Small prizes increased healthful school lunch selection in a Midwestern school district

A Randomized Controlled Trial Comparing Loss versus Gain Incentives to Improve Adherence to an Obesity Treatment Intervention in Adolescents

BACKGROUND/OBJECTIVES

Adherence to pediatric obesity treatment can be challenging. Monetary incentives improve adherence to lifestyle interventions, with incentives framed as loss often more effective than those framed as gain. The objectives of this study were to determine if monetary incentives in the form of gift cards would improve adherence to an obesity treatment intervention and whether framing the incentive as either loss or gain affected adherence.

METHODS

Sixty adolescents with obesity (body mass index of ≥95th percentile for age and sex) were recruited from our pediatric obesity treatment program. They were randomized into one of three groups and given a monthly adherence score (AS) of up to 100 points. These points were based on completing a medical visit, reporting on diet intake, and measuring daily steps on a wearable tracker. The Gain Group (GG), N = 20, started each month with USD 0 in a virtual account and increased their monetary reward up to USD 100 depending on AS. The Loss Group (LG), N = 21, began each month with USD 100 in their virtual account, which decreased based on adherence. The Control Group (CG), N = 19, received USD 10 monthly.

RESULTS

Adherence was highest in the GG, with 66.0 points, compared to the LG, with 54.9 points, and CG, with 40.6 points, with p < 0.01. The GG had greater adherence to their step goal (14.6) and dietary reporting (18.7) compared to the LG (10.0 and 13.9) and the CG (3.9 and 8.1), p < 0.005.

CONCLUSIONS

Gain-framed incentives are superior to loss-framed ones in improving adherence to pediatric obesity treatments.

Behavioral Economics: A Primer and Applications to the UN Sustainable Development Goal of Good Health and Well-Being

Behavioral economics (BE) is a relatively new field within economics that incorporates insights from psychology that can be harnessed to improve economic decision making with the potential to enhance good health and well-being of individuals and societies, the third of the United Nations Sustainable Development Goals. While some of the psychological principles of economic decision making were described as far back as the 1700s by Adam Smith, BE emerged as a discipline in the 1970s with the groundbreaking work of psychologists Daniel Kahneman and Amos Tversky. We describe the basic concepts of BE, heuristics (decision-making shortcuts) and their associated biases, and the BE strategies framing, incentives, and economic nudging to overcome these biases. We survey the literature to identify how BE techniques have been employed to improve individual choice (focusing on childhood obesity), health policy, and patient and healthcare provider decision making. Additionally, we discuss how these BE-based efforts to improve health-related decision making can lead to sustaining good health and well-being and identify additional health-related areas that may benefit from including principles of BE in decision making.

A Community Bundle to Lower School-Aged Obesity Rates in a Small Midwestern City

Background: Multi-component interventions in large communities such as Philadelphia can effectively lower childhood obesity rates. It is less clear whether this type of intervention can be successful in smaller communities with more limited resources. Norwood, Ohio is a small Midwestern city with a population of 19,207. In 2010, Ohio passed a school health law requiring Body Mass Index (BMI) screening of students in kindergarten and grades 3, 5 and 9 along with restrictions on competitive foods and vending machine products and a physical education requirement of 30 min per day. In 2014, Norwood implemented a multi-component childhood obesity prevention and treatment bundle of interventions. Our objective was to describe the effects if this bundle on childhood overweight/obesity (OW/OB) rates. We hypothesized that implementation of the bundle would lower the prevalence of OW/OB in Norwood school children. Methods: In 2012, the Healthy Kids Ohio Act was fully implemented in the Norwood City School District (NCSD). In 2014 a comprehensive bundle was implemented that included: 1. A student gardening program; 2. Supplementation of fresh produce to a local food pantry and a family shelter; 3. A farmers market; 4. A health newsletter; 5. Incentives in the school cafeterias to promote healthy food selection; 6. A 100-mile walking club; 7. “Cook for America” (a “cooked from scratch” intervention for school cafeterias); 8. A school-based obesity treatment clinic; Results: The OW/OB rate in the NCSD was 43% at the time of the Bundle implementation in 2014 and 37% in 2016 (p = 0.029). Conclusions: A childhood OW/OB prevention bundle can be implemented in a small city and is associated with a favorable change in BMI.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

Healthier Choices in School Cafeterias: A Systematic Review of Cafeteria Interventions

OBJECTIVE

To describe school cafeteria interventions in terms of a behavioral economics scheme and to assess which system is more likely to be effective in improving food selection or consumption.

STUDY DESIGN

With this systematic review, we categorize cafeteria interventions using the behavioral economics theory of Kahneman into system 1 (fast and intuitive thinking) and system 2 (slow and cognitively demanding) or mixed (having elements of system 1 and system 2). Pertinent studies were identified from review of the literature of interventions performed in school and cafeteria settings in children grades K-12 within the past 5 years (2012-2017) at time of search.

RESULTS

In all, 48 of 978 studies met inclusion criteria. By defining success as a 30% improvement in a desired outcome or statistically significant reduction in body mass index, 89% of system 1, 67% of mixed (had both system 1 and 2 elements), and only 33% of system 2 interventions were successful.

CONCLUSIONS

This review found successful system 1 type school cafeteria interventions to be more common than system 2 type interventions and system 2 type interventions are less effective than system 1.

Variation in Nutritional Quality of School Lunches With Implementation of National School Lunch Program Guidelines

BACKGROUND

School lunches must meet National School Lunch Program (NSLP) requirements to receive reimbursement. In this study, we sought to determine whether there are significant differences in nutrient content and nutritional quality between 2 menus meeting NSLP requirements.

METHODS

A cross-sectional content analysis compared 6 weeks of a typical school lunch menu (TM) from an actual school district to a best practice school lunch menu (BPM) created by a registered dietitian based on Child and Adult Care Food Program (CACFP) best practices and Dietary Guidelines for Americans (DGA) healthy meal pattern recommendations. Daily nutrient content was determined using nutrient analysis software. Nutritional quality was computed using Healthy Eating Index (HEI) 2010.

RESULTS

For nutrients required for analysis, the BPM was lower in calories, saturated fat, and sodium and higher in protein, carbohydrate, and fiber (ps < .01). For other nutrients of concern, the BPM was higher in vitamin A, vitamin D, phosphorus, and magnesium (ps < .01). The BPM had higher HEI scores for nutritional quality (p < .001).

CONCLUSIONS

Results indicate the possibility for significant variation in nutritional quality of NSLP-qualifying lunches. Using CACFP best practices and DGA recommendations may significantly impact school lunch dietary quality.