What Do Secondary Schools Need to Create Healthier Canteens? The Development of an Implementation Plan.

Introduction: The Netherlands Nutrition Centre developed guidelines to improve the availability and accessibility of healthier food products in Dutch canteens. This paper describes the development of an implementation plan to facilitate implementation of Guidelines for Healthier Canteens in Dutch secondary schools. Materials and Methods: In cooperation with stakeholders (i.e., school/caterer managers/employees, school canteen advisors, researchers) and based on theory, we developed an implementation plan in three steps. First, we identified factors that impede/facilitate stakeholders to create a healthier school canteen during 14 interviews. Second, 25 experts discussed and prioritized these identified factors in an expert meeting. Third, we translated these factors into tools to be included in the implementation plan, by making use of behavior change taxonomies and evidence-based implementation strategies. Results: The plan aims to support stakeholders in implementing healthier school canteens and consists of five tools: (1) tailored advice based on an online questionnaire to assess schools' and stakeholders' context and the Canteen Scan (i.e., an online tool to assess the availability and accessibility of food/drink products); (2) communication materials with information and examples; (3) online community for support by sharing experiences/questions; (4) digital newsletter as reminder/support; (5) fact sheet with students' needs/wishes to tailor the canteen. Discussion: This study illustrates how collaboration between science, policy and practice resulted in a tailored implementation plan aimed to support schools to adhere to school canteen policy. This development serves as a good example for researchers, health promotion policymakers, and practitioners how to create an implementation plan that fits the needs of stakeholders.

The Effect of Supportive Implementation of Healthier Canteen Guidelines on Changes in Dutch School Canteens and Student Purchase Behaviour.

We developed an implementation plan including several components to support implementation of the "Guidelines for Healthier Canteens" in Dutch secondary schools. This study evaluated the effect of this plan on changes in the school canteen and on food and drink purchases of students. In a 6 month quasi-experimental study, ten intervention schools (IS) received support implementing the guidelines, and ten control schools (CS) received only the guidelines. Changes in the health level of the cafeteria and vending machines were assessed and described. Effects on self-reported purchase behaviour of students were analysed using mixed logistic regression analyses. IS scored higher on healthier availability in the cafeteria (77.2%) and accessibility (59.0%) compared to CS (60.1%, resp. 50.0%) after the intervention. IS also showed more changes in healthier offers in the cafeteria (range -3 to 57%, mean change 31.4%) and accessibility (range 0 to 50%, mean change 15%) compared to CS (range -9 to 46%, mean change 9.7%; range -30 to 20% mean change 7% resp.). Multi-level logistic regression analyses on the intervention/control and health level of the canteen in relation to purchase behaviour showed no relevant relations. In conclusion, the offered support resulted in healthier canteens. However, there was no direct effect on students' purchase behaviour during the intervention.

Implementation of Guidelines for Healthier Canteens in Dutch Secondary Schools: A Process Evaluation.

The Netherlands Nutrition Centre has developed 'Guidelines for Healthier Canteens'. To facilitate their implementation, implementation tools were developed: stakeholders' questionnaires, the 'Canteen Scan' (an online tool to assess product availability/accessibility), a tailored advisory meeting/report, communication materials, establishment of an online community, newsletters, and a fact sheet with students' wishes/needs. In this quasi-experimental study, we investigated the effect of these tools in secondary schools on (a) factors perceived by stakeholders as affecting implementation; (b) the quality of implementation. For six months, ten intervention schools implemented the guidelines, supported by the developed implementation tools. Ten control schools received the guidelines without support. School managers, caterers, and canteen employees (n = 33) reported on individual and environmental factors affecting implementation. Implementation quality was determined by dose delivered, dose received, and satisfaction. Stakeholders (n = 24) in intervention schools scored higher on the determinants' knowledge and motivation and lower on need for support (p < 0.05). Dose received (received and read) and satisfaction was highest for the advisory meeting/report (67.9%, 64.3%, 4.17), communication materials (60.7%, 50.0%, 3.98), and fact sheet (80%, 60%, 4.31). Qualitative analyses confirmed these quantitative results. In conclusion, a combination of implementation tools that includes students' wishes, tailored information/feedback, reminders and examples of healthier products/accessibility supports stakeholders in creating a healthier school canteen.

Development and Evaluation of the Implementation of Guidelines for Healthier Canteens in Dutch Secondary Schools: Study Protocol of a Quasi-Experimental Trial.

Introduction: To encourage healthier food/drink choices, the "Guidelines for Healthier Canteens" were developed by the Netherlands Nutrition Centre. This paper describes (1) how we developed a plan to support implementation of the "Guidelines for Healthier Canteens" in Dutch secondary schools, and (2) how we will evaluate this plan on process and effect level. Materials and Methods: The implementation plan (consisting of several tools) was developed in cooperation with stakeholders. Barriers/facilitators to implement the guidelines were identified by 14 interviews and prioritized during one expert meeting. Thereafter, these barriers were translated into implementation tools using behavioral change methods and implementation strategies. The implementation plan consists of the tools: tailored advice provided via an advisory meeting and report, based on a questionnaire about the stakeholders'/school's context and the "Canteen Scan," an online tool to assess the product availability and accessibility; communication materials; an online community; newsletters; a factsheet with students' wishes/needs. This implementation plan will be evaluated on process and effect in a 6-month quasi-experimental controlled design with 10 intervention and 10 matched control schools. Process outcomes will be measured: (1) factors affecting implementation and (2) the quality of implementation, both collected via a questionnaire among involved stakeholders. Effect outcomes will be collected pre/post-intervention with: (1) self-reported purchase behavior among around 100 students per school; (2) the "health level" of the school canteen. Linear and linear/logistic two-level regression analyses will be performed. Discussion: The implementation tools are developed by combining a theory and practice-based approach, with input from different stakeholders. If these tools are evaluated positive, it will support schools/stakeholders to create a healthier school canteen. Trial Registration: Dutch Trial register no.: NTR5922, date of registration June 20, 2016; METC no.: 2015.331; EMGO+ project number: WC2015-008.

'I've worked so hard, I deserve a snack in the worksite cafeteria': A focus group study.

This study obtained insight in motivation regarding food choices of Dutch employees, especially when visiting the worksite cafeteria. We also aimed to know why employees visit the worksite cafeteria. These insights are useful for intervention development to encourage healthier purchases in worksite cafeterias. We conducted seven focus groups among 45 employees of seven Dutch companies. The topics were 1) drivers and motives for food selection; 2) motives for visiting the worksite cafeteria; 3) motives for food selection in the worksite cafeteria; 4) perceptions of healthiness of products in the worksite cafeteria and 5) solutions brought up by the employees to encourage healthier eating. Thematic analyses were conducted with MAXQDA software. Qualitative analyses revealed that this group of Dutch employees mentioned 'healthiness', 'price' and 'taste' as most important drivers food selection. These employees generally visit the worksite cafeteria to have a break from their work setting. Healthiness played a less important role in visiting or making food choices in the worksite cafeteria. Reasons for buying unhealthy food items were being tempted and the feeling to 'deserve' it. In order to choose healthier foods employees suggested a bigger offer of healthy food options, providing knowledge, changing prices and prominent placing of healthy foods. This focus group study shows that drivers for food selection can differ from motives for visiting the worksite cafeteria and when choosing food there. Health is important for food choice in general, but less important in the worksite cafeteria. The results of this study could be used in the development of strategies that aim to change people's food choice behavior.

Nudging and social marketing techniques encourage employees to make healthier food choices: a randomized controlled trial in 30 worksite cafeterias in The Netherlands.

Background: Currently, many studies focus on how the environment can be changed to encourage healthier eating behavior, referred to as choice architecture or "nudging." However, to date, these strategies are not often investigated in real-life settings, such as worksite cafeterias, or are only done so on a short-term basis. Objective: The objective of this study is to examine the effects of a healthy worksite cafeteria ["worksite cafeteria 2.0" (WC 2.0)] intervention on Dutch employees' purchase behavior over a 12-wk period. Design: We conducted a randomized controlled trial in 30 worksite cafeterias. Worksite cafeterias were randomized to either the intervention or control group. The intervention aimed to encourage employees to make healthier food choices during their daily worksite cafeteria visits. The intervention consisted of 14 simultaneously executed strategies based on nudging and social marketing theories, involving product, price, placement, and promotion. Results: Adjusted multilevel models showed significant positive effects of the intervention on purchases for 3 of the 7 studied product groups: healthier sandwiches, healthier cheese as a sandwich filling, and the inclusion of fruit. The increased sales of these healthier meal options were constant throughout the 12-wk intervention period. Conclusions: This study shows that the way worksite cafeterias offer products affects purchase behavior. Situated nudging and social marketing-based strategies are effective in promoting healthier choices and aim to remain effective over time. Some product groups only indicated an upward trend in purchases. Such an intervention could ultimately help prevent and reduce obesity in the Dutch working population. This trial was registered at the Dutch Trial Register (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5372) as NTR5372.

Using nudging and social marketing techniques to create healthy worksite cafeterias in the Netherlands: intervention development and study design.

BACKGROUND: The worksite cafeteria is a suitable setting for interventions focusing on changing eating behavior, because a lot of employees visit the worksite cafeteria regularly and a variety of interventions could be implemented there. The aim of this paper is to describe the intervention development and design of the evaluation of an intervention to make the purchase behavior of employees in the worksite cafeteria healthier. The developed intervention called "the worksite cafeteria 2.0" consists of a set of 19 strategies based on theory of nudging and social marketing (marketing mix). The intervention will be evaluated in a real-life setting, that is Dutch worksite cafeterias of different companies and with a number of contract catering organizations. METHODS/DESIGN: The study is a randomized controlled trial (RCT), with 34 Dutch worksite cafeterias randomly allocated to the 12-week intervention or to the control group. Primary outcomes are sales data of selected products groups like sandwiches, salads, snacks and bread topping. Secondary outcomes are satisfaction of employees with the cafeteria and vitality. DISCUSSION: When executed, the described RCT will provide better knowledge in the effect of the intervention "the worksite cafeteria 2.0" on the purchasing behavior of Dutch employees in worksite cafeterias. TRIAL REGISTRATION: Dutch Trial register: NTR5372 .

'I don't have to go to the gym because I ate very healthy today': the development of a scale to assess diet-related compensatory health beliefs.

OBJECTIVE: Nutritional interventions to decrease energy intake, aimed at portion sizes and front-of-package labelling, are effective only if people do not compensate for their reduced energy intake. Since several observational studies indicate that these interventions could prompt compensation behaviour, it is important to assess underlying beliefs. Therefore, the purpose of the two studies reported here was to develop a Diet-related Compensatory Health Beliefs Scale (Diet-CHBS). DESIGN: Cross-sectional surveys were conducted for the scale development. Study 1 provided data on the factor analysis and convergent validity, while Study 2 assessed the Diet-CHBS' test-retest reliability. Settings VU University Amsterdam (Study 1) and twenty-five worksite cafeterias in the Netherlands (Study 2). SUBJECTS: Study 1 was conducted among 179 students and their parents; Study 2 was conducted among 119 worksite cafeteria visitors. RESULTS: The results of Study 1 showed that the scale consisted of the hypothesized factors of compensation beliefs with regard to portion sizes (α = 0·73), front-of-package health logos (α = 0·77) and exercise (α = 0·75). The scale's overall Cronbach's α was 0·82. The Diet-CHBS had a Pearson correlation of 0·32 with a general health compensatory beliefs scale, signifying satisfactory convergent validity. Study 2 showed that the intra-class correlation coefficient between T1 and T2 was 0·69, indicating adequate test-retest reliability. CONCLUSION: The Diet-CHBS is a valid and reliable instrument for assessing diet-related compensatory health beliefs in response to nutritional interventions. It is important to take such beliefs into account in further intervention studies aimed at preventing overweight and obesity.

Methodological quality of front-of-pack labeling studies: a review plus identification of research challenges.

This review evaluates the methodological quality of current front-of-pack labeling research and discusses future research challenges. Peer-reviewed articles were identified using a computerized search of the databases PubMed and Web of Science (ISI) from 1990 to February 2011; reference lists from key published articles were used as well. The quality of the 31 included studies was assessed. The results showed that the methodological quality of published front-of-pack labeling research is generally low to mediocre; objective observational data-based consumer studies were of higher quality than consumer studies relying on self-reports. Experimental studies that included a control group were lacking. The review further revealed a lack of a validated methodology to measure the use of front-of-pack labels and the effects of these labels in real-life settings. In conclusion, few methodologically sound front-of-pack labeling studies are presently available. The highest methodological quality and the greatest public health relevance are achieved by measuring the health effects of front-of-pack labels using biomarkers in a longitudinal, randomized, controlled design in a real-life setting.

A nutrition labeling intervention in worksite cafeterias: an implementation evaluation across two large catering companies in the Netherlands.

By both increasing the availability of healthy foods and labeling these products with the Choices logo, caterers may facilitate employees to make a healthier choice in their worksite cafeterias. The aim of this study was to explore which attributes influence the implementation of the Choices logo in worksite cafeterias in the Netherlands. Questionnaires were completed by catering managers of 316 cafeterias of two large caterers in the Netherlands (response rate 49.8%). Attributes from the Diffusion of Innovations Theory were used to investigate whether they could predict implementation. Compatibility (consistency with the beliefs of the catering manager; OR = 1.52), voluntariness (perception of the implementation as voluntary; OR = 0.50), result demonstrability (ability to communicate the implementation; OR = 1.52) and complexity in the sense of time (time needed for implementation; OR = 0.70) were the best predictors for the frequency of offering fresh Choices products (all significant). For the frequency of using Choices promotion material, voluntariness (OR = 0.54), result demonstrability (OR = 1.51) and relative advantage (perceived advantage of the implementation; OR = 1.44) were the best predictors (all significant). In conclusion, this study provides unique insights into which perceived attributes influence the implementation of a nutrition logo in worksite cafeterias. To increase the implementation, the Choices logo should be consistent with catering managers' ideas about healthy food, the workload of implementing the logo should be limited and it could be recommended to incorporate the logo in the health policy of the caterer.

Influence of placement of a nutrition logo on cafeteria menu items on lunchtime food Choices at Dutch work sites.

This study investigated the effectiveness of labeling foods with the Choices nutrition logo on influencing cafeteria menu selection and the behavioral determinants of menu choices in work site cafeterias in the Netherlands. A cluster randomized controlled trial was conducted. Intervention cafeterias (n=13), where the Choices logo was used to promote healthier eating for a 3-week period, were compared with control cafeterias (n=12), which offered the same menu without the logo. Sales data were collected daily for 9 weeks, from March to May 2009. In addition, employees from one intervention and one control company completed an online questionnaire at baseline and after the intervention (n=368) in which the behavioral determinants of food choice (ie, attitude, self-efficacy, and intention) and logo use were measured. Generalized estimating equation analyses, χ² tests, t tests and linear regression analyses were performed. No nutritionally meaningful intervention effects were found in the sales of sandwiches, soups, snacks, fruit, and salads. Also, no significant differences in behavioral determinants were found. "Intention to eat healthier" and "paying attention to product information" were positively associated with self-reported consumption of foods with the Choices logo at lunch. The intervention did not have a significant effect on employees' lunchtime food choices. Labeling healthy choices might be useful for health-conscious employees in the volitional phase of behavior change. Further research should focus on the possible health benefits of menu reformulation in the catering sector.

Front-of-pack nutrition label stimulates healthier product development: a quantitative analysis.

BACKGROUND: In addition to helping consumers make healthier food choices, front-of-pack nutrition labels could encourage companies to reformulate existing products and develop new ones with a healthier product composition. This is the largest study to date to investigate the effect of a nutrition logo on the development of healthier products by food manufacturers. METHODS: A total of 47 food manufacturers joining the Choices Foundation in the Netherlands (response: 39.5%) indicated whether their Choices products were newly developed, reformulated or already complied with the Choices criteria and provided nutrient composition data for their products (n = 821; 23.5% of the available Choices products in August 2009). RESULTS: Most products carrying the logo as a result of reformulation and new product development were soups and snacks. Sodium reduction was the most common change found in processed meats, sandwiches, soups and sandwich fillings. Dietary fiber was significantly increased in most newly developed Choices product groups; for example, in fruit juices, processed meats, dairy products, sandwiches and soups. Saturated fatty acids (SAFA) and added sugar were significantly decreased both in reformulated and newly developed dairy products. Caloric content was significantly decreased only in reformulated dairy products, sandwich fillings and in some newly developed snacks. CONCLUSIONS: The results indicate that the Choices logo has motivated food manufacturers to reformulate existing products and develop new products with a healthier product composition, especially where sodium and dietary fiber are concerned.

Actual use of a front-of-pack nutrition logo in the supermarket: consumers' motives in food choice.

OBJECTIVE: A front-of-pack nutrition logo on products with relatively favourable product compositions might help consumers to make more healthful choices. Studies investigating actual nutrition label use in point-of-purchase settings are scarce. The present study investigates the use of the 'Choices' nutrition logo in Dutch supermarkets. DESIGN: Adults were asked to complete a validated questionnaire about motivation for food choice and their purchased products were scored for the Choices logo after they had done their shopping. SETTING: Nine supermarkets in The Netherlands. SUBJECTS: A total of 404 respondents participated. RESULTS: Of the respondents, 62 % reported familiarity with the logo. The motivations for food choice that were positively associated with actually purchasing products with the logo were attention to 'weight control' and 'product information'. The food choice motive 'hedonism' was negatively associated with purchasing products with the logo. CONCLUSIONS: This is the first study to investigate actual use of the Choices logo. In order to stimulate consumers to purchase more products with a favourable product composition, extra attention should be paid to hedonistic aspects such as the tastefulness and the image of healthy products.

A front-of-pack nutrition logo: a quantitative and qualitative process evaluation in the Netherlands.

This study aimed to perform a quantitative and qualitative process evaluation of the introduction of the Choices logo, a front-of-pack nutrition logo on products with a favorable product composition, adopted by many food producers, retail and food service organizations, conditionally endorsed by the Dutch government, validated by scientists, and in the process of international dissemination. An online questionnaire was sent to adult consumers 4 months after the introduction of the logo (n = 1,032) and 1 year later (n = 1,127). Additionally, seven consumer focus groups (n = 41) were conducted to provide more insight into the questionnaire responses. Quantitative analyses showed that exposure to the logo had significantly increased. Elderly and obese respondents reported to be more in need of a logo than younger and normal-weight individuals. Women perceived the logo more attractive and credible than men did. Further qualitative analyses indicated that the logo's credibility would improve if it became known that governmental and scientific authorities support it. Elderly respondents indicated that they needed a logo due to health concerns. Consumers interested in health reported that they used the logo. Further research focusing on specific target groups, forming healthful diets, and health outcomes is needed to investigate the effectiveness of the Choices logo.