Influence of Placement of a Nutrition Logo on Cafeteria Menu Items on Lunchtime Food Choices at Dutch Work Sites

Influence of qualitative menu labeling on diners' food choices: A controlled quasi-experiment in self-service buffet restaurants

Menu labeling is a strategy to promote healthier food choices in restaurants. This study aimed to analyze the influence of a qualitative menu labeling on the healthfulness of diners' food choices in self-service buffet restaurants. A controlled quasi-experiment comparing parallel groups at baseline and intervention periods was conducted in a control restaurant and an intervention restaurant. Qualitative labels provided information on the name and ingredients list of the dish, highlighting the use of organic vegetables. The same food menu was served in both restaurants. Menu labeling was implemented at the intervention restaurant for six dishes each day, three considered healthier and three less healthy. Dishes were weighed at the beginning and at the end of the service to estimate the average portion size (g) of diners, during five consecutive days at baseline and intervention. Diners who had lunch at the intervention restaurant were invited to participate in a survey on the use of menu labels. Of the 153 interviewed diners, 31% reported noticing menu labels. Of these, 57% said menu labeling had influenced their food choices at the restaurant. No changes in portion sizes were observed between baseline and intervention periods within control and intervention restaurants. However, it was found that the provision of qualitative menu labeling sparked the interest of restaurant managers in improving meal quality and modifying recipes to eliminate ultra-processed ingredients. Thus, the implementation of the proposed menu labeling model can promote healthier food choices through the reformulation of culinary recipes. However, it is essential to adopt strategies to enable its direct impact.

Nudging strategies to improve food choices of healthcare workers in the workplace cafeteria: A pragmatic field study

BACKGROUND & AIMS

Dutch healthcare workers experience the highest workload and absenteeism rates compared to all other professions. This has been associated with a more unhealthy diet. Nudging strategies in the workplace have been shown to improve food choices. We studied the potential of a combination of evidence and practice-based nudging strategies; determined their feasibility in a real-life setting; and explored their effectiveness on healthier purchases over a two-month period in a hospital workplace cafeteria.

METHODS

We conducted an explorative, prospective field study. Based on information gathered through a literature search and a qualitative field study, we selected the potentially most effective and feasible nudges. These were subsequently implemented in a commercial workplace cafeteria of a Dutch academic medical centre. The selected nudging strategies included product placement, increasing the ratio of healthy to unhealthy product options, and providing nutritional information and motivational statements. Data on the products purchased was collected using photographs of the lunch trays of healthcare workers, with the products then labelled and their nutritional value calculated. Effects were evaluated after one and two months. Chi-square analyses were used to analyse differences over time.

RESULTS

A total of 905 photographs of lunches were analysed (approximately 300 at each time point). The nudging strategies implemented resulted in a 41% increase in the purchase of whole-wheat products at the expense of non-whole-wheat products, between baseline and final measurement (p = 0.012). The purchases of healthy and unhealthy bread fillings and beverages did not significantly change during the study period.

CONCLUSION

This explorative study showed that a combination of three nudging strategies partly improved healthy food choices for lunch in a Dutch healthcare setting. These results may help guide other professionals to implement nudging strategies to improve employee food choices. Future research should evaluate the effect over a longer period of time, thereby identifying the most effective combination of nudging strategies and investigate how these effect the health of hospital employees.

Effects of Digitalized Front-of-Package Food Labels on Healthy Food-Related Behavior: A Systematic Review

Front-of-package (FOP) food labels may impact healthy food-related behavior. However, such labels may be presented using new technology and they may impact behavior differently than physical labels. This systematic review investigated the effects of physical and digitalized labels on healthy food-related behavior. This review used four search engines to collect articles that investigated the effects of food labels on the purchase, consumption, hypothetical choice, and self-reports of healthy foods. General findings, types of labels, or whether the articles used physical versus digitalized static, interactive, or technology-enabled labels were synthesized. The dependent variables were categorized according to whether they were under full, partial, or no control of the independent variables. The risk of bias was measured by the RoB 2 tool and adapted Joanna Briggs Institute Checklist. The search strategy identified 285 records and 30 articles were included. While digitalized static and physical labels did not differ in their effects on healthy food-related behavior, technology-enabled labels were more predictive of healthy food-related behavior than interactive labels.

Sensory Appeal and Routines Beat Health Messages and Visibility Enhancements: Mixed-Methods Analysis of a Choice-Architecture Intervention in a Workplace Cafeteria

Easier recognition and enhanced visibility of healthy options supposedly increase healthy choices, but real-world evidence remains scarce. Addressing this knowledge gap, we promoted nutritionally favourable foods in a workplace cafeteria with three choice-architectural strategies-priming posters, point-of-choice nutrition labels, and improved product placement-and assessed their effects on visual attention, food choices, and food consumption. Additionally, we developed a method for analysing real-world eye-tracking data. The study followed a pretest-posttest design whereby control and intervention condition lasted five days each. We monitored visual attention (i.e., total number and duration of fixations) and food choices with eye tracking, interviewed customers about perceived influences on food choices, and measured cafeteria-level food consumption (g). Individual-level data represents 22 control and 19 intervention participants recruited at the cafeteria entrance. Cafeteria-level data represents food consumption during the trial (556/589 meals sold). Results indicated that the posters and labels captured participants' visual attention (~13% of fixations on defined areas of interest before food choices), but the intervention had insignificant effects on visual attention to foods, on food choices, and on food consumption. Interviews revealed 17 perceived influences on food choices, the most common being sensory appeal, healthiness, and familiarity. To conclude, the intervention appeared capable of attracting visual attention, yet ineffective in increasing healthier eating. The developed method enabled a rigorous analysis of visual attention and food choices in a natural choice setting. We discuss ways to boost the impact of the intervention on behaviour, considering target groups' motives. The work contributes with a unique, mixed-methods approach and a real-world setting that enabled a multi-dimensional effects evaluation with high external validity.

Nudging food service users to choose fruit- and vegetable-rich items: Five field studies

Although nudging has been found to promote the choice of healthy foods in lab studies and ad-hoc field studies, relatively little research is available regarding effectiveness in real food venues that operate for profit. The paucity of empirical studies providing "proof of implementation" reveals the difficulty of applying previous empirical findings on nudging to mass-eating food services contexts, which serve meals to a lot of individuals daily. Based on the typology of choice architecture in food choice contexts, we closely collaborated with the in-house food service operator to devise and implement five nudge interventions to promote fruits and vegetables (FV) in university cafeterias. Each study was conducted for one 12-week semester or more over a three-year period. In the first two studies, non-verbal point-of-purchase prompting increased the choice of kale/spinach supplemented smoothies and whole fruits from baskets. In Study 3, the combination of sizing and point-of-purchase non-verbal prompting increased the sale of large size vegetable-rich bowls from a stir-fry grill. In Study 4, the proximity type of nudging by altering the position of the healthier option in a sandwich bar in combination with non-verbal prompting increased the sale of sandwiches containing spinach. In Study 5, the combination of sizing and proximity of large vs. small sized plates and serving spoons had no effect on sale of self-serve items in a salad bar. All the interventions except for Study 5 produced a moderate effect in increasing the choice of FV-rich items. We recommend that hospitality and food service operators consider operational parameters and simultaneously adopt more than one nudging components to achieve a sizable effect. Future randomized controlled trials are needed to implement choice architecture techniques in collaboration with food service companies.

Environmental Intervention in a University Canteen with Focus on Decision Guidance-Effects on Sale and Daily Consumption of Vegetables and Fruit

The purpose of the study was to evaluate whether an environmental intervention in a university canteen changes the sale and daily consumption of vegetables and fruit among canteen users. The intervention focused on decision guidance, including a positive incentive and nudging. In a pretest−posttest-design, daily sales data of pieces (pcs) of vegetable components and fruit, as well as the sale per main component (pcs/mc), were assessed. Here, 20 opening days were analyzed, each after the intervention (t1) and in the same period of the previous year (t0). Vegetable and fruit consumption were assessed in a controlled pretest−posttest design (3-day-dietary-record, t0 and t1). The intervention group (IG; n = 46) visited the canteen ≥ once/week, and the control group (CG; n = 49) < once/week. At t1, the sale of absolute vegetable components did not change (t0: 132.3 ± 49.7 pcs, p > 0.05), but more per main component were sold at t1 (t0: 0.54 ± 0.09, Δ: 0.09 ± 0.13 pcs/mc, p < 0.05). In addition, the sale of fruit (t0: 17.4 ± 11.6, Δ: 8.3 ± 10.8 pcs, p < 0.05; t0: 0.07 ± 0.03, Δ: 0.05 ± 0.07 pcs/mc, p < 0.001) increased after the intervention. The total consumption of vegetables (IG, t0: 260 ± 170 g/d, CG, t0: 220 ± 156 g/d; p > 0.05) and fruit (IG, t0: 191 ± 109 g/d; CG, t0: 186 ± 141 g/d; p > 0.05), however, did not change. To effectively change daily consumption, the intervention needs to be expanded.

Nudging healthy college dining hall choices using behavioral economics

To apply behavioral economics strategies (i.e., placement changes and signage) to nudge university students' healthy dining hall eating. Participants: A convenience sample of 4208 students exiting a university dining hall were asked to take a brief survey on meal selections. Methods: Three unique nudges (related to beverage, snack and dessert) were individually introduced and then removed for a week using a quasi-experimental design. Exit surveys during non-nudge and intervention periods were compared using chi-square analysis. Results: The beverage nudge significantly increased water consumption (p=.03) and the dessert nudge significantly increased healthy dessert consumption (p<.001) between comparison and intervention weeks. The snack intervention did not significantly affect snack choice. Conclusions: Simple signage interventions may be effective to encourage healthy eating behaviors in a college dining hall setting. Student health may be improved by nudging students to select healthier beverage and dessert options.

Factors Influencing Fidelity to a Calorie Posting Policy in Public Hospitals: A Mixed Methods Study

Background: Labelling menus with nutrition information has increasingly become an important obesity policy option. While much research to-date has focused on determining its effectiveness, few studies report the extent to which menu labelling is implemented as designed. The aim of this study was to explore factors influencing fidelity to a calorie posting policy in Irish acute public hospitals.

Methods: A mixed methods sequential explanatory study design was employed, with a nested case study for the qualitative component. Quantitative data on implementation fidelity at hospitals were analysed first and informed case sampling in the follow-on qualitative phase. Maximum variation sampling was used to select four hospitals with high and low levels of implementation and variation in terms of geographic location, hospital size, complexity of care provided and hospital type. Data were collected using structured observations, unstructured non-participant observations and in-depth semi-structured interviews. The Consolidated Framework for Implementation Research guided qualitative data collection and analysis. Using framework analysis, factors influencing implementation were identified. A triangulation protocol was used to integrate fidelity findings from multiple sources. Data on influencing factors and fidelity were then combined using joint displays for within and cross-case analysis.

Results: Quantitative fidelity data showed seven hospitals were categorised as low implementers and 28 hospitals were high implementers of the policy. Across the four hospitals selected as cases, qualitative analysis revealed factors influencing implementation and fidelity were multiple, and operated independently and in combination. Factors were related to the internal hospital environment (e.g., leadership support, access to knowledge and information, perceived importance of calorie posting implementation), external hospital environment (e.g., national policy, monitoring), features of the calorie posting policy (e.g., availability of supporting materials), and the implementation process (e.g., engaging relevant stakeholders). Integrated analysis of fidelity indicated a pattern of partial adherence to the calorie posting policy across the four hospitals. Across all hospitals, there was a consistent pattern of low adherence to calorie posting across all menu items on sale, low adherence to calorie information displayed per standard portion or per meal, low adherence to standardised recipes/portions, and inaccurate calorie information.

Conclusion: Efforts to maximise fidelity require multi-level, multi-component strategies in order to reduce or mitigate barriers and to leverage facilitators. Future research should examine the relative importance of calorie posting determinants and the association between implementation strategies and shifts in fidelity to intervention core components.

Workplace cafeteria and other multicomponent interventions to promote healthy eating among adults: A systematic review

The objective of this review is to evaluate evidence for the effectiveness of workplace cafeteria and other supporting multicomponent interventions to promote healthy eating and reductions in health risks among adults. We conducted an electronic search in EMBASE, CINAHL, EconLit, Ovid, Cochrane, Web of Science and PubMed for English-language articles published from 1985 to July 2019. Studies were original articles reporting the results of workplace cafeteria interventions to promote healthy eating and reduction in health risks. Outcomes were classified as changes in fruit and vegetable intake, health risk indicators, dietary intake, and food sales. Interventions were categorized as interventions targeting food quality or quantity, targeting price, targeting food choice at point of purchase, targeting improved supply, targeting client's information, education or motivation and targeting organization policies. Behavioral change conditions used in interventions were identified using the COM-B system of behavioral change. Results were presented in a narrative summary. A total of 55 studies out of 6285 articles were identified for this review. Several studies used multicomponent interventions and the most featured interventions included interventions targeting food quality or quantity, targeting client's information, education or motivation and targeting food choice at point of purchase. There is evidence that workplace cafeteria and other supporting multicomponent interventions resulted in higher intake of fruit and vegetables, improved dietary intake, improved health outcomes and healthy food sales. The findings of this review have the potential to inform future cafeteria-based and other supporting multicomponent workplace health interventions. The review protocol was not registered in a repository.

Dietary Interventions to Promote Healthy Eating among Office Workers: A Literature Review

Our aim is to review published studies on dietary interventions to promote healthy eating habits among office workers. The databases PubMed, EBSCO (MEDLINE, Academic Search Elite, CINAHL Plus, PsycARTICLES, PsycINFO), Cochrane Library, SCOPUS, and Google Scholar were searched between February and April 2019. Initially, 6647 articles were identified, and the final number of articles that met the inclusion criteria was 25. We identified four different types of interventions that included educational and/or environmental components, where environmental components provided healthy food in a work-related context. The interventions at the offices included web-based material, availability of food, provision of information in various ways, and a combination of environmental, educational and theory-based psychological approaches (i.e., multicomponent). The most commonly used designs were web-based and information interventions, respectively, which are the least expensive ways to intervene. The interventions assessed a range of outcomes, but this literature review focused on three, i.e., dietary intake, dietary behavior and health-related outcomes. Although the studies were heterogenous in terms of outcomes, design, number of participants, gender distribution and duration, all studies reported at least one positive effect. Thus, workplace dietary interventions are an unutilized area to positively influence dietary intake and health outcomes among office workers. However, the intervention needs to be tailored to the workplace.

What Makes a Front-of-Pack Nutritional Labelling System Effective: The Impact of Key Design Components on Food Purchases

The relative impacts on food purchases of many alternative front-of-pack nutritional labelling systems were tested, with various methods—from opinion pool to nationwide experiments. Clearly, some systems induce better purchasing responses, having better nutritional impacts on food baskets. Nonetheless, we still ignore what the ingredients of an efficient label are. Here, we propose guidance for label designers. To do so, we first propose a typology that breaks down established labelling systems into four elementary components: Directiveness, Scope and Gradation, Set of Reference and Sign. On this basis, we then build seven alternative generic labelling systems that we test in a framed-field experiment enabling us to measure the effect of each component on food purchases in isolation. Our results show that an effective front-of-pack labelling system should be Food-Directive (instead of Diet-Directive) and be displayed on both healthy and unhealthy food. The reference set, which is across categories or within categories, produces the same average nutrition score but generates contrasting behavioural responses.

The effects of nudges on purchases, food choice, and energy intake or content of purchases in real-life food purchasing environments: a systematic review and evidence synthesis

Background

Adults with a low socioeconomic position (SEP) are more likely to engage in unhealthy diets as compared to adults with high SEP. However, individual-level educational interventions aiming to improve food choices have shown limited effectiveness in adults with low SEP. Environmental-level interventions such as nudging strategies however, may be more likely to benefit low SEP groups. We aimed to review the evidence for the effectiveness of nudges as classified according to interventions in proximal physical micro-environments typology (TIPPME) to promote healthy purchases, food choice, or affecting energy intake or content of purchases, within real-life food purchasing environments. Second, we aimed to investigate the potentially moderating role of SEP.

Methods

We systematically searched PubMed, EMBASE, and PsycINFO until 31 January 2018. Studies were considered eligible for inclusion when they i) complied with TIPPME intervention definitions; ii) studied actual purchases, food choice, or energy intake or content of purchases, iii) and were situated in real-life food purchasing environments. Risk of bias was assessed using a quality assessment tool and evidence was synthesized using harvest plots.

Results

From the 9210 references identified, 75 studies were included. Studies were generally of weak to moderate quality. The most frequently studied nudges were information (56%), mixed (24%), and position nudges (13%). Harvest plots showed modest tendencies towards beneficial effects on outcomes for information and position nudges. Less evidence was available for other TIPPME nudging interventions for which the harvest plots did not show compelling patterns. Only six studies evaluated the effects of nudges across levels of SEP (e.g., educational level, food security status, job type). Although there were some indications that nudges were more effective in low SEP groups, the limited amount of evidence and different proxies of SEP used warrant caution in the interpretation of findings.

Conclusions

Information and position nudges may contribute to improving population dietary behaviours. Evidence investigating the moderating role of SEP was limited, although some studies reported greater effects in low SEP subgroups. We conclude that more high-quality studies obtaining detailed data on participant’s SEP are needed.

Registration

This systematic review is registered in the PROSPERO database (CRD42018086983).

Improvement in Healthy Meal Index, Lunch Quality, and Diversity Scores Following an Integrated Nutritional Intervention in a Communal Dining Room: The NEKST Study

The objective of the NEKST (Nutrition Environmental Kibbutzim Study), a nonrandomized interventional study, was to evaluate the effect of an integrated intervention program on participants’ lunch quality and diversity in two communal dining rooms (intervention n = 58 vs. control n = 54). The intervention included recipe modification, environmental changes, and an education program. The outcomes included simple healthy meal index (SHMI), lunch quality (LQS), and diversity scores (LDS) calculated based on photographs of lunch trays. A nutrition questionnaire assessed the changes in fruit and vegetable intake at baseline and 3 months following the intervention. The mean SHMI, LQS, and LDS increased in the intervention group (0.51, p < 0.001; 0.27, p = 0.045; 0.95, p < 0.001, respectively) but not in the control group (p = 0.865; p = 0.339; p = 0.354, respectively). Multivariable linear models demonstrate an increase in the SHMI (β = 0.26, 95% CI [0.12–0.76], p = 0.015), LQS (β = 0.23, 95% CI [0.06–0.83], p = 0.024), and LDS (β = 0.34, 95% CI [0.41–1.39], p < 0.001) of the participants in the intervention group. More participants in the intervention group raised their daily fruit intake compared with the control. We conclude that this integrated intervention program was effective in improving lunch healthy meal index, quality, and diversity in a communal dining room, with a modest halo effect of the intervention throughout the day.

Barriers and facilitators to implementation of menu labelling interventions from a food service industry perspective: a mixed methods systematic review

Background

Eating outside the home contributes to poor dietary habits worldwide and is associated with increased body fat and weight gain. Evidence shows menu labelling is effective in promoting healthier food choices; however, implementation issues have arisen. The purpose of this systematic review was to synthesise the evidence on the perceived barriers and facilitators to implementation of menu labelling interventions from the perspective of the food service industry.

Methods

Peer-reviewed and grey literature were searched using databases, specialised search engines and public health organisation websites. Screening reference lists, citation chaining and contacting authors of all included studies were undertaken. Primary research studies relevant to direct supply-side stakeholders were eligible for inclusion. There were no restrictions on menu labelling scheme or format, study methods, publication year or language. At least two independent reviewers performed study selection, data extraction and quality appraisal. The results were synthesised using the ‘best fit’ framework synthesis approach, with reference to the Consolidated Framework for Implementation Research (CFIR).

Results

Seventeen studies met the eligibility criteria, with the majority rated as average quality (n = 10). The most frequently cited barriers were coded to the CFIR constructs ‘Consumer Needs & Resources’ (e.g. lack of customer demand for/interest in menu labelling, risk of overwhelmed/confused customers) and ‘Compatibility’ with organisation work processes (e.g. lack of standardised recipes, limited space on menus). Frequently cited facilitators were coded to the CFIR constructs ‘Relative Advantage’ of menu labelling (e.g. improved business image/reputation) and ‘Consumer Needs & Resources’ (e.g. customer demand for/interest in menu labelling, providing nutrition information to customers). An adapted framework consisting of a priori and new constructs was developed, which illustrates the relationships between domains.

Conclusion

This review generates an adapted CFIR framework for understanding implementation of menu labelling interventions. It highlights that implementation is influenced by multiple interdependent factors, particularly related to the external and internal context of food businesses, and features of the menu labelling intervention. The findings can be used by researchers and practitioners to develop or select strategies to address barriers that impede implementation and to leverage facilitators that assist with implementation effort.

Trial registration

Systematic review registration: PROSPERO CRD42017083306.

Factors influencing employees' eating behaviours in the office-based workplace: A systematic review

Employees spend a large proportion of their time at work and typically consume a third of their total calories during the working day. Research suggests that the workplace environment can affect employees' eating behaviours, leading to various related health consequences. This systematic review aimed to identify and synthesize the evidence surrounding factors influencing eating behaviours within an office-based workforce. The literature search was restricted to studies published in English between January 2008 and April 2018. A total of 5,017 articles were screened and assessed for eligibility, of which 22 articles (n=23 studies) were included in the review. All included studies were subjected to quality assessment and were summarized into groups (themes) of "factors" affecting any aspect of eating behaviour at work. The findings revealed a number of factors influencing eating behaviours at work relating to the job role, workplace food environment, and social aspects of the office-based workplace. Most of the existing research implies the office-based workplace has a negative influence on eating behaviours. The findings of this review provide an evidence based, comprehensive summary of the possible determinants of eating behaviours in the workplace, which may help researchers to identify factors that are potential targets for intervention.

The Effect of Randomly Providing Nutri-Score Information on Actual Purchases in Colombia

Recently, front-of-package (FOP) food labeling systems have captured the attention of researchers and policy makers. Several Latin American governments are currently considering employing different FOP labeling systems. However, there is much need for more research-based evidence in these countries. In this paper, we study whether food-purchasing decisions and the nutritional qualities of those purchases are influenced by randomly informing some customers and not others about an FOP label known as Nutri-Score. We also separate the information effect from the effect of being aware of the system. We combined a randomized field intervention in a university cafeteria in Bogotá, Colombia with data from an after-purchase survey and receipts. We found that randomly providing information on Nutri-Score increased total expenditure by $0.18. Additional spending on healthier items was 21% or $0.26 higher, with no change for less healthy items. Expenditure estimates were higher among customers who were aware of the system’s existence. Customers in the study were also 10% more likely to buy a healthier item than control customers were, and the concentration of protein in their purchases was greater. Information on the Nutri-Score system increased the store’s sales. This potential financial incentive may facilitate the implementation of Nutri-Score.

Choice architecture interventions to improve diet and/or dietary behaviour by healthcare staff in high-income countries: a systematic review

OBJECTIVES

We were commissioned by the behavioural insights team at Public Health England to synthesise the evidence on choice architecture interventions to increase healthy purchasing and/or consumption of food and drink by National Health Service (NHS) staff.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Central register of Controlled Trials, PsycINFO, Applied Social Sciences Index and Abstracts and Web of Science were searched from inception until May 2017 and references were screened independently by two reviewers.

DESIGN

A systematic review that included randomised experimental or intervention studies, interrupted time series and controlled before and after studies.

PARTICIPANTS

Healthcare staff of high-income countries.

INTERVENTION

Choice architecture interventions that aimed to improve dietary purchasing and/or consumption (outcomes) of staff.

APPRAISAL AND SYNTHESIS

Eligibility assessment, quality appraisal, data abstraction and analysis were completed by two reviewers. Quality appraisal of randomised trials was informed by the Cochrane Handbook, and the Risk of Bias Assessment Tool for Nonrandomized Studies was used for the remainder. Findings were narratively synthesised.

RESULTS

Eighteen studies met the inclusion criteria. Five studies included multiple workplaces (including healthcare settings), 13 were conducted in healthcare settings only. Interventions in 10 studies were choice architecture only and 8 studies involved a complex intervention with a choice architecture element. Interventions involving a proximity element (making behavioural options easier or harder to engage with) appear to be frequently effective at changing behaviour. One study presented an effective sizing intervention. Labelling alone was generally not effective at changing purchasing behaviour. Interventions including an availability element were generally reported to be successful at changing behaviour but no included study examined this element alone. There was no strong evidence for the effect of pricing on purchasing or dietary intake.

CONCLUSION

Proximity, availability and sizing are choice architecture elements that are likely to be effective for NHS organisations.

TRIAL REGISTRATION NUMBER

CRD42017064872.

Strategies to improve the implementation of workplace-based policies or practices targeting tobacco, alcohol, diet, physical activity and obesity

BACKGROUND

Given the substantial period of time adults spend in their workplaces each day, these provide an opportune setting for interventions addressing modifiable behavioural risk factors for chronic disease. Previous reviews of trials of workplace-based interventions suggest they can be effective in modifying a range of risk factors including diet, physical activity, obesity, risky alcohol use and tobacco use. However, such interventions are often poorly implemented in workplaces, limiting their impact on employee health. Identifying strategies that are effective in improving the implementation of workplace-based interventions has the potential to improve their effects on health outcomes.

OBJECTIVES

To assess the effects of strategies for improving the implementation of workplace-based policies or practices targeting diet, physical activity, obesity, tobacco use and alcohol use.Secondary objectives were to assess the impact of such strategies on employee health behaviours, including dietary intake, physical activity, weight status, and alcohol and tobacco use; evaluate their cost-effectiveness; and identify any unintended adverse effects of implementation strategies on workplaces or workplace staff.

SEARCH METHODS

We searched the following electronic databases on 31 August 2017: CENTRAL; MEDLINE; MEDLINE In Process; the Campbell Library; PsycINFO; Education Resource Information Center (ERIC); Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Scopus. We also handsearched all publications between August 2012 and September 2017 in two speciality journals: Implementation Science and Journal of Translational Behavioral Medicine. We conducted searches up to September 2017 in Dissertations and Theses, the WHO International Clinical Trials Registry Platform, and the US National Institutes of Health Registry. We screened the reference lists of included trials and contacted authors to identify other potentially relevant trials. We also consulted experts in the field to identify other relevant research.

SELECTION CRITERIA

Implementation strategies were defined as strategies specifically employed to improve the implementation of health interventions into routine practice within specific settings. We included any trial with a parallel control group (randomised or non-randomised) and conducted at any scale that compared strategies to support implementation of workplace policies or practices targeting diet, physical activity, obesity, risky alcohol use or tobacco use versus no intervention (i.e. wait-list, usual practice or minimal support control) or another implementation strategy. Implementation strategies could include those identified by the Effective Practice and Organisation of Care (EPOC) taxonomy such as quality improvement initiatives and education and training, as well as other strategies. Implementation interventions could target policies or practices directly instituted in the workplace environment, as well as workplace-instituted efforts encouraging the use of external health promotion services (e.g. gym membership subsidies).

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently performed citation screening, data extraction and 'Risk of bias' assessment, resolving disagreements via consensus or a third reviewer. We narratively synthesised findings for all included trials by first describing trial characteristics, participants, interventions and outcomes. We then described the effect size of the outcome measure for policy or practice implementation. We performed meta-analysis of implementation outcomes for trials of comparable design and outcome.

MAIN RESULTS

We included six trials, four of which took place in the USA. Four trials employed randomised controlled trial (RCT) designs. Trials were conducted in workplaces from the manufacturing, industrial and services-based sectors. The sample sizes of workplaces ranged from 12 to 114. Workplace policies and practices targeted included: healthy catering policies; point-of-purchase nutrition labelling; environmental supports for healthy eating and physical activity; tobacco control policies; weight management programmes; and adherence to guidelines for staff health promotion. All implementation interventions utilised multiple implementation strategies, the most common of which were educational meetings, tailored interventions and local consensus processes. Four trials compared an implementation strategy intervention with a no intervention control, one trial compared different implementation interventions, and one three-arm trial compared two implementation strategies with each other and a control. Four trials reported a single implementation outcome, whilst the other two reported multiple outcomes. Investigators assessed outcomes using surveys, audits and environmental observations. We judged most trials to be at high risk of performance and detection bias and at unclear risk of reporting and attrition bias.Of the five trials comparing implementation strategies with a no intervention control, pooled analysis was possible for three RCTs reporting continuous score-based measures of implementation outcomes. The meta-analysis found no difference in standardised effects (standardised mean difference (SMD) -0.01, 95% CI -0.32 to 0.30; 164 participants; 3 studies; low certainty evidence), suggesting no benefit of implementation support in improving policy or practice implementation, relative to control. Findings for other continuous or dichotomous implementation outcomes reported across these five trials were mixed. For the two non-randomised trials examining comparative effectiveness, both reported improvements in implementation, favouring the more intensive implementation group (very low certainty evidence). Three trials examined the impact of implementation strategies on employee health behaviours, reporting mixed effects for diet and weight status (very low certainty evidence) and no effect for physical activity (very low certainty evidence) or tobacco use (low certainty evidence). One trial reported an increase in absolute workplace costs for health promotion in the implementation group (low certainty evidence). None of the included trials assessed adverse consequences. Limitations of the review included the small number of trials identified and the lack of consistent terminology applied in the implementation science field, which may have resulted in us overlooking potentially relevant trials in the search.

AUTHORS' CONCLUSIONS

Available evidence regarding the effectiveness of implementation strategies for improving implementation of health-promoting policies and practices in the workplace setting is sparse and inconsistent. Low certainty evidence suggests that such strategies may make little or no difference on measures of implementation fidelity or different employee health behaviour outcomes. It is also unclear if such strategies are cost-effective or have potential unintended adverse consequences. The limited number of trials identified suggests implementation research in the workplace setting is in its infancy, warranting further research to guide evidence translation in this setting.

Performance Nutrition Dining Facility Intervention Improves Special Operations Soldiers' Diet Quality and Meal Satisfaction

OBJECTIVE

To assess the impact of the Special Operations Forces Human Performance Program dining facility (DFAC) intervention on patron diet quality and meal satisfaction.

DESIGN

Nonrandomized, controlled time series study using digital food photography and surveys pre-post intervention (0, 4, 8, and 12 months).

SETTING

Two Fort Bragg, NC military installation DFACs.

PARTICIPANTS

Volunteers (n = 688 total; n = 573 complete dataset) were US Army active duty soldiers.

INTERVENTION

The DFAC intervention included food choice architecture, new performance-optimizing food recipes to increase nutrient density, revised menus to offer more performance foods daily, and nutrition labeling to influence food choice.

MAIN OUTCOME MEASURES

Daily DFAC nutrient intake and Healthy Eating Index (HEI) 2010 scores.

ANALYSIS

Descriptive and ANOVA statistical analyses were performed between control and intervention groups and from baseline to 4, 8, and 12 months postintervention (α = .05; 80% power).

RESULTS

The intervention resulted in a higher posttest HEI score (60.1 ± 8.8 points; +3.4%; P = .005) and DFAC satisfaction compared with control (49.0 ± 10.4 points; P > .05). Improved intervention HEI scores were attributed to changes in citrus and melon fruit (+46%), red and orange vegetables (+35%), whole grains (+181%), legumes (65%), yogurt (+45%), oils (-26%), and solid fat (-18%) consumption (all P < .05).

CONCLUSIONS AND IMPLICATIONS

These data illustrate that the Special Operations Forces Human Performance Program military DFAC nutrition intervention was feasible to implement and was associated with diet quality improvements. Access to high-quality ingredients and recipes may improve soldier meal quality and acceptance in other settings and warrants further investigation.

A systematic review and meta-analysis of the effectiveness of nudging to increase fruit and vegetable choice

Background

Nudging refers to interventions that organize the choice architecture in order to alter people's behaviour in a predictable way without forbidding any options or significantly changing their economic incentives. As a strategy to encourage healthy behaviour, nudging can serve as a complement to health education. However, the empirical evidence regarding the effectiveness of nudging as a way to influence food choice remains contradictory. To address this issue, a systematic review and meta-analysis was conducted to test the effects of nudging to encourage people to select more fruit and vegetables.

Methods

A systematic literature search was performed on PubMed, Medline, PsycInfo, Cochrane library, Scopus and Google Scholar. After quality assessment, 20 articles (23 studies) were retained for narrative synthesis. Twelve articles (14 studies) contained enough information to calculate effect-sizes for meta-analysis using Comprehensive Meta-analysis software.

Results

The meta-analysis shows that nudging interventions that aim to increase fruit and/or vegetable choice/sales/servings have a moderately significant effect (d = 0.30), with the largest effect for altering placement (d = 0.39) and combined nudges (d = 0.28).

Conclusion

The results of this review provide an indication of the effectiveness of nudging on fruit and vegetable choice in terms of actual effect-sizes, while also highlighting the problems that must be addressed before more definitive conclusions can be drawn.

Barriers and facilitators to implementation of menu labelling interventions to support healthy food choices: a mixed methods systematic review protocol

BACKGROUND

Menu labelling is continuing to gather public and legislative support as one of the potential environmental strategies for addressing the obesity pandemic. However, issues relating to implementation have been reported in countries where menu labelling has been introduced on a voluntary or mandatory basis. The aim of this mixed methods systematic review is to synthesise the empirical evidence on the barriers and facilitators to implementation of menu labelling interventions to support healthy food choices.

METHODS

This review will use the 'best fit' framework synthesis approach to synthesise qualitative, quantitative and mixed methods evidence. Peer-reviewed publications will be accessed through PubMed, EMBASE, CINAHL, PsycINFO, Web of Science and Scopus. Grey literature will be accessed through Google Scholar, OpenGrey, RIAN, EThOS, ProQuest, WorldCat, Networked Digital Library of Theses and Dissertations, Open Access Theses and Dissertations, and public health organisation websites. Screening reference lists, citation chaining and contacting authors of all included studies will be undertaken. There will be no restriction on menu labelling scheme or format, publication year or language; however, only primary research studies relevant to supply-side stakeholders will be eligible for inclusion. Study quality will be assessed using the Mixed Methods Appraisal Tool. At least two independent reviewers will perform study selection, data extraction and quality appraisal; if consensus is required, another independent reviewer will be consulted. A combination of deductive coding, using the Consolidated Framework for Implementation Research as the a priori framework, and inductive analysis, using secondary thematic analysis, will be used. The overall process will assist in the construction of a new evidence-based conceptual model regarding the implementation of menu labelling interventions. The new model will be assessed for bias and a sensitivity analysis performed.

DISCUSSION

Given the growing consensus that a systemic, sustained portfolio of obesity prevention strategies, delivered at scale, is needed to address the obesity epidemic, greater understanding of the practical issues relating to implementation of such strategies is required. Findings from this review will be used to develop a set of best-practice guidelines to enhance the adoption, implementation and sustainability of menu labelling interventions across countries worldwide.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017083306.

The effect of a portion size intervention on French fries consumption, plate waste, satiety and compensatory caloric intake: an on-campus restaurant experiment

Background

One of the driving factors of dietary overconsumption throughout the last decennia is the increase of food portion sizes. Larger portions induce higher daily energy intake, so reducing portion size may reduce intake of excess calories. However, real-life studies about the effects of portion size reduction are lacking. Therefore, this study examined the effect of a French fries portion size reduction on French fries consumption, French fries plate waste, satiety and caloric intake during the subsequent afternoon among university students and employees in a Belgian on-campus restaurant setting. Moreover, this study evaluated consumers’ perception about the portion size reduction.

Methods

The study took place over a two-time (i.e. baseline and intervention week) 4-day period (Tuesday–Friday) in the on-campus restaurant where ±1200 meals are served every day. French fries’ portions were reduced by 20% by replacing the usual porcelain bowl served during the baseline week (±200 g) with smaller volume paper bags during the intervention week (±159 g) in a pre-post real-life experiment. French fries consumption and plate waste were measured in 2056 consumers at baseline and 2175 consumers at intervention. Additionally, interviews were conducted directly after lunch and again between 4 and 6 p.m. on the same day to assess satiety and caloric intake at pre and post in a small subsample of both French fries consumers (n = 19) and non-French fries consumers (n = 14). Post-intervention, the same subsample was interviewed about their perception of the portion size reduction (n = 28).

Results

Total French fries intake decreased by 9.1%, and total plate waste decreased by 66.4%. No differences were found in satiety or caloric intake between baseline and intervention week among the French fries’ consumers. The majority (n = 24, 86%) of French fries consumers noticed the reduction in portion size during the intervention. Although most participants (n = 19, 68%) perceived the reduced portion size as sufficient, only a minority of participants (n = 9, 32%) indicated post-intervention that they would agree with a permanent implementation.

Conclusions

Reducing portion size may lead to reduced caloric intake, without changing perceived levels of satiety.

Information-based cues at point of choice to change selection and consumption of food, alcohol and tobacco products: a systematic review

BACKGROUND

Reducing harmful consumption of food, alcohol, and tobacco products would prevent many cancers, diabetes and cardiovascular disease. Placing information-based cues in the environments in which we select and consume these products has the potential to contribute to changing these behaviours.

METHODS

In this review, information-based cues are defined as those which comprise any combination of words, symbols, numbers or pictures that convey information about a product or its use. We specifically exclude cues which are located on the products themselves. We conducted a systematic review of randomised, cluster- randomised, and non-randomised controlled trials to assess the impact of such cues on selection and consumption. Thirteen studies met the inclusion criteria, of which 12 targeted food (most commonly fruit and vegetables), one targeted alcohol sales, and none targeted tobacco products.

RESULTS

Ten studies reported statistically significant effects on some or all of the targeted products, although studies were insufficiently homogenous to justify meta-analysis. Existing evidence suggests information-based cues can influence selection and consumption of food and alcohol products, although significant uncertainty remains.

CONCLUSIONS

The current evidence base is limited both in quality and quantity, with relatively few, heterogeneous studies at unclear or high risk of bias. Additional, more rigorously conducted studies are warranted to better estimate the potential for these interventions to change selection and consumption of food, alcohol and tobacco products.

TRIAL REGISTRATION

PROSPERO. 2016; CRD42016051884 .

Nutritional labelling for healthier food or non-alcoholic drink purchasing and consumption

BACKGROUND

Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour.

OBJECTIVES

To assess the impact of nutritional labelling for food and non-alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption.

SEARCH METHODS

We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries.

SELECTION CRITERIA

Eligible studies: were randomised or quasi-randomised controlled trials (RCTs/Q-RCTs), controlled before-and-after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non-alcoholic drinks in real-world or laboratory settings.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary.

MAIN RESULTS

We included 28 studies, comprising 17 RCTs, 5 Q-RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28).Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real-world settings, including purchases from vending machines (one cluster-RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q-RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta-analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD -46.72 kcal, 95% CI -78.35, -15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta-analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias.Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta-analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD -50 kcal, 95% CI -104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies.Six laboratory studies (four RCTs and two Q-RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta-analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI -0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies.There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high-energy foods) during a snack or meal. A meta-analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI -0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate.

AUTHORS' CONCLUSIONS

Findings from a small body of low-quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality.Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high-quality research in real-world settings is needed to enable more certain conclusions.Further high-quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status.

The role of nutritional labelling and signposting from a European perspective

The past half-century has been characterised by major technological developments and massive societal change, which have profoundly changed how food is produced, processed, sold and consumed. These days we are faced with a huge choice of pre-packaged foods when we shop in modern supermarkets and we can buy seasonal food all year round, in and out of season. For decades now, the need to guide choice has been recognised, and retailers and many manufacturers have provided increasing amounts of on-pack information and signposting, and more recently UK retailers have led the way in championing front-of-pack information provision, to supplement the standard back-of-pack nutrient composition table. From a European perspective, the present paper summarises developments in nutrition labelling information and signposting, the legislation that controls on-pack declarations, and research conducted to assess whether or not the information is used, understood and supports healthier choices. It also considers whether more could be done to influence behaviour change positively, giving examples of approaches identified in the research.

Nutrient profiling for front of pack labelling: how to align logical consumer choice with improvement of products?

The primary goal of front of pack (FOP) labelling is to help consumers make healthier choices through communication. A secondary goal is to encourage producers to improve the nutritional composition of their products. Evidence has shown that (FOP) labelling can help consumers to make healthier food choices and has been an incentive for producers to improve product composition. As FOP labelling is seen as an important tool to improve food environments for public health purposes, the WHO supports initiatives of governments to implement an FOP labelling system. Based on the experiences of a wide range of countries over many years, possible success factors for such an FOP system have been defined, six of which are discussed in the present paper and used to evaluate the Dutch Choices Programme that was started in 2006. In the course of time a large number of producers joined the programme and the logo was recognised by more than 90 % of the consumers, but by 2016 the Dutch consumer organisation argued on the basis of their own research that a quarter of the consumers did not understand the colour coding of the logo and as a result the Dutch government decided to no longer support this logo and to introduce a nutrition app. The challenge that remains is to find a system that consumers understand well and that still encourages manufacturers of food to improve product composition. New technology-based data collecting initiatives might provide the right tools to develop such a system.

Influence of menu labeling on food choices in real-life settings: a systematic review

CONTEXT

Evidence that menu labeling influences food choices in real-life settings is lacking. Reviews usually focus on calorie counts without addressing broader issues related to healthy eating.

OBJECTIVE

This systematic review assessed the influence of diverse menu-labeling formats on food choices in real-life settings.

DATA SOURCES

Several databases were searched: Cochrane Library, Scopus, MEDLINE, Web of Science, Food Science and Technology Abstracts, Biological Abstracts, CAB Abstracts, EconLit, SciELO, and LILACS.

STUDY SELECTION

Articles reporting experiments, quasi-experiments, and observational studies using control or preintervention groups were selected blindly by two reviewers.

DATA EXTRACTION

Data was extracted using a standard form. Analyses differentiated between foodservice types. The quality of the 38 included studies was assessed blindly by two reviewers.

DATA ANALYSIS

The results were mixed, but a partial influence of menu labeling on food choices was more frequent than an overall influence or no influence. Menu labeling was more effective in cafeterias than in restaurants. Qualitative information, such as healthy-food symbols and traffic-light labeling, was most effective in promoting healthy eating. In general, the studies were of moderate quality and did not use control groups.

CONCLUSIONS

Calorie labeling in menus is not effective to promote healthier food choices. Further research in real-life settings with control groups should test diverse qualitative information in menu labeling.

Testing a Beverage and Fruit/Vegetable Education Intervention in a University Dining Hall

OBJECTIVE

To test the effect of a nutrition intervention that included education and 2 labeling components on students' food choices.

DESIGN

Repeat cross-sectional study taking place on 6 dinner occasions before and 6 afterward.

SETTING

The study was conducted during dinner meals in a buffet-style dining hall in a university campus residence, where students paid a set price and consumed all they cared to eat.

PARTICIPANTS

University students (n = 368 to 510) visited the cafeteria on each of the data collection dates.

INTERVENTION

Fruit and vegetable consumption were encouraged; sugar-sweetened beverage consumption was discouraged using physical activity calorie equivalent labeling.

MAIN OUTCOME MEASURES

Beverage choices and vegetable/fruit bar visits.

ANALYSIS

Logistic regression was used to compare the proportion of student who selected each beverage, fruit, or vegetable before and after the intervention, while controlling for menu and gender as covariates.

RESULTS

There was a significant decrease in the proportion of students selecting a sugar-sweetened beverage before vs after the intervention (49% vs 41%, respectively; P = .004) and an increase in students choosing water (43% vs 54%, respectively; P < .001). There was a significant increase in students who took fruit after the intervention (36%; P < .001) vs before (30%). The number of students visiting the vegetable bar significantly increased from 60% to 72% (P < .001).

CONCLUSIONS

This intervention may be a way to encourage healthy dietary choices in campus dining halls.

Impact of worksite cafeteria interventions on fruit and vegetable consumption in adults

Purpose

Increasing obesity rates and health care costs have prompted worksites to investigate interventions to improve employee health. The purpose of this paper is to determine the effect of worksite cafeteria interventions on fruit and vegetable (F/V) consumption.

Design/methodology/approach

This review was guided by the preferred reporting items for systematic reviews and meta-analyses method. After a thorough literature search and screening process, 18 studies were included in the review. Data were extracted, and a risk of bias assessment was created for the primary studies. An un-weighted average was used to determine the overall ranking for each study.

Findings

There appears to be a moderately strong association toward a positive impact of cafeteria interventions to increase F/V consumption. Of the 18 studies in the review, 13 reported a statistically significant increase, one reported a significant decrease, three reported mixed results, and one did not assess a change in consumption.

Research limitations/implications

Most of the data were self-reported and is subject to error. Furthermore, the heterogeneity of study design, method, and outcome measures among the studies warrants additional research with consistent methodology.

Practical implications

A positive impact on F/V consumption may be realized by the following techniques: price-point subsidies, point-of-purchase materials, and menu modification.

Originality/value

This new information on increasing F/V consumption in workplace cafeterias may improve employee health and reduce the risk of chronic disease.

Environmental interventions for altering eating behaviours of employees in the workplace: a systematic review

Environmental, or 'choice-architecture', interventions aim to change behaviour by changing properties/contents of the environment and are commonly used in the workplace to promote healthy behaviours in employees. The present review aimed to evaluate and synthesize the evidence surrounding the effectiveness of environmental interventions targeting eating behaviour in the workplace. A systematic search identified 8157 articles, of which 22 were included in the current review. All included studies were coded according to risk of bias and reporting quality and were classified according to the emergent typology of choice-architecture interventions. More than half of included studies (13/22) reported significant changes in primary measures of eating behaviour (increased fruit/veg consumption, increased sales of healthy options and reduction in calories purchased). However, only one study produced a small significant improvement in weight/body mass index. Many studies had a high or unknown risk of bias; reporting of interventions was suboptimal; and the only trial to measure compensatory behaviours found that intervention participants who ate less during the intervention ate more out with the workplace later in the day. Hence, we conclude that more rigorous, well-reported studies that account for compensatory behaviours are needed to fully understand the impact of environmental interventions on diet and importantly on weight/body mass index outcomes.

Using nudging and social marketing techniques to create healthy worksite cafeterias in the Netherlands: intervention development and study design

Background

The worksite cafeteria is a suitable setting for interventions focusing on changing eating behavior, because a lot of employees visit the worksite cafeteria regularly and a variety of interventions could be implemented there.

The aim of this paper is to describe the intervention development and design of the evaluation of an intervention to make the purchase behavior of employees in the worksite cafeteria healthier. The developed intervention called “the worksite cafeteria 2.0” consists of a set of 19 strategies based on theory of nudging and social marketing (marketing mix). The intervention will be evaluated in a real-life setting, that is Dutch worksite cafeterias of different companies and with a number of contract catering organizations.

Methods/design

The study is a randomized controlled trial (RCT), with 34 Dutch worksite cafeterias randomly allocated to the 12-week intervention or to the control group. Primary outcomes are sales data of selected products groups like sandwiches, salads, snacks and bread topping. Secondary outcomes are satisfaction of employees with the cafeteria and vitality.

Discussion

When executed, the described RCT will provide better knowledge in the effect of the intervention “the worksite cafeteria 2.0” on the purchasing behavior of Dutch employees in worksite cafeterias.

Trial registration

Dutch Trial register: NTR5372.

The incidence of calorie labeling on fast food choices: A comparison between stated preferences and actual choices

In order to test the effect of calorie information on fast food choices, we conducted a questionnaire employing two types of stated preferences methods (the best-worst-scaling and intentional questions) and a follow-up randomized field experiment in a sample of 119 participants. This combined approach allowed us to test the internal validity of preferences for fast food meals across elicitation scenarios. The results showed that calorie information reduces the probability of selecting high calorie meals only in the questionnaire, while it did not have any significant impact on actual purchasing behavior in the field experiment. Thus, the findings show that there is a clear difference between the role of calorie information on immediate stated preference choices, and the relatively low level of responsiveness in real choices in a restaurant. We believe that the current results are quite suggestive, indicating the limits of predicting actual fast food behavior, and may open the way to using data sources that combine stated methods with field experiments.

Construct and criterion-related validation of nutrient profiling models: A systematic review of the literature

Nutrient profiling (NP) is defined as the science of ranking foods according to their nutritional composition for the purpose of preventing disease or promoting health. The application of NP is ultimately to assist consumers to make healthier food choices, and thus provide a cost effective public health strategy to reduce the incidence of diet-related chronic disease. To our knowledge, no review has assessed the evidence to confirm the validity of NP models. We conducted a systematic review to investigate the construct and criterion-related validity of NP models in ranking food according to their nutritional composition for the purpose of preventing disease and promoting health. We searched peer-reviewed research published to 30 June 2015 and used PUBMED, Global Health (CABI), and SCOPUS databases. Within study bias was assessed using an adapted version of the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies -2) tool for all diagnostic studies and the Cochrane Collaboration's Risk of Bias tool for all non-diagnostic studies. The GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach was used to guide our judgement of the quality of the body of evidence for each outcome measure. From a total of 83 studies, 69 confirmed the construct validity of NP models; however most of these studies contained methodological weaknesses. Six studies used objective external measures to confirm the criterion-related validity of NP models; which inherently improved quality. The overall quality of evidence on the accuracy of NP models was judged to be very low to moderate using the GRADE approach. Many carefully designed studies to establish both construct and criterion-related validity are necessary to authenticate the application of NP models and provide the evidence to support the current definition of NP.

The growing role of front-of-pack nutrition profile labeling: a consumer perspective on key issues and controversies

Nutrition-related diseases, such as some cancers, heart diseases, and obesity, belong to the most challenging health concerns of our time. Communicating intuitive and simple nutrition information by means of front-of-pack (FOP) nutrition profile signpost labeling is increasingly seen as an essential tool in efforts to combat unhealthy food choices and improve public health. Consequently, much attention in policy and research is given to nutrient profiling methods and the determination of optimal nutrition criteria. Although consumer research on nutrition signpost labeling is now gradually appearing in the literature, the value and meaning of these labeling systems for consumers have received less attention. In the current debate a concise overview is lacking of the consumer perspective, including relevant psychological phenomena, in relation to much debated controversies surrounding these labels and their further development, such as the most effective type of signpost labeling system and varying stakeholder interests. Therefore, this paper aims to critically review the literature in the consumer domain of FOP nutrition labeling in order to illustrate the strengths and weaknesses of this form of nutrition education from a consumer perspective.

The use of food composition data in the Choices International Programme

Food composition data have extensively been used in the Choices International Programme: they formed the basis of both criteria development and nutrient intake modeling. Criteria were developed for key nutrients linked to non communicable diseases by an independent scientific committee. The criteria can be used for the logo assignment on food products, in order to stimulate producers to improve their products and to stimulate consumers to purchase these products. Insights in steps of development of the criteria for the Choices program illustrates the importance of food composition data in this process. Modeling studies with the criteria for the Dutch Choices program showed an improved nutrient intake profile if consumers would choose products fulfilling the criteria of the Dutch logo as part of their diets. The role and availability of food composition databases in the development of the criteria and the modeling studies is discussed.

Smart food policies for obesity prevention

Prevention of obesity requires policies that work. In this Series paper, we propose a new way to understand how food policies could be made to work more effectively for obesity prevention. Our approach draws on evidence from a range of disciplines (psychology, economics, and public health nutrition) to develop a theory of change to understand how food policies work. We focus on one of the key determinants of obesity: diet. The evidence we review suggests that the interaction between human food preferences and the environment in which those preferences are learned, expressed, and reassessed has a central role. We identify four mechanisms through which food policies can affect diet: providing an enabling environment for learning of healthy preferences, overcoming barriers to the expression of healthy preferences, encouraging people to reassess existing unhealthy preferences at the point-of-purchase, and stimulating a food-systems response. We explore how actions in three specific policy areas (school settings, economic instruments, and nutrition labelling) work through these mechanisms, and draw implications for more effective policy design. We find that effective food-policy actions are those that lead to positive changes to food, social, and information environments and the systems that underpin them. Effective food-policy actions are tailored to the preference, behavioural, socioeconomic, and demographic characteristics of the people they seek to support, are designed to work through the mechanisms through which they have greatest effect, and are implemented as part of a combination of mutually reinforcing actions. Moving forward, priorities should include comprehensive policy actions that create an enabling environment for infants and children to learn healthy food preferences and targeted actions that enable disadvantaged populations to overcome barriers to meeting healthy preferences. Policy assessments should be carefully designed on the basis of a theory of change, using indicators of progress along the various pathways towards the long-term goal of reducing obesity rates.

Guiding healthier food choice: systematic comparison of four front-of-pack labelling systems and their effect on judgements of product healthiness

Different front-of-pack (FOP) labelling systems have been developed in Europe by industry and organisations concerned with health promotion. A study (n 2068) was performed to establish the extent to which inclusion of the most prevalent FOP systems--guideline daily amounts (GDA), traffic lights (TL), GDA+TL hybrid (HYB) and health logos (HL)--impact consumer perceptions of healthiness over and above the provision of a FOP basic label (BL) containing numerical nutritional information alone. The design included within- and between-subjects factors. The within-subjects factors were: food (pizzas, yogurts and biscuits), healthiness of the food (high health, medium health and low health) and the repeated measurements under BL and test FOP label conditions. The between-subjects factors were: the system (GDA, TL, GDA+TL hybrid, HL), portion size (typical portion size and a 50% reduction of a typical portion) and country (the UK, Germany, Poland and Turkey). Although the FOP systems tested did result in small improvements for objective understanding under some conditions, there was little difference between the provision of an FOP label containing basic numerical nutritional information alone or between the various systems. Thus, any structured and legible presentation of key nutrient and energy information on the FOP label is sufficient to enable consumers to detect a healthier alternative within a food category when provided with foods that have distinctly different levels of healthiness. Future research should focus on developing greater understanding of the psychological and contextual factors that impact motivation and the opportunity to use the various FOP systems in real-world shopping settings.

The Influence of Nutrition Labeling and Point-of-Purchase Information on Food Behaviours

Point-of-purchase information on packaged food has been a highly debated topic. Various types of nutrition labels and point-of-purchase information have been studied to determine their ability to attract consumers' attention, be well understood and promote healthy food choices. Country-specific regulatory and monitoring frameworks have been implemented to ensure reliability and accuracy of such information. However, the impact of such information on consumers' behaviour remains contentious. This review summarizes recent evidence on the real-world effectiveness of nutrition labels and point-of-purchase information.

Effects of interpretive front-of-pack nutrition labels on food purchases: protocol for the Starlight randomised controlled trial

Background

Interpretive front-of-pack nutrition labels are better understood than non-interpretive labels. However, robust evidence on the effects of such labels on consumer food purchases in the real-world is lacking. Our aim is to assess the effects of two interpretive front-of-pack nutrition labels, compared with a non-interpretive label, on the healthiness of consumer food purchases.

Methods/Design

A five-week (1-week baseline and 4-week intervention) three-arm parallel randomised controlled trial will be conducted using a bespoke smartphone application, which will administer study questionnaires and deliver intervention (Multiple Traffic Light and Health Star Rating) and control (Nutrition Information Panel) labels. To view their allocated nutrition label, participants scan the barcode of packaged food products using their smartphone camera. The assigned label is displayed instantly on the smartphone screen.1500 eligible participants (New Zealand adult smartphone owners who shop in a supermarket at least once a week and are main household shoppers) will be randomised in a 1:1:1 ratio to one of the three nutrition label formats, using computer-generated randomisation sequences. Randomisation will be stratified by ethnicity and interest in healthy eating. Food and beverage purchase data will be collected continuously throughout the study via hard copy till receipts and electronic grocery purchase lists recorded and transmitted using the smartphone application. The primary outcome will be healthiness of food purchases in each trial arm, assessed as mean Food Standards Australia New Zealand nutrient profiling score criterion score for all food and beverages purchased over the intervention period. Secondary outcomes will include saturated fat, sugar, sodium and energy content of food purchases; food expenditure; labelling profile of food purchases (i.e. mean number of Health Star Rating stars and proportion of red, green and amber traffic lights); nutrient profiling score over time and by food categories; purchases of unpackaged foods; self-reported nutrition knowledge and recorded use of assigned labelling system.

Discussion

The Starlight randomised, controlled trial will determine the effects of interpretive front-of-pack nutrition labels on the healthiness of consumer food purchases in the real world.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12614000644662 (registered 18 June 2014).

Does nutrition information on menus impact food choice? Comparisons across two hospital cafeterias

OBJECTIVE

Food prepared and consumed away from home accounts for a significant proportion of dietary intake among Canadians. Currently, Canadians receive little or no nutrition information when eating in restaurant and fast-food outlets. The present study examined the impact of nutrition information on menus in hospital cafeterias on noticing and perceived influence of nutrition information and on food consumption.

DESIGN

Cross-sectional surveys.

SETTING

Exit surveys (n 1003) were conducted in two hospital cafeterias. The 'intervention' site featured energy (calorie), sodium and fat content on digital menu boards, as well as a health logo for 'healthier' items. The intervention site had also revised its menu items to improve the nutrient profiles. The 'control' site provided limited nutrition information at the point of sale.

SUBJECTS

Cafeteria patrons recruited using the intercept technique.

RESULTS

Significantly more respondents at the intervention site reported noticing nutrition information (OR = 7·6, P < 0·001) and using nutrition information to select their food items (OR = 3·3, P < 0·001) compared with patrons at the control site, after adjusting for sociodemographic factors. Patrons at the intervention site consumed significantly less energy (-21 %, P < 0·001), sodium (-23 %, P < 0·001), saturated fat (-33 %, P < 0·001) and total fat (-37 %, P < 0·001) than patrons at the control site.

CONCLUSIONS

A nutritional programme, including nutrition information on menus and improved nutrition profile of food offerings, was associated with substantial reductions in energy, sodium and fat consumption. The results are consistent with a positive impact of menu labelling.

Hands4U: the effectiveness of a multifaceted implementation strategy on behaviour related to the prevention of hand eczema-a randomised controlled trial among healthcare workers

Objectives

To investigate the effects of a multifaceted implementation strategy on behaviour, behavioural determinants, knowledge and awareness of healthcare workers regarding the use of recommendations to prevent hand eczema.

Methods

The Hands4U study is a randomised controlled trial. A total of 48 departments (n=1649 workers) were randomly allocated to the multifaceted implementation strategy or the control group (minimal implementation strategy). Within the departments designated to the multifaceted implementation strategy, participatory working groups were set up to enhance the implementation of the recommendations for hand eczema. In addition, working group members were trained to become role models, and an education session was given within the department. Outcome measures were awareness, knowledge, receiving information, behaviour and behavioural determinants. Data were collected at baseline, with a 3- and 6-month follow-up.

Results

Statistically significant effects were found after 6 months for awareness (OR 6.30; 95% CI 3.41 to 11.63), knowledge (B 0.74; 95% CI 0.54 to 0.95), receiving information (OR 9.81; 95% CI 5.60 to 17.18), washing hands (B −0.40; 95% −0.51 to −0.29), use of moisturiser (B 0.29; 95% CI 0.20 to 0.38), cotton under gloves (OR 3.94; 95% CI 2.04 to 7.60) and the overall compliance measure (B 0.14; 95% CI 0.02 to 0.26), as a result of the multifaceted implementation strategy. No effects were found for behavioural determinants.

Conclusions

The multifaceted implementation strategy can be used in healthcare settings to enhance the implementation of recommendations for the prevention of hand eczema.

Trial registration number

NTR2812.

Choosing healthier foods in recreational sports settings: a mixed methods investigation of the impact of nudging and an economic incentive

BACKGROUND

Nudging is an approach to environmental change that alters social and physical environments to shift behaviors in positive, self-interested directions. Evidence indicates that eating is largely an automatic behavior governed by environmental cues, suggesting that it might be possible to nudge healthier dietary behaviors. This study assessed the comparative and additive efficacy of two nudges and an economic incentive in supporting healthy food purchases by patrons at a recreational swimming pool.

METHODS

An initial pre-intervention period was followed by three successive and additive interventions that promoted sales of healthy items through: signage, taste testing, and 30% price reductions; concluding with a return to baseline conditions. Each period was 8 days in length. The primary outcome was the change in the proportion of healthy items sold in the intervention periods relative to pre- and post-intervention in the full sample, and in a subsample of patrons whose purchases were directly observed. Secondary outcomes included change in the caloric value of purchases, change in revenues and gross profits, and qualitative process observations. Data were analyzed using analysis of covariance, chi-square tests and thematic content analysis.

RESULTS

Healthy items represented 41% of sales and were significantly lower than sales of unhealthy items (p < 0.0001). In the full sample, sales of healthy items did not differ across periods, whereas in the subsample, sales of healthy items increased by 30% when a signage + taste testing intervention was implemented (p < 0.01). This increase was maintained when prices of healthy items were reduced by 30%, and when all interventions were removed. When adults were alone they purchased more healthy items compared to when children were present during food purchases (p < 0.001), however parental choices were not substantially better than choices made by children alone.

CONCLUSIONS

This study found mixed evidence for the efficacy of nudging in cueing healthier dietary behaviors. Moreover, price reductions appeared ineffectual in this setting. Our findings point to complex, context-specific patterns of effectiveness and suggest that nudging should not supplant the use of other strategies that have proven to promote healthier dietary behaviors.

Effectiveness of offering healthy labelled meals in improving the nutritional quality of lunch meals eaten in a worksite canteen

Healthier meal selections at restaurants and canteens are often limited and not actively promoted. In this Danish study the effectiveness of a healthy labelling certification program in improving dietary intake and influencing edible plate waste was evaluated in a quasi-experimental study design. Employees from an intervention worksite canteen and a matched control canteen were included in the study at baseline (February 2012), after completing the certification process (end-point) and six month from end-point (follow-up) (total n=270). In order to estimate nutrient composition of the consumed lunch meals and plate waste a validated digital photographic method was used combining estimation of food intake with food nutrient composition data. Food satisfaction was rated by participants using a questionnaire. Several significant positive nutritional effects were observed at the intervention canteen including a mean decrease in energy density in the consumed meals from 561kJ/100g at baseline to 368 and 407kJ/100g at end-point and follow-up, respectively (P<0.001). No significant changes were seen with regard to food satisfaction and plate waste. In the control canteen no positive nutritional effects were observed. The results of the study highlight the potential of using healthy labelling certification programs as a possible driver for increasing both the availability and awareness of healthy meal choices, thereby improving dietary intake when eating out.

A traffic light food labeling intervention increases consumer awareness of health and healthy choices at the point-of-purchase

OBJECTIVE

We surveyed customers in a hospital cafeteria in Boston, Massachusetts before and after implementation of traffic light food labeling to determine the effect of labels on customers' awareness and purchase of healthy foods.

METHODS

Cafeteria items were identified as red (unhealthy), yellow (less healthy), or green (healthy). Customers were interviewed before (N=166) and after (N=223) labeling was implemented. Each respondent was linked to cash register data to determine the proportion of red, yellow, and green items purchased. Data were collected from February-April 2010. We compared responses to survey questions and mean proportion of red, yellow, and green items per transaction between customers interviewed during baseline and customers interviewed during the intervention. Survey response rate was 60%.

RESULTS

Comparing responses during labeling intervention to baseline, more respondents identified health/nutrition as an important factor in their purchase (61% vs. 46%, p=0.004) and reported looking at nutrition information (33% vs. 15%, p<0.001). Respondents who noticed labels during the intervention and reported that labels influenced their purchases were more likely to purchase healthier items than respondents who did not notice labels (p<0.001 for both).

CONCLUSION

Traffic light food labels prompted individuals to consider their health and to make healthier choices at point-of-purchase.