Our results demonstrate that a simple color-coded labeling intervention increased sales of healthy items and decreased sales of unhealthy items in a large hospital cafeteria. A choice architecture intervention that improved the visibility and convenience of healthy items further improved the effectiveness of labeling. By addressing low nutrition literacy and decision biases with our intervention, we saw significant improvements in food and beverage choices of cafeteria patrons over the 6-month period.
Menu labeling with calories is a public health policy that has already been implemented insome US cities and will soon be required by federal law.8,9
The evidence for the effectiveness of this policy is unclear. Some studies suggest that consumers purchase slightly fewer calories with calorie labeling,12–15
whereas others have shown no change in calories purchased.12,16–18
Most studies rely on cross-sectional designs and register receipts, self-report, or direct observation.
Reading and understanding nutrition labels is a complex task.10,11
Even highly literate consumers may have difficulty interpreting labels because of low numeracy skills.11
Interpreting the meaning of caloric information on a menu requires an understanding of one’stotal caloric needs, an accurate estimation of a serving size, and adequate time at the point of purchase to consider and act on the information. Phase 1 of our intervention tested a simplified labeling scheme. Although this scheme provided the consumer with less precise information than does calorie labeling, it conveyed complex information in a way that could be easily understood and acted on immediately. The effectiveness of this system was most striking for beverage sales, with red beverages decreasing 16.5% and green beverages increasing 9.6%.
Any information-based labeling intervention, however, does not account for decision biases inherent in many individuals’ health behaviors.19,20
Phase 2 of our study tested whether changing the choice architecture by rearranging the presentation of the food or beverage options would increase healthier choices. The strongest example of the effectiveness of this intervention was the increase in bottled water purchases. During phase 1, bottled water remained in 2 refrigerators that were not centrally located in the cafeteria (), and despite the green label, there was a slight decrease in sales. During phase 2, bottles of water were placed in every refrigerator in the cafeteria at eye level as well as in baskets near several of the food stations (), and water sales increased 25.8%. By making water the default choice, the choice architecture reduced the likelihood that patrons would be tempted by sugared beverages that were less prominently displayed but still available for purchase.
The consumption of sugar-sweetened beverages in the United States has increased dramatically in recent decades, and there is strong epidemiologic evidence for the association between sugared beverages and poor health outcomes, including obesity, diabetes, and heart disease.25–28
By phase 2, the cafeteria sold 238 fewer red beverages per day and 190 fewer regular sodas. Although our study does not examine individual-level data, significant changes in the beverage habits of employees who visit the cafeteria regularly could translate into health benefits over time.
A limitation of this study is that there was no control cafeteria. However, we were able to compare sales data for some items at 2 on-site cafeterias that had no intervention, and the changes in the intervention cafeteria were significantly different from those of the comparison cafeterias. We were not able to create a washout period after phase 2 to assess the effectiveness of a choice architecture–only intervention because the changes to the menu boards and displays in the cafeteria for the Choose Well, Eat Well program were designed as permanent changes to the cafeteria. Another limitation to this study is that we could not assess longitudinal change for individuals over time.
This study demonstrated the effectiveness of a labeling and choice architecture intervention in promoting healthy food and beverage choices in a large hospital cafeteria. Without changing the price or selection, we saw significant increases in healthy choices that were sustained over a 6-month period. Our results suggest that a simple information-based nutrition intervention is effective and is enhanced by an additional intervention that takes decision biases into account. In the future, these types of interventions could be integrated with menu calorie labeling to improve the reach and effectiveness of this policy.