Impact of increasing the proportion of healthier foods available on energy purchased in worksite cafeterias: A stepped wedge randomized controlled pilot trial

The impact of introducing alcohol-free beer options in bars and public houses on alcohol sales and revenue: A randomised crossover field trial

AIMS

The study aimed to estimate the impact of introducing a draught alcohol-free beer, thereby increasing the relative availability of these products, on alcohol sales and monetary takings in bars and pubs in England.

DESIGN

Randomised crossover field trial.

SETTING

England.

PARTICIPANTS

Fourteen venues that did not previously sell draught alcohol-free beer.

INTERVENTION AND COMPARATOR

Venues completed two intervention periods and two control periods in a randomised order over 8 weeks. Intervention periods involved replacing one draught alcoholic beer with an alcohol-free beer. Control periods operated business as usual.

MEASUREMENTS

The primary outcome was mean weekly volume (in litres) of draught alcoholic beer sold. The secondary outcome was mean weekly revenue [in GBP (£)] from all drinks. Analyses adjusted for randomised order, special events, season and busyness.

FINDINGS

The adjusted mean difference in weekly sales of draught alcoholic beer was -20 L [95% confidence interval (CI) = -41 to +0.4], equivalent to a 4% reduction (95% CI = 8% reduction to 0.1% increase) in the volume of alcoholic draught beer sold when draught alcohol-free beer was available. Excluding venues that failed at least one fidelity check resulted in an adjusted mean difference of -29 L per week (95% CI = -53 to -5), equivalent to a 5% reduction (95% CI = 8% reduction to 0.8% reduction). The adjusted mean difference in weekly revenue was +61 GBP per week (95% CI = -328 to +450), equivalent to a 1% increase (95% CI = 5% decrease to 7% increase) when draught alcohol-free beer was available.

CONCLUSIONS

Introducing a draught alcohol-free beer in bars and pubs in England reduced the volume of draught alcoholic beer sold by 4% to 5%, with no evidence of the intervention impacting net revenue.

Health Promotion and Chronic Disease Prevention at the Workplace

The concept of workplace safety and health has focused largely on preventing accidents and on minimizing hazardous exposures. However, because workers spend a substantial part of their waking hours at the workplace, the potential to influence the health of a large proportion of the world's population through the workplace is enormous. The opportunities to carry out health promotion and chronic disease prevention activities at the workplace are countless, including (a) health screening; (b) tobacco cessation activities; (c) the promotion of healthy food choices and weight loss; (d) active breaks with physical exercise in terms of microexercise, enhancement of infrastructure to stimulate physical activity, and organization of work tasks to facilitate incidental physical activity; and (e) routine vaccinations. This review discusses the key factors necessary to implement health promotion and chronic disease prevention programs at the workplace (SWOLE model) and discusses the different foci and possibilities with respect to the differing nature of work for the blue- versus white-collar workforce.

Simple dietary substitutions can reduce carbon footprints and improve dietary quality across diverse segments of the US population

Changing what foods we eat could reduce environmental harms and improve human health, but sweeping dietary change is challenging. We used dietary intake data from a nationally representative sample of 7,753 US children and adults to identify simple, actionable dietary substitutions from higher- to lower-carbon foods (for example, substituting chicken for beef in mixed dishes such as burritos, but making no other changes to the diet). We simulated the potential impact of these substitutions on dietary carbon emissions and dietary quality. If all consumers who ate the high-carbon foods instead consumed a lower-carbon substitute, the total dietary carbon footprint in the United States would be reduced by more than 35%. Moreover, if adopted, these substitutions would improve consumers' overall dietary quality by 4-10%, with benefits projected for all age, gender, and racial and ethnic groups. These results suggest that a 'small changes' approach could be a valuable starting point for addressing diet's impact on climate and health.

How to enable healthier and more sustainable food practices in collective meal contexts: A scoping review

Collective meal contexts such as restaurants, cafeterias and canteens can help accelerate transitions to healthier and more sustainable diets. However, evidence from intervention studies on these contexts lacks integration. This scoping review aimed to map determinants of dietary change in collective meal contexts across multiple settings, interventions, target groups, and target behaviors. The review provided two main outcomes: (i) identifying intervention components to promote dietary change in collective meal contexts, based on the existing body of evidence; and (ii) classifying and integrating these intervention components into an overarching framework of behavior change (i.e., COM-B system). The review encompassed twenty-eight databases via two indexing services and extracted information from 232 primary sources (27,458 records selected for title and abstract screening, 574 articles selected for full-text screening). We identified a total of 653 intervention activities, which were classified into intervention components and grouped under three broad themes, namely contextual and environmental changes, social influence, and knowledge and behavioral regulation. Multi-component interventions tended to report overall positive outcomes. The review proposes several directions for future research, including: (i) moving toward more theory-based interventions in collective meal contexts; (ii) providing more detailed information about intervention settings, implementation, target groups, activities, and materials; and (iii) improving the use of open science practices in the field. Furthermore, the review offers a free, original, open-access list and synthesis of 277 intervention studies in collective meal contexts, which can help intervention planners and evaluators optimize their efforts to promote healthier and more sustainable food practices in these contexts.

Environmental intervention in a university canteen with focus on decision guidance: An evaluation study regarding food consumption, nutrient intake, perception, and satisfaction by canteen users

Background

An environmental intervention with focus on Decision Guidance was implemented in a university canteen. It comprised the offer of a health promoting food option (HPFO), including a health promoting lunch option and health promoting snacks.

Design and methods

Possible changes of food consumption and nutrient intake of student canteen users (substudy A), perception of the HPFO by canteen users (substudy B.1), and possible changes of their satisfaction regarding the canteen (substudy B.2) at least 10 weeks after the start of the intervention were examined. Substudy A used a controlled pretest-posttest-design (paired sample). The students were assigned to intervention group (canteen visits ≥ once/week, n = 27) or control group (canteen visits < once/week, n = 39). Substudy B.1 used a cross-sectional design, and substudy B.2 a pretest-posttest-design (paired sample). Only canteen users (≥once/week) were included (substudy B.1 n = 89, substudy B.2 n = 30).

Results

Food consumption and nutrient intake did not change (p > 0.05) in the intervention group versus control group (substudy A). In substudy B.1 canteen users were aware of the HPFO, appreciated it highly, and were satisfied with it. In substudy B.2 canteen users were at posttest more satisfied regarding service and health value of offered lunches (p < 0.05).

Conclusions

Although the HPFO was positively percepted, no effects on the daily diet were observed. The offered proportion of the HPFO should be increased.

The impact of increasing the availability of lower energy foods for home delivery and socio-economic position: a randomised control trial examining effects on meal energy intake and later energy intake

Increasing the availability of lower energy food options is a promising public health approach. However, it is unclear the extent to which availability interventions may result in consumers later 'compensating' for reductions in energy intake caused by selecting lower energy food options and to what extent these effects may differ based on socio-economic position (SEP). Our objective was to examine the impact of increasing availability of lower energy meal options on immediate meal energy intake and subsequent energy intake in participants of higher v. lower SEP. In a within-subjects design, seventy-seven UK adults ordered meals from a supermarket ready meal menu with standard (30 %) and increased (70 %) availability of lower energy options. The meals were delivered to be consumed at home, with meal intake measured using the Digital Photography of Foods Method. Post-meal compensation was measured using food diaries to determine self-reported energy intake after the meal and the next day. Participants consumed significantly less energy (196 kcal (820 kJ), 95 % CI 138, 252) from the menu with increased availability of lower energy options v. the standard availability menu (P < 0·001). There was no statistically significant evidence that this reduction in energy intake was substantially compensated for (33 % compensated, P = 0·57). The effects of increasing availability of lower energy food items were similar in participants from lower and higher SEP. Increasing the availability of lower energy food options is likely to be an effective and equitable approach to reducing energy intake which may contribute to improving diet and population health.

Explaining the effect on food selection of altering availability: two experimental studies on the role of relative preferences

BACKGROUND

Increasing the availability of healthier or plant-based foods increases their selection. The current studies aimed to examine the extent to which relative preferences account for food selections following availability interventions. In particular, (a) whether increasing the availability of lower-energy options increases the likelihood that individuals' highest-ranked option is lower-energy, and (b) the extent to which selections reflect individuals' highest-ranked option from the available range.

METHODS

UK adults (Study 1: n = 1976; Study 2: n = 1078) took part in within-subjects online studies. In both studies, the order of preference between food options was established by participants choosing the option that they would prefer "to eat right now" from every possible pairing within a pool of eight options. Then, participants were shown either predominantly higher-energy options (three higher- and one lower-energy) or predominantly lower-energy options (vice versa), presented in a random order.

RESULTS

When predominantly lower-energy options were presented, the odds of the highest-ranked option being a lower-energy option increased ten-fold (Study 1: odds ratio: 10.1; 95%CI: 8.9,11.4; Study 2: odds ratio: 10.4; 95%CI: 7.4,14.7), compared to when predominantly higher-energy options were available. In both studies, around 90% of selections reflected the highest-ranked option in the range offered in the studied availability conditions (range 88-92%).

CONCLUSIONS

These studies suggest that increased availability of lower-energy options increases the likelihood of an individual's highest-ranked option being lower-energy, and that the highest-ranked option has the greatest likelihood of selection. As such, preferences may be a key contributor to the effects of altering availability on food selections.

TRIAL REGISTRATION

ISRCTN ( http://www.isrctn.com/ISRCTN27598623 ; 3/12/19 [Study 1]; http://www.isrctn.com/ISRCTN61010183 ; 20/4/20 [Study 2]).

Work site food purchases among healthcare staff: Relationship with healthy eating and opportunities for intervention

Aim

The current study describes food‐purchasing behaviours of healthcare staff, determines whether purchasing food at work is associated with overall indicators of healthy eating, and explores opportunities for improving the hospital food environment.

Methods

A secondary analysis of a health and wellbeing survey of healthcare workers (n = 501) in Queensland, Australia. Multiple regression models describe the associations between food purchases and indicators of healthy eating, while controlling for age, gender and work role.

Results

More than 60% of staff purchased food/drinks at work in the past week, and this was inversely associated with indicators of healthy eating. For example, among those purchasing food/drinks at work on most days, only 18% reported their overall diet as excellent or very good, compared to 50% of those who do not purchase food/drink at work (odds ratio [OR] = 0.24; 95% confidence interval [CI] = [0.12,0.48] in adjusted models). Staff feedback prioritised strategies to make healthy meals more accessible and affordable.

Conclusion

Improvements to the retail food environment in hospitals could have a positive impact on the overall nutritional wellbeing of staff.

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.

Impact of altering the available food options on selection: Potential mediation by social norms

Increasing the availability of lower-energy foods increases their selection. The current studies examine the extent to which this effect could be mediated by social norms - assessed by perceived popularity of foods - which may be implied by their relative availability. Study 1 (Online): 2340 UK adults estimated the perceived popularity of products. Participants were randomised to see photos of cafeteria shelves varying in the availability of lower-energy options (1/4 lower-energy; 1/2 lower-energy; 3/4 lower-energy) and fullness of shelves (fuller; emptier). Study 2 (Laboratory): 139 English adults were asked to select a snack. Participants were randomised to select from trays varying in the availability of the lower-energy option (1/3 lower-energy; 2/3 lower-energy) and fullness of tray (fuller; emptier). In Study 1, evidence for an interaction was found, such that when shelves were fuller, a higher proportion of lower-energy options led to greater perceived popularity of lower-energy products (1/4 lower-energy: 40.9% (95%CIs: 40.1,41.8); 3/4 lower-energy: 47.2% (46.3,48.0)), whereas when shelves were emptier, a higher proportion of lower-energy options led to lower perceived popularity (1/4 lower-energy: 48.4% (47.5,49.2); 3/4 lower-energy: 39.2% (38.3,40.0)). In Study 2, when the tray was fuller, participants were more likely - albeit non-significantly - to select a lower-energy snack when 2/3 of the available snacks were lower-energy (35.7% (18.5,52.9)) than when 1/3 were lower-energy (15.4% (4.2,26.5)). For emptier trays, lower-energy selections decreased as the relative availability of lower-energy snacks increased (1/3 lower-energy snacks: 36.0% (17.9,54.1); 2/3 lower-energy snacks: 27.8% (13.9,41.7)). These studies provide novel evidence that social norms may mediate the impact of availability on food selection. In addition, they suggest that the effect of availability may be moderated by display layout through its impact on perceived product popularity.

Impact of decreasing the proportion of higher energy foods and reducing portion sizes on food purchased in worksite cafeterias: A stepped-wedge randomised controlled trial

BACKGROUND

Overconsumption of energy from food is a major contributor to the high rates of overweight and obesity in many populations. There is growing evidence that interventions that target the food environment may be effective at reducing energy intake. The current study aimed to estimate the effect of decreasing the proportion of higher energy (kcal) foods, with and without reducing portion size, on energy purchased in worksite cafeterias.

METHODS AND FINDINGS

This stepped-wedge randomised controlled trial (RCT) evaluated 2 interventions: (i) availability: replacing higher energy products with lower energy products; and (ii) size: reducing the portion size of higher energy products. A total of 19 cafeterias were randomised to the order in which they introduced the 2 interventions. Availability was implemented first and maintained. Size was added to the availability intervention. Intervention categories included main meals, sides, cold drinks, snacks, and desserts. The study setting was worksite cafeterias located in distribution centres for a major United Kingdom supermarket and lasted for 25 weeks (May to November 2019). These cafeterias were used by 20,327 employees, mainly (96%) in manual occupations. The primary outcome was total energy (kcal) purchased from intervention categories per day. The secondary outcomes were energy (kcal) purchased from nonintervention categories per day, total energy purchased per day, and revenue. Regression models showed an overall reduction in energy purchased from intervention categories of -4.8% (95% CI -7.0% to -2.7%), p < 0.001 during the availability intervention period and a reduction of -11.5% (95% CI -13.7% to -9.3%), p < 0.001 during the availability plus size intervention period, relative to the baseline. There was a reduction in energy purchased of -6.6% (95% CI -7.9% to -5.4%), p < 0.001 during the availability plus size period, relative to availability alone. Study limitations include using energy purchased as the primary outcome (and not energy consumed) and the availability only of transaction-level sales data per site (and not individual-level data).

CONCLUSIONS

Decreasing the proportion of higher energy foods in cafeterias reduced the energy purchased. Decreasing portion sizes reduced this further. These interventions, particularly in combination, may be effective as part of broader strategies to reduce overconsumption of energy from food in out-of-home settings.

TRIAL REGISTRATION

ISRCTN registry ISRCTN87225572.

Increasing availability of lower energy meals vs. energy labelling in virtual full-service restaurants: two randomized controlled trials in participants of higher and lower socioeconomic position

Background

There are a range of interventions designed to promote healthier food choices in full-service restaurants. However, it is unclear how these interventions affect dietary choices in people of lower and higher socioeconomic position (SEP).

Methods

A total of 2091 US participants recruited online completed Study 1 (n = 1001) and Study 2 (n = 1090). Recruitment was stratified by participant highest education level, resulting in higher SEP and lower SEP groups. In a between-subjects design, participants made hypothetical food choices (main dish, plus optional sides and desserts) from six restaurants menus in the absence vs. presence of menu energy labelling and from menus with baseline (10%) vs. increased availability (50%) of lower energy main dishes. Data were collected and analysed in 2019. Two studies were conducted in order to examine replicability and generalisability of findings across different restaurant menu types.

Results

Across both studies, increasing the availability of lower energy main menu options decreased the average energy content of the ordered main dish (− 129 kcal, 95% CI [− 139; − 119]) and total energy ordered (− 117 kcal, 95% CI [− 138; − 95]) in both higher and lower SEP participants. Energy labelling significantly reduced the energy content of ordered main dishes in higher SEP participants (− 41 kcal, 95% CI [− 54; − 29]), but not lower SEP participants (− 5 kcal, 95% CI [− 22; 11]). However, energy labelling reduced total energy ordered (− 83 kcal, 95% CI [− 105; − 60]) irrespective of SEP.

Conclusions

In two virtual experiments, increasing the availability of lower energy restaurant main menu options impacted on main menu dish choice and decreased total energy ordered irrespective of SEP. Energy labelling had a less pronounced effect on total energy ordered and had a larger impact on the energy content of main menu dish choice in higher as opposed to lower SEP participants.

Trial registration

Clinicaltrials.gov NCT04336540 retrospectively registered (7 April, 2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11007-0.

Creating supportive eating places: a systematic review of food service initiatives

Obesity and diet-related health problems are complex, multi-factorial issues. Individual food choices are shaped by the wider context, and food environment level change is needed to support individual behaviour change. The food service sector can play an integral role, changing aspects of the food environment and contributing to improved consumer health. This systematic review aimed to analyse food service schemes that aimed to improve consumer health. Ten electronic databases were systematically searched to identify articles, supplemented with checking of reference lists from similar reviews and forward and backward searches to identify articles describing food service sector schemes. Sixteen schemes were identified, documented in 36 articles/reports. The schemes aimed to improve consumer health through one of three approaches-informing, enabling or engineering. In this order, these approaches involved increasing levels of effort from food services, corresponding with decreasing levels of effort for consumers. Half the schemes were informing, relying on an informed consumer to make a healthy choice. Most informing schemes had been evaluated to determine their impact on consumer choice and/or health, the evidence showed these schemes were generally ineffective. The effect of the enabling or engineering schemes on consumer choice and health had not been measured. Instead, evaluations focussed on process or business engagement rather than behavioural change assessments. This review indicates the food sector has the potential to contribute to consumer health through enabling and engineering; however, detailed outcome assessments are needed to draw definitive conclusions.

Are meat options preferred to comparable vegetarian options? An experimental study

OBJECTIVE

Reducing meat consumption would have substantial benefits both in terms of health and environmental impact, but meat options may be more attractive to customers than meat-free options. This study tested this by presenting UK adults (n = 540) with a series of pictures showing two meal options and asking them to select which they would prefer to eat right now. They completed this task for every possible pair from a pool of six comparator meat-based options and six target options (66 pairs). Participants all saw identical comparator options, and were randomised to see the same pictures of target options but with descriptions that suggested they were either meat-based or vegetarian.

RESULTS

Selections were used to rank the options for each individual from 1 (most-selected) to 12 (least-selected). Vegetarian target options were ranked worse [by 1.23 places (95% CI: 1.02, 1.44)] than meat target options. Higher self-reported consumption of meat predicted worse mean rankings of target options when these were vegetarian, but not when target options were meat-based. This suggests meat options are preferred to equivalent vegetarian options and may be more likely to be selected. This has implications for interventions aiming to reduce meat consumption to make diets healthier and more sustainable.

Impact of health warning labels on snack selection: An online experimental study

Excessive consumption of energy-dense food increases the risk of obesity, which in turn increases the risk of non-communicable diseases, including heart disease, type 2 diabetes and most non-smoking-related cancers. Health warning labels (HWLs) that communicate the adverse health consequences of excess energy consumption could reduce intake of energy-dense foods. The aim of the current study was to estimate the impact on selection of energy-dense snacks of (a) image-and-text HWLs (b) text-only HWLs and (c) calorie information. In a between-subjects, 3 (HWL: image-and-text, text-only, no label) x 2 (calorie information: present, absent), factorial experimental design, participants (N = 4134) were randomised to view a selection of energy-dense and non-energy-dense snacks with one of five label types or no label. The primary outcome was the proportion of participants selecting an energy-dense snack in a hypothetical vending machine task. The proportion of participants selecting an energy-dense snack was reduced in all label groups, relative to the no label group (no label: 59%; calories only: 54%; text-only HWL: 48%; text-only HWL with calories: 44%; image-and-text HWL: 37%; image-and-text HWL with calories: 38%). Compared to the no label group, participants were least likely to select an energy-dense snack in the image-and-text HWL group (OR = 0.46, 95%CI = 0.40, 0.54, p < 0.001). Health warning labels - particularly those including an image and text - have the potential to reduce selection of energy-dense snacks in an online setting. Their impact on selection and consumption in real-world settings awaits testing.

Communicating evidence about the environment's role in obesity and support for government policies to tackle obesity: a systematic review with meta-analysis

Public support for many policies that tackle obesity by changing environments is low. This may reflect commonly held causal beliefs about obesity, namely that it is due to failures of self-control rather than environmental influences. Several studies have sought to increase public support by changing these and similar causal beliefs, with mixed results. The current review is the first systematic synthesis of these studies. Searches of PsycInfo, Medline, Web of Science, Scopus, and Open Grey yielded 20 eligible studies (N = 8977) from 11,776 abstracts. Eligible studies were controlled experiments with an intervention group that communicated information about the environment’s role in obesity, and a measure of support for environment-based obesity policies. The protocol was prospectively registered on PROSPERO. Meta-analyses showed no evidence that communicating information about the environment’s influence on obesity changed policy support or the belief that the environment influences obesity. A likely explanation for this null effect is the ineffectiveness of interventions that were designed to change the belief that the environment influences obesity. The possibility remains, however, that the association observed between beliefs about the causes of obesity and attitudes towards obesity policies is correlational and not causal.

Design, rationale and analysis plan for the Stand Up for Health trial in contact centres: a stepped wedge feasibility study

Background

Contact centres are one of the most sedentary workplaces, with employees spending a very high proportion of their working day sitting down. About a quarter of contact centre staff regularly experience musculoskeletal health problems due to high levels of sedentary behaviour, including lower back pain. There have been no previous randomised studies specifically aiming to reduce sedentary behaviour in contact centre staff. To address this gap, the Stand Up for Health (SUH) study aims to test the feasibility and acceptability of a complex theory-based intervention to reduce sedentary behaviour in contact centres.

Methods

The Stand Up for Health study has a stepped wedge cluster randomised trial design, which is a pragmatic design whereby clusters (contact centres) are randomised to time points at which they will begin to receive the intervention. All contact centre staff have the opportunity to experience the intervention. To minimise the resource burden in this feasibility study, data collection is not continuous, but undertaken on a selective number of occasions, so the stepped wedge design is “incomplete”. Eleven contact centres in England and Scotland have been recruited, and the sample size is approximately 27 per centre (270 in total). The statistical analysis will predominantly focus on assessing feasibility, including the calculation of recruitment rates and rates of attrition. Exploratory analysis will be performed to compare objectively measured sedentary time in the workplace (measured using an activPAL™ device) between intervention and control conditions using a linear mixed effects regression model.

Discussion

To our knowledge, this is the first stepped wedge feasibility study conducted in call centres. The rationale and justification of our novel staircase stepped wedge design has been presented, and we hope that by presenting our study design and statistical analysis plan, it will contribute to the literature on stepped wedge trials, and in particular feasibility stepped wedge trials. The findings of the study will also help inform whether this is a suitable design for other settings where data collection is challenging.

Trial registration

The trial has been registered on the ISRCTN database: http://www.isrctn.com/ISRCTN11580369

Increasing the Proportion of Plant-Based Foods Available to Shift Social Consumption Norms and Food Choice among Non-Vegetarians

Increasing the relative availability of plant-based (versus animal source) foods seems promising in shifting consumption, but it remains unknown how and under what circumstances this happens. We performed two availability manipulations including different foods. The impact on food choice, social norm perceptions about what others do (descriptive) or approve of (injunctive), and salience was assessed. Non-vegetarian participants were visually (Study 1, n = 184) or physically (Study 2, n = 276) exposed to (a) four plant-based and two animal source foods or (b) vice versa. Participants chose one food item, either hypothetically (Study 1) or actually (Study 2), and reported the perceived social norms and salience of plant-based and animal source foods. The results showed no direct effects on food choice, injunctive norms, or salience. An increased proportion of plant-based (versus animal source) foods was interpreted in Study 1 as plant-based foods being less often chosen by others, whereas in Study 2, these foods were interpreted as being more often chosen (marginally significant), while animal source foods were interpreted as being less often chosen. The results suggest that a higher availability of plant-based foods influences descriptive norms, but future research should examine aspects potentially contributing to the contradictory normative interpretations (e.g., norm salience).

Altering the availability of products within physical micro-environments: a conceptual framework

Altering the availability of products (e.g. food, alcohol or tobacco products) is one potential intervention to change behaviours to help reduce preventable premature deaths worldwide. However, research on these interventions lacks consistent conceptualisation, hindering clear reporting and cumulative synthesis. This paper proposes a conceptual framework – categorising intervention types and summarising constituent components – with which interventions can be reliably described and evidence synthesised. Three principal distinctions are proposed: interventions altering: (i) Absolute Availability (changing the overall number of options, while keeping the proportions comprised by any subsets of options constant); (ii) Relative Availability (changing the proportion comprised by a subset of options, yet keeping the overall number of options constant); (iii) Absolute and Relative Availability (changing both the overall number of options and the proportions comprised by subsets of options). These are subdivided into those targeting (a) a product or (b) a category of products. Mechanisms that might underlie each of these intervention types are discussed, and implications for future research highlighted. The proposed framework aims to facilitate study of a set of interventions that could contribute significantly to healthier behaviour across populations.

The Impact of a Gradual Healthier Assortment among Vocational Schools Participating in a School Canteen Programme: Evidence from Sales and Student Survey Data

Many adolescents have poor eating habits. As a major part of their caloric intake takes place at school, the present study aims to examine the effect of increasing the availability of healthier foods in school canteens on sales, student attitude and self-reported behaviour. A quasi-experimental study was carried out at two vocational schools in the Netherlands over a 10-month period, where the visible share of healthier products was gradually or abruptly increased from 60% to 80%. Outcome measures were sales data for healthier and less healthy foods and drinks in the canteens, as well as surveys. The proportion of healthier products sold increased from 31.1% during the baseline period to 35.9% in the final period. A gradual increase led to higher relative sales of healthier products (40%) than an abrupt change (34.5%). Survey data showed that students’ moderate satisfaction remained insensitive to the changes over time. Overall, results suggest that increasing the availability of healthier products in school canteens leads to small positive changes in sales of products, particularly in the product groups beverages and sandwiches. A gradual introduction may ensure that students slowly get used to assortment changes.

The impact on selection of non-alcoholic vs alcoholic drink availability: an online experiment

BACKGROUND

Increasing the availability of healthier food increases its selection and consumption. However, there is an absence of evidence related to alcohol. This study aimed to estimate the impact of increasing the absolute and relative availability of non-alcoholic compared to alcoholic drinks on selection. We also assessed whether effects were modified by cognitive resource.

METHODS

UK adult weekly alcohol consumers (n = 808) were recruited to an online experiment with a hypothetical drink selection task. Participants were randomly assigned to one of eight conditions, in a 4 (availability) × 2 (cognitive resource) factorial design. The four availability conditions were: i. Reference 1 (two non-alcoholic, two alcoholic drinks); ii. Reference 2 (four non-alcoholic, four alcoholic drinks); iii. Increased non-alcoholic drinks (six non-alcoholic, two alcoholic drinks); iv. Increased alcoholic drinks (two non-alcoholic, six alcoholic drinks). The two cognitive resource conditions were: a. Low (high time pressure); b. High (low time pressure). Logistic regression was used to assess selection of a non-alcoholic drink.

RESULTS

49% of participants selected a non-alcoholic drink in the Increased non-alcoholic drinks condition, compared to 36% in Reference 1, 39% in Reference 2, and 26% in the Increased alcoholic drinks condition. Non-alcoholic drink selection was similar between Reference 1 and 2 when the total number of drinks increased (absolute availability) but the proportion of non-alcoholic compared to alcoholic drinks (relative availability) was unchanged (OR = 1.15, 95% CI 0.77, 1.73). In contrast, the odds of selecting a non-alcoholic drink were 71% higher when both absolute and relative availability of non-alcoholic compared to alcoholic drinks was increased from Reference 1 to the Increased non-alcoholic drinks condition (OR: 1.71, 95% CI 1.15, 2.54), and 48% higher when increased from Reference 2 to the Increased non-alcoholic drinks condition (OR: 1.48, 95% CI 0.99, 2.19). There was no evidence of an effect of cognitive resource.

CONCLUSIONS

Greater availability of non-alcoholic drinks, compared to alcoholic drinks, increased their online selection, an effect that may be larger when changing their relative availability, i.e., increasing the proportion of non-alcoholic drinks. Naturalistic studies are needed to determine the impact of availability interventions on reducing alcohol purchasing and consumption.

Socioeconomic position and the impact of increasing availability of lower energy meals vs. menu energy labelling on food choice: two randomized controlled trials in a virtual fast-food restaurant

BACKGROUND

Food consumed outside of the home is often high in energy and population level interventions that reduce energy intake of people from both lower and higher socioeconomic position (SEP) are needed. There is a lack of evidence on the effectiveness and SEP equity of structural-based (e.g. increasing availability of lower energy options) and information provision (e.g. menu energy labelling) interventions on food choice.

METHODS

Across two online experiments, participants of lower and higher SEP made meal choices in a novel virtual fast-food restaurant. To be eligible to take part, participants were required to be UK residents, aged 18 or above, fluent in English, have access to a computer with an internet connection and have no dietary restrictions. Participants were randomized to one of four conditions in a 2 × 2 between-subjects design: menu energy labelling present vs. absent and increased availability of lower energy options (75% of menu options lower energy) vs. baseline availability (25% of menu options lower energy). Participants also completed measures of executive function and food choice motives.

RESULTS

The analysis of pooled data from both studies (n = 1743) showed that increasing the availability of lower energy options resulted in participants ordering meals with significantly less energy on average (- 71 kcal, p <  0.001, partial η² = 0.024) and this effect was observed irrespective of participant SEP. Menu labelling had no significant effect on energy ordered (- 18 kcal, p = 0.116, partial η² = 0.001) in participants from both higher and lower SEP. Furthermore, we found no evidence that executive function or food choice motives moderated the effect of increasing lower energy menu options or energy labelling on total energy ordered.

CONCLUSIONS

In a virtual fast-food environment, energy labelling was ineffective in reducing total energy ordered for both higher and lower SEP participants. Increasing the availability of lower energy options had an equitable effect, reducing total energy ordered in participants from higher and lower SEP.

TRIAL REGISTRATION

Study protocols and analysis plans were pre-registered on the Open Science Framework (https://osf.io/ajcr6/).

Increasing the proportion of healthier foods available with and without reducing portion sizes and energy purchased in worksite cafeterias: protocol for a stepped-wedge randomised controlled trial

BACKGROUND

Overconsumption of energy from food contributes to high rates of overweight and obesity in many populations. A promising set of interventions tested in pilot studies in worksite cafeterias, suggests energy intake may be reduced by increasing the proportion of healthier - i.e. lower energy - food options available, and decreasing portion sizes. The current study aims to assess the impact on energy purchased of i. increasing the proportion of lower energy options available; ii. combining this with reducing portion sizes, in a full trial.

METHODS

A stepped-wedge randomised controlled trial in 19 worksite cafeterias, where the proportion of lower energy options available in targeted food categories (including main meals, snacks, and cold drinks) will be increased; and combined with reduced portion sizes. The primary outcome is total energy (kcal) purchased from targeted food categories using a pooled estimate across all sites. Follow-up analyses will test whether the impact on energy purchased varies according to the extent of intervention implementation.

DISCUSSION

This study will provide the most reliable estimate to date of the effect sizes of two promising interventions for reducing energy purchased in worksite cafeterias.

TRIAL REGISTRATION

The study was prospectively registered on ISRCTN (date: 24.05.19; TRN: ISRCTN87225572; doi: https://doi.org/10.1186/ISRCTN87225572).

Impact of increasing vegetarian availability on meal selection and sales in cafeterias

Shifting people in higher income countries toward more plant-based diets would protect the natural environment and improve population health. Research in other domains suggests altering the physical environments in which people make decisions ("nudging") holds promise for achieving socially desirable behavior change. Here, we examine the impact of attempting to nudge meal selection by increasing the proportion of vegetarian meals offered in a year-long large-scale series of observational and experimental field studies. Anonymized individual-level data from 94,644 meals purchased in 2017 were collected from 3 cafeterias at an English university. Doubling the proportion of vegetarian meals available from 25 to 50% (e.g., from 1 in 4 to 2 in 4 options) increased vegetarian meal sales (and decreased meat meal sales) by 14.9 and 14.5 percentage points in the observational study (2 cafeterias) and by 7.8 percentage points in the experimental study (1 cafeteria), equivalent to proportional increases in vegetarian meal sales of 61.8%, 78.8%, and 40.8%, respectively. Linking sales data to participants' previous meal purchases revealed that the largest effects were found in the quartile of diners with the lowest prior levels of vegetarian meal selection. Moreover, serving more vegetarian options had little impact on overall sales and did not lead to detectable rebound effects: Vegetarian sales were not lower at other mealtimes. These results provide robust evidence to support the potential for simple changes to catering practices to make an important contribution to achieving more sustainable diets at the population level.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption

BACKGROUND

Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers.

OBJECTIVES

1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches.

SELECTION CRITERIA

We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product.

DATA COLLECTION AND ANALYSIS

We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE.

MAIN RESULTS

We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias.

AUTHORS' CONCLUSIONS

The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

Public acceptability of nudging and taxing to reduce consumption of alcohol, tobacco, and food: A population-based survey experiment

There is growing evidence for the effectiveness of choice architecture or 'nudge' interventions to change a range of behaviours including the consumption of alcohol, tobacco and food. Public acceptability is key to implementing these and other interventions. However, few studies have assessed public acceptability of these interventions, including the extent to which acceptability varies with the type of intervention, the target behaviour and with evidence of intervention effectiveness. These were assessed in an online study using a between-participants full factorial design with three factors: Policy (availability vs size vs labelling vs tax) x Behaviour (alcohol consumption vs tobacco use vs high-calorie snack food consumption) x Evidence communication (no message vs assertion of policy effectiveness vs assertion and quantification of policy effectiveness [e.g., a 10% change in behaviour]). Participants (N = 7058) were randomly allocated to one of the 36 groups. The primary outcome was acceptability of the policy. Acceptability differed across policy, behaviour and evidence communication (all ps < .001). Labelling was the most acceptable policy (supported by 78%) and Availability the least (47%). Tobacco use was the most acceptable behaviour to be targeted by policies (73%) compared with policies targeting Alcohol (55%) and Food (54%). Relative to the control group (60%), asserting evidence of effectiveness increased acceptability (63%); adding a quantification to this assertion did not significantly increase this further (65%). Public acceptability for nudges and taxes to improve population health varies with the behaviour targeted and the type of intervention but is generally favourable. Communicating that these policies are effective can increase support by a small but significant amount, suggesting that highlighting effectiveness could contribute to mobilising public demand for policies. While uncertainty remains about the strength of public support needed, this may help overcome political inertia and enable action on behaviours that damage population and planetary health.

Plate size and food consumption: a pre-registered experimental study in a general population sample

BACKGROUND

There is considerable uncertainty regarding the impact of tableware size on food consumption. Most existing studies have used small and unrepresentative samples and have not followed recommended procedures for randomised controlled trials, leading to increased risk of bias. In the first pre-registered study to date, we examined the impact on consumption of using larger versus smaller plates for self-served food. We also assessed impact on the underlying meal micro-structure, such as number of servings and eating rate, which has not previously been studied.

METHODS

The setting was a purpose-built naturalistic eating behaviour laboratory. A general population sample of 134 adult participants (aged 18-61 years) was randomly allocated to one of two groups varying in the size of plate used for self-serving lunch: large or small. The primary outcome was amount of food energy (kcal) consumed during a meal. Additionally, we assessed impact on meal micro-structure, and examined potential modifying effects of executive function, socio-economic position, and sensitivity to perceptual cues.

RESULTS

There was no clear evidence of a difference in consumption between the two groups: Cohen's d = 0.07 (95% CI [- 0.27, 0.41]), with participants in the large plate group consuming on average 19.2 (95% CI [- 76.5, 115.0]) more calories (3%) compared to the small plate group (large: mean (SD) = 644.1 (265.0) kcal, versus small: 624.9 (292.3) kcal). The difference between the groups was not modified by individual characteristics. There was no evidence of impact on meal micro-structure, with the exception of more food being left on the plate when larger plates were used.

CONCLUSIONS

This study suggests that previous meta-analyses of a low-quality body of evidence may have considerably overestimated the effects of plate size on consumption. However, the possibility of a clinically significant effect - in either direction - cannot be excluded. Well-conducted trials of tableware size in real-world field settings are now needed to determine whether changing the size of tableware has potential to contribute to efforts to reduce consumption at population-level.

TRIAL REGISTRATION

The study protocol ( https://osf.io/e3dfh/ ) and data analysis plan ( https://osf.io/sh5u7/ ) were pre-registered on the Open Science Framework.

Altering the availability or proximity of food, alcohol, and tobacco products to change their selection and consumption

BACKGROUND

Overconsumption of food, alcohol, and tobacco products increases the risk of non-communicable diseases. Interventions to change characteristics of physical micro-environments where people may select or consume these products - including shops, restaurants, workplaces, and schools - are of considerable public health policy and research interest. This review addresses two types of intervention within such environments: altering the availability (the range and/or amount of options) of these products, or their proximity (the distance at which they are positioned) to potential consumers.

OBJECTIVES

1. To assess the impact on selection and consumption of altering the availability or proximity of (a) food (including non-alcoholic beverages), (b) alcohol, and (c) tobacco products.2. To assess the extent to which the impact of these interventions is modified by characteristics of: i. studies, ii. interventions, and iii.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and seven other published or grey literature databases, as well as trial registries and key websites, up to 23 July 2018, followed by citation searches.

SELECTION CRITERIA

We included randomised controlled trials with between-participants (parallel group) or within-participants (cross-over) designs. Eligible studies compared effects of exposure to at least two different levels of availability of a product or its proximity, and included a measure of selection or consumption of the manipulated product.

DATA COLLECTION AND ANALYSIS

We used a novel semi-automated screening workflow and applied standard Cochrane methods to select eligible studies, collect data, and assess risk of bias. In separate analyses for availability interventions and proximity interventions, we combined results using random-effects meta-analysis and meta-regression models to estimate summary effect sizes (as standardised mean differences (SMDs)) and to investigate associations between summary effect sizes and selected study, intervention, or participant characteristics. We rated the certainty of evidence for each outcome using GRADE.

MAIN RESULTS

We included 24 studies, with the majority (20/24) giving concerns about risk of bias. All of the included studies investigated food products; none investigated alcohol or tobacco. The majority were conducted in laboratory settings (14/24), with adult participants (17/24), and used between-participants designs (19/24). All studies were conducted in high-income countries, predominantly in the USA (14/24).Six studies investigated availability interventions, of which two changed the absolute number of different options available, and four altered the relative proportion of less-healthy (to healthier) options. Most studies (4/6) manipulated snack foods or drinks. For selection outcomes, meta-analysis of three comparisons from three studies (n = 154) found that exposure to fewer options resulted in a large reduction in selection of the targeted food(s): SMD -1.13 (95% confidence interval (CI) -1.90 to -0.37) (low certainty evidence). For consumption outcomes, meta-analysis of three comparisons from two studies (n = 150) found that exposure to fewer options resulted in a moderate reduction in consumption of those foods, but with considerable uncertainty: SMD -0.55 (95% CI -1.27 to 0.18) (low certainty evidence).Eighteen studies investigated proximity interventions. Most (14/18) changed the distance at which a snack food or drink was placed from the participants, whilst four studies changed the order of meal components encountered along a line. For selection outcomes, only one study with one comparison (n = 41) was identified, which found that food placed farther away resulted in a moderate reduction in its selection: SMD -0.65 (95% CI -1.29 to -0.01) (very low certainty evidence). For consumption outcomes, meta-analysis of 15 comparisons from 12 studies (n = 1098) found that exposure to food placed farther away resulted in a moderate reduction in its consumption: SMD -0.60 (95% CI -0.84 to -0.36) (low certainty evidence). Meta-regression analyses indicated that this effect was greater: the farther away the product was placed; when only the targeted product(s) was available; when participants were of low deprivation status; and when the study was at high risk of bias.

AUTHORS' CONCLUSIONS

The current evidence suggests that changing the number of available food options or altering the positioning of foods could contribute to meaningful changes in behaviour, justifying policy actions to promote such changes within food environments. However, the certainty of this evidence as assessed by GRADE is low or very low. To enable more certain and generalisable conclusions about these potentially important effects, further research is warranted in real-world settings, intervening across a wider range of foods - as well as alcohol and tobacco products - and over sustained time periods.

Interventions for excessive energy drink use

PURPOSE OF REVIEW

Given the increased and sometimes excessive consumption of energy drinks containing caffeine and other drugs, often sugar-sweetened, especially among young people, interventions that reduce consumption are needed. We review current findings related to interventions at the individual, outlet and regulatory levels to reduce energy drink consumption.

RECENT FINDINGS

Few interventions to reduce excess energy drink consumption have been tested. Interventions to reduce consumption of sugar-sweetened beverages and caffeinated beverages are reviewed. A manual-only intervention to reduce caffeinated beverages shows promise, whereas reducing availability at outlets and in communities as a whole shows some effectiveness.

SUMMARY

Although some recent studies can provide guidance on interventions to reduce energy drink consumption, no clear 'best practice' has emerged to reduce energy drink consumption. The literature reviewed points toward interventions at different levels which need further testing and could benefit from adaptation to the youth and young adult consumer.

Nudging to get our food choices on a sustainable track

Food production is one of the major contributors to environmental damage. Adaptations in our food choices are needed to preserve resources for the needs of future generations. More sustainable consumption patterns have been encouraged by economic incentives, laws, education and communication campaigns. Nonetheless, consumers still find difficulties in trying to change their current food habits. This review takes a behavioural approach in encouraging sustainable food choices among consumers. From a nudging perspective, many behavioural changes can be encouraged in a non-obtrusive way by adapting the complex food environment in which consumers are operating. These interventions do not restrict consumers' choices but rather adapt the choice architecture wherein food decisions are made. Drawing on the literature from diverse theoretical perspectives, we provide an overview of the application of nudging for more sustainable food choices and highlight where more research is needed. More specifically, we discuss research that used nudging to engender cognitive impact (i.e. the use of labels or visibility enhancements), affective responses (i.e. sensorial and social influence cues) and behavioural effects (i.e. adjustments in convenience and product size). We conclude that this review only shows the tip of the iceberg of the research on nudging and sustainable consumption that is likely forthcoming in the next few years, following the successes of nudging applications in other domains. Nonetheless, each individual nudging intervention requires careful examination. Personal predispositions towards the environment should be considered when designing interventions, demonstrating the complementarity of nudging with education on sustainable consumption.

What is the impact of increasing the prominence of calorie labelling? A stepped wedge randomised controlled pilot trial in worksite cafeterias

Background

Calorie labelling may help to reduce energy consumption, but few well-controlled experimental studies have been conducted in real world settings. In a previous randomised controlled pilot trial we did not observe an effect of calorie labelling on energy purchased in worksite cafeterias. In the present study we sought to enhance the effect by making the labels more prominent, and to address the operational challenges reported previously by worksites.

Methods

Three worksite cafeterias were randomised in a stepped wedge design to start the intervention at one of three fortnightly periods between March and July 2018. The intervention comprised introducing prominent calorie labelling for all cafeteria products for which calorie information was available (on average 87% of products offered across the three sites were labelled). Calorie content was displayed in bold capitalised Verdana typeface with a minimum font size of 14 e.g.120 CALORIES. Feasibility and acceptability were assessed using post-intervention surveys with cafeteria patrons and semi-structured interviews with managers. Effectiveness was assessed using total daily energy (kcal) purchased from intervention items across the three sites, analysed using semi-parametric GAMLSS models.

Results

Recruitment and retention of worksite cafeterias proved feasible: all three randomised sites successfully completed the study. Post-intervention feedback suggested high levels of intervention acceptability: 87% of responding patrons wanted calorie labelling to remain in place. No effect of the intervention on daily energy purchased was observed: −0.6% (95%CI -2.5 to 1.2, p = .487). By-site analyses showed similar null effects at each of the three sites, all ps > .110.

Conclusions

There was no evidence that prominent calorie labelling changed daily energy purchased across three English-based worksite cafeterias. The intervention was feasible to implement and acceptable to patrons and managers.

Characteristics of Canteens at Elementary Schools, Upper Secondary Schools and Workplaces that Comply with Food Service Guidelines and Have a Greater Focus on Food Waste

Policy actions to improve the nutritional environment include the provision of official food service guidelines. This study aimed to examine compliance with food service guidelines for hot meals as well as self-evaluated focus on food waste reduction across settings, i.e., elementary schools, upper secondary schools and workplaces, and different canteen characteristics. The same five criteria for hot meals were applied for all settings with regard to serving of fruit and vegetables, fish, wholegrain product and high fat meat and dairy products. A self-administered questionnaire survey was conducted as a cross-sectional study among 680 Danish canteens. Canteens having a high degree of organic food procurement were more likely to comply with the five criteria for hot meals combined (OR 2.00 (Cl 1.13,3.53)). Also, the use of organic food together with having a meal policy was associated with reported focus on food waste reduction (OR 1.91 (CI 1.12,3.25) and 1.84 (Cl 1.31,2.59), respectively). Compliance with individual criteria varied across settings with elementary schools being more likely to comply with criteria on, e.g., maximum serving of non-wholegrain products, whereas workplaces were more likely to comply with criteria on, e.g., minimum fruit and vegetable content and serving of fish. In addition, specific characteristics, e.g., serving system, were found to predict compliance with some of the criteria. These findings highlight the need to address differences in canteen characteristics when planning implementation support for both guideline and food waste reduction initiatives.

Availability of healthier vs. less healthy food and food choice: an online experiment

BACKGROUND

Our environments shape our behaviour, but little research has addressed whether healthier cues have a similar impact to less healthy ones. This online study examined the impact on food choices of the number of (i) healthier and (ii) less healthy snack foods available, and possible moderation by cognitive load and socioeconomic status.

METHODS

UK adults (n = 1509) were randomly allocated to one of six groups (two cognitive load x three availability conditions). Participants memorised a 7-digit number (7777777: low cognitive load; 8529713: high cognitive load). While remembering this number, participants chose the food they would most like to eat from: (a) two healthier and two less healthy foods, (b) six healthier and two less healthy foods, or (c) two healthier and six less healthy foods.

RESULTS

Compared to being offered two healthier and two less healthy options, the odds of choosing a healthier option were twice as high (Odds Ratio (OR): 2.0, 95%CI: 1.6, 2.6) with four additional healthier options, while the odds of choosing a less healthy option were four times higher (OR: 4.3, 95%CI: 3.1, 6.0) with four additional less healthy options. There were no significant main effects or interactions with cognitive load or socioeconomic status.

CONCLUSIONS

This study provides a novel test of the impact of healthier vs. less healthy food cues on food choice, suggesting that less healthy food cues have a larger effect than healthier ones. Consequently, removing less healthy as opposed to adding healthier food options could have greater impact on healthier choices. Studies are now needed in which choices are made between physically-present foods.