3. Bezerra I, Souza A, Pereira R, Sichieri R. Consumption of foods away from home in Brazil. Rev Saude Publica 2013; 47(Supl. 1):200-211.. This illustrates the growth in food consumption at restaurants. Consequently, these places have an important impact not only on the economy, but also on food consumption. From an economic point of view, the foodservice industry generates more than 500 billion transactions per day⁴4. Newson R, Maas R, Beijersbergen A, Carlson L, Rosenbloom C. International consumer insights into the desires and barriers of diners in choosing healthy restaurant meals. Food Quality and Preference 2015; 43:63-70.. On the other hand, one-third of the population’s daily energy consumption comes from fast food shops, restaurants and other food establishments⁵5. Lin B-H, Morrison R. Food and Nutrient Intake Data: Looking at the Nutritional Quality of Foods Eaten at Home and Away From Home.USDA.[Internet]. 2012 [citado 2016 Dic 15]; 10(2):1-2.Disponible en: https://www.ers.usda.gov/amber-waves/2012/june/data-feature-food-and-nutrient-intake-data/
https://www.ers.usda.gov/amber-waves/201... .

Eating places creates cenarios for making food choices and influencing collective health; for example, the World Health Organization (WHO) addresses out-of-home food as an environmental determinant of health⁶6. World Health Organization (WHO). Diet and physical activity for health. European Charter on counteracting obesity. World Health Organization Europe [Internet]. European Ministerial Conference on Counteracting Obesity. 15-17 Noviembre 2006. [citado 2016 Dic 15]. Disponible en: http://www.euro.who.int/__data/assets/pdf_file/0006/96459/E90143.pdf
http://www.euro.who.int/__data/assets/pd... . Specifically, food environments can be broadly conceptualized as any opportunity to obtain food at or away from home⁷7. Townshend T, Lake A. Obesogenic urban form: Theory, policy and practice. Health & Place 2009; 15(4):909-916.. However, in the case of food consumption away from home, elements are considered related to marketing, advertising, access, geographical availability, among others. Particularly, Minaker et al.⁸8. Minaker L, Shuh A, Olstad D, Engler-Stringer R, Black J, Mah C. Retail food environments research in Canada: A scoping review. Can J Public Health 2016; 107(Supl. 1):s4-s13. point out that geographic access to food sources as well as marketing within those sources are associated with dietary behaviors and downstream effects on health status. Similarly, other scientific reports show that environments influence food consumption⁹9. Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Office of Disease Prevention. [Internet]. 2015. [citado 2016 Dic 15]. Disponible: https://health.gov/dietaryguidelines/committee/
https://health.gov/dietaryguidelines/com... . Due to these factors, it is recognized that restaurants generate conditions in which food is found and choices are made.

It would be expected that food choices made by individuals away from home maximize their wellness, particularly considering the relationship between health and food intake. For this reason, a balanced diet is included in several strategies to generate optimal conditions for growth and development in childhood¹⁰10. Rush E, Cairncross C, Williams M, Tseng M, Coppinger T, McLennan S, Latimer K. Project Energize: intervention development and 10 years of progress in preventing childhood obesity. BMC Research Notes 2016; 9(1):2-7., productivity in adult life¹¹11. Poscia A, Moscato U, La Milia D, Milovanovic S, Stojanovic J, Borghini A, Collamati A, Ricciardi W, Magnavita N. Workplace health promotion for older workers: a systematic literature review. BMC Health Services Research 2016; 16(Supl. 5):415-479., and active aging¹²12. McNaughton S, Crawford D, Ball K, Salmon J. Understanding determinants of nutrition, physical activity and quality of life among older adults: the Wellbeing, Eating and Exercise for a Long Life (WELL) study. Health Qual Life Outcomes 2012; 10:109.. To illustrate this, from a public health perspective, multiple dietary guidelines are implemented for different countries to give recommendations for a balanced diet among their populations. Examples are the guidelines developed in countries such as Mexico¹³13. Academia Nacional de Medicina. Guías Alimentarias y de Actividad Física [Internet]. Intersiste. México; 2015. 1-188 p. [citado 2016 Dic 15]. Disponible: https://ods.od.nih.gov/pubs/2015_DGAC_Scientific_Report_ODS_Compiled_DS_Statements.pdf
https://ods.od.nih.gov/pubs/2015_DGAC_Sc... , Argentina¹⁴14. Argentina. Ministerio de Salud de la Nación. Guías Alimentarias para la Población Argentina. [Internet]. Buenos Aires, Argentina; 2016. 259 p. [citado 2016 Dic 15]. Disponible en: http://www.msal.gob.ar/images/stories/bes/graficos/0000000817cnt-2016-04_Guia_Alimentaria_completa_web.pdf
http://www.msal.gob.ar/images/stories/be... or Colombia¹⁵15. Instituto Colombiano de Bienestar Familiar (ICBF), Organización de las Naciones Unidas para la Alimentación y Agricultura (FAO). Guías Alimentarias Basadas en Alimentos para la Población Colombiana Mayor de 2 años. Documento técnico. [Internet]. Bogotá, Colombia; 2015. 314 p [citado 2016 Dic 15]. Disponible en: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/PP/SNA/guias-alimentarias-basadas-en-alimentos.pdf
https://www.minsalud.gov.co/sites/rid/Li... . However, choosing meals in food establishments is determined by other economic, physical and social variables. In fact, food consumption decisions involve a multifactorial process. In the case of the decisions made in restaurants, they are influenced by price promotion, characteristics of products, physical layout, among others¹⁶16. Engler-Stringer R, Le H, Gerrard A, Muhajarine N. The community and consumer food environment and children’s diet: a systematic review. BMC Public Health 2014; 14(1):522..

Given the exposed relationships and the complexity of food choices in out-of-home environments, there is a need to establish ways to promote healthy eating in food establishments, particularly in restaurants, due to their availability in urban areas and their economic impact. Consequently, the objective of this study was to identify relevant topics in the recent scientific literature about healthy eating and restaurants. A systematic review of research in this area published between 2011 and 2016 was conducted, which resulted in updated research on the subject as well as opportunities to influence collective health.

Methods

The review considered scientific articles published from January 1,2011 to April 30, 2016. Seven databases were consulted: Web of Science, Scopus, PubMed, Ebsco Host (Medline full text), Science Direct (Elsevier), Redalyc and Dialnet. The pre-defined search terms and text words used across all the databases included: “Healthy eating” AND “Choices” AND “Restaurants”; “Healthy eating” AND “Choices” AND “Food service”; “Healthy eating” AND “Dining” AND “Food service”; “Healthy eating” AND “Dining” AND “Restaurants”; “Healthy” AND “Offer” AND “Food service”; “Healthy” AND “Offer” AND “Restaurants”; “Healthy food” AND “Food service”; “Healthy food” AND “Restaurant”; “Healthy offers” AND “Food service”; “Healthy offers” AND “Restaurant”.

Documents were eligible for inclusion if (1) they addressed healthy eating in restaurants; (2) they were presented in research articles or reviews; and (3) they were written either in English or Spanish. First, documents were identified through search terms and filters on the databases. Following this, titles and abstracts were screened for inclusion based on the eligibility criteria. Finally, the full-text records were read to select the documents that were part of this literature review.

The articles included in the final sample were recorded in a data table, which listed title, year and country of publication, study place, type of study, objective, summary of results, main ideas of discussion and conclusions. Additionally, for those who had a more extensive description of healthy eating in restaurants, analytical summaries were written. The selection of the documents, the registration in the data table and the preparation of analytical summaries were carried out by the two authors.

Content analyses of the data table and summaries were independently conducted by the authors using NVivo 10.0. First, the information was coded focusing on healthy eating criteria used in the studies as well as descriptions of interventions to promote healthy eating and their effectiveness. After that, emerging themes were identified, and similarities and differences between articles were analyzed. Disagreements among the researchers were settled through discussion until consensus was reached. Recurrence tables, flowcharts and cloud maps were used to target dominant subjects. Eventually, narrative syntheses with the predominant topics were written. The topics included were those repetitive in the literature, those that contributed to understanding healthy eating promotion in restaurants or those that had a strong relationship with recognized dietary guidelines.

Results

This review included 20 documents published between 2011 and 2016 in well-known scientific databases. Figure 1 shows the selection process of the articles included in this study.

From the selected articles, 50% of the studies were completed in U.S. and 20% in the United Kingdom (4 articles). In contrast, only one study was conducted in Latin America, specifically in Brazil. The documents included experimental investigation (65%) and descriptive studies (20%), and only three (15%) were the result of reviews. Chart 1 shows the 20 review articles.

From the content analysis, three relevant themes emerged: Food supply modifications, promotion of healthy choices and barriers against healthy eating promotion in restaurants. Each of them is described in a narrative synthesis below.

Food supply modifications

In the studies included, there was a clear statement about the importance of environmental factors over health promotion. Researchers such as Caraher et al.¹⁷17. Caraher M, O’Keefe E, Lloyd S, Madelin T. The planning system and fast food outlets in London: lessons for health promotion practice. Revista Portuguesa de Saúde Pública 2013; 31(1):49-57., Martínez-Donate et al.¹⁸18. Martínez-Donate A, Riggall A, Meinen A, Malecki K, Escaron A, Hall B, Menzies A, Garske G, Nieto J, Nitzke S. Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial. BMC Public Health 2015; 15:136.and Skov et al.¹⁹19. Skov LR, Lourenço S, Hansen GL, Mikkelsen BE, Schofield C. Choice architecture as a means to change eating behaviour in self-service settings: a systematic review. Obesity Reviews 2013; 14(3):187-196.described health behaviors as the result of interaction between individuals’ attributes and environmental factors, like food availability in restaurants. For this reason, they pointed out the need to adjust food supply in these establishments. Specifically, inclusion of health-friendly options in menus was a recurrent topic, mentioning fruits and vegetables as a regular example⁴4. Newson R, Maas R, Beijersbergen A, Carlson L, Rosenbloom C. International consumer insights into the desires and barriers of diners in choosing healthy restaurant meals. Food Quality and Preference 2015; 43:63-70.,¹⁸18. Martínez-Donate A, Riggall A, Meinen A, Malecki K, Escaron A, Hall B, Menzies A, Garske G, Nieto J, Nitzke S. Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial. BMC Public Health 2015; 15:136.,²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.

21. Bedard K, Kuhn P. Micro-marketing healthier choices: Effects of personalized ordering suggestions on restaurant purchases. J Health Econ 2015; 39:106-122.

22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638.

23. Anzman-Frasca S, Dawes F, Sliwa S, Dolan P, Nelson M, Washburn K, Economos C. Healthier side dishes at restaurants: an analysis of children’s perspectives, menu content, and energy impacts. Int J Behav Nutr Phys Act 2014; 11(1):1-12

24. Martins A, Pacheco da Costa R, Marino M, Rataichesck G. Overweight/obesity is associated with food choices related to rice and beans, colors of salads, and portion size among consumers at a restaurant serving buffet-by-weight in Brazil. Appetite 2012; 59(2):305-311.-²⁵25. Kleef E, Broek O, Trijp H. Exploiting the Spur of the Moment to Enhance Healthy Consumption: Verbal Prompting to Increase Fruit Choices in a Self-Service Restaurant. Applied Psychology: Health and Well-Being 2015; 7(2):149-166.. Predominantly, concern was expressed about providing meals that contribute to wellness, given the close relationship between food consumption and health.

Other food supply modifications were justified by the link between high intake of specific nutrients and prevalence of chronic diseases. For this reason, reduction of unhealthy options in menus was recommended in different studies. Particularly, an important percentage of documents referred to the need to include meals with a low calorie count due to the obesity epidemic. According to the articles, low calorie dishes may be included in restaurants’ menus through modifying cooking methods⁴4. Newson R, Maas R, Beijersbergen A, Carlson L, Rosenbloom C. International consumer insights into the desires and barriers of diners in choosing healthy restaurant meals. Food Quality and Preference 2015; 43:63-70.,²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.,²²22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638.,²⁴24. Martins A, Pacheco da Costa R, Marino M, Rataichesck G. Overweight/obesity is associated with food choices related to rice and beans, colors of salads, and portion size among consumers at a restaurant serving buffet-by-weight in Brazil. Appetite 2012; 59(2):305-311., reducing portion size⁴4. Newson R, Maas R, Beijersbergen A, Carlson L, Rosenbloom C. International consumer insights into the desires and barriers of diners in choosing healthy restaurant meals. Food Quality and Preference 2015; 43:63-70.,¹⁷17. Caraher M, O’Keefe E, Lloyd S, Madelin T. The planning system and fast food outlets in London: lessons for health promotion practice. Revista Portuguesa de Saúde Pública 2013; 31(1):49-57.,¹⁹19. Skov LR, Lourenço S, Hansen GL, Mikkelsen BE, Schofield C. Choice architecture as a means to change eating behaviour in self-service settings: a systematic review. Obesity Reviews 2013; 14(3):187-196.,²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.,²²22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638.

23. Anzman-Frasca S, Dawes F, Sliwa S, Dolan P, Nelson M, Washburn K, Economos C. Healthier side dishes at restaurants: an analysis of children’s perspectives, menu content, and energy impacts. Int J Behav Nutr Phys Act 2014; 11(1):1-12-²⁴24. Martins A, Pacheco da Costa R, Marino M, Rataichesck G. Overweight/obesity is associated with food choices related to rice and beans, colors of salads, and portion size among consumers at a restaurant serving buffet-by-weight in Brazil. Appetite 2012; 59(2):305-311.or adding appetizers with lower calories⁴4. Newson R, Maas R, Beijersbergen A, Carlson L, Rosenbloom C. International consumer insights into the desires and barriers of diners in choosing healthy restaurant meals. Food Quality and Preference 2015; 43:63-70.,¹⁸18. Martínez-Donate A, Riggall A, Meinen A, Malecki K, Escaron A, Hall B, Menzies A, Garske G, Nieto J, Nitzke S. Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial. BMC Public Health 2015; 15:136.,²³23. Anzman-Frasca S, Dawes F, Sliwa S, Dolan P, Nelson M, Washburn K, Economos C. Healthier side dishes at restaurants: an analysis of children’s perspectives, menu content, and energy impacts. Int J Behav Nutr Phys Act 2014; 11(1):1-12,²⁴24. Martins A, Pacheco da Costa R, Marino M, Rataichesck G. Overweight/obesity is associated with food choices related to rice and beans, colors of salads, and portion size among consumers at a restaurant serving buffet-by-weight in Brazil. Appetite 2012; 59(2):305-311.. Likewise, sugar reduction in meals offered in these establishments was discussed⁴4. Newson R, Maas R, Beijersbergen A, Carlson L, Rosenbloom C. International consumer insights into the desires and barriers of diners in choosing healthy restaurant meals. Food Quality and Preference 2015; 43:63-70.,¹⁷17. Caraher M, O’Keefe E, Lloyd S, Madelin T. The planning system and fast food outlets in London: lessons for health promotion practice. Revista Portuguesa de Saúde Pública 2013; 31(1):49-57.,²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.,²²22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638.,²⁶26. Crixell S, Friedman B, Fisher D, Biediger-Friedman L. Improving Children’s Menus in Community Restaurants: Best Food for Families, Infants, and Toddlers (Best Food FITS) Intervention, South Central Texas, 2010-2014. Prev Chronic Dis 2014; 11:E223.,²⁷27. Choi J, Zhao J. Consumers’ behaviors when eating out. Does eating out change consumers’ intention to eat healthily? British Food Journal. 2014; 116(3):494-509.. On the other hand, reduction of sodium and saturated fat was mentioned repeatedly due to the high prevalence of cardiovascular disease in the population⁴4. Newson R, Maas R, Beijersbergen A, Carlson L, Rosenbloom C. International consumer insights into the desires and barriers of diners in choosing healthy restaurant meals. Food Quality and Preference 2015; 43:63-70.,²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.,²⁴24. Martins A, Pacheco da Costa R, Marino M, Rataichesck G. Overweight/obesity is associated with food choices related to rice and beans, colors of salads, and portion size among consumers at a restaurant serving buffet-by-weight in Brazil. Appetite 2012; 59(2):305-311.,²⁷27. Choi J, Zhao J. Consumers’ behaviors when eating out. Does eating out change consumers’ intention to eat healthily? British Food Journal. 2014; 116(3):494-509.

28. Batada A, Bruening M, Marchlewicz E, Story M, Wootan M. Poor Nutrition on the Menu: Children’s Meals at America’s Top Chain Restaurants. Chilhood Obes 2012; 8(3):251-255.-²⁹29. Edwards J. The foodservice industry: Eating out is more than just a meal. Quality and Preference 2013; 27(2):223-229.. For example, the study led by Bagwell proposed to eliminate salt shakers from the tables and reduce salt addition during cooking²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.. In this way, it was highlighted that restaurants may contribute to the prevention of prevalent chronic diseases.

Promotion of healthy choices

According to the documents reviewed, it is crucial not only to modify the food supply, but also to favor healthy decisions by consumers in restaurants. Specifically, the articles referred to strategies such as providing information at points of sale, events and sales promotions. In terms of information to promote healthy choices, menu labeling to show nutrition facts was recurrently mentioned¹⁷17. Caraher M, O’Keefe E, Lloyd S, Madelin T. The planning system and fast food outlets in London: lessons for health promotion practice. Revista Portuguesa de Saúde Pública 2013; 31(1):49-57.

18. Martínez-Donate A, Riggall A, Meinen A, Malecki K, Escaron A, Hall B, Menzies A, Garske G, Nieto J, Nitzke S. Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial. BMC Public Health 2015; 15:136.-¹⁹19. Skov LR, Lourenço S, Hansen GL, Mikkelsen BE, Schofield C. Choice architecture as a means to change eating behaviour in self-service settings: a systematic review. Obesity Reviews 2013; 14(3):187-196.,²¹21. Bedard K, Kuhn P. Micro-marketing healthier choices: Effects of personalized ordering suggestions on restaurant purchases. J Health Econ 2015; 39:106-122.

22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638.-²³23. Anzman-Frasca S, Dawes F, Sliwa S, Dolan P, Nelson M, Washburn K, Economos C. Healthier side dishes at restaurants: an analysis of children’s perspectives, menu content, and energy impacts. Int J Behav Nutr Phys Act 2014; 11(1):1-12,³⁰30. Kang J, Jun J, Arendt S. Understanding customers’ healthy food choices at casual dining restaurants: Using the Value – Attitude – Behavior model. International Journal of Hospitality Managment 2015; 48:12-21.

31. Elbel B. Consumer Estimation of Recommended and Actual Calories at Fast Food Restaurants. Obesity 2011; 19(10):1971-1978

32. Sinclair S, Cooper M, Mansfield E. The Influence of Menu Labeling on Calories Selected or Consumed: A Systematic Review and Meta-Analysis. Journal of the Academy Nutrition and Dietetics 2014; 114(9):1375-1388.-³³33. Chen R, Smyser M, Chan N, Ta M, Saelens B, Krieger J. Changes in awareness and use of calorie information after mandatory menu labeling in restaurants in King County, Washington. Am J Public Health 2015; 105(3):546-553.. This considers that awareness of calorie content of meals would influence mindful food choices. Also, informative slogans to highlight healthier items¹⁸18. Martínez-Donate A, Riggall A, Meinen A, Malecki K, Escaron A, Hall B, Menzies A, Garske G, Nieto J, Nitzke S. Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial. BMC Public Health 2015; 15:136.,²²22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638., communication through information technologies¹⁸18. Martínez-Donate A, Riggall A, Meinen A, Malecki K, Escaron A, Hall B, Menzies A, Garske G, Nieto J, Nitzke S. Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial. BMC Public Health 2015; 15:136.,²¹21. Bedard K, Kuhn P. Micro-marketing healthier choices: Effects of personalized ordering suggestions on restaurant purchases. J Health Econ 2015; 39:106-122. and logos to promote nutritious food were suggested¹⁸18. Martínez-Donate A, Riggall A, Meinen A, Malecki K, Escaron A, Hall B, Menzies A, Garske G, Nieto J, Nitzke S. Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial. BMC Public Health 2015; 15:136.,¹⁹19. Skov LR, Lourenço S, Hansen GL, Mikkelsen BE, Schofield C. Choice architecture as a means to change eating behaviour in self-service settings: a systematic review. Obesity Reviews 2013; 14(3):187-196.,²²22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638.,³⁴34. Papies E, Veling H. Healthy dining. Subtle diet reminders at the point of purchase increase low-calorie food choices among both chronic and current dieters. Appetite 2013; 61(1):1-7.. Alternatively, only one study referred to verbal guidelines given by servers as a communication tactic²⁵25. Kleef E, Broek O, Trijp H. Exploiting the Spur of the Moment to Enhance Healthy Consumption: Verbal Prompting to Increase Fruit Choices in a Self-Service Restaurant. Applied Psychology: Health and Well-Being 2015; 7(2):149-166..

Regarding events and sales promotions to facilitate healthier behaviors in restaurants, a smaller number of publications referred to these strategies. In the case of events, local initiatives with awards to “healthy” caterers²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46. and competitions around better food choices between customers³⁰30. Kang J, Jun J, Arendt S. Understanding customers’ healthy food choices at casual dining restaurants: Using the Value – Attitude – Behavior model. International Journal of Hospitality Managment 2015; 48:12-21. were mentioned. Regarding sales promotion, the literature referred to interventions in means of payment¹⁹19. Skov LR, Lourenço S, Hansen GL, Mikkelsen BE, Schofield C. Choice architecture as a means to change eating behaviour in self-service settings: a systematic review. Obesity Reviews 2013; 14(3):187-196., lower prices for nutritious food²²22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638. and product bundling¹⁸18. Martínez-Donate A, Riggall A, Meinen A, Malecki K, Escaron A, Hall B, Menzies A, Garske G, Nieto J, Nitzke S. Evaluation of a pilot healthy eating intervention in restaurants and food stores of a rural community: a randomized community trial. BMC Public Health 2015; 15:136.,²¹21. Bedard K, Kuhn P. Micro-marketing healthier choices: Effects of personalized ordering suggestions on restaurant purchases. J Health Econ 2015; 39:106-122.

22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638.-²³23. Anzman-Frasca S, Dawes F, Sliwa S, Dolan P, Nelson M, Washburn K, Economos C. Healthier side dishes at restaurants: an analysis of children’s perspectives, menu content, and energy impacts. Int J Behav Nutr Phys Act 2014; 11(1):1-12 – all to persuade consumers to make healthier choices.

Barriers against healthy eating promotion in restaurants

Although the literature reported different initiatives to encourage healthy eating in restaurants, the obstacles were clearly highlighted, specifically barriers associated with consumer perception and profitability of healthier food supply. Some of the articles discussed the low popularity of and reduced demand for healthy foods among clients due to less pleasant flavor¹⁷17. Caraher M, O’Keefe E, Lloyd S, Madelin T. The planning system and fast food outlets in London: lessons for health promotion practice. Revista Portuguesa de Saúde Pública 2013; 31(1):49-57.,¹⁹19. Skov LR, Lourenço S, Hansen GL, Mikkelsen BE, Schofield C. Choice architecture as a means to change eating behaviour in self-service settings: a systematic review. Obesity Reviews 2013; 14(3):187-196.,²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.,²²22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638.. To illustrate this, Newson et al.⁴4. Newson R, Maas R, Beijersbergen A, Carlson L, Rosenbloom C. International consumer insights into the desires and barriers of diners in choosing healthy restaurant meals. Food Quality and Preference 2015; 43:63-70. asserted that healthy choices are often linked to the perception of less taste, less satiety and higher price. Given this trend, several establishments assume that providing this type of food will harm their profits²²22. Lee-kwan S, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J, Hamouda M, Gittelsohn J. Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results. BMC Public Health 2013; 13:638.,³⁴34. Papies E, Veling H. Healthy dining. Subtle diet reminders at the point of purchase increase low-calorie food choices among both chronic and current dieters. Appetite 2013; 61(1):1-7., even more so if foods with lower nutritional quality have a higher profit margin²⁵25. Kleef E, Broek O, Trijp H. Exploiting the Spur of the Moment to Enhance Healthy Consumption: Verbal Prompting to Increase Fruit Choices in a Self-Service Restaurant. Applied Psychology: Health and Well-Being 2015; 7(2):149-166.,²⁶26. Crixell S, Friedman B, Fisher D, Biediger-Friedman L. Improving Children’s Menus in Community Restaurants: Best Food for Families, Infants, and Toddlers (Best Food FITS) Intervention, South Central Texas, 2010-2014. Prev Chronic Dis 2014; 11:E223.. In fact, one study indicated a potential conflict between health promotion and profit generation in food outlets³⁵35. Hanratty B, Milton B, Ashton M, Whitehead M. “McDonalds and KFC, it’s never going to happen”: the challenges of working with food outlets to tackle the obesogenic environment. J Public Health 2012; 34(4):548-554.. For instance, offering healthy ingredients represents a higher cost that not all customers are willing to pay for¹⁷17. Caraher M, O’Keefe E, Lloyd S, Madelin T. The planning system and fast food outlets in London: lessons for health promotion practice. Revista Portuguesa de Saúde Pública 2013; 31(1):49-57.,²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.. Similarly, reducing portion sizes may affect price and restaurants’ incomes as well²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.,²⁵25. Kleef E, Broek O, Trijp H. Exploiting the Spur of the Moment to Enhance Healthy Consumption: Verbal Prompting to Increase Fruit Choices in a Self-Service Restaurant. Applied Psychology: Health and Well-Being 2015; 7(2):149-166.. However, other authors asserted that healthy eating promotion may be commercially interesting, considering a new market of health-conscious consumers³⁴34. Papies E, Veling H. Healthy dining. Subtle diet reminders at the point of purchase increase low-calorie food choices among both chronic and current dieters. Appetite 2013; 61(1):1-7..

Discussion

This review provides updated literature regarding healthy eating in restaurants and research opportunities. For instance, minimal research was found in Latin American countries. In fact, one study pointed out that even though U.S. research has provided information on the topic, other countries may face unique food environment issues⁸8. Minaker L, Shuh A, Olstad D, Engler-Stringer R, Black J, Mah C. Retail food environments research in Canada: A scoping review. Can J Public Health 2016; 107(Supl. 1):s4-s13.. Given differences in economy and culture, it is imperative to study these environments in different contexts. However, developing valid scales and instruments for evaluation is part of the challenge. For example, in the review, there were not specific tools reported. In contrast, the literature about institutional foodservices refers to the “Nutrition Environments Survey” (NEMRS) as a valid checklist to evaluate healthy eating promotion³⁶36. Saelens B, Glanz K, Sallis J, Frank L. Nutrition Environment Measures Study in Restaurants (NEMS-R) Development and Evaluation. J Prevent Med 2007; 32(4):273-281.

37. Lesser L, Hunnes D, Reyes P, Arab L, Ryan G, Brook R, Choen D. Assessment of Food Offerings and Marketing Strategies in the Food-Service Venues at California Children’s Hospitals. Academic Pediatrics Association 2012; 12(1):62-67.

38. Tseng M, DeGreef K, Fishler M, Gipson R, Koyano K, Neill D. Assessment of a University Campus Food Environment, California, 2015. Preventing Chronic Disease. [Internet]. 2016. [citado 2016 Dic 15]; 13:150455. Disponible en: http://www.cdc.gov/pcd/issues/2016/15_0455.htm
http://www.cdc.gov/pcd/issues/2016/15_04... -³⁹39. Carins J, Rundle-Thiele S. Fighting to eat healthfully: measurements of the military food environment. Journal of Social Marketing 2014; 4(3):223-239.. Nevertheless, that survey has different versions, and one of them already is used in restaurants⁴⁰40. Wang J, Engler-Stringer R, Muhajarine N. Assessing the Consumer Food Environment in Restaurants by Neighbourhood Distress Level across Saskatoon, Saskatchewan. Canadian Journal of Dietetic Practice and Research 2016; 77(1):9-16.. Although there are numerous studies about healthy diets in institutional food services like workplaces, gardens, hospitals, among others⁴¹41. Geaney F, Harrington J, Fitzgerald A, Perry I. The impact of a workplace catering initiative on dietary intakes of salt and other nutrients: a pilot study. Public Health Nutrition 2011; 14(8):1345-1349.

42. Stites S, Singletary S, Menasha A, Cooblall C, Hantula D, Axelrod S, Figueredo V, Phipps E. Pre-ordering lunch at work. Results of the what to eat for lunch study. Appetite 2015; 84:88-97.

43. Donohoe C, McGurk M. Promoting Healthy Snack and Beverage Choices in Hawai ‘i Worksites: The Choose Healthy Now! Pilot Project. Hawai’i Journal of Medicine Public Health 2014; 73(11):365-371.-⁴⁴44. Olstad D, Lieffers J, Raine K, McCargar L. Implementing the Alberta nutrition guidelines for children and youth in a recreational facility. Revue Canadienne de la Pratique et de la Recherche en Diététique 2011; 72(4):177., still there are few in restaurants, despite higher decision-making power of the consumer in these establishments. Therefore, characterizing and intervening in food supply in restaurants represents a research opportunity.

Regarding the findings, some of them are congruent with public health concerns and other scientific evidence. In the case of calorie reduction in restaurants’ meals, this strategy is justified by findings about obesogenic factors. For example, previous studies emphasize that eating away from home impacts caloric intake and weight gain⁴⁵45. Lachat C, Nago E, Verstraeten R, Roberfroid D, Van Camp J, Kolsteren P. Eating out of home and its association with dietary intake: a systematic review of the evidence. Obesity Reviews 2011; 13(4):329-346.

46. McGuire S. Todd J, Mancino L, Lin B, Jessica E. The impact of food away from home on adult diet quality, ERR-90. United States Department of Agriculture. [Internet]. 2010. Economic Research Service. [citado 2016 Dic 15]). Disponible en: https://www.ers.usda.gov/webdocs/publications/err90/8170_err90_1_.pdf
https://www.ers.usda.gov/webdocs/publica... -⁴⁷47. Ruopeng A. Beverage Consumption in Relation to Discretionary Food Intake and Diet Quality among US Adults, 2003 to 2012. J Acad Nutr Diet 2015; 116(1):28-37.. This explains the relationship between obesity and environmental aspects⁴⁸48. Jaime P, Duran A, Sarti F, Lock K. Investigating environmental determinants of diet, physical activity, and overweight among adults in Sao Paulo, Brazil. Journal of Urban Health 2011; 88(3):567-581.. Given that overweight and obesity are common and serious problemsnowadays⁴⁹49. Cleobury L, Tapper K. Reasons for eating “unhealthy” snacks in overweight and obese males and females. Journal of Human Nutrition and Dietetics 2014; 27(4):333-341., intervention over calorie count in restaurants may contribute to the solution.

The prevalence in non-communicable diseases (NCDs)explained our findings in reference to interventions in sugar, sodium and saturated fat in restaurants’ meals. In 2015, WHO reported that 38 million people around the world die each year from conditions such as cardiovascular disease, respiratory disease, diabetes or cancer⁵⁰50. World Health Organization (WHO). Noncommunicable diseases [Internet]. WHO; 2015. [citado 2016 Dic 15]. Disponible en: http://www.who.int/mediacentre/factsheets/fs355/en/
http://www.who.int/mediacentre/factsheet... . Such diseases were caused by inadequate eating habits among other factors⁵¹51. World Health Organization (WHO). Informe sobre la situacion de las enfermedades no transmisibles [Internet]. WHO; 2010. Vol. 11. [citado 2016 Dic 15]. Disponible en: http://apps.who.int/iris/bitstream /10665/149296/1/WHO_NMH_NVI_15.1_spa.pdf
http://apps.who.int/iris/bitstream /1066... . That is why diet has become an important factor to prevent these diseases. There is enough evidence about the relationship between excess salt intake and cardiovascular disease⁵²52. Eckel R, Jakicic J, Ard J, De Jesus J, Houston Miller N, Hubbard V, Lee I-M, Lichtenstein AH, Loria CM, Millen BE, Nonas CA, Sacks FM, Smith Junior SC, Svetkey LP, Wadden TA, Yanovski SZ. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: A report of the American College of cardiology/American Heart Association task force on practice guidelines. [Internet] 2013. Vol. 129, American Heart Association. [citado 2016 Dic 15]. Disponible en: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437740.48606.d1
http://circ.ahajournals.org/content/earl...

53. Kloss L, Meyer J, Graeve L, Vetter W. Sodium intake and its reduction by food reformulation in the European Union-A review. NFS Journal 2015; 1:9-19.-⁵⁴54. Baldo M, Rodrigues S, Mill J. High salt intake as a multifaceted cardiovascular disease: new support from cellular and molecular evidence. Heart Fail Reviews 2015; 20(4):461-474.,or about high-sugar consumption and cellular deterioration, diabetes and cardiovascular disease⁵⁵55. Leung C, Laraia B, Needham B, Rehkopf D, Adler N, Lin J, Blackburn EH, Epel ES. Soda and Cell Aging: Associations Between Sugar-Sweetened Beverage Consumption and Leukocyte Telomere Length in Healthy Adults From the National Health and Nutrition Examination Surveys. Am J Public Health 2014; 104(12):2425-2431.

56. Stanhope KL. Sugar consumption, metabolic disease and obesity: The state of the controversy. Crit Rev Clin Lab Sci 2015; 53(1):52-67.-⁵⁷57. Shearrer GE, Daniels MJ, Toledo-Corral CM, Weigensberg MJ, Spruijt-Metz D, Davis JN. Associations among sugar sweetened beverage intake, visceral fat, and cortisol awakening response in minority youth. Physiology & Behavior 2016; 167:188-193.. For this reason, the Global Action Plan for the Prevention and Control of NCDs describes the need to regulate sugar, sodium and saturated fat in population diet⁵⁸58. World Health Organization (WHO). Plan de acción mundial para la prevención y el control de las enfermedades no transmisibles 2013-2020. [Internet]. 2013. 44 p. [citado 2016 Dic 15]. Disponible en: http://www.who.int/cardiovascular_diseases/15032013_updated_revised_draft_action_plan_spanish.pdf
http://www.who.int/cardiovascular_diseas... . Therefore, food supply modifications regarding these nutrients are fundamental to respond to public health concerns.

Increased availability of fruits and vegetables in restaurants’ menus may promote healthier population eating patterns. Consumption of fruits and vegetables is recognized as part of a healthy diet. A balanced diet is recognized as fundamental for maintaining health. The Scientific Report of the Dietary Guidelines for the United States, in 2015, considered healthy eating as one of the pillars of well-being during life⁹9. Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Office of Disease Prevention. [Internet]. 2015. [citado 2016 Dic 15]. Disponible: https://health.gov/dietaryguidelines/committee/
https://health.gov/dietaryguidelines/com... . In the case of fruits and vegetables, they are associated with numerous health benefits. For example, they are rich in fiber that favors gastrointestinal well-being and reduces absorption of nutrients like carbohydrates⁶²62. Grundy M, Edwards C, Mackie A, Gidley M, Butterworth P, Ellis P. Re-evaluation of the mechanisms of dietary fi bre and implications for macronutrient bioaccessibility , digestion and postprandial metabolism. Br J Nutr 2016; 116(5):816-833. Similarly, fruits and vegetables provide secondary metabolites with antioxidants and vasodilatoreffects⁵⁹59. Zapata S, Piedrahita A, Rojano B. Capacidad atrapadora de radicales oxígeno (orac) y fenoles totales de frutas y hortalizas de Colombia. Perspectivas en Nutricion Humana 2014; 16(1):25-36.

60. Quideau S, Deffieux D, Douat-Casassus C, Pouysegu L. Plant polyphenols: chemical properties, biological activities, and synthesis. Angew Chem Int Ed Engl 2011; 50(3):586-621.-⁶¹61. Lara M, Bustos P, Amigo H. Consumo de frutas, verduras y presión arterial. Un estudio poblacional. Archivos Latinoamericanos de Nutricion 2015; 65(1):21-26.that are crucial to cardiovascular performance. In light of these benefits, the recurrent allusion to the importance fruits and vegetables’ availability in restaurants is validated.

Despite awareness of the relevance of a healthy diet, the findings showed a misalignment with recent definitions of healthy eating. Today, the definitions include an approach to both food and nutrients aimed at optimizing health, which not only addresses the consumption of fruits and vegetables and discourages the consumption of food sources with nutrients related to disease. It is also necessary to include healthy fats, whole grains, nuts and water and moderate alcohol consumption⁶³63. Willett WC, Stampfer MJ. Current evidence on healthy eating. Annual Review Public Health 2013; 34:77-95.

64. Organización Mundial de la Salud (OMS). Alimentación Sana [Internet]. Nota descriptiva Nº 394. 2015. [citado 2016 Dic 15]. Disponible en: http://www.who.int/mediacentre/factsheets/fs394/es/
http://www.who.int/mediacentre/factsheet...

65. United States Departament of Agriculture (USDA), Department of Health and Human Services (HHS). Dietary Guidelines for Americans 2015-2020. 8th ed. [Internet]. 2015. [citado 2016 Dic 15]. Disponible en: http://ninindia.org/DietaryguidelinesforIndians-Finaldraft.pdf
http://ninindia.org/Dietaryguidelinesfor... -⁶⁶66. Ruxton C, Derbyshire E. The health benefits of whole grains and fibre. Nutrition. Emerald, Nutrition Food Science 2016; 44(6):492-519.. In our literature review, only one article referred to healthy fats, whole grains and water²⁰20. Bagwell S. Healthier catering initiatives in London, UK: an effective tool for encouraging healthier consumption behaviour? Critical Public Health 2014; 24(1):35-46.. In fact, the principal focus was fruits and vegetables. Thus, there is room for progress to a holistic approach about what healthy eating may bein restaurants.

Our findings point out not only the importance of food supply modification in restaurants, but also the promotion of healthy food choices. Particularly, it is recommended that food establishments provide support, access to information and opportunities to make healthy decisions. An example of this kind of support is the menu-labeling strategy. In 2006, the State of New York in the U.S. made calorie labels compulsory in certain restaurant chains⁶⁷67. Vadiveloo M, Dixon L, Elbel B. Consumer purchasing patterns in response to calorie labeling legislation in New York City. Internation Journal Behavioral Nutrition Physical Activity 2011; 8(1):51.. Nevertheless, the findings about its effectiveness are still ambiguous⁶⁸68. Swartz J, Braxton D, Viera A. Calorie menu labeling on quick-service restaurant menus: an updated systematic review of the literature. Internation Journal Behavioral Nutrition 2011; 8(1):135.

69. Kiszko K, Martinez O, Abrams C, Elbel B. The influence of calorie labeling on food orders and consumption: a review of the literature. Journal Community Health 2012; 100(2):130-134.-⁷⁰70. Bollinger B, Leslie P, Sorensen A. Calorie posting in chain restaurants. American Economic Journal Economic Policy 2011; 3(1):91-128.. Different tactics to promote healthier food decisions in restaurants still need to be studied, even more in the case of countries where there is no such regulation.

One may assume that healthy eating is not, in a strict sense, an issue that should be addressed by restaurants. Food establishments create conditions for food consumption. Consequently, they are responsible for these conditions and their impact on collective health. In fact, the Ottawa Charter states that health promotion is not only the responsibility of the health sector, and that actions from other economic and social sectors are required⁷¹71. Conferencia Internacional sobre la Promoción de la Salud. Carta de Ottawa para la Promoción de la Salud [Internet]. Revista de sanidad e higiene pública 1987 p. 129. [citado 2016 Mayo 15]. Disponible en: http://amro.who.int/Spanish/AD/SDE/HS/OttawaCharterSp.pdf
http://amro.who.int/Spanish/AD/SDE/HS/Ot... . Similarly, other authors remark that it is crucial that the foodservice industry take responsibility for the health of customers¹1. Mikkelsen BE. Images of foodscapes: Introduction to foodscape studies and their application in the study of healthy eating out-of-home environments. Perspect Public Health 2011; 131(5):209-216.. However, deep work with the population and their perceptions about healthy food is also required. Restaurants can help in this effort as well. For example, developing appealing healthy dishes may affect perceptions. Nowadays, taste is well known as a decision-making trigger for food choices⁷²72. Bezbaruah N, Brunt A. The Influence of Cartoon Character Advertising on Fruit and Vegetable Preferences of 9- to 11-Year-Old Children. Journal Nutrition Education Behavior 2012; 44(5):438-441.

73. Olsen A, Ritz C, Kramer L, Møller P. Serving styles of raw snack vegetables. What do children want? Appetite 2012; 59(2):556-562.

74. Zeinstra GG, Koelen MA, Kok FJ, de Graaf C. Children’s hard-wired aversion to pure vegetable tastes. A “failed” flavour-nutrient learning study. Appetite 2009; 52(2):528-530.

75. Laureati M, Pagliarini E, Mojet J, Köster E. Incidental learning and memory for food varied in sweet taste in children. Food Quallity Preference 2011; 22(3):264-270.

76. Dammann K, Smith C. Food-related Attitudes and Behaviors at Home, School, and Restaurants: Perspectives from Racially Diverse, Urban, Low-income 9- to 13-year-old Children in Minnesota. Journal Nutrition Education Behavior 2010; 42(6):389-397.

77. Atik D, Ertekin Z. Children’s perception of food and healthy eating: dynamics behind their food preferences. International Journal Consumer Studies 2011; 37(1):59-65.

78. Holsten J, Deatrick J, Kumanyika S, Pinto-Martin J, Compher C. Children’s food choice process in the home environment. A qualitative descriptive study. Appetite 2012; 58(1):64-73.-⁷⁹79. Liem D, Zandstra L. Children’s liking and wanting of snack products: Influence of shape and flavour. Int J Behav Nutr Phys Act 2009; 6:38.. Therefore, attractive healthy meals may positively influence their consumption and perceptions. On the other hand, restaurants could profitably help clients make healthier choices, considering a higher demand of healthy options recently⁸⁰80. Unilever. Nutrición que atrae Reporte Mundial del Menú Hallazgos del Estudio Global. Bogotá [Internet] Unilever Food Solution 2012. [citado 2016 Mayo 15]. Disponible: http://docplayer.es/3890451-Reporte-mundial-del-menu-hallazgos-del-estudio-global-2012-nutricion-que-atrae.html
http://docplayer.es/3890451-Reporte-mund... ,⁸¹81. Chandon P, Wansink B. Does food marketing need to make us fat? A review and solutions. Nutrition Reviews 2012; 70(10):571-593.. In other words, a collective effort is necessary with benefits for customers and restaurants.

Even though this study provides updated research on healthy eating in restaurants, it has limitations as well. Particularly, we did not evaluate methods and designs of the studies included. Future studies are needed to explore the integrity of measures and study designs in this field. Similarly, we did not include documents about public policies on this topic. However, it is well known that still there are opportunities for governments to regulate marketing in restaurants and create healthier food environments⁶⁵65. United States Departament of Agriculture (USDA), Department of Health and Human Services (HHS). Dietary Guidelines for Americans 2015-2020. 8th ed. [Internet]. 2015. [citado 2016 Dic 15]. Disponible en: http://ninindia.org/DietaryguidelinesforIndians-Finaldraft.pdf
http://ninindia.org/Dietaryguidelinesfor... ,⁸²82. Schramm F, Kottow M. Principios bioéticos en salud pública: limitaciones y propuestas. Cad Saude Publica 2001; 17(4):949-956.

83. Brambila-macias J, Shankar B, Capacci S, Mazzocchi M, Perez-cueto F, Verbeke W, Traill WB. Policy interventions to promote healthy eating: A review of what works, what does not, and what is promising. Food Nutr Bull 2012; 32(4):365-376.-⁸⁴84. World Health Organization (WHO). Alimentación Sana [Internet]. Centro de prensa, Nota descriptiva 394. 2015. [citado 2016 Dic 15]. Disponible en: http://www.who.int/mediacentre/factsheets/fs394/es/
http://www.who.int/mediacentre/factsheet... . Nowadays, restaurants are recognized as ideal settings to promote health. In fact, they are part of future lines of research in reports like the U.S. Nutrition Research Plan 2016–2021 or the Scientific Report of the U.S. Dietary Guidelines, from 2015⁹9. Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Office of Disease Prevention. [Internet]. 2015. [citado 2016 Dic 15]. Disponible: https://health.gov/dietaryguidelines/committee/
https://health.gov/dietaryguidelines/com... ,⁸⁵85. Interagency Committee on Human Nutrition Research. National Nutrition Research Roadmap 2016-2021: Advancing Nutrition Research to Improve and Sustain Health. [Internet] 2016. Interagency Committee on Human Nutrition Research. Washington, DC [serial on the internet] 2016; 176. [citado 2016 Dic 15] Disponible en: https://www.nal.usda.gov/sites/default/files/fnic_uploads/2016-03-30-%20ICHNR%20NNRR%20(2).pdf
https://www.nal.usda.gov/sites/default/f... . Therefore, with the dominant subjects identified, research in Latin America may also establish an academic agenda to explore the topic in our countries.

Conclusion

The literature review presented three dominant subjects regarding healthy eating in restaurants, specifically, food supply modifications, promotion of healthy choices and barriers against healthy eating in these establishments. So far, food environments and restaurants have been principally studied in countries like the United States or the United Kingdom, while there is a need to research them more in Latin American countries. The studies examined pointed out the importance of different strategies to promote healthier food environments, given their impact on collective health.

Acknowledgements

We thank Professor Luz Nayibe Vargas, member of the research group “Food, Nutrition and Health” at Pontificia Universidad Javeriana, who gave feedback about the preliminary findings. We also thank Professor Jonathon Day at Purdue University for reviewing the final draft of this manuscript in English.

Funding for this research was provided by Pontificia Universidad Javeriana in Bogotá, Colombia. This publication is part of the study “Healthy eating in restaurants with higher sales in Bogotá: A qualitative analysis of the information available on the web”.

References

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