Investigating differences between traditional (paper bag) ordering and online ordering from primary school canteens: a cross-sectional study comparing menu, usage and lunch order characteristics.

OBJECTIVE: To assess differences between traditional paper bag ordering and online ordering from primary school canteens in terms of menu, usage and lunch order characteristics. DESIGN: A cross-sectional study. SETTING: New South Wales (NSW) primary schools that offered both paper bag and online canteen ordering. PARTICIPANTS: Students (aged 5-12 years) with a lunch order on the day of the observation. RESULTS: Across the six school canteens, 59-90 % of all available items were listed on both the online and paper menus, with no significant differences in the nutritional quality ('Everyday'/'Occasional') or nutritional content (kJ/saturated fat/sugar/sodium) of menu items. In total, 387 student lunch orders were placed, containing 776 menu items. Most orders (68 %) were placed online. There were no significant differences between order modality in the quantity of items ordered or the cost of orders, or the nutritional quality of orders based on the classification system of the NSW Healthy School Canteen Strategy ('Everyday'/'Occasional'). However, nutritional analysis revealed that paper bag orders contained 222 fewer kJ than online orders (P = 0·001), 0·65 g less saturated fat (P = 0·04) and 4·7 g less sugar (P < 0·001). CONCLUSIONS: Online canteens are commonly used to order canteen lunches for primary school children. This is the first study to investigate differences between traditional paper bag ordering and online ordering in this setting. Given the rapid increase in the use of online ordering systems in schools and other food settings and their potential to deliver public health nutrition interventions, additional research is warranted to further investigate differences in ordering modalities.

Long-term Effectiveness of a Multistrategy Behavioral Intervention to Increase the Nutritional Quality of Primary School Students' Online Lunch Orders: 18-Month Follow-up of the Click & Crunch Cluster Randomized Controlled Trial.

BACKGROUND: School food services, including cafeterias and canteens, are an ideal setting in which to improve child nutrition. Online canteen ordering systems are increasingly common and provide unique opportunities to deliver choice architecture strategies to nudge users to select healthier items. Despite evidence of short-term effectiveness, there is little evidence regarding the long-term effectiveness of choice architecture interventions, particularly those delivered online. OBJECTIVE: This study determined the long-term effectiveness of a multistrategy behavioral intervention (Click & Crunch) embedded within an existing online school lunch-ordering system on the energy, saturated fat, sugar, and sodium content of primary school students' lunch orders 18 months after baseline. METHODS: This cluster randomized controlled trial (RCT) involved a cohort of 2207 students (aged 5-12 years) from 17 schools in New South Wales, Australia. Schools were randomized to receive either a multistrategy behavioral intervention or the control (usual online ordering only). The intervention strategies ran continuously for 14-16.5 months until the end of follow-up data collection. Trial primary outcomes (ie, mean total energy, saturated fat, sugar and sodium content of student online lunch orders) and secondary outcomes (ie, the proportion of online lunch order items that were categorized as everyday, occasional, and caution) were assessed over an 8-week period at baseline and 18-month follow-up. RESULTS: In all, 16 schools (94%) participated in the 18-month follow-up. Over time, from baseline to follow-up, relative to control orders, intervention orders had significantly lower energy (-74.1 kJ; 95% CI [-124.7, -23.4]; P=.006) and saturated fat (-0.4 g; 95% CI [-0.7, -0.1]; P=.003) but no significant differences in sugar or sodium content. Relative to control schools, the odds of purchasing everyday items increased significantly (odds ratio [OR] 1.2; 95% CI [1.1, 1.4]; P=.009, corresponding to a +3.8% change) and the odds of purchasing caution items significantly decreased among intervention schools (OR 0.7, 95% CI [0.6, 0.9]; P=.002, corresponding to a -2.6% change). There was no between-group difference over time in canteen revenue. CONCLUSIONS: This is the first study to investigate the sustained effect of a choice architecture intervention delivered via an online canteen ordering systems in schools. The findings suggest that there are intervention effects up to 18-months postbaseline in terms of decreased energy and saturated fat content and changes in the relative proportions of healthy and unhealthy food purchased for student lunches. As such, this intervention approach may hold promise as a population health behavior change strategy within schools and may have implications for the use of online food-ordering systems more generally; however, more research is required. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000855224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075.

Effectiveness of a Multistrategy Behavioral Intervention to Increase the Nutritional Quality of Primary School Students' Web-Based Canteen Lunch Orders (Click & Crunch): Cluster Randomized Controlled Trial.

BACKGROUND: 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. OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. TRIAL REGISTRATION: 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.

A Cluster Randomized Controlled Trial Evaluating the Impact of Tailored Feedback on the Purchase of Healthier Foods from Primary School Online Canteens.

Few online food ordering systems provide tailored dietary feedback to consumers, despite suggested benefits. The study aim was to determine the effect of providing tailored feedback on the healthiness of students' lunch orders from a school canteen online ordering system. A cluster randomized controlled trial with ten government primary schools in New South Wales, Australia was conducted. Consenting schools that used an online canteen provider ('Flexischools') were randomized to either: a graph and prompt showing the proportion of 'everyday' foods selected or a standard online ordering system. Students with an online lunch order during baseline data collection were included (n = 2200 students; n = 7604 orders). Primary outcomes were the proportion of foods classified as 'everyday' or 'caution'. Secondary outcomes included: mean energy, saturated fat, sugar, and sodium content. There was no difference over time between groups on the proportion of 'everyday' (OR 0.99; p = 0.88) or 'caution' items purchased (OR 1.17; p = 0.45). There was a significant difference between groups for average energy content (mean difference 51 kJ; p-0.02), with both groups decreasing. There was no difference in the saturated fat, sugar, or sodium content. Tailored feedback did not impact the proportion of 'everyday' or 'caution' foods or the nutritional quality of online canteen orders. Future research should explore whether additional strategies and specific feedback formats can promote healthy purchasing decisions.

Cluster randomised controlled trial of an online intervention to improve healthy food purchases from primary school canteens: a study protocol of the 'click & crunch' trial.

INTRODUCTION: School canteens are the most frequently accessed take-away food outlet by Australian children. The rapid development of online lunch ordering systems for school canteens presents new opportunities to deliver novel public health nutrition interventions to school-aged children. This study aims to assess the effectiveness and cost-effectiveness of a behavioural intervention in reducing the energy, saturated fat, sugar and sodium content of online canteen lunch orders for primary school children. METHODS AND ANALYSIS: The study will employ a cluster randomised controlled trial design. Twenty-six primary schools in New South Wales, Australia, that have an existing online canteen ordering system will be randomised to receive either a multi-strategy behavioural intervention or a control (the standard online canteen ordering system). The intervention will be integrated into the existing online canteen system and will seek to encourage the purchase of healthier food and drinks for school lunch orders (ie, items lower in energy, saturated fat, sugar and sodium). The behavioural intervention will use evidence-based choice architecture strategies to redesign the online menu and ordering system including: menu labelling, placement, prompting and provision of feedback and incentives. The primary trial outcomes will be the mean energy (kilojoules), saturated fat (grams), sugar (grams) and sodium (milligrams) content of lunch orders placed via the online system, and will be assessed 12 months after baseline data collection. ETHICS AND DISSEMINATION: The study was approved by the ethics committees of the University of Newcastle (H-2017-0402) and the New South Wales Department of Education and Communities (SERAP 2018065), and the Catholic Education Office Dioceses of Sydney, Parramatta, Lismore, Maitland-Newcastle, Bathurst, Canberra-Goulburn, Wollongong, Wagga Wagga and Wilcannia-Forbes. Study results will be disseminated through peer-reviewed publications, reports, presentations at relevant national and international conferences and via briefings to key stakeholders. Results will be used to inform future implementation of public health nutrition interventions through school canteens, and may be transferable to other food settings or online systems for ordering food. TRIAL REGISTRATION NUMBER: ACTRN12618000855224.