School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
Hunter New England Population Health, Wallsend, New South Wales, Australia.
J Med Internet Res. 2021 Sep 7;23(9):e26054. doi: 10.2196/26054.
School food outlets represent a key setting for public health nutrition intervention. The recent proliferation of web-based food ordering systems provides a unique opportunity to support healthy purchasing from schools. Embedding evidence-based choice architecture strategies within these routinely used systems provides the opportunity to impact the purchasing decisions of many users simultaneously and warrants investigation.
This study aims to assess the effectiveness of a multistrategy behavioral intervention implemented via a web-based school canteen lunch ordering system in reducing the energy, saturated fat, sugar, and sodium content of primary students' web-based lunch orders.
The study used a parallel-group, cohort, cluster randomized controlled trial design with 2207 students from 17 Australian primary schools. Schools with a web-based canteen lunch ordering system were randomly assigned to receive either a multistrategy behavioral intervention that included choice architecture strategies embedded in the web-based system (n=9 schools) or the standard web-based ordering system only (n=8 control schools). Automatically collected student purchasing data 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. Secondary outcomes included the proportion of all web-based lunch order items classified as everyday, occasional, and caution (based on the New South Wales Healthy School Canteen Strategy) and canteen revenue.
From baseline to follow-up, the intervention lunch orders had significantly lower energy content (-69.4 kJ, 95% CI -119.6 to -19.1; P=.01) and saturated fat content (-0.6 g, 95% CI -0.9 to -0.4; P<.001) than the control lunch orders, but they did not have significantly lower sugar or sodium content. There was also a small significant between-group difference in the percentage of energy from saturated fat (-0.9%, 95% CI -1.4% to -0.5%; P<.001) but not in the percentage of energy from sugar (+1.1%, 95% CI 0.2% to 1.9%; P=.02). Relative to control schools, intervention schools had significantly greater odds of having everyday items purchased (odds ratio [OR] 1.7, 95% CI 1.5-2.0; P<.001), corresponding to a 9.8% increase in everyday items, and lower odds of having occasional items purchased (OR 0.7, 95% CI 0.6-0.8; P<.001), corresponding to a 7.7% decrease in occasional items); however, there was no change in the odds of having caution (least healthy) items purchased (OR 0.8, 95% CI 0.7-1.0; P=.05). Furthermore, there was no change in schools' revenue between groups.
Given the evidence of small statistically significant improvements in the energy and saturated fat content, acceptability, and wide reach, this intervention has the potential to influence dietary choices at a population level, and further research is warranted to determine its impact when implemented at scale.
Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000855224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-030538.
学校食品店是公共卫生营养干预的重要场所。最近，基于网络的食品订购系统的激增为支持学校的健康购买提供了一个独特的机会。在这些常用系统中嵌入基于证据的选择架构策略有机会同时影响许多用户的购买决策，值得研究。
本研究旨在评估通过基于网络的学校食堂午餐订购系统实施的多策略行为干预措施在降低小学生基于网络的午餐订单的能量、饱和脂肪、糖和钠含量方面的有效性。
本研究采用了平行组、队列、聚类随机对照试验设计，共有来自澳大利亚 17 所小学的 2207 名学生参与。具有基于网络的食堂午餐订购系统的学校被随机分配接受多策略行为干预，包括基于网络系统的选择架构策略（n=9 所学校）或仅接受标准基于网络的订购系统（n=8 所对照学校）。在基线（2018 年第 2 学期）和 12 个月后（2019 年第 2 学期）自动收集学生购买数据，用于评估试验结果。主要试验结果包括学生午餐订单的平均能量（kJ）、饱和脂肪（g）、糖（g）和钠（mg）含量。次要结果包括所有基于网络的午餐订单项目被归类为日常、偶尔和谨慎（基于新南威尔士州健康学校食堂策略）的比例以及食堂收入。
从基线到随访，干预组的午餐订单的能量含量（-69.4 kJ，95%CI -119.6 至 -19.1；P=.01）和饱和脂肪含量（-0.6 g，95%CI -0.9 至 -0.4；P<.001）均显著低于对照组的午餐订单，但糖或钠含量没有显著降低。组间还存在一个小的、有统计学意义的差异，即饱和脂肪摄入百分比（-0.9%，95%CI -1.4% 至 -0.5%；P<.001），而糖摄入百分比（+1.1%，95%CI 0.2% 至 1.9%；P=.02）则没有。与对照组学校相比，干预学校购买日常食品的可能性显著增加（优势比[OR] 1.7，95%CI 1.5-2.0；P<.001），对应日常食品的购买量增加了 9.8%，而购买偶尔食品的可能性降低（OR 0.7，95%CI 0.6-0.8；P<.001），对应偶尔食品的购买量减少了 7.7%；然而，购买谨慎（最不健康）食品的可能性没有变化（OR 0.8，95%CI 0.7-1.0；P=.05）。此外，两组学校的收入没有变化。
鉴于在能量和饱和脂肪含量、可接受性和广泛覆盖方面有统计学意义的小改善的证据，该干预措施有可能在人群层面上影响饮食选择，进一步的研究是必要的，以确定其在大规模实施时的影响。
澳大利亚和新西兰临床试验注册中心（ANZCTR）ACTRN12618000855224；https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075.
国际注册报告标识符（IRRID）：RR2-10.1136/bmjopen-2019-030538.
