Andrew S. Hanks

Pre-Sliced Fruit in School Cafeterias: Children's Selection and Intake

BACKGROUND It is often assumed that children avoid fruit in school cafeterias because of higher relative prices and preferences for other foods. Interviews with children reveal that eating whole fresh fruit can be difficult for those with small mouths or braces. Older girls find whole fruits messy and unattractive to eat. PURPOSE To determine the effect of offering pre-sliced fruit in schools on selection and intake. DESIGN Three of six schools were assigned randomly to serve apples in slices. Three control schools served apples whole. Selection, consumption, and waste of apples were measured prior to and during treatment. SETTING/PARTICIPANTS Cafeterias in six public middle schools in Wayne County NY in 2011. Participants included all students who purchased lunch on days when data were collected. INTERVENTION Treatment schools were provided with a standard commercial fruit slicer, and cafeteria staff members were instructed to use it when students requested apples. Trained researchers recorded how much of each apple was consumed and how much was wasted in both control and treatment schools. MAIN OUTCOME MEASURES Daily apple sales, percentage of an apple serving consumed per student, and percentage of an apple serving wasted per student. RESULTS Data were analyzed in 2012. Schools that used fruit slicers to pre-slice fruit increased average daily apple sales by 71% compared to control schools (p<0.01). The percentage of students who selected apples and ate more than half increased by 73% (p=0.02) at schools that served pre-sliced fruit, and the percentage that wasted half or more decreased by 48% (p=0.03). CONCLUSIONS Sliced fruit is more appealing to children than whole fruit because it is easier and tidier to eat. This study applies the principle of convenience from behavioral economics and provides an example of a scalable, low-cost environmental change that promotes healthy eating and decreases waste.

Reliability and Accuracy of Real-Time Visualization Techniques for Measuring School Cafeteria Tray Waste: Validating the Quarter-Waste Method

Measuring food waste is essential to determine the impact of school interventions on what children eat. There are multiple methods used for measuring food waste, yet it is unclear which method is most appropriate in large-scale interventions with restricted resources. This study examines which of three visual tray waste measurement methods is most reliable, accurate, and cost-effective compared with the gold standard of individually weighing leftovers. School cafeteria researchers used the following three visual methods to capture tray waste in addition to actual food waste weights for 197 lunch trays: the quarter-waste method, the half-waste method, and the photograph method. Inter-rater and inter-method reliability were highest for on-site visual methods (0.90 for the quarter-waste method and 0.83 for the half-waste method) and lowest for the photograph method (0.48). This low reliability is partially due to the inability of photographs to determine whether packaged items (such as milk or yogurt) are empty or full. In sum, the quarter-waste method was the most appropriate for calculating accurate amounts of tray waste, and the photograph method might be appropriate if researchers only wish to detect significant differences in waste or consumption of selected, unpackaged food.

Slim by Design: Serving Healthy Foods First in Buffet Lines Improves Overall Meal Selection

Objective Each day, tens of millions of restaurant goers, conference attendees, college students, military personnel, and school children serve themselves at buffets – many being all-you-can-eat buffets. Knowing how the food order at a buffet triggers what a person selects could be useful in guiding diners to make healthier selections. Method The breakfast food selections of 124 health conference attendees were tallied at two separate seven-item buffet lines (which included cheesy eggs, potatoes, bacon, cinnamon rolls, low-fat granola, low-fat yogurt, and fruit). The food order between the two lines was reversed (least healthy to most healthy, and vise-versa). Participants were randomly assigned to choose their meal from one line or the other, and researchers recorded what participants selected. Results With buffet foods, the first ones seen are the ones most selected. Over 75% of diners selected the first food they saw, and the first three foods a person encountered in the buffet comprised 66% of all the foods they took. Serving the less healthy foods first led diners to take 31% more total food items (p<0.001). Indeed, diners in this line more frequently chose less healthy foods in combinations, such as cheesy eggs and bacon (r = 0.47; p<0.001) or cheesy eggs and fried potatoes (r = 0.37; p<0.001). This co-selection of healthier foods was less common. Conclusions Three words summarize these results: First foods most. What ends up on a buffet diner’s plate is dramatically determined by the presentation order of food. Rearranging food order from healthiest to least healthy can nudge unknowing or even resistant diners toward a healthier meal, helping make them slim by design. Health-conscious diners, can proactively start at the healthier end of the line, and this same basic principle of “first foods most” may be relevant in other contexts – such as when serving or passing food at family dinners.

Preordering School Lunch Encourages Better Food Choices by Children

Nearly 1/3 of children between ages 6 and 19 are considered obese and their choosing of less healthy foods in school lunchrooms may contribute. To encourage students to select healthier foods, recent research has focused on how environmental changes and behavioral economics can guide children to make healthier choices. This includes the pre-ordering of lunch. Pre-ordering could pre-empt hunger-based, spontaneous selections and eliminate the sensory cues – evocative smells and sights – that lead to less healthy choices. We examine whether having students pre-order their entree (main dish) improves the healthfulness of entrees selected for lunch.

Calorie reductions and within-meal calorie compensation in children's meal combos: Within-Meal Compensation

What happens if a fast‐food restaurant chain lowers the calories in a childrens meal bundle (CMB), mainly by reducing the portion size of French fries? This study examines how such changes may influence within‐meal selections. Specifically, do lower‐calorie changes lead to within‐meal calorie compensation?

Chocolate Milk Consequences: A Pilot Study Evaluating the Consequences of Banning Chocolate Milk in School Cafeterias

Objectives Currently, 68.3% of the milk available in schools is flavored, with chocolate being the most popular (61.6% of all milk). If chocolate milk is removed from a school cafeteria, what will happen to overall milk selection and consumption? Methods In a before-after study in 11 Oregon elementary schools, flavored milk–which will be referred to as chocolate milk–was banned from the cafeteria. Milk sales, school enrollment, and data for daily participation in the National School Lunch Program (NSLP) were compared year to date. Results Total daily milk sales declined by 9.9% (p<0.01). Although white milk increased by 161.2 cartons per day (p<0.001), 29.4% of this milk was thrown away. Eliminating chocolate milk was also associated with 6.8% fewer students eating school lunches, and although other factors were also involved, this is consistent with the notion of psychological reactance. Conclusions Removing chocolate milk from school cafeterias may reduce calorie and sugar consumption, but it may also lead students to take less milk overall, drink less (waste more) of the white milk they do take, and no longer purchase school lunch. Food service managers need to carefully weigh the costs and benefits of eliminating chocolate milk and should consider alternative options that make white milk more convenient, attractive, and normal to choose.

Slim by Design Kitchen Counter Correlates of Obesity

Background. The home is one place where people can control what foods are available and how the environment is arranged. Given the impact of environments on health, the objective of this study is to determine whether the presence of foods on a person’s kitchen counter are associated with their body mass index (BMI). Method. In Study 1, a nationwide sample of 500 households was asked to inventory their kitchen and provide their height and weight. In Study 2, researchers photographed and catalogued 210 households in Syracuse, New York, and measured the occupants’ height and weight. Main outcome measures for the study were BMI differences between households that had various foods visible on the counter compared with those that did not. Findings. The presence of fruit on the counter was associated with lower BMI in both studies, but the presence of foods such as candy, cereal, soft drinks, and dried fruit were associated with weight differences that ranged from 9.4 to 14.4 kg. Interpretations. Although correlational, the findings from these two studies suggest that when counseling patients regarding their weight, physicians also suggest they clear their kitchen counter of all food except a fruit bowl.

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.

Trigger Foods: The Influence of “Irrelevant” Alternatives in School Lunchrooms

Rational choice theory commonly assumes that the presence of unselected choices cannot impact which among the remaining choices is selected—often referred to as “independence of irrelevant alternatives.” We show that such seemingly irrelevant alternatives influence choice in a school lunch setting. In these lunchrooms, we provide evidence that the presence of specific side dishes—trigger foods—can strongly increase the sales of unhealthy à la carte options, even when the trigger foods are not selected. This behavioral anomaly can be exploited to lead children to healthier choices. We also offer a method that can be used to identify such foods.

Chefs Move to Schools: A Pilot Examination of How Chef-Created Dishes Can Increase School Lunch Participation and Fruit and Vegetable Intake

To demonstrate the feasibility of introducing a main dish designed by a professional chef in the National School Lunch Program and to document the impact on child participation, a chef was recruited to design pizza to be served in an upstate New York school district. The pizza was designed to meet both the cost and ingredient requirements of the NSLP. High school students were significantly more likely to select the pizza prepared by the chef. While the chef had no significant impact on main dish consumption given selection, more students took a vegetable and vegetable consumption increased by 16.5%. This pilot study demonstrates the plausibility of using chefs to boost participation in the school lunch program, and potentially increase nutrition through side selection, among high school students.