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Background: US law mandates that chain restaurants with 20 or more locations post calorie information on their menus to inform consumers and encourage healthy choices. Few qualitative studies have assessed how parents perceive and use this information when ordering for their children and what types of accompanying messages might increase use of calorie labels when ordering food., Objective: We aimed to better understand parents' perceptions and use of calorie labeling and the types of messages that might increase use., Design: We conducted 10 focus groups (n = 58) and 20 shop-along interviews (n = 20). Focus group participants discussed their hypothetical orders and restaurant experiences when dining with their children, and shop-along participants verbalized their decision processes while ordering at a restaurant. Both groups gave feedback on 4 public service messages aimed to increase healthier ordering for children. All interviews were voice-recorded and transcribed., Participants/setting: Participants were primary caregivers of at least 1 child between 6 and 12 years who reported having less than a college education at the time of screening and who commonly ate at chain restaurants. Focus groups were conducted in a conference room, and shop-alongs were conducted in quick-serve and full-service chain restaurants around Philadelphia between August 2016 and May 2017., Analyses: A modified grounded theory approach was used to extract themes from transcripts., Results: Thematic analysis of transcripts revealed 5 key themes: (1) parents' use of calorie labels; (2) differences across restaurant settings; (3) nonjudgmental information; (4) financial value and enjoyment of food; and (5) message preferences. These themes suggested that nonjudgmental, fact-based messages that highlight financial value, feelings of fullness, and easy meal component swaps without giving up the treatlike aspect of eating out may be particularly helpful for consumers., Conclusions: These findings can inform current US Food and Drug Administration campaign efforts to support consumer use of calorie labels on menus., (Copyright © 2020 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objective: To compare federally reimbursable school meals served when competitive foods are removed and when marketing and nudging strategies are used in school cafeterias operating the National School Lunch Program (NSLP). The second objective was to determine how marketing and nudging strategies influence competitive food sales., Design: In the Healthy Choices School, all competitive foods were removed; the Healthy Nudging School retained competitive foods and promoted the school meal programme using marketing and nudging strategies; a third school made no changes. Cafeteria register data were collected from the beginning of the 2013-2014 school year through the four-week intervention. Outcome measures included daily entrées served; share of entrées served with vegetables, fruit and milk; and total competitive food sales. Difference-in-difference models were used to examine outcome measure changes., Setting: Three high schools in a diverse, Northeast US urban district with universally free meals., Participants: High-school students participating in the NSLP., Results: During the intervention weeks, the average number of entrées served daily was significantly higher in the Healthy Choices School (82·1 (se 33·9)) and the Healthy Nudging School (107·4 (se 28·2)) compared with the control school. The only significant change in meal component selection was a 6 % (se 0·02) higher rate of vegetable servings in the Healthy Choices School compared with the control school. Healthy Nudging School competitive food sales did not change., Conclusions: Both strategies - removing competitive foods and marketing and nudging - may increase school meal participation. There was no evidence that promoting school meals decreased competitive food sales.

Objective: To test an obesity prevention strategy derived from behavioural economics (optimal defaults plus delay), focused on changing the college dining hall service method., Design: After a uniform pre-load, participants attended an experimental lunch in groups randomized to one of three conditions: a nutrient-dense, lower-fat/energy lunch as an optimal default (OD); a less-nutrient-dense, higher-fat/energy lunch as a suboptimal default (SD); or a free array (FA) lunch. In the OD condition, students were presented a menu depicting healthier vegetarian and omnivore foods as default, with opt-out alternatives (SD menu) available on request with a 15 min wait. In the SD condition, the same menu format was used with the positioning of food items switched. In the FA condition, all choices were presented in uniform fonts and were available immediately., Setting: Private rooms designed to provide a small version of a college dining hall, on two campuses of a Northeastern US university., Subjects: First-year college students (n 129)., Results: There was a significant main effect for condition on percentage of optimal choices selected, with 94 % of food choices in the OD condition optimal, 47 % in the FA condition optimal and none in the SD condition optimal. Similarly, energy intake for those in the SD condition significantly exceeded that in the FA condition, which exceeded that in the OD condition., Conclusions: Presenting menu items as optimal defaults with a delay had a significant impact on choice and consumption, suggesting that further research into its long-term applicability is warranted.

Background: Previous studies document decreases in lunchtime milk consumption immediately after flavored milk is removed. Less is known about longer-term effects., Objective: Plain milk selection and consumption were measured the first year flavored milk was removed in a school district (2010 to 2011 [Time 1]) and 2 years later (2012 to 2013 [Time 2]). Four behavioral economic interventions to promote milk were tested in one school at Time 2., Design: This was a longitudinal, observational study., Participants/setting: Participants were kindergarten through grade 8 students in two schools in an urban district. Primary data were collected 10 times per school year at Time 1 and Time 2, yielding 40 days of data and 13,883 student observations. The milk promotion interventions were tested on 6 additional days., Main Outcome Measures: Outcomes were the percentage of students selecting milk at lunch, the ounces of milk consumed per carton, and the ounces of milk consumed school-wide per student., Statistical Analyses: Logistic regressions were used to assess how sex, grade, time, availability of 100% juice, and behavioral interventions affected milk selection and consumption., Results: At Time One, 51.5% of students selected milk and drank 4 oz (standard deviation=3.2 oz) per carton, indicating school-wide per-student consumption of 2.1 oz (standard deviation=3.0 oz). At Time Two, 72% of students selected milk and consumed 3.4 oz per carton (standard deviation=3.2 oz), significantly increasing the school-wide per-student consumption to 2.5 oz (standard deviation=3.1 oz). Older students and boys consumed significantly more milk. Availability of 100% fruit juice was associated with a 16-percentage point decrease in milk selection. None of the behavioral economic interventions significantly influenced selection., Conclusions: These data suggest that after flavored milk is removed from school cafeterias, school-wide per-student consumption of plain milk increases over time. In addition, the presence of 100% juice is associated with lower milk selection., (Copyright © 2018 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: In this study, we applied behavioral economics to optimize elementary school lunch choices via parent-driven decisions. Specifically, this experiment tested an optimal defaults paradigm, examining whether strategically manipulating the health value of a default menu could be co-opted to improve school-based lunch selections., Methods: The design was a randomized comparison of optimal versus suboptimal (standard) default lunch menus for all first-graders in a school district for a period of 1 week. We hypothesized that making the default lunch option healthier, while providing parents the opportunity to access and choose from the standard school menu for their child, would yield more frequent selection of healthier items than when the default option was suboptimal., Results: Overall, 127 (93%) first-grade children's families participated. Among those families randomized to receive the nutritionally optimized default menu, all but one remained with these options; of those parents randomized to the standard menu (suboptimal default), all parents remained with these options (Χ 2 = 123.06, df = 1, p < .001)., Conclusions: The mere positioning of choices, without restricting options, significantly affected which menu items the children received during the test period. Results are proof of concept for a strategy to increase health-promoting school lunch content, procedures, and policies., (© 2018, American School Health Association.)

Background: The Healthy, Hunger-Free Kids Act of 2010 (HHFKA) directed the US Department of Agriculture (USDA) to revise school meal standards. Students are most affected by efforts to improve the school food environment; yet, few studies directly include students. This study examined high school students' experiences of school meal reform to gain insight into implementation recommendations., Methods: We conducted 5 focus groups with high school students (N = 15) from high schools across 9 states. We also conducted follow-up interviews to further explore personal experiences. Focus groups and interview transcripts were coded and organized in Atlas.ti v7 by analysts, following principles of constant comparative analysis., Results: Students reported overall positive perceptions of the revised school meal standards and supported continued efforts to improve the food environment. Recommendations to improve the food environment included engaging students, focusing on the quality and palatability of meal items, moving toward scratch-cooking, and addressing cafeteria infrastructure., Conclusions: Students' recommendations point to opportunities where school districts, as well as local, state, and federal organizations can work to improve the school food environment. Their insights are directly relevant to USDA's recently released Local School Wellness Policy final rule, of which school meal standards are one provision., (© 2017, American School Health Association.)

Optimal defaults is a compelling model from behavioral economics and the psychology of human decision-making, designed to shape or "nudge" choices in a positive direction without fundamentally restricting options. The current study aimed to test the effectiveness of optimal (less obesogenic) defaults and parent empowerment priming on health-based decisions with parent-child (ages 3-8) dyads in a community-based setting. Two proof-of-concept experiments (one on breakfast food selections and one on activity choice) were conducted comparing the main and interactive effects of optimal versus suboptimal defaults, and parent empowerment priming versus neutral priming, on parents' health-related choices for their children. We hypothesized that in each experiment, making the default option more optimal will lead to more frequent health-oriented choices, and that priming parents to be the ultimate decision-makers on behalf of their child's health will potentiate this effect. Results show that in both studies, default condition, but not priming condition or the interaction between default and priming, significantly predicted choice (healthier vs. less healthy option). There was also a significant main effect for default condition (and no effect for priming condition or the interaction term) on the quantity of healthier food children consumed in the breakfast experiment. These pilot studies demonstrate that optimal defaults can be practicably implemented to improve parents' food and activity choices for young children. Results can inform policies and practices pertaining to obesogenic environmental factors in school, restaurant, and home environments., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Public health interventions must address poor diet among U.S. children, but research is needed to better understand factors influencing children's food choices. Using an online grocery store simulation, this research piloted a novel method to assess children's snack selection in a controlled but naturalistic laboratory setting, evaluate predictors of choice, and experimentally test whether promotions on food packages altered choices. Children (7-12 years, N = 61) were randomly assigned to one of three conditions: promotions on healthy products; promotions on unhealthy products; and no promotions (control). They selected from a variety of healthy and unhealthy foods and beverages and rated all products on healthfulness and taste. Promotions on food packaging did not affect snack selection in this study, but findings supported our other hypothesis that perceived taste would be the strongest predictor of food choice. Children accurately rated product healthfulness, but these ratings did not predict healthy snack choices or taste ratings for healthy or unhealthy snacks. These results suggest that interventions to improve children's food choices should focus on increasing availability of healthy options and identifying opportunities to enhance children's liking of healthy options. However, nutrition education alone is unlikely to improve children's diets. Further testing is required, but the simulated online grocery store method shows potential for measuring children's food choices., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Preschoolers do not consume whole fruit and vegetables (FVs) in recommended quantities. Two strategies to increase FV intake were tested., Methods: One Head Start preschool participated. Two variations of family-style feeding were compared to usual practice: (1) Fruits, vegetables, and milk were served before the main meal (first course); and (2) fruits, vegetables, and milk were served before the main meal and meats and grains were removed from the table after the first serving (combination). A within-subject crossover design was used to test each condition for three meals. The amount of food served and consumed was weighed and converted to Child and Adult Care Feeding Program (CACFP) standard serving sizes for analysis., Results: Eighty-five children ages 3-5 participated. The sample was 81% Hispanic with diverse racial backgrounds. Thirty percent of the children were overweight. FV consumption was at CACFP recommended levels at baseline and remained consistent across conditions. The average amount served for each meal component was at or above CACFP recommendations for all foods except milk, which was consistently served in small portions. Meat and grains servings were frequently 2-3 times larger than CACFP recommendations. Milk consumption was significantly higher in the Combined intervention for two meals. Children ate significantly less meat during the Combined intervention for one meal., Conclusions: The intervention led to significant increases in milk consumption, which was the only underconsumed meal component. These strategies should be tested with children who have lower baseline intake of FVs.

Objective: The U.S. Food and Drug Administration and Institute of Medicine are currently investigating front-of-package (FOP) food labelling systems to provide science-based guidance to the food industry. The present paper reviews the literature on FOP labelling and supermarket shelf-labelling systems published or under review by February 2011 to inform current investigations and identify areas of future research., Design: A structured search was undertaken of research studies on consumer use, understanding of, preference for, perception of and behaviours relating to FOP/shelf labelling published between January 2004 and February 2011., Results: Twenty-eight studies from a structured search met inclusion criteria. Reviewed studies examined consumer preferences, understanding and use of different labelling systems as well as label impact on purchasing patterns and industry product reformulation., Conclusions: The findings indicate that the Multiple Traffic Light system has most consistently helped consumers identify healthier products; however, additional research on different labelling systems' abilities to influence consumer behaviour is needed.

Background: Laboratory and home-based research suggest that repeated exposure to vegetables may increase consumption among children. Effectiveness of repeated exposure to vegetables has not been tested in a community-based preschool setting., Objective: This randomized controlled trial tested the hypotheses that children who are served unfamiliar vegetables repeatedly in the preschool lunch setting will increase consumption of them, and that consumption will be influenced by peer eating behaviors and parental feeding behaviors., Subjects/setting: Data were collected in two private preschools in a small northeastern city in 2007. Ninety-six children (aged 3 to 6 years) participated., Design: Schools were randomly assigned to condition. During the first 6 weeks, Preschool A served three vegetables at lunch on 10 separate occasions (ie, 30 days of exposure), while Preschool B continued routine practice. In the 7th week, schools reversed conditions and Preschool B served the vegetables for the next 6 weeks. Consumption data were collected daily in the intervention school and at baseline and post-intervention meals in the control school. PRIMARY OUTCOMES/STATISTICAL ANALYSES: Analysis of variance was used to examine the effect of vegetable exposure on vegetable intake; multilevel models were used to examine the effect of peer eating behaviors and parental feeding practices on vegetable intake., Results: Repeated exposure did not increase vegetable consumption. Greater consumption by tablemates was a significant predictor of greater vegetable consumption; across the three vegetables, 1 g of peer intake was associated with roughly a 1/5-g intake increase among the subjects. Overall, children demonstrated wide fluctuation in vegetable consumption from day to day, creating as much variability within subjects as between them., Conclusions: Further research should explore the conditions necessary for repeated exposure to increase vegetable consumption in preschool settings. Creating opportunities for young children to serve as peer models has promise as a strategy to promote vegetable consumption., (Copyright © 2012 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objective: To examine parents' beliefs about the meaning of common front-of-package nutrition-related claims on children's cereals and determine whether the claims would make them more willing to buy the cereals., Design: Parents viewed images of box fronts for children's cereals of below-average nutritional quality, as assessed by a validated nutrient profiling model. These boxes featured various nutrition-related claims including 'supports your child's immunity', 'whole grain', 'fibre', 'calcium and vitamin D' and 'organic'. Participants were provided possible meanings for these claims and asked to select any that applied with the option to write in additional meanings. They also indicated how the claim would affect their willingness to buy the product., Setting: Online survey., Subjects: Parents with children between the ages of 2 and 11 years (n 306) recruited through an online panel., Results: The majority of parents misinterpreted the meaning of claims commonly used on children's cereals. They inferred that cereals with claims were more nutritious overall and might provide specific health-related benefits for their children; and these beliefs predicted greater willingness to buy the cereals., Conclusions: These findings indicate that common front-of-package nutrition-related claims are potentially misleading, especially when placed on products with high levels of nutrients to limit (e.g. sugar, sodium) and low levels of other nutrients to encourage (e.g. fibre, protein). Additional regulation is needed to protect consumers in the USA.

Childhood obesity has become a public health epidemic, and currently a battle exists over how to frame and address this problem. This paper explores how public policy approaches can be employed to address obesity. We present the argument that obesity should be viewed as the consequence of a "toxic environment" rather than the result of the population failing to take enough "personal responsibility." In order to make progress in decreasing the prevalence of obesity, we must shift our view of obesity away from the medical model (which focuses on the individual) to a public health model (which focuses on the population). At the same time, we must be sensitive to the problem of weight bias. Potential obstacles to taking a public policy approach are identified, as well as suggestions on how to overcome them.

This pilot study tested the influence of nutrition message framing on snack choice among kindergarteners. Three classrooms were randomly assigned to watch one of the following 60s videos: (a) a gain-framed nutrition message (i.e. the positive benefits of eating apples) (n=14); (b) a loss-framed message (i.e. the negative consequences of not eating apples) (n=18); or (c) a control scene (children playing a game) (n=18). Following this, the children were offered a choice between animal crackers and an apple for their snack. Among the children who saw one of the nutrition message videos, 56% chose apples rather than animal crackers; in the control condition only 33% chose apples. This difference was statistically significant (chi2=7.56, p<0.01). These results suggest that videos containing nutritional messages may have a positive influence on children's short-term food choices.

Aim: This study aimed to assess the impact of the Supporting Wellness at Pantries (SWAP) system on client food selections at a food pantry. Subject and methods: In a pre–post comparison study design, a client-choice food pantry implemented SWAP by reorganizing its inventory to promote healthy options. Each product was ranked as "choose often" (green), "sometimes" (yellow), or "rarely" (red) based on saturated fat, sodium, and sugar. Signage was added to indicate each item's SWAP rank and healthier foods were placed at eye level. Client food baskets were assessed at time 1 (n = 121) and time 2 (n = 101). The proportions of green and red foods selected were compared using regression analyses. Results: The regression analyses showed that the proportion of green foods selected by clients increased by 11% (p < 0.001) and the proportion of red foods selected decreased by 7% (p < 0.001) after SWAP was implemented (n = 222). Conclusions: SWAP has the potential to positively shift client choices among the items available in a food pantry setting. SWAP is one component of a suite of changes to the charitable food system that have the potential to alleviate food insecurity, improve diet quality, and assist clients in managing diet-related diseases. [ABSTRACT FROM AUTHOR]

Objective: The present study examined the effect of ingredient bundles (i.e. measured ingredients with recipes) and recipe tastings as a strategy to increase the selection of healthy, target foods (kale, brown rice and whole-wheat pasta).Design: Each of the three conditions was tested once per week for three weeks. The conditions were: Treatment 1 (T1), recipe tastings only; Treatment 2 (T2), ingredient bundle plus recipe tastings; and Control, no intervention.Setting: A food pantry in Bridgeport, CT, USA.ParticipantsFood pantry clients.Results: Controlling for family size and intervention week, the likelihood of clients in T2 (n 160) selecting at least one target item compared with the Control group (n 160) was 3·20 times higher for kale, 4·76 times higher for brown rice and 7·25 times higher for whole-wheat pasta. Compared with T1 (n 128), T2 clients were 2·67 times more likely to select kale, 7·67 times more likely to select brown rice and 11·43 times more likely to select whole-wheat pasta. No differences between T1 and the Control group were found.Conclusions: Findings suggest that innovative, nudging strategies such as ingredient bundles may increase appeal of foods and encourage pantry clients to select healthier options. [ABSTRACT FROM AUTHOR]

Objective: Appetite regulation is influenced by the environment, and the environment is shaped by food-related policies. This review summarizes the environment and policy research portion of an NIH Workshop (Bethesda, MD, 2015) titled "Self-Regulation of Appetite-It's Complicated."Methods: In this paper, we begin by making the case for why policy is an important tool in efforts to improve nutrition, and we introduce an ecological framework that illustrates the multiple layers that influence what people eat. We describe the state of the science on how policies influence behavior in several key areas: the federal food programs, schools, child care, food and beverage pricing, marketing to youth, behavioral economics, and changing defaults. Next, we propose novel approaches for multidisciplinary prevention and intervention strategies to promote breastfeeding, and examine interactions between psychology and the environment.Results: Policy and environmental change are the most distal influences on individual-level appetite regulation, yet these strategies can reach many people at once by changing the environment in which food choices are made. We note the need for more research to understand compensatory behavior, reactance, and how to effectively change social norms.Conclusions: To move forward, we need a more sophisticated understanding of how individual psychological and biological factors interact with the environment and policy influences. [ABSTRACT FROM AUTHOR]

Objective: To assess potential misperceptions among parents regarding the healthfulness of sugary drinks for their children.Design: Online survey of parents. Participants identified the categories and specific brands of sugary drinks they provided for their children. They also indicated their perceptions of sugary drink categories and brands as healthy options for children, perceived importance of on-package claims in purchase decisions and their concerns about common sugary drink ingredients.Setting: Online market research panel.Subjects: Parents (n 982) of 2- to 17-year-olds, 46 % non-white or Hispanic.Results: Ninety-six per cent of parents provided on average 2·9 different categories of sugary drinks for their children in the past month. Flavoured waters, fruit drinks and sports drinks were rated as the healthiest sugary drink categories. Across all categories and brands, parents who purchased specific products rated them as significantly healthier than those who did not (P<0·05). Over half of parents reported concern about caffeine, sugar and artificial sweeteners in sugary drinks that their children consume and approximately one-third reported that on-package ingredient claims were important in their purchase decisions.Conclusions: Nearly all parents provide sugary drinks for their children and many believe that some sugary drinks are healthy options for children, particularly flavoured waters, fruit drinks and sports drinks. Furthermore, many parents rely upon on-package claims in their purchase decisions. Given excessive consumption of added sugar by children in the home, there is a continuing need to address parents' misperceptions about the healthfulness of many sugary drink products. [ABSTRACT FROM AUTHOR]

Abstract Objective To compare beverages and foods selected by high school students on days when juice was offered (juice days) and not offered (non-juice days) with the reimbursable school meal. Methods Lunch register data from 386 days across 3 low-income Northeast high schools were used to compare juice and non-juice days for average daily selections of meal components and à la carte water and 100% juice sales. Results On juice days, 9.9% fewer milks (P <.01) and 7.4% fewer fruits (P <.01) were selected with lunches. In addition, on juice days, 8.2% fewer bottles of water and 24.4% fewer bottles of 100% juice were sold à la carte (P <.05). Conclusions and Implications Reducing juice availability in the reimbursable school lunch may increase selection of milk and fruit. Future research is warranted to assess how juice availability influences selection of milk, fruit, and water across a range of student populations. [ABSTRACT FROM AUTHOR]

The US food banking network serves about 46.5 million individuals with food insecurity yearly. People living with food insecurity are at risk of diet-related chronic diseases and evidence suggests that foods available in food pantries are mostly nutritionally poor. In response, the Supporting Wellness at Pantries (SWAP) system ranks food into green, yellow, and red categories based on the levels of saturated fat, sodium, and sugar. SWAP is designed to increase the supply and demand for healthy food in pantries. To assess the nutritional quality of clients' selections before and after implementing the SWAP system. Availability of green, yellow, and red items was captured pre- and post-intervention using a pantry inventory assessment. For the intervention, foods in the pantry were rearranged by SWAP ranking and signage was added to educate clients about which items to choose often (green), sometimes (yellow), or rarely (red). Two-hundred twenty-two clients participated in the pre-post study. Clients' selections were recorded and the proportion of green and red selections in total and per food group were calculated. Primary analyses compared the proportion of green and red foods chosen by clients before and after SWAP implementation using independent t-tests. A regression model was used to compare clients' selection pre to post while controlling for food pantry inventory. There was not a significant change in the overall pantry inventory over time. However, the proportion of healthy (ie, green) food selections significantly increased and less healthy (ie, red) food selections significantly decreased. The overall improvement in nutritional quality of the clients' carts remained significant while controlling for the pantry inventory. Results suggest that nutrition information provided through stoplight signage and clear messages on items to choose often, sometimes, and rarely can shift client choices in the pantry setting. [ABSTRACT FROM AUTHOR]