The impact of nutritional labeling on adult snack choices: A controlled field experiment in a non-commercial professional setting

Each year, 2.8 million people die because of comorbidities associated with being overweight. Snacking substantially contributes to people's calorie intake. One way to nudge consumers towards healthier alternatives is the implementation of nutritional labeling. This study reports on a controlled field experiment that evaluates the effect of two nutritional labels on free snack choices (n = 739). Participants at a conference could choose between nuts, cookies, and candy bars as a snack, presented at the bar at six different locations across 2 bar counters. The labels were set up in front of each snack in three conditions: no labeling (control), a calorie label, or a traffic light label (i.e., the Nutri-Score). The location of the snacks on the counter (Either side of the counter; Center, Right, Left) and the time-of-day (Morning (=reference) vs Afternoon) were statistically controlled for. The results show that calorie labels could not successfully nudge consumers toward healthier snack choices (nuts instead of candy bars or cookies). In contrast, the Nutri-Score label significantly increased the probability of choosing nuts over candy bars. The Nutri-Score also increased the chance of choosing nuts over cookies, but the difference was not significant. No prior studies to our knowledge have directly compared calorie labels to the Nutri-Score. This study suggests that the Nutri-Score label can be a more successful intervention than calorie labels to nudge consumers towards healthier choices in situations were free snacks are offered, like many modern workplaces. Changing snacking behavior is challenging and naturalistic field experiments like this one are needed to translate the theory from previous laboratory studies to real-life settings.

Nudging food choice in a prison setting: an investigation using food choice data

BACKGROUND

The prison population presents complex health needs and is disproportionately affected by poor health, compared to the general population. Diet has a clear role in prisoner health, and the prison food environment within which food choices are made is relatively under-researched. The aim of this study was to examine whether food choices in a women's prison changed after the introduction of a new menu design by the catering team.

METHODS

The adjusted menu design incorporated an emoticon (a smiley face) placed next to designated 'Healthy Choice' foods on the menu sheets, which were used to preselect meals. Data comprised all women's (n = 865) food choices (more than 115,000 selections) for a period of 8 weeks (with the new menu) as well as 8 weeks prior (baseline period). The study design was a pre-post intervention study, and food selection was examined using chi-square tests and binary logistic regression models.

RESULTS

The selection of promoted foods overall significantly increased under the new menu design (with the emoticon nudge strategy) compared to baseline; the effect size, however, was small according to the usual guidelines (21.4% compared to 20% at baseline; χ2 (1) = 32.6, p < 0.001, φ = 0.02). Individuals were 11% more likely (p < 0.001) to select the promoted 'Healthy Choice' foods under the adjusted food choice architecture. A significant effect was found for lunch and evening meal - but not for desserts. A minority of individual food items that were promoted had significant positive changes in selection, and were 1.3-4 times as likely to be selected when emoticons had been introduced, compared to baseline.

CONCLUSIONS

Further research is needed to examine the potential added benefit of multiple complementary nudge strategies, and the relevance of the preselection of foods in advance of consumption.

Identifying barriers and facilitators to adopting healthier dietary choices in clinical care: a cross-sectional observational study

Background and aims

Adopting healthier diets can drastically improve societal health. Our environment plays a crucial role in daily dietary choices and hospitals in particular can stimulate patients to adopt healthier eating habits. Unfortunately, no robust clinically applicable cuing tools exist to help guide in-hospital dietary interventions. The purpose of this study was to identify patient-related barriers and facilitators to adopting healthier dietary choices.

Methods and results

This cross-sectional observational study was conducted on the cardiology ward of a university medical center between June 2020 and January 2021. Of the 594 patients asked and the 312 completed surveys on healthy eating intentions, 285 responses were considered for analysis. Notably, the majority of respondents were male (68.8%), with an average hospital stay of 3.3 days. The results indicate that cardiac patients attribute significantly greater influence on their dietary behavior to doctors compared to other caregivers, including dieticians (X2 = 37.09, df = 9, p < 0.001). Also, younger patients (below 70 years of age) were more inclined to plan changing dietary behavior than older patients. Most mentioned facilitators for adopting a healthier diet were more information/counseling, help in preparing food, support from family and friends, and more emphasis from a doctor.

Conclusion

The study highlights the importance of involving doctors in formulating dietary policies and patient-directed interventions within hospital settings. It also sheds light on the barriers and facilitators for promoting healthier dietary behaviors among patients during their hospitalization.

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.

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.

Health Literacy, Numeracy, and Health Promotion: A Secondary Analysis of the Choosewell 365 Workplace Trial

INTRODUCTION

Health literacy and numeracy are linked to obesity and dietary behaviors. This study investigates whether the effect of a workplace behavioral intervention to prevent weight gain and improve diet differed by employee health literacy and numeracy.

METHODS

ChooseWell 365 was an RCT of hospital employees testing a 12-month intervention using nudges and feedback to promote healthier choices, building on existing cafeteria traffic light labels (e.g., green=healthy, red=unhealthy). Health literacy and numeracy were measured with the Newest Vital Sign (range=0-6) and General Numeracy Scale (range=0-3). Mixed-effects linear models examined if intervention effects on cafeteria purchases, diet quality (Healthy Eating Index 2015, range=0-100), and weight change over 24 months differed by higher versus lower health literacy or numeracy. Data were collected in 2016-2020 and analyzed in 2020-2021.

RESULTS

In 12 months, 510 participants completed the Newest Vital Sign and General Numerancy Scale; 36.7% had Newest Vital Sign<6 (lower health literacy) and 31.6% had General Numerancy Scale<2 (lower numeracy). Intervention participants increased healthy purchases over 24 months compared with controls in both higher and lower health literacy and numeracy groups. At 12 months, Healthy Eating Index 2015 scores increased in intervention versus control participants with lower health literacy (5.5 points, 95% CI=1.51, 9.54) but not in those with higher health literacy (p-interaction=0.040). BMI did not differ by health literacy or numeracy.

CONCLUSIONS

A behavioral intervention improved cafeteria food choices of hospital employees of varying health literacy and numeracy levels and improved diet quality among employees with lower health literacy, suggesting this group also improved food choices outside of work.

Availability of Healthy Food and Beverages in Hospital Outlets and Interventions in the UK and USA to Improve the Hospital Food Environment: A Systematic Narrative Literature Review

The aims of this systematic review are to determine the availability of healthy food and beverages in hospitals and identify interventions that positively influence the hospital food environment, thereby improving the dietary intake of employees and visitors. Embase, Medline, APA PsycInfo, Scopus, Google Scholar and Google were used to identify publications. Publications relating to the wider hospital food environment in the UK and USA were considered eligible, while those regarding food available to in-patients were excluded. Eligible publications (n = 40) were explored using a narrative synthesis. Risk of bias and research quality were assessed using the Quality Criteria Checklist for Primary Research. Although limited by the heterogeneity of study designs, this review concludes that the overall quality of hospital food environments varies. Educational, labelling, financial and choice architecture interventions were shown to improve the hospital food environment and/or dietary intake of consumers. Implementing pre-existing initiatives improved food environments, but multi-component interventions had some undesirable effects, such as reduced fruit and vegetable intake.

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.

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.

The effectiveness of nudging interventions to promote healthy eating choices: A systematic review and an intervention among Italian university students

Nudges are changes in choice architecture (i.e., the environment in which people make decisions) aiming to steer a person's decision to a particular choice, without restricting alternative options or changing financial incentives. These strategies have been extensively used to promote healthy eating, above all among youths, whose behaviors can still be easily shaped compared to older people's. The current paper describes two studies aiming to investigate the effectiveness of nudging interventions in promoting healthy eating among university students. The first study consisted of a systematic review mapping all the published studies which describe the effectiveness of this kind of intervention worldwide. Twelve eligible records were selected after a search of three different databases. Information about the publication of the record, the adopted research methods and the described intervention was retrieved from each selected record. Based on this review's results, a new nudging intervention was developed to promote healthy food choice among Italian university students. The intervention aimed to modify students' choice for each of the Italian meal courses: first course (pasta, rice or soup), second course (meat, fish, cheese or cured meat), side dish, bread, and fruit. An Italian university cafeteria was observed in two phases: a pre-intervention phase (baseline) and a post-intervention phase (nudging strategies were implemented in the cafeteria's architecture). The applied nudging intervention was effective in promoting healthy choices in relation to the second course, the side dish, and the bread, but it did not significantly affect choices related to the first course or the fruit. Implications of these results and suggestions for future interventions are discussed.

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.

Effect of front-of-package nutrition labeling on food purchases: a systematic review

OBJECTIVES

This study systematically reviewed evidence from interventions on the effect of front-of-package (FOP) nutrition labeling on food purchases.

STUDY DESIGN

The study design used in this study is a systematic review.

METHODS

Keyword search was performed in PubMed, Web of Science, Scopus, and Cochrane Library.

RESULTS

Fifteen studies (10 randomized controlled trials, four pre-post studies, and one case-control study) met the eligibility criteria and were included in the review. Five studies were conducted in a controlled setting through the establishment of an online virtual supermarket or physical laboratory food store solely for the intervention. In contrast, the remaining ten studies were conducted in a naturalistic setting where people commonly purchase foods (e.g., supermarket, grocery store, school/hospital cafeteria, or vending machine). FOP labels assessed included traffic lights, health star rating, daily intake guides, health warnings, and high sugar symbol labels. Compared with the control, FOP labels were effective for helping participants make healthier food purchase decisions in five of the 12 studies that assessed traffic lights labels, in one of the two studies that assessed health warning labels, and in one study that assessed high sugar symbol labels. Three assessed health star ratings and one assessed daily intake guide labels, but none revealed an effect on food purchases compared with the control.

CONCLUSIONS

Findings on the effectiveness of FOP nutrition labels in 'nudging' consumers toward healthier food purchases remain mixed and inconclusive. Future studies should examine other types of FOP labels beside the traffic lights labels and explore the different effects by consumer affordability, population subgroup, and shopping environment.

Nudging healthier food choices in a cafeteria setting: A sequential multi-intervention field study

Creating more health-fostering environments is high on the agenda of public and private actors. The behavioral approach to nudge people towards healthier food choices is gaining popularity despite limited understanding about where, and for whom, which specific nudges work. This study contributes by reporting on three different nudging interventions in the same setting and presents effects on different sub-populations. We find overall small effects that are heterogeneous, ranging from robustly more to even less healthy choices. We discuss the importance of transparency and reactance to health interventions and the potential interplay of interventions with habitual behavior among different sub-populations.

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).

Prompting consumers to make healthier food choices in hospitals: a cluster randomised controlled trial

BACKGROUND

Hospitals in the UK offer snacks for sale to patients, staff and visitors. Despite the NHS's health promoting role, and tightening of regulations around which foods can be sold in hospitals, many snacks purchased in this setting are unhealthy. The present project tests the effectiveness of theory-based point of purchase prompts (PPPs; a form of cognitive nudge) designed to make it cognitively easier for consumers to compare available products and choose healthier options.

METHODS

Hospital shops in Scotland (n = 30) were recruited into a cluster randomised controlled trial to test whether a PPP could reduce the average calorie, fat and/or sugar content of purchased snacks. Inclusion criteria stated that eligible sites; sold food; were located in a hospital; and were accessible to staff, patients and visitors. The PPP intervention was a theory-based sign (tailored to the available range in each location) designed to cognitively simplify healthier snack choices by facilitating cross-product comparison. Shops were randomised to display PPPs (intervention; n = 15) or not (control; n = 15) using block randomisation controlling for shop size. Data on all snacks purchased from participating shops were obtained from retailers for a 12-week baseline and 12-week follow-up period. Primary outcomes were the average calorie (kcals), fat(g) and sugar(g) content of snacks purchased each day. Secondary outcomes were the average customer spend per item purchased (£,p) and the total number of snacks purchased daily. Shop staff were not blinded to group assignment but data providers were. Data were analysed using mixed effects multi-level regression models.

RESULTS

Data from > 1 million snack purchases were analysed. Snacks purchased from intervention sites were on average significantly lower in calorie (γ = - 1.84, p < .001) and sugar (γ = - 0.18, p = .030) at follow up relative to baseline but only the reduction in calories was significantly different to control. Average spend per item also reduced significantly in intervention (but not control) sites (γ = - 0.89, p < .001). The intervention had no effect on the fat content of snacks or the number of snacks sold.

CONCLUSIONS

Simple, theory-based point of purchase prompts can produce small but statistically significant reductions in the energy content of snack purchases from hospital shops.

TRIAL REGISTRATION

Retrospectively registered (8/Oct/2018) with ISRCTN (ID: ISRCTN90365793 ).

Front-of-pack nutritional labels: Understanding by low- and middle-income Mexican consumers

Front-of-pack labeling is a cost-effective strategy to decrease population consumption of sodium, sugar, saturated fat, total fat, and trans-fatty acids, considered critical nutrients for chronic disease. Our main objective was to explore the subjective understanding of labels that are currently used internationally among low- and middle-income Mexican consumers. We performed two phases of 10 focus groups with adolescents (13–15 y), young adults (21–23 y), mothers of children 3–12 y, fathers of children 3–12 y and older adults (55–70 y). Seven FOPL were evaluated: Guideline Daily Amounts, Multiple Traffic Light, Chilean Warning labels, Warning labels in Red, 5-Color Nutrition Label, Health Star Rating, and Healthy Choice label. Data was analyzed with a triangulation of researchers using a content analysis, based on three codes: 1) awareness and use of the Guideline Daily Amounts, 2) acceptability, and 3) subjective understanding of labels. Most participants were aware of the Guideline Daily Amounts, however they rarely used it because interpreting the information displayed on the label was too complicated. Health Star Rating, Warning labels, Multiple Traffic Light and the Healthy Choice logo labels were the most understandable, however the acceptability of the The Healthy Choice logo decreased as it did not provide information on specific ingredients. The Warning labels was the only label able to warn about critical nutrients that could represent a health risk. The Warning labels in red was more accepted compared to Warning labels in black. Results show that directive and semi-directive labels, such as Warning labels, Health Star Rating or Multiple Traffic Light, may be better at helping population of low- and middle income make healthier food choices, than non-directive FOPL such as the Guideline Daily Amounts implemented in México. The study results highlight the potential of Warning labels to support decreases in the consumption of critical ingredients in low- and middle-income Mexican consumers.