July 2009 - Hot Topic

Farewell to Eat Smart! Ontario’s Healthy Restaurant Program

by Connie Uetrecht, Executive Director, OPHA

In 1997, an integrated, provincially supported award program for restaurants was born: It was called Eat Smart! The program acknowledged, through an award of excellence, restaurants that met exceptional standards for nutrition, food safety, and smoke-free dining. The stringency of the criteria was designed to increase over time as smoking by-laws changed, food safety practices improved, and more healthy choices became available in restaurants. In health promotion terms, it was primarily an environmental support program with some public awareness-raising components delivered by public health inspectors – since they already inspected restaurants against food safety requirements. The restaurant program gained popularity very quickly and, as a result, it was introduced into schools and cafeterias. For 12 years, this program provided support for a healthier environment. In 2009, the provincial support for Eat Smart! Ontario’s Healthy Restaurant Program was discontinued. It is survived by its siblings Eat Smart for Schools and Eat Smart! for Workplace Cafeterias.

As a member of the team that laboured to give birth to Eat Smart!, I would like to invite Ontario’s public health community to reflect on three points of discussion raised by reflection on the Eat Smart experience, that will serve public health professionals well as we move forward into the future. The story of Eat Smart! points to the need for three elements in public health programming: provincial support, integration, and evaluation.

1. Provincial Support

When I moved to Ontario in 1985, I immediately noted an inadequate level of provincial government support for public health programming. Duplication was rampant across the province as health units attempted to deliver their mandated programs as well as heart health initiatives without provincial support or coordination.

I was very pleased, however, in the late 1990s as a Nutritionist with the former North York Public Health Department, to receive funding from the former Public Health Division of MOHLTC to develop and pilot test, in partnership with the Canadian Cancer Society - Ontario Division and the Heart and Stroke Foundation of Ontario, a province-wide healthy restaurant program. Our development team included inspectors, dietitians and tobacco control staff, chefs from the restaurant industry, communication specialists, and evaluators. Through extensive consultation and formative evaluation, an integrated food safety, healthy eating, and food service program with a focus on restaurants was developed with over 30 health units committing to implement at the outset.

There was great enthusiasm for the program in the first years of its life. But its limitations became apparent over time. One major limitation was inadequate funding for a province-wide social marketing campaign to raise public awareness about the program. Public health units also struggled with resources for implementation. Also, new pressures were placed on health units to fully implement restaurant inspection standards as a result of the “safe dining” investigation in The Toronto Star. New restaurant disclosure programs were introduced in response to The Toronto Star series and public health inspectors turned their attention to their renewed mandate on food safety.

At the same time, there was movement in tobacco control. In 2006, the Smoke-Free Ontario Act was passed, making restaurants 100% smoke-free. In spite of the important role that Eat Smart! played in the incremental increases to local smoke-free dining, the Eat Smart! non-smoking seating standard became all but redundant.

Recently, the Heart and Stroke Foundation began to expand its Health Check program to restaurants. This program uses menu labeling to identify healthier menu items. Eat Smart! was never able to do this due to interpretation of labeling laws at the time of its development. Health Check menu labeling makes it easier for consumers to identify healthy options on the menu in contrast to Eat Smart!, which relied upon the consumer to request the healthier items that were available on the menu.

Menu labeling has become an important tool to help consumers make healthier choices when eating out. For these key reasons, by the middle years of this decade, health units lost enthusiasm for the Eat Smart! restaurant program. However, their participation in the Eat Smart! School and Workplace Cafeteria programs gradually increased.

The Smoke-Free Ontario program stands as a positive example of the benefits of strong provincial support to public health and health promotion programming. We are now at a critical stage in Ontario as the Ministry of Health Promotion implements a new strategic direction. We need to continue working with MHP to ensure adequate provincial support for the development and continuation of provincial programs.

2. Integration

From its inception, Eat Smart! was a good example of integrated programming. It combined elements of food safety, healthy eating, and smoke-free environments. It took a settings approach (restaurants as public gathering places and workplaces, as well as school and workplace cafeterias). It also leveraged existing public health capacity for delivery through public health inspectors who were already inspecting restaurants. However, the success of the single-risk programs such as DineSafe in Toronto and the Smoke Free Ontario strategy, which were supported by legislation with follow-up enforcement and implementation, put into question the effectiveness of a totally integrated programming.

Did the “integrated” Eat Smart! approach contribute to legislative change on single issues like tobacco? (I would like to think so. But we will never know because we have not really asked nor attempted to answer the question.) Or, is it that we need a combination of approaches to make progress? Going forward, we need to carefully define “integration” and articulate when to integrate and when to focus on a single issue separately. We need to begin with integrated planning and also look at the evidence before making a single-minded commitment to amalgamating everything.

In the end, we will likely need a combination of approaches. I am pleased to see that MHP has provided options in its Healthy Communities Approach and has not required integration of more that two issues. We must ensure that evaluation informs future implementation of such programs.

3. Evaluation

Tragically for the Eat Smart! restaurant program, an outcome evaluation was never conducted; funding constraints did not make this critical process possible. Perhaps Eat Smart! was before its time in this regard. It would have been helpful to have a fully functioning Ontario Agency for Health Protection and Promotion to assist with program evaluation or to have one of the emerging schools of public health undertake research on Eat Smart!.

OPHA is pleased to be collaborating with McGill University in a research project that is examining the impact of Eat Smart! in workplaces. We are anxiously awaiting the results of that evaluation to inform new developments in that program. I am pleased to see the positive evaluation of Toronto’s DineSafe program, one of the few on public health food safety protocols. The successful elements of the DineSafe program, mandatory food handler training, was a component of the Eat Smart! Restaurant program.

So as we bid farewell to Eat Smart! Ontario’s Healthy Restaurant Program, we anticipate future programs to take its place, fully informed by evidence.