Efforts can be made in the restaurant environment to reduce sodium exposure and generate greater consumer awareness on how much sodium is in foods consumed away from home. However, certain barriers to sodium reduction do exist. Economos et al reported that a major challenge for independent restaurant owners when conducting nutrition analysis is the lack of standardized recipes (20
). Accurate recipe analysis and subsequent menu labeling require a great degree of specificity and can impose cost and time constraints. Concerns about profitability have also been reported as barriers to changing menus (21
Consumers report that, when dining out, overall nutritional value of the meal is more important to them than individual factors such as sodium (22
). However, restaurant customers typically underestimate calorie, sodium, and fat content of restaurant foods (23
). Because consumers have less control over the way in which meals are prepared outside the home, it is challenging to simply look at a meal and discern the amount of sodium it contains. Furthermore, options that are popular because they seem healthful, such as salads, can be laden with sodium (ie, ingredients such as cheese, bacon, or croutons are added.) (6
). The availability of calorie information on menus or menu boards and other nutrient information upon request may encourage restaurateurs to improve the healthfulness of their menu items, similar to the reformulation of products and reduction in the use of trans fatty acids that was seen after trans fat was added as a component of the Nutrition Facts label.
Given that the menu labeling law affects restaurants with 20 or more locations, the main impact will be on chain restaurants. Food obtained from restaurants is from either an independent or chain restaurant. Independent restaurants are not associated with a national or regional name; therefore, these establishments may have greater flexibility in the types of food served (1
). By comparison, chain restaurants are a group of restaurants with the same name and marketing strategy and with standardized menu items across locations; they may be fast food-type restaurants or sit-down restaurants, and they typically serve many more customers and meals than do independent restaurants. Restaurants, regardless of size or type, often use prepared or partially prepared processed foods to develop new menu items. Substantial amounts of sodium may be obtained from processed ingredients used in the development of meals, given that large volumes of food are purchased from distributors. For independent operations, menu decisions are typically made by owners or head chefs and may occur frequently (24
). For chains, menu decisions are made at the corporate level and are implemented at each restaurant in the chain (1
A 2012 study assessed the sodium content of 7 product categories for the 6 largest transnational fast food chains and found sodium content varied across product categories in every country, and individual items marketed as the same product in different countries had very different levels of salt (25
). These findings indicate that suppliers are responsive to company needs and reducing salt in restaurant foods is feasible.
Current sodium reduction recommendations focus on gradual reductions of sodium in the food supply to reduce population sodium intake (1
). Research suggests consumers may not notice sodium reductions of up to 20%, depending on the food product (1
). In addition, as exposure to sodium decreases so can preference for sodium in the diet. However, for gradual sodium reductions to affect population sodium intake without noticeable changes to consumers, reductions will likely need to occur across the food supply and not just in restaurants.
Large restaurants typically have the ability to work with their suppliers to reformulate proprietary ingredients to change or improve the nutritional quality of menu items. Smaller restaurants may not have this ability because of smaller buying power and reach. Independent restaurants may have fewer resources than do chains and may benefit to a greater extent from working with public health practitioners. Consumers’ ability to exercise control over their away-from-home sodium intake is difficult because of the high levels of sodium in restaurant foods. Public health practitioners are uniquely poised to protect the health of the population through efforts such as sodium reduction in restaurants, but appropriate strategies will vary according to the particular needs and characteristics of each community.
The strategies provided in this article are examples of what can be done given the current restaurant food environment and are not an exhaustive list of existing opportunities. Sodium-reduction efforts, especially in restaurants, still encompass a new area of work, and evaluation efforts are ongoing. By supporting sodium-reduction efforts through systems and environmental changes, state and local governments may assist in providing a more healthful food supply, resulting in a healthier population.