JMIR Publications

ABSTRACT

Background:

School food outlets including cafeterias and canteens play an important role in children’s nutrition and represent a key setting for public health nutrition intervention. The recent proliferation of online food ordering systems provides a unique opportunity to support healthy purchasing from school canteens. Embedding evidence-based choice architecture strategies within these routinely used systems provides the opportunity to impact the purchasing decision of many people simultaneously at low cost and warrants investigation

Objective:

The study aim was to assess the effectiveness of a multi-strategy behavioral intervention, implemented via an online school canteen lunch ordering system, in reducing the energy, saturated fat, sugar, and sodium content of primary school students’ online lunch orders.

Methods:

: The study employed a parallel group, cohort, cluster randomized controlled trial design with 2,207 students from 17 primary schools in New South Wales, Australia. Schools with an online canteen lunch ordering system were randomly assigned to receive either a multi-strategy behavioral intervention which included choice-architecture strategies (menu-labelling, positioning, prompting, feedback and incentives) embedded in the online system (N=9 schools) or a control which received the standard online ordering system only (N=8 schools). Intervention fidelity was assessed quarterly. Student purchasing data that were automatically collected by the online system at baseline (Term 2, 2018) and 12-months later (Term 2, 2019) were used to assess trial outcomes. Primary trial outcomes included the mean energy (kJ), saturated fat (g), sugar (g) and sodium (mg) content of student lunch orders, and secondary outcomes included the proportion of all online lunch order items that were classified as ‘Everyday’, ‘Occasional’; and ‘Caution’ (based on the NSW Healthy School Canteen Strategy) and canteen revenue.

Results:

Analysis of purchasing data indicated that, from baseline to follow-up, intervention lunch orders had significantly lower energy (-69.4kJ; 95% CI -119.6, -19.1; P=.010) and saturated fat content (-0.6g; 95% CI -0.9, -0.4; P <.001) compared to control lunch orders, but not significantly lower sugar or sodium content. Relative to control schools, intervention schools had significantly greater odds of having ‘Everyday’ items purchased (OR: 1.7, P<.001) corresponding to a 9.8% increase in ‘Everyday’ items, and lower odds of having ‘Occasional’ items purchased (OR: 0.7, P<.001; corresponding to a 7.7% decrease in ‘Occasional’ items).

Conclusions:

This cluster RCT found that using an online canteen lunch ordering system to deliver choice architecture strategies was effective in improving the healthiness of student lunch orders. Given evidence of its effectiveness, acceptability and wide reach, this intervention has potential to influence dietary choices at a population level, and further research is warranted to determine its impact when implemented at scale. Clinical Trial: This trial was prospectively registered at anzctr.org.au as ACTRN12618000855224.