In Western countries an increasing proportion of meals are being eaten outside the home, in restaurants, schools and from take-away stores(Reference Lachat, Naska and Trichopoulou1). From a public health perspective this development raises expectations as to the quality of foods served. In this issue we offer several papers that examine the ways in which stakeholders can be involved in planning and implementing changes in meal service and in the evaluation of meal services in schools and restaurants.
Restaurant meals
In order to increase sales and capture customer interest, restaurateurs seek to specialize, offering exceptional experiences and culturally unique culinary pleasures to their customers. Meanwhile, studies show that the meals offered are far from healthy or balanced and that their frequent consumption is linked with overweight and obesity(2–Reference Burns, Jackson and Gibbons4). Even if going to a restaurant is a matter of personal choice, what the restaurant offers is dependent on the restaurateur. Public health nutritionists and other designers of public health interventions and training courses, together with policy makers, have a role in providing support and resources to promote changes in the provision of and demand for healthy meals in restaurants and other food establishments. The accessibility and availability of balanced meal options is all the more important when choice of restaurants is limited due to work or personal circumstances.
In this issue, Lachat et al. present findings from the HECTOR project, which examines participatory strategies to improve the nutritional value of meals eaten outside the home(Reference Lachat, Naska and Trichopoulou1). Results from stakeholder workshops suggest that a focus on healthy eating may necessitate trend setting and business reorientation, but this would pose financial risks, often not willingly taken. There is among restaurateurs a fear of losing customers by removing favourite dishes from the menu, and a loss of investment in the training of staff due to high turnover. While the willingness to participate is there, caterers put the onus on consumer-oriented awareness campaigns and supportive procedures to increase the demand for and supply of healthier, local and seasonal foods(Reference Lachat, Naska and Trichopoulou1).
Cross-sectional studies of the food offered or consumed in restaurants or canteens can identify associations between diet quality and the use of such food services, but cannot determine whether offering healthier food changes people's behaviour. A previous study from Finland(Reference Raulio, Roos and Prättäla5) found that people who ate in school or staff canteens had better diet quality than those who did not, but this may reflect that people with better diets prefer to eat in canteens. However, even where nutritional recommendations, guidelines and government support for the catering services exist, guidelines are not always met and some form of monitoring is required. In Finland, nutrition policies have supported the improvement of institutional kitchens since the 1970s, but it was only last year that guidelines for the monitoring of quality were issued(6).
Intake of ready meals
In this issue, a study of Swiss adults(Reference van der Horst, Brunner and Siegrist7) shows how lack of cooking skills was related to more frequent use of ready meals, defined as meals requiring few or no extra ingredients and designed to replace the main course of a home-made meal. Ready meals are typically high in energy, fat, salt and sugar, and have inadequate amounts of vegetables. In the Swiss study, ready-meal consumption was associated with overweight and a positive opinion about their nutritional content. The finding that ready-meal consumption was highest in the youngest age group (17–39-year-olds), may suggest a need to boost confidence in cooking skills and nutritional knowledge among those still at school and in training. Courses to that effect could also be offered as part of public health interventions and made relevant to people with limited time and cooking facilities. As suggested by the authors, more attention should be given to the composition of ready meals and the ways in which more vegetables could be included with such meals when served at home.
School meals
School breakfast and lunch programmes may help set an example for good food behaviours, as indicated by five studies in this issue; two from England(Reference Golley, Pearce and Nelson8, Reference Haroun, Harper and Wood9) and one each from New Zealand(Reference Rockell, Parnell and Wilson10), France(Reference Dubuisson, Lioret and Dufour11) and Wales(Reference Murphy, Moore and Tapper12). The two English studies evaluated the quality of lunch meals provided and consumed in primary schools since the introduction of new standards aiming to ensure that all food and drink choices provided by school caterers are ‘healthier’(Reference Golley, Pearce and Nelson8, Reference Haroun, Harper and Wood9). Both studies report that foods offered in schools were in line with the standards and that the composition had improved since their introduction(Reference Haroun, Harper and Wood9). Compared with lunches brought from home, school lunches were more nutrient-dense and adhered more closely to the standards(Reference Golley, Pearce and Nelson8). In contrast to this, the New Zealand cross-sectional study(Reference Rockell, Parnell and Wilson10) suggests that in countries with no lunch provision at school, such as New Zealand, Australia and Denmark, children's nutritional intake during school days was less in line with the recommendations than during non-school days. In that study, 84 % of the children reported that they brought most of the food consumed at school from home.
The French study of schoolchildren aged 3–17 years(Reference Dubuisson, Lioret and Dufour11) found that while 65·6 % of children had a school lunch at least once weekly, children from more deprived economic backgrounds had more limited consumption of school lunches. Therefore moves to improve dietary intake among French schoolchildren through regulation of school lunch quality may not prove to be effective(Reference Dubuisson, Lioret and Dufour11). Increasing the number of children eligible for free or reduced-price meals may increase uptake in the lower socio-economic status groups, as has happened in the USA(Reference Probart, McDonnell and Hartman13).
As the school breakfast and lunch programmes aim to secure children's health, equal access to good nutrition and educational achievement, it is important to achieve high participation rates among children. In Wales, a study on the impact of a national school programme of universal free healthy breakfast provision demonstrated some improvement in the nutritional quality of breakfasts consumed in primary schools and a more positive attitude towards breakfast among children(Reference Murphy, Moore and Tapper12). However, breakfast skippers did not start having breakfast, and no improvements were seen in episodic memory or classroom behaviour, the primary outcomes(Reference Murphy, Moore and Tapper12). Interventions to increase the number of students participating in school food programmes may be more successful in achieving these outcomes.
The studies described here demonstrate the ongoing efforts to improve dietary intake by influencing the meals offered. However, it is not enough to develop recommendations and guidelines alone. These changes will need to be backed by programmes encouraging consumers to demand more healthy options. It is becoming clear that caterers require training to prepare and promote the new healthier choices; while schools have to support the future changes to meals with ongoing education(Reference Moore, Murphy and Tapper14). For example, in the USA, the new (2010) guidelines and recommendations issued by Institute of Medicine(15) to improve school meals reflect the commitment by state and federal governments to offer training and support for implementation, followed by monitoring of quality and fiscal action when necessary. As the proportion of food consumed outside the home continues to increase, it is essential that the nutritional quality be improved. There is no reason for food provided by food services to be of poorer quality than that provided at home. Indeed, the challenge will be to ensure that all food is made healthy, which requires changes in training, policy and provision.
