Do Behavioral Interventions Increase the Intake of Biofortified Foods in School Lunch Meals? Evidence from a Field Experiment with Elementary School Children in Ethiopia.

BACKGROUND: Many African countries are seeking to improve nutrition by introducing biofortified foods in school feeding programs. These programs are generally designed to create demand for biofortified foods both in and outside of school. Finding ways to encourage child acceptance of novel biofortified foods is key to the success of this strategy. OBJECTIVES: The aim was to assess effects of 2 behavioral interventions in promoting the consumption of biofortified foods as part of school lunch meals. METHODS: The study is based on a field experiment involving 360 school-going children of in the third, fourth, and sixth grades. We tested if structured provision of information about the nutritional benefits of a biofortified food and its association with an aspirational figure influence its consumption when served alongside a favorite local food as part of school lunch meal. Six schools in Tigray, Ethiopia, were randomly selected to participate, with 4 participating in the Orange-Fleshed Sweetpotato (OFSP) Program. Of the 4 participating in the program, 2 were assigned to provide educational information about sweetpotato, whereas 2 presented the same information plus depictions of an aspirational figure (a famous local athlete) associated with the sweetpotato. RESULTS: Provision of information on the nutritional benefits of biofortified food combined with an aspirational figure resulted in increased consumption of biofortified food by children. However, provision of the information alone did not detectably increase consumption. An analysis of trends over the course of the study revealed no discernable decay effect. CONCLUSIONS: Our results highlight the potential for relatively inexpensive behavioral interventions to increase acceptance of novel biofortified foods among children in a developing-country context. Larger studies with more varied interventions and larger numbers of participating schools could address several of the weaknesses in this study and establish more robust findings.

Enhancing measures of ESE to incorporate aspects of place: Personal reputation and place-based social legitimacy.

We argue that existing measures of entrepreneurial self-efficacy (ESE) are underspecified in the context of tight-knit communities, where personal reputation plays a major role. We propose a new place-based ESE dimension that measures assessment by individuals of their ability to elicit respect from their community. This integral ESE component points to the very meaning of entrepreneurship in highly relational contexts. Although our enhanced ESE measure incorporates some influences of place, other aspects, such as geographical context, continue to moderate the relationship between ESE and entrepreneurial aptitude. We conclude with a discussion of the relevance and utility of this enhanced measure.

Methodological Challenges in Estimating the Lifetime Medical Care Cost Externality of Obesity.

There is a great deal of variability in estimates of the lifetime medical care cost externality of obesity, partly due to a lack of transparency in the methodology behind these cost models. Several important factors must be considered in producing the best possible estimate, including age-related weight gain, differential life expectancy, identifiability, and cost model selection. In particular, age-related weight gain represents an important new component to recent cost estimates. Without accounting for age-related weight gain, a study relies on the untenable assumption that people remain the same weight throughout their lives, leading to a fundamental misunderstanding of the evolution and development of the obesity crisis. This study seeks to inform future researchers on the best methods and data available both to estimate age-related weight gain and to accurately and consistently estimate obesity's lifetime external medical care costs. This should help both to create a more standardized approach to cost estimation as well as encourage more transparency between all parties interested in the question of obesity's lifetime cost and, ultimately, evaluating the benefits and costs of interventions targeting obesity at various points in the life course.

Predicted Lifetime Third-Party Costs of Obesity for Black and White Adolescents with Race-Specific Age-Related Weight Gain.

OBJECTIVE: There exists enormous variation in estimates of the lifetime cost of adolescent obesity by race. To justify policy measures to reduce obesity rates nationally in this demographic, the costs of obesity in late adolescence must first be discerned. Although several researchers have sought to quantify obesity's true cost, none has accounted for race-specific age-related weight gain, a vital component in producing an accurate estimate. METHODS: This paper employs a Markov model of BMI category state changes separately for black and white males and females from age 18 to 75 applied to updated estimates of obesity's costs and effect on mortality to quantify the median lifetime cost of obesity at age 18. RESULTS: This study found lower lifetime costs than previously, largely because of the dramatic gain in weight among normal-weight individuals, particularly black males, that occurs in early adulthood. CONCLUSIONS: A substantial portion of obesity's prevalence, and therefore cost, for black males and females comes from age-related weight gain in early adulthood. This speaks to the persistent threat of obesity beyond adolescence for this demographic, and further research should focus on whether policy can modify the behaviors and environment through which and in which this sharp increase in weight occurs.

"Big men" in the office: The gender-specific influence of weight upon persuasiveness.

Height has been closely studied as a factor that influences myriad measures of leadership; however, the potential influence of weight on socially beneficial traits has been neglected. Using the anthropological concept of "big men" who relied on influence to lead their communities, we examine the role of weight upon persuasiveness. We present the results of six studies that suggest a tendency for raters to expect larger body mass to correspond with more persuasiveness among men. In the sixth, pre-registered study, we find evidence that fits the hypothesis that weight among men is positively associated with perceived persuasiveness. While the "big man" leadership concept is based on studies of pre-industrial societies where weight embodied status, our findings suggest an evolved bias to favor moderately big men-with respect to perceived persuasiveness-even in environments where there is no reason to interpret over-consumption of food and conservation of energy as a signal of wealth. Our studies contribute novel perspectives on the relevance of weight as an understudied dimension of "big" and offer an important qualification informed by evolutionary perspectives for the stigmatizing effects of relatively large body mass.

Understanding the effect of producers' attitudes, perceived norms, and perceived behavioral control on intentions to use antimicrobials prudently on New York dairy farms.

Understanding farmers' behavior, motivations, and perceptions toward antimicrobial use can influence how veterinarians translate research into practice and guide effective ways of implementing protocols. A multidisciplinary team investigated behavioral tendencies of New York dairy farmers toward antimicrobial use by administering a survey modeled with the reasoned action approach. This approach is a framework from social psychology containing the constructs attitude, perceived norms, and perceived behavioral control, and is used in combination with structural equation modeling to determine what drives intentions. Multiple indicators and multiple causes (MIMIC) models were then used to determine the effects of beliefs on their underlying constructs. The objective of the study was to provide direct and indirect measures of the constructs using survey data to determine importance of and associations with intention to use antimicrobials prudently. The structural equation model indicated that perceived behavioral control explained intention. Thus, farmers who feel capable of prudent use expressed positive intentions. Attitude and perception of others also had influence to a lesser extent. MIMIC models showed that the most important attributes of instrumental attitude were increasing profitability, decreasing risk of residues, and increasing herd health. Contributing attributes of affective attitude were job satisfaction, decreasing resistance, and increasing milk production. For perceived norms, the attributes were opinions/approval of family and peers, veterinarians, and milk processors. Finally, for perceived behavioral control, attributes focused on saving money on labor and treatment, ability to fit into the daily routine, and effectiveness with veterinary guidance. In conclusion, the best approach for adoption of practices might be presentation of examples of successful strategies by other producers, particularly in peer groups. In addition, veterinarians should provide the tools and guidance needed to produce economic gain, reduction of risks associated with residues and resistance, and positive experiences when using the tactics.

Fruit-Promoting Smarter Lunchrooms Interventions: Results From a Cluster RCT.

INTRODUCTION: The Smarter Lunchrooms Movement was developed to provide schools with simple, low-cost solutions to encourage students to make healthier food choices at school. The objective of this study was to evaluate the impact of fruit-promoting Smarter Lunchroom interventions on middle school students' selection and consumption of fruits. DESIGN: A 9-week cluster RCT was conducted using a pre-test/post-test control group design in upstate New York in February-April 2014. SETTING/PARTICIPANTS: Ten middle schools (Grades 5-8) were recruited and randomized into a fruit intervention (n=4), vegetable intervention (n=3), or control group (n=3). This article focuses only on the fruit intervention and control groups. INTERVENTION: The fruit intervention group made changes to the convenience, visibility, and attractiveness of fruit in their lunchrooms for a period of 6 weeks. The control group made no changes, and were offered Smarter Lunchrooms training post-intervention. MAIN OUTCOME MEASURES: Selection and plate waste data were collected from February to April 2014, and analyzed in 2014-2015. Average selection, waste, and consumption of food items were computed, and the statistical differences between treatment and control groups were analyzed using t-test statistics and difference-in-difference analysis. RESULTS: Fruit selection increased overall by 36% (p<0.001), and fruit consumption increased overall by 23% (p<0.017). Vegetable selection and consumption and white milk selection also increased significantly in the treatment schools (p<0.001), though were not significant overall. CONCLUSIONS: The fruit intervention increased the selection and consumption of fruits overall, and increased the selection and consumption of vegetables and the selection of white milk in treatment schools. These findings provide evidence supporting the use of fruit-promoting Smarter Lunchrooms techniques in middle schools to increase the selection and consumption of healthy food items.

Appetite self-regulation: Environmental and policy influences on eating behaviors.

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.

Healthy Concessions: High School Students' Responses to Healthy Concession Stand Changes.

BACKGROUND: A previous sales data analysis demonstrated success in selling healthier items at a concession stand. Questions remained regarding student satisfaction and whether the intervention reached non-health-conscious students. METHODS: Cross-sectional anonymous samples of students at a large midwestern high school were surveyed before and after an intervention improved the number of healthier items available at the concession stand. RESULTS: The survey was completed by 301 students preintervention and 314 students postintervention. Satisfaction remained good (3.7 preintervention and 3.6 postintervention). Satisfaction with the variety and taste of foods increased. We compared students who felt having healthy items were important at the concessions to those who did not. Overall satisfaction with concessions did not differ between groups. The latter group (healthy items not important) reported improved satisfaction with food variety (2.8 to 3.1, p = .02) and the former reported improved satisfaction with healthy foods (2.5 to 2.9, p = .03) and overall taste (3.2 to 3.4, p = .02). Of the healthy items not important students 76% reported purchasing at least 1 new healthier food. CONCLUSIONS: Adding healthier foods to school concession stands has positive effects on student satisfaction, sales, and reaches all students whether or not they care about having healthy items available.

Who's adopting the smarter lunchroom approach? Individual characteristics of innovative food service directors.

School cafeterias and, subsequently, food service directors (FSDs) play a vital role in feeding children in the U.S. This study investigates which FSDs with different characteristics and organizational affiliations are most willing to embrace and implement new programs in their cafeterias. In 2014 we surveyed a representative sample of 8143 school FSDs across the U.S. regarding their knowledge and use of innovative methods that encourage children to select healthy food options. Nearly all of the surveyed FSDs (93%) are aware of behavioral strategies to promote healthier eating in school lunchrooms, and nearly 93% report having made at least one change in their lunchroom. Male FSDs are more likely to be aware of new programs, though they are less likely to adopt them relative to female FSDs. In addition, membership in a professional organization increases awareness as well as the number of changes made by 0.14 (p<0.01). Finally, 22% of all respondents say they know about the Smarter Lunchrooms approach, a set of research-based lunchroom behavioral strategies that positively influence children to select healthy foods. The findings highlight the importance of participation in professional associations which provide career-building activities for school FSDs increasing awareness and adoption of innovative approaches to motivate children to eat the nutritious foods. Given these findings, there is reason for policy makers and school districts to consider allocating funds to encourage FSDs to engage more fully in professional association meetings and activities.

Food pantry selection solutions: a randomized controlled trial in client-choice food pantries to nudge clients to targeted foods.

Background: Food pantries and food banks are interested in cost-effective methods to encourage the selection of targeted foods without restricting choices. Thus, this study evaluates the effectiveness of nudges toward targeted foods. Methods: In October/November 2014, we manipulated the display of a targeted product in a New York State food pantry. We evaluated the binary choice of the targeted good when we placed it in the front or the back of the category line (placement order) and when we presented the product in its original box or unboxed (packaging). Results: The average uptake proportion for the back treatment was 0.231, 95% CI = 0.179, 0.29, n = 205, and for the front treatment, the proportion was 0.337, 95% CI = 0.272, 0.406, n = 238 with an odds ratio of 1.688, 95% CI = 1.088, 2.523. The average uptake for the unboxed treatment was 0.224, 95% CI = 0.174, 0.280, n = 255, and for the boxed intervention, the proportion was 0.356, 95% CI = 0.288, 0.429, n = 188 with an odds ratio of 1.923, 95% CI = 1.237, 2.991. Conclusions: Nudges increased uptake of the targeted food. The findings also hold when we control for a potential confounder. Low cost and unobtrusive nudges can be effective tools for food pantry organizers to encourage the selection of targeted foods. Trial Registration Number: NCT02403882.

Marketing Vegetables in Elementary School Cafeterias to Increase Uptake.

OBJECTIVES: Children do not eat enough servings of vegetables, underscoring the need for effective interventions encouraging this behavior. The purpose of this research was to measure the impact that daily exposure to branded vegetable characters has on vegetable selection among boys and girls in elementary schools. METHODS: In a large urban school district, 10 elementary schools agreed to participate in the study. They were randomly assigned to a control condition or 1 of 3 treatment conditions: (1) a vinyl banner displaying vegetable characters that was fastened around the base of the salad bar; (2) short television segments with health education delivered by vegetable characters; or (3) a combination of the vinyl banner and television segments. We collected 22 206 student-day observations over a 6-week period by tallying the number of boys and girls taking vegetables from the school's salad bar. RESULTS: Results show that 90.5% (from 12.6% to 24.0%; P = .04) more students took vegetables from the salad bar when exposed to the vinyl banner only, and 239.2% (from 10.2% to 34.6%; P < .001) more students visited the salad bar when exposed to both the television segments and vinyl banners. Both boys and girls responded positively to the vinyl banners (P < .05 in both cases). CONCLUSIONS: Evidence from this study highlights the positive impact of branded media on children's vegetable selection in the school cafeteria. Results from this study suggest potential opportunities for using branded media to encourage healthier choices for children.

The limits of defaults: why french fries trump apple slices.

BACKGROUND: Healthy default food choices have been suggested as a way to encourage better nutrition without restricting choice. Will they work with children and their favorite foods? METHODS: A group of children, 6-8 years old, were treated to lunch at fast food restaurant on 2 days 2 weeks apart. On both days the children were served chicken nuggets and a drink. On the first day, half were given French fries unless they asked for apple slices and the other half were given apples unless they asked for fries. The order switched on the second day. RESULTS: When the default changed from fries to apples, 86.7 % opted out of the default to order fries. CONCLUSION: Defaults may be ineffective when children have a strong preference for the less healthy option. Allowing children to take both sides may lead to healthier consumption than constructing an artificial default choice.

Trayless cafeterias lead diners to take less salad and relatively more dessert.

OBJECTIVE: Many colleges are removing trays from their dining facilities in hope of reducing waste. How does not having a tray impact food choice? DESIGN: A field study was conducted in a university cafeteria (n 417) on two evenings with identical menus, one with tray service and one without. SETTING: A dining hall of a large north-eastern university, USA. SUBJECTS: Undergraduate students. RESULTS: Trayless dining decreased the percentage of diners (average age 19.1 years) who took salad by 65.2% but did not decrease the percentage who took dessert, leading to a markedly higher ratio of dessert to salad. CONCLUSIONS: Cafeterias going trayless should consider complementary policies to encourage balanced diets.

A plant to plate pilot: a cold-climate high school garden increased vegetable selection but also waste.

AIM: Can high school gardens in cold climates influence vegetable intake in the absence of nutrition education? METHODS: This study followed a before/after design where student tray-waste data were collected using the quarter-waste method. The study took place March-April 2012 in a high school in upstate New York. The subjects were 370 enrolled high school students that purchased lunch from the school cafeteria. Prior to the introduction of garden greens in the salad, salads were served as usual. On April 24, harvested greens were included in the salad, and changes in selection and plate waste were measured. RESULTS: When the salad bar contained garden produce, the percentage of students selecting salad rose from 2% to 10% (p < 0.001), and on average, students ate two-thirds of the serving they took. Although waste increased relative to the control (from 5.56% to 33.33% per serving; p = 0.007), more students were consuming at least some salad. CONCLUSION: This preliminary investigation suggests that school gardens increased selection and intake of school-raised produce. Although a third was not eaten, it is promising to see that still more produce was consumed compared to the past.