Restaurant-based interventions: a new approach topromote healthier and allergy-adapted meals
- Autores: Floriana Mandracchia
- Directores de la Tesis: Rosa Solà i Alberich (dir. tes.), Elisabet Llauradó Ribé (dir. tes.), Lucía Tarro Sánchez (dir. tes.)
- Lectura: En la Universitat Rovira i Virgili ( España ) en 2021
- Idioma: español
- Tribunal Calificador de la Tesis: Yolanda Ortega Vila (presid.), María Auladell Bernat (secret.), Carmen Cabezas Peña (voc.)
- Programa de doctorado: Programa de Doctorado en Biomedicina por la Universidad Rovira i Virgili
- Materias:
- Enlaces
- Tesis en acceso abierto en: TDX
- Resumen
JUSTIFICATION: The daily meals consumed outside of the home has increased substantially in recent years among adults and children; however, these meals are associated with an unhealthy diet that may increase predisposal to obesity and other related chronic diseases in the long term. Thus, health promotion in community settings such as restaurants is fundamental to encourage healthier dietary habits when eating out.
HYPOTHESIS: The use of innovative strategies and the inclusion of digital technologies such as mobile and web apps in restaurant-based interventions could offer new opportunities to improve restaurant meal offerings and food allergen management.
OBJECTIVE: This thesis aims to provide evidence about potential innovative strategies and technologies to be used in restaurant-based interventions to increase healthy meal offerings and food choices and improve restaurant food allergen management.
SPECIFIC OBJECTIVES Study 1: To assess the Mediterranean diet adherence, healthiness, nutritional quality, and food allergen management of meals at restaurants in Tarragona Province (Catalonia, Spain) using a cross-sectional study.
Study 2: To elucidate the effectiveness of independent full-service restaurant- and canteen-based interventions targeting children, adolescents and adults in increasing the availability, purchase and intake of healthy meals using a systematic review and meta-analysis.
Study 3: To assess the potential of self-monitoring mobile phone health (mHealth) apps to increase fruit and vegetable intake using a systematized review.
Study 4: To assess the food allergy or intolerance apps in app stores. The multidimensional Mobile App Rating Scale (MARS) was used to rate these apps’ objective and subjective quality and to identify critical points for future improvements using a systematic search and quality assessment.
Study 5: To describe the development of the Healthy Meals web app and evaluate its usability, quality, and validity according to a panel of restaurateurs and nutritionists.
METHODS Study 1: This cross-sectional analysis had the following primary outcomes: (1) adherence to criteria for the Mediterranean diet (AMed) and gluten management (SMAP); (2) the nutritional quality of dishes indicated by a green traffic light rating; and (3) meal nutrient content and allergen-free options. Secondary outcomes included restaurant staff knowledge about the Mediterranean diet and food allergens.
Study 2: This systematic review and meta-analysis included studies from 2000–2020 searched in Medline, Scopus, and the Cochrane Library using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Randomized Controlled Trials (RCTs) and non-RCTs were included in the systematic review, but only RCTs were included in the meta-analysis. Studies were analysed using the following criteria: (1) outcome category (dietary intake, food availability and food purchase); (2) strategies applied (consumer- and/or establishment-based); and (3) intervention setting (school, community, and workplace) reflecting the age of the target population, i.e., children and/or adults.
Study 3: In this systematized review, searches in PubMed and the Web of Science were conducted and had the following inclusion criteria: RCTs evaluating mobile phone apps (mHealth) focused on increasing fruit and/or vegetable intake as a primary or secondary outcome performed from 2008 to 2018.
Study 4: This systematic search identified apps through the keywords “food allergy,” “food intolerance,” and “allergens” in English, Spanish, and Italian in the Apple App Store (iOS) and Google Play Store (Android). The inclusion criteria were a user star rating of ≥3 (of 5 stars) to limit the selection to the most highly rated apps; ≥1000 reviews identified on the presenting page of the app in the app store to identify the apps that were most commonly used and experienced; and the most recent update performed from 2017 to present. Then, the identified apps were divided according to their purpose: a) searching for allergen-free “food products,” b) “restaurants,” or c) recipes in “meal planners”. Then, apps were evaluated on a scale from 1 to 5 points using the MARS in terms of the following: (1) app subjective and objective quality categories, comprising various sections such as engagement, functionality, aesthetics, and information (Medline was searched for eligible apps to check whether they had been tested in trials); and (2) an optional app-specific MARS section to collect further information about the perceived impact of the app on the user (awareness, knowledge, attitudes, intention to change, help-seeking, and behavioural change). Furthermore, the output and input features of the included apps were evaluated. Differences between MARS sections and app purposes were assessed. Additionally, correlations among MARS sections, star ratings, and numbers of reviews were evaluated.
Study 5: The Healthy Meals web app was based on the nutritional content of restaurant meals assessed in the form of Multiple Traffic Light (MTL) labels and the detection of 14 recognized food allergens. App evaluation included the following: 1) usability evaluation, by 6 restaurateurs and 10 nutritionists who entered a recipe sheet into the web app, and then completed the Computer System Usability Questionnaire (CSUQ), which assessed four factors (system, interface, information, and overall usability) with a maximum score of 7 points; 2) quality evaluation, by the same 10 nutritionists who performed the usability evaluation, and then completed the Mobile App Rating Scale (MARS), with a maximum score of 5 points in the following domains: (a) objective app quality (engagement, functionality, aesthetics, and information), (b) subjective app quality, and (c) user’s impacts on the app; 3) validation evaluation, according to the differences in nutrient contents between 2 different nutritionists who entered the same 10 recipe sheets into the web app. Reliability of the ratings was assessed by the Interclass Correlation Coefficient (ICC) to measure the replicability of ratings and was considered moderate (ICC 0.50 to 0.75), good (ICC 0.75 to 0.90) or excellent (ICC >0.90). Furthermore, nutritionists and restaurateurs were asked two open-ended questions to identify critical points to improve.
RESULTS Study 1: This cross-sectional study included forty-four restaurants and analysed 297 restaurant dishes. Regarding the Mediterranean-adherent diet and food allergen management, restaurants fulfilled an average (mean±Standard Deviation (SD)) of 5.1±1.6 of 9 compulsory AMed criteria and 12.9±2.8 of 18 SMAP criteria, respectively. Dishes were mainly rated green for sugar (n=178/297, 59.9%) but not for calories (n=23/297, 7.7%) or total fat (n=18/297, 6.1%). Waiters and cooks received passing scores for food allergen knowledge (5.8±1.7 and 5.5±1.5 out of 10 points, respectively).
Study 2: A total of 35 RCTs and 6 non-RCTs were included in the systematic review. The meta-analysis included 16 RCTs (excluding non-RCTs to obtain higher quality results). The results for the assessed outcome categories were the following: a) For dietary intake, the included RCTs increased healthy foods (+0.20 servings/day, 0.12 to 0.29, p<0.001) and decreased fat intake (-9.90 g/day, -12.61 to -7.19, p<0.001), favouring the intervention group; b) For food availability, intervention in schools reduced the risk of offering unhealthy menu items by 47% (RR 0.53, 0.34 to 0.85, p=0.008); and c) For food purchases, the systematic review of RCTs and non-RCTs showed that interventions could be partially effective in improving healthy foods.
Study 3: This systematized review included eight RCTs evaluating mobile phone apps focused on increasing fruit and/or vegetable intake. The interventions described in six of these RCTs were effective in increasing fruit and/or vegetable intake. The key aspects identified for the effectiveness of the intervention were the following: a) targeting stratified populations and b) using long-lasting interventions.
Study 4: In this systematic search of the 1376 apps identified, 14 apps were included for the quality assessment: 12 apps were related to food allergies and intolerances that detect 2-16 food allergens and 2 apps were related only to gluten intolerance. The mean (SD) MARS scores (maximum of 5 points) were 3.8/5 (SD 0.4) for objective quality, highlighting whether any app had been tested in trials; 3.5/5 (SD 0.6) for subjective quality; and 3.6/5 (SD 0.7) for the app-specific section. Therefore, a rating ≥3 out of 5 points indicated overall acceptable quality. From the between-section comparison, engagement (mean 3.5/5, SD 0.6) obtained significantly lower scores than functionality (mean 4.1/5, SD 0.6), aesthetics (mean 4/5, SD 0.5), and information (mean 3.8/5, SD 0.4). However, when the apps were compared by purpose, significantly higher engagement was identified for meal planner apps (mean 4.1/5, SD 0.4) than for food product (mean 3.0/5, SD 0.6; p=.05) and restaurant (mean 3.2/5, SD 0.3; p=.02) apps.
Study 5: Users agreed with the web app usability according to the CSUQ (mean 5.6/7 points, SD 0.9), with moderate reliability among ratings (ICC=0.57; 95% CI, 0.18 to 0.82). Factors with lower scores were interface and information usability (mean 5.6/7 points, SD 1.2; mean 5.5/7 points, SD 1.2, respectively). The web app showed good objective quality according to the MARS (mean 4.0/5 points, SD 0.4), with excellent reliability among nutritionists (ICC=0.91; 95% CI, 0.85 to 0.96). Sections with lower scores were engagement, information and subjective quality (mean 3.4/5 points, SD 0.7; mean 3.9/5 points, SD 0.6; mean 3.1/5, SD 0.4, respectively). For web app validation, no significant differences were observed between the two nutritionists’ data, with excellent reliability (ICC=0.98; 95% CI, 0.97 to 0.99). Regarding the points for improvement identified, users proposed ameliorating app data entry by improving the availability of the food database.
CONCLUSIONS Study 1: Restaurants partially met the AMed and SMAP criteria, demonstrating that further efforts are needed to improve Mediterranean diet-adherent menu offerings and food allergen management. Increasing fibre and decreasing saturated fat are necessary to improve the nutritional content of restaurant meals and consequently consumers’ adherence to a healthy diet. Additionally, for restaurant staff, training courses should be considered as a way to reinforce adequate food allergen management in restaurants.
Study 2: Restaurant- and canteen-based interventions improved the dietary intake of healthy foods, reduced fat intake, and increased the availability of healthy menus, mainly in schools. However, higher-quality RCTs are needed to strengthen these results. Moreover, from our results, intervention strategy recommendations are provided.
Study 3: The present review demonstrates that mHealth app-based interventions, lasting from two to nine months and characterized by a stratified population that shares the same motivation to achieve better dietary habits, are effective in increasing fruit and vegetable consumption. Furthermore, the inclusion of behavioural change techniques, such as dietary feedback together with self-monitoring and remote coaching support, has been identified as a key element that can definitively facilitate the adoption of new dietary habits. This issue strongly suggests that behavioural theory-based strategies must be considered when designing dietary mHealth interventions. Further research on mHealth apps is needed to design more effective interventions and to determine their efficacy over the long term.
Study 4: Food allergy or intolerance apps showed acceptable MARS quality (≥3 out of 5 points), although the engagement section for food product and restaurant purpose apps should be improved, and the effectiveness of the applications has yet to be tested in trials. The critical points identified can help improve the innovativeness and applicability of future food allergy and intolerance apps.
Study 5: The Healthy Meals web app was demonstrated to be usable, of good quality and a valid tool for the nutritional assessment and food allergen identification of dishes. Points to improve were identified, while the effectiveness of the app should be tested in scientific trials.
GLOBAL CONCLUSION In conclusion, innovative strategies have been identified and evaluated, obtaining tailored recommendations for restaurants to improve the healthiness and the Mediterranean diet-adherent offering of their menus and to ameliorate allergen management. Regarding the inclusion of digital technologies, mHealth and eHealth technologies have been demonstrated to be innovative strategies that can be included in restaurant-based interventions. Existing apps for food allergies or intolerances have shown acceptable quality. Additionally, the Healthy Meals web app has proven its usability, quality, and validity to help restaurateurs assess dish nutritional content and the presence of food allergens.
