Lillian Sonnenberg

A 2-Phase Labeling and Choice Architecture Intervention to Improve Healthy Food and Beverage Choices

OBJECTIVES We assessed whether a 2-phase labeling and choice architecture intervention would increase sales of healthy food and beverages in a large hospital cafeteria. METHODS Phase 1 was a 3-month color-coded labeling intervention (red = unhealthy, yellow = less healthy, green = healthy). Phase 2 added a 3-month choice architecture intervention that increased the visibility and convenience of some green items. We compared relative changes in 3-month sales from baseline to phase 1 and from phase 1 to phase 2. RESULTS At baseline (977,793 items, including 199,513 beverages), 24.9% of sales were red and 42.2% were green. Sales of red items decreased in both phases (P < .001), and green items increased in phase 1 (P < .001). The largest changes occurred among beverages. Red beverages decreased 16.5% during phase 1 (P < .001) and further decreased 11.4% in phase 2 (P < .001). Green beverages increased 9.6% in phase 1 (P < .001) and further increased 4.0% in phase 2 (P < .001). Bottled water increased 25.8% during phase 2 (P < .001) but did not increase at 2 on-site comparison cafeterias (P < .001). CONCLUSIONS A color-coded labeling intervention improved sales of healthy items and was enhanced by a choice architecture intervention.

Traffic-Light Labels and Choice Architecture Promoting Healthy Food Choices

BACKGROUND Preventing obesity requires maintenance of healthy eating behaviors over time. Food labels and strategies that increase visibility and convenience of healthy foods (choice architecture) promote healthier choices, but long-term effectiveness is unknown. PURPOSE Assess effectiveness of traffic-light labeling and choice architecture cafeteria intervention over 24 months. DESIGN Longitudinal pre-post cohort follow-up study between December 2009 and February 2012. Data were analyzed in 2012. SETTING/PARTICIPANTS Large hospital cafeteria with a mean of 6511 transactions daily. Cafeteria sales were analyzed for (1) all cafeteria customers and (2) a longitudinal cohort of 2285 hospital employees who used the cafeteria regularly. INTERVENTION After a 3-month baseline period, cafeteria items were labeled green (healthy); yellow (less healthy); or red (unhealthy) and rearranged to make healthy items more accessible. MAIN OUTCOME MEASURES Proportion of cafeteria sales that were green or red during each 3-month period from baseline to 24 months. Changes in 12- and 24-month sales were compared to baseline for all transactions and transactions by the employee cohort. RESULTS The proportion of sales of red items decreased from 24% at baseline to 20% at 24 months (p<0.001), and green sales increased from 41% to 46% (p<0.001). Red beverages decreased from 26% of beverage sales at baseline to 17% at 24 months (p<0.001); green beverages increased from 52% to 60% (p<0.001). Similar patterns were observed for the cohort of employees, with the largest change for red beverages (23%-14%, p<0.001). CONCLUSIONS A traffic-light and choice architecture cafeteria intervention resulted in sustained healthier choices over 2 years, suggesting that food environment interventions can promote long-term changes in population eating behaviors.

Clinical and Cost Outcomes of Medical Nutrition Therapy for Hypercholesterolemia: A Controlled Trial

OBJECTIVE To compare the results and cost-effectiveness of a cholesterol lowering protocol implemented by registered dietitians with cholesterol lowering advice by physicians. DESIGN Six month randomized controlled trial, cost-effectiveness analysis. Subjects included 90 ambulatory care patients (60 men, 30 women), age range 21 to 65 years, with hypercholesterolemia and not taking hypolipidemic drugs. Patients were randomly assigned to receive medical nutrition therapy (MNT) from dietitians using a NCEP based lowering protocol or usual care (UC) from physicians. Outcome measures were plasma lipid profiles, dietary intake, weight, activity, patient satisfaction, and costs of MNT. Changes from baseline for each variable of interest were compared between treatment groups using analysis of covariance controlling for baseline value of the variable and gender. RESULTS MNT achieved a 6% decrease in total and LDL cholesterol levels at 3 and 6 months compared with a 1% increase and a 2% decrease in both values at 3 and 6 months with UC (P<.001 and P<.05, respectively). Weight loss (1.9 vs 0 kg, P<.001) and dietary intake of saturated fat (7% of energy vs 10%, P<.001) were better in the MNT than the UC group. The additional costs of MNT were

Prevention of Weight Gain Following a Worksite Nutrition and Exercise Program: A Randomized Controlled Trial

217 per patient to achieve a 6% reduction in cholesterol and

Diet and plasma lipids in women. II. Macronutrients and plasma triglycerides, high-density lipoprotein, and the ratio of total to high-density lipoprotein cholesterol in women: The Framingham Nutrition Studies

98 per patient to sustain the reduction. The cost-effectiveness ratio for MNT was

Diet and plasma lipids in women. I. Macronutrients and plasma total and low-density lipoprotein cholesterol in women: The Framingham Nutrition Studies

36 per 1% decrease in cholesterol and LDL level. APPLICATIONS/CONCLUSIONS MNT from registered dietitians is a reasonable investment of resources because it results in significantly better lipid, diet, activity, weight, and patient satisfaction outcomes than UC.

Dietary predictors of serum cholesterol in men: The framingham cohort population

BACKGROUND Many employers are now providing wellness programs to help employees make changes in diet and exercise behaviors. Improving health outcomes and reducing costs will depend on whether employees sustain lifestyle changes and maintain a healthy weight over time. PURPOSE To determine if a 9-month maintenance intervention immediately following a 10-week worksite exercise and nutrition program would prevent regain of the weight lost during the program. DESIGN RCT. SETTING/PARTICIPANTS In 2008, a total of 330 employees from 24 teams completed a 10-week exercise and nutrition program at a large hospital worksite and were randomized by team to maintenance or control (usual care) for 9 months. INTERVENTION Internet support with a website for goal-setting and self-monitoring of weight and exercise plus minimal personal support. MAIN OUTCOME MEASURES Weight loss, percentage weight loss, time spent in physical activity, and frequency of consumption of fruits/vegetables, fatty foods, and sugary foods at 1 year compared to baseline. One-year follow-up was completed in 2010, and data were analyzed in 2011. RESULTS At 1 year, 238 subjects (72%) completed follow-up assessments. Mean baseline BMI was 27.6 and did not differ between intervention and control. Compared to baseline, both groups lost weight during the 10-week program and maintained 65% of weight loss at 1 year (p<0.001). There was no difference in weight loss between groups at the end of the 10-week program (4.8 lbs vs 4.3 lbs, p=0.53 for group X time interaction) or end of maintenance at 1 year (3.4 lbs vs 2.5 lbs, p=0.40 for group X time interaction). All subjects had improvements in physical activity and nutrition (increased fruits/vegetables and decreased fat and sugar intake) at 1 year but did not differ by group. CONCLUSIONS An intensive 10-week team-based worksite exercise and nutrition program resulted in moderate weight loss and improvements in diet and exercise behaviors at 1 year, but an Internet-based maintenance program immediately following the 10-week program did not improve these outcomes. TRIAL REGISTRATION This study is registered at clinicaltrials.gov NCT00707577.

Participation and cardiovascular risk reduction in a voluntary worksite nutrition and physical activity program

This study examined relationships between macronutrients and plasma triglycerides, HDL, and the total-to-HDL cholesterol ratio (T/H ratio) in a population-based sample of 695 premenopausal and 727 postmenopausal women participating in the Framingham Offspring/Spouse Study. Multivariate regression analyses revealed that plasma triglycerides were inversely related to protein, fiber, and polyunsaturated fat and directly related to saturated fat and oleic acid. Alcohol intake was directly related to HDL cholesterol and inversely related to the T/H ratio in all subgroups of women, except for postmenopausal women with the 3/2 or 2/2 apolipoprotein E phenotype. Similarly, a direct relationship between dietary fat and HDL cholesterol was limited to this single subgroup of postmenopausal women. Since dietary fat and alcohol do not appear to have consistent effects on plasma lipids in all groups of women, it is important to consider the genetic contribution to diet/lipid relationships in epidemiological studies and when evaluating lipid-lowering interventions.

Activity monitor intervention to promote physical activity of physicians-in-training: randomized controlled trial.

This study examined relationships between diet and plasma total and LDL cholesterol levels in a population-based sample of 695 premenopausal and 727 postmenopausal women participating in the Framingham Offspring/Spouse Study. Regression analyses controlled for age, caloric intake, apolipoprotein E isoform type, estrogen use, and important CVD risk factors indicated that plasma total and LDL-cholesterol levels were directly associated with consumption of saturated fat and inversely associated with total calorie intake. In contrast, dietary cholesterol was not a predictor of plasma total or LDL cholesterol levels. Total cholesterol levels were also directly associated with total fat, oleic acid, and animal fat, and inversely associated with carbohydrate intake. Stepwise regressions with key nutrients indicated that saturated fat was consistently associated with total and LDL cholesterol levels in Framingham women. These analyses suggest that diet explains 2% of the variability in these lipid levels in a cross-sectional sample of women; the full model explains 22-27%.

Comparison of Energy Assessment Methods in Overweight Individuals

This study examines the cross-sectional relationships between diet and serum cholesterol in a sample of 413 Framingham cohort males, ages 37-70. Regression analyses controlling for age, calories, and coronary heart disease risk factors showed that the direct predictors of serum cholesterol included: fat (g) (p less than 0.05), cholesterol (mg/1000 calories) (p less than 0.05), protein (g and calorie density) (p less than 0.05 and p less than 0.001, respectively), Metropolitan relative weight (p less than 0.05), and systolic blood pressure (p less than 0.001). Fat (calorie density) and cholesterol (mg) were marginally significant direct positive predictors (0.05 less than or equal to p less than or equal to 0.10). Inverse correlates of serum cholesterol were total carbohydrate (g and calorie density) and simple carbohydrate (calorie density) (p less than 0.001). A marginally inverse correlate of serum cholesterol was complex carbohydrate (calorie density) (0.05 less than or equal to p less than or equal to 0.10). These cross-sectional results show that dietary variables predict serum cholesterol levels in men independent of other coronary heart disease risk factors.