Partnering with REACH to Create a “Diabetes-Friendly” Restaurant - A Restaurant Owner's Experience

Abstract

We describe a Latino restaurateur's perspectives and partnership with Seattle-King County REACH to improve the healthfulness of his restaurant as a step toward tackling diabetes in his community. We interviewed the owner and reviewed other documentation to capture his perspectives and identify key elements in this restaurant intervention.

The impact of diabetes in the owner's family and Latino community motivated him to make changes at his restaurant. If changes were successful, he hoped this would motivate other Latino restaurateurs to make similar changes. At his request, REACH gathered consumer feedback, provided diabetes education and nutritional guidance, and worked with him to develop simple, economically-feasible, healthier items. Positive consumer response and media coverage motivated the owner to explore additional changes at his restaurant and encourage other restaurateurs to make healthful changes. This intervention illustrates the potential for local businesses to collaborate with community partners, like REACH, to promote healthy food environments.

Introduction

Type 2 diabetes disproportionately impacts Latinos and other communities of color in the United States.^1,2 Strategies to reduce diabetes prevalence and improve blood glucose control include modifying individual diet and lifestyle and improving diabetes self-management.^3,4,5 Greater emphasis has been placed of late on modifying environmental factors that contribute to the prevalence and control of diabetes, such as the availability of healthy food.⁶

Restaurants offer an opportunity to modify the food environment to promote healthier eating since a large proportion of meals are eaten in restaurants.^7,8,9,10 Interventions involving the provision of nutritional information at restaurants reported positive changes in consumer food choices,^11,12 including two diabetes-motivated interventions focused specifically on Mexican restaurants.^13,14 Most of these interventions were initiated by external organizations or as part of research projects. The literature regarding interventions initiated by restaurant owners is limited. Restaurant interventions refer to actions to modify consumer food choices, including menu nutrition-labeling, menu changes, or health promotional activities at or initiated by restaurants.

This paper describes a restaurant intervention at Galerias, a Mexican restaurant in Seattle, WA, that was initiated by the owner, Ramiro Rubio, in collaboration with the Seattle-King County REACH Coalition (REACH), as a first step toward tackling the problem of diabetes in the Latino and broader community. The primary objectives of this paper are to share the perspectives of Mr. Rubio throughout the process of this intervention, and describe his partnership with REACH in making his vision a reality.

Methods

Community Context

The underlying motivation for all partners involved in the Galerias intervention was the increasing number of Latinos in the region with or at-risk for diabetes. The Latino population in King County has increased from 95,242 (5.5% of King County population) to 1,916,441 (8.1%) between 2000 and 2009.^15,16 The national trend toward a growing prevalence of diabetes among Latinos is mirrored among Latinos with diabetes in King County, which has increased from 4.5% to 6.0% (1994–1996¹⁷ and 2002–2006 averages¹⁸, respectively).

Community Partnerships

The three partners involved in this effort were (1) Ramiro Rubio, owner of Galerias; (2) Seattle-King County REACH Coalition and REACH US initiative, housed at the local health department, Public Health-Seattle & King County (PHSKC); and (3) Sea Mar Community Health Centers, a key REACH Coalition partner and Federally-Qualified Community Health Center that provides comprehensive healthcare services for the Latino community and does extensive community engagement and policy work within that community.

Mr. Rubio has lived in Seattle since 1986, opening Galerias in 1993. Galerias serves 2000 to 2500 patrons per month. Its menu includes Mexican appetizers, salads and meat, seafood and vegetarian entrees. Mr. Rubio is actively involved in the Latino community and well-connected with other local Latino restaurant owners because he and the majority of Latino restaurateurs in the Seattle area are from the same town in Mexico (Cuauhtla, Jalisco).

The Seattle-King County REACH Coalition (REACH) is focused on eliminating diabetes disparities and is funded by the Centers for Disease Control & Prevention to address racial and ethnic health disparities. REACH is composed of a diverse range of community organizations and members, including PHSKC, the University of Washington, the American Diabetes Association (ADA), and community-based organizations and health clinics with a focus on communities of color. Its actions are grounded in community-based participatory research principles¹⁹, prioritizing community-expressed needs and wants, and stressing equal power-sharing and decision-making.

Sea Mar Community Health Centers has been a member of REACH since 1999. Their approach to chronic disease management includes operationalizing the chronic care model²⁰ and providing culturally-tailored self-management education. In 2009, Sea Mar hired a community mobilizer to further REACH and Sea Mar's goals to effect community-level change and impact social determinants. The mobilizer's role is to actively develop and strengthen relationships with community leaders, organizations and businesses in the Latino community and find ways for REACH and Sea Mar to partner with them to improve access to healthy eating and active living or address other social determinants to improve Latino health.

Mr. Rubio led the intervention, with REACH providing resources as requested, such as nutrition and diabetes expertise, and evaluation support. REACH staff informally interviewed Mr. Rubio to ascertain his perspectives, needs, and priorities throughout the process of developing and implementing the intervention. Evaluators reviewed notes from discussions and meetings between Mr. Rubio and REACH staff, PHSKC and Sea Mar progress reports, and interviewed staff to identify key steps in the process.

Mr. Rubio wished to canvass Galerias' patrons regarding their opinions about healthy eating to guide him in developing the intervention. Evaluators developed an online questionnaire which included closed and open-ended questions about patrons' food preferences when eating out and opinions about healthy menu options. Apart from respondents who submitted email addresses to enter the raffle, survey responses were anonymous. Links to English and Spanish translations of the survey were sent to Galerias' email distribution list.

Discussions with the University of Washington's Human Subjects Division confirmed that the activities involved in this intervention did not require review by the Institutional Review Board. Mr. Rubio consented to our using his name in this manuscript.

Results – Views of the Restaurant Owner

Forming Partnerships

Mr. Rubio was motivated by the impact of diabetes in his family and Latino community to make changes at his restaurant, but was unsure how to make this a reality. A key connection leading to the Galerias intervention was between Mr. Rubio and Sea Mar's Vice President (VP) for Community Relations. Sea Mar's VP joined ADA's board in 2009 and initiated meetings with Mr. Rubio and other community leaders concerned about diabetes in the Latino community. The VP approached Sea Mar's REACH coordinator about the opportunity to work with Galerias. This seemed a logical connection since one of REACH's objectives is to change King County's restaurant environment to be more “diabetes friendly,” i.e., make it easier for people at risk or with diabetes, to eat healthfully in restaurants. The coordinator linked Mr. Rubio with REACH staff from Sea Mar and PHSKC to assist him. This included Sea Mar's community mobilizer to coordinate activities, a health educator and a certified diabetes educator from Sea Mar and PHSKC, respectively, and REACH evaluators.

Diabetes Education & Menu Changes

Before making menu changes, Mr. Rubio felt he needed a better understanding about diabetes and nutrition. At his request, REACH staff provided him with diabetes education in both English and Spanish, covering a range of topics, including basic diabetes physiology and rationale behind diet modifications for diabetes management. Staff worked with Mr. Rubio to develop lower calorie entrees, lower carbohydrate side dishes as substitutes for traditional beans and rice, and baked goods incorporating whole wheat flour to increase fiber. Modifications were relatively simple and economically-feasible. Together they created a “lighter” menu that included ingredient descriptions and suggestions for selecting a diabetes-friendly meal, to allow patrons with diabetes to make appropriate choices from the standard menu. See Figure 1 for insert.

Figure 1.

Galerias' lighter menu insert

Consumer Preferences

A total of 144 patrons completed the survey (140 in English, 4 in Spanish) out of 1283 who were sent invitations (11.2% response rate). Results are presented in Table 1. Respondents included less regular patrons (42% ate at Galerias less than once/quarter) and regulars (36% ate there more than once/month). The majority of respondents were aged 30–49 (52%) and women (58%). Most came to Galerias for the quality of the food (72%). Almost all (96%) ranked “taste” first or second as their primary reason for choosing an entree. Almost half (47%) ranked “healthfulness” first or second when choosing an entree. Respondents were open to choosing healthier entrees: 90% were either somewhat (46%) or very likely (44%) to choose a healthier option, if offered. Most (76%) wanted a special symbol designating these options on the menu. When asked about other ways of getting health information, the two most often selected options were “table tents”, e.g., nutrition information cards on each table (55%), and brochures or handouts (34%).

Table 1.

Results from an Online Survey of Galerias Patrons

Variable	Percent
Number of respondents	144
How often come to Galerias
Less than once/quarter	42%
More than once/quarter, less than once/month	22%
Once/month	22%
More than once/month	14%
Age
Less than 30 years old	15%
30–49 years old	52%
50–64 years old	25%
65 and older	8%
Gender
Female	58%
Male	42%
Reason for coming to Galerias
Quality of food	72%
Convenient location	6%
Atmosphere in restaurant	9%
Value/price of food	4%
Other	9%
Reason for choosing an entree (% ranking 1st or 2nd)
Taste	96%
Healthfulness (e.g., low fat)	47%
Price	37%
Quantity (hunger satisfaction)	22%
Calories	13%
How likely to choose healthier option
Not likely to choose the healthier options	10%
Somewhat likely	46%
Very likely	44%
How to indicate healthier menu items 1
Use a special symbol to highlight healthier items	76%
Group the healthier items together in one section	27%
Don't indicate them in any special way	3%
Other option	3%
Other ways of getting health information 1
Table tents (nutrition information cards on each table)	55%
Brochures or handouts	34%
Presentations by nutrition experts at specific times	2%
Other information sources	8%

Notes:

¹Respondents could check more than one item for this question

Piloting “Lighter” Menu

Mr. Rubio typically holds screenings to pilot new menu items. For his lighter menu, he hosted a screening in which he and REACH staff invited representatives from Sea Mar, PHSKC, ADA, and others, including the host of a Spanish radio station. Mr. Rubio finalized the menu using survey and screening feedback, and launched the lighter menu insert in August 2010. He tracked the number of items ordered from the insert during a 6-week pilot period to determine which items to incorporate into his permanent menu. Approximately 11.6% of entrees sold (300 out of 2581 in August) were from the lighter menu.

Next Steps

The partnership between Mr. Rubio, Sea Mar, and REACH has strengthened since launching the diabetes-friendly “lighter menu”. Newspaper coverage of Mr. Rubio's healthy menu intervention generated interest among others wanting to address diabetes in their own communities. Students from Distributive Education Clubs of America (DECA) in Auburn, a city near Seattle, approached Mr. Rubio seeking direction on how to promote a healthier food environment in their city. Mr. Rubio and REACH's certified diabetes educator worked with them to develop their plans and launch “Dine Out to Beat Diabetes” Week in Auburn, and are providing guidance on how to improve the healthfulness of foods sold in the students' high school DECA store.

Mr. Rubio continues to be motivated to promote change. Following the lighter menu pilot, he hosted an ADA Board of Directors' meeting at Galerias, in which he screened a new menu of diabetes-friendly items and co-presented with REACH about the pilot and Auburn DECA effort it inspired. He and Sea Mar's health educators plan to do cooking demonstrations at Seattle-area Latino markets that include diabetes education.

One of Mr. Rubio's larger goals is to increase diabetes awareness among Mexican restaurateurs and inspire them to make changes at their restaurants. Mr. Rubio is an active member of “Club de los Jalisciences” (Club of the people of Jalisco), which includes most of the Mexican restaurant owners in Seattle and nearby areas. He plans to call a meeting to present his experience with healthful menus, and have Sea Mar and REACH educators talk about diabetes, its impact on the Latino community, and how they can assist owners if they want to improve the healthfulness of their menus. REACH is currently developing a standardized technical assistance protocol for use in future work with restaurants.

Conclusions – Lessons Learned

The Galerias story illustrates how one person's vision for improving health in his community can be advanced with a network of supportive collaborators. It also highlights key factors that facilitated change. Unlike other restaurant interventions described in the literature, this was initiated by Mr. Rubio, not a funding organization or research institution. His concern over the impact of diabetes on Latinos drove him to pursue this intervention. Given his time constraints, Mr. Rubio found the assistance of the mobilizer and educators invaluable in making changes at Galerias. Sustainable restaurant change may be dependent on the ongoing motivation of the owner to promote change and committed support from community partners.

Other issues should be addressed by restaurateurs and partners considering similar efforts. These include owners' time, readiness, and capacity to make changes, type and extent of change desired, simplicity, economic-feasibility and profitability of changes, and other resources needed (e.g., diabetes and nutrition expertise).

Widespread restaurant change requires broader community support to make healthful restaurants a financially-attractive, sustainable option for restaurateurs. This involves relationship-building at multiple levels: between restaurant owners and community partners like REACH to create platforms for collaborative action, with patrons to ensure changes meet their preferences, and with other restaurants to promote a culture of healthful restaurants. Relationship-building can be time-intensive. However, stronger ties with partners can beget additional ties and access to valuable resources. Stronger relationships with patrons can solidify a loyal consumer base and support for healthful changes. Mutual trust between restaurateurs is more likely to cultivate support for changes in one's own restaurant and beyond.

Mr. Rubio's advice to other restaurateurs is to “know your clients. Work with others to help make changes. Learn about diabetes. It will give you more confidence with making changes.”