摘要：Objectives. We assessed whether a 2-phase labeling and choice architecture intervention would increase sales of healthy food and beverages in a large hospital cafeteria. Methods. Phase 1 was a 3-month color-coded labeling intervention (red = unhealthy, yellow = less healthy, green = healthy). Phase 2 added a 3-month choice architecture intervention that increased the visibility and convenience of some green items. We compared relative changes in 3-month sales from baseline to phase 1 and from phase 1 to phase 2. Results. At baseline (977 793 items, including 199 513 beverages), 24.9% of sales were red and 42.2% were green. Sales of red items decreased in both phases ( P < .001), and green items increased in phase 1 ( P < .001). The largest changes occurred among beverages. Red beverages decreased 16.5% during phase 1 ( P < .001) and further decreased 11.4% in phase 2 ( P < .001). Green beverages increased 9.6% in phase 1 ( P < .001) and further increased 4.0% in phase 2 ( P < .001). Bottled water increased 25.8% during phase 2 ( P < .001) but did not increase at 2 on-site comparison cafeterias ( P < .001). Conclusions. A color-coded labeling intervention improved sales of healthy items and was enhanced by a choice architecture intervention. New public health strategies are needed to combat the rising prevalence of obesity. A major contributor to obesity is the consumption of energy-dense food purchased outside the home. 1,2 Interventions targeting the point of purchase have the potential to reduce obesity at the population level. 3–5 Menu labeling with calories is a policy that has been gaining public and legislative support since 2006 and will soon be mandated as part of the Patient Protection and Affordable Health Care Act for restaurants and food vendors with more than 20 locations. 3,6–9 However, listing calorie information is effective only if consumers understand how to interpret it. 10 Previous research has demonstrated that the ability to correctly interpret nutrition information requires not only high literacy but also high numeracy skills. 11 Evidence for the effectiveness of calorie labeling has been equivocal, 12–18 and one study of a low-income, minority population in New York City found no effect of calorie labeling on food purchases. 17 Information-based labeling policies were created with the assumption that, given calorie information, consumers will make a rational choice by choosing lower calorie options. 19,20 However, behavioral economists and psychologists have identified decision biases that explain why individuals often make choices, such as overeating, leading to poor health outcomes. 19,21 Patterns of behavior that may play a role in poor nutrition choices include individuals’ tendency to stay with the usual or default option, to be motivated by actions with immediate benefit, and to be less motivated by actions with long-term benefit as well as limitations of self-control. 19,20 “Choice architecture” refers to the framing or presentation of choice options. 21 Strategies to change choice architecture by setting specific default choices have been successful in increasing individuals’ retirement savings and organ donations. 22,23 One study demonstrated that changing the location of healthy sandwiches to the front page of a menu was more effective than was providing calories. 16 We conducted a 2-phase food-labeling intervention that addressed low nutritional literacy and decision biases during 6 months in a large hospital cafeteria. Phase 1 was a simple color-coded labeling intervention of food and beverages. Phase 2 was a choice architecture intervention to increase visibility and convenience of healthy items in the cafeteria. We compared the change in sales of healthy and unhealthy items from baseline to phase 1 and from phase 1 to phase 2.
