The Quality of Menu Offerings in Independently Owned Restaurants in Baltimore, Maryland: Results from Mixed-Methods Formative Research for the FRESH Trial.

(1) Background: Independently owned restaurants (IORs) are prevalent in under-resourced racial and ethnic minority communities in the US and present a unique setting for public health nutrition interventions. (2) Methods: We conducted 14 in-depth interviews with IOR owners in Baltimore about their perceptions of healthy food, and customers' acceptance of healthier menus and cooking methods and concurrent observations of the availability of healthy options on their menus. Qualitative data were coded and analyzed using ATLAS.ti. Observations were analyzed with statistical analysis performed in R. (3) Results: Owners perceived non-fried options, lean proteins, and plant-based meals as healthy. While open to using healthier cooking fats, they had mixed feelings about reducing salt, adopting non-frying methods for cooking, and adding vegetables and whole grains to the menu, and were reluctant to reduce sugar in recipes and beverages. Only 17.5% of 1019 foods and 27.6% of 174 beverages in these IORs were healthy, with no significant differences in the healthfulness of restaurant offerings within low-healthy-food-access/low-income neighborhoods and those outside. (4) Conclusion: Healthy options are generally scarce in Baltimore's IORs. Insights from owners inform future interventions to tailor healthy menu offerings that are well-received by customers and feasible for implementation.