title: Effects of choice architecture and chef-enhanced meals on the selection and consumption of healthier school foods: a randomized clinical trial.
abstract: OBJECTIVE
  Little is known about the long-term effect of a chef-enhanced menu on healthier food selection and consumption in school lunchrooms. In addition, it remains unclear if extended exposure to other strategies to promote healthier foods (eg, choice architecture) also improves food selection or consumption.
  
  
  OBJECTIVE
  To evaluate the short- and long-term effects of chef-enhanced meals and extended exposure to choice architecture on healthier school food selection and consumption.
  
  
  METHODS
  A school-based randomized clinical trial was conducted during the 2011-2012 school year among 14 elementary and middle schools in 2 urban, low-income school districts (intent-to-treat analysis). Included in the study were 2638 students in grades 3 through 8 attending participating schools (38.4% of eligible participants).
  
  
  METHODS
  Schools were first randomized to receive a professional chef to improve school meal palatability (chef schools) or to a delayed intervention (control group). To assess the effect of choice architecture (smart café), all schools after 3 months were then randomized to the smart café intervention or to the control group.
  
  
  METHODS
  School food selection was recorded, and consumption was measured using plate waste methods.
  
  
  RESULTS
  After 3 months, vegetable selection increased in chef vs control schools (odds ratio [OR], 1.75; 95% CI, 1.36-2.24), but there was no effect on the selection of other components or on meal consumption. After long-term or extended exposure to the chef or smart café intervention, fruit selection increased in the chef (OR, 3.08; 95% CI, 2.23-4.25), smart café (OR, 1.45; 95% CI, 1.13-1.87), and chef plus smart café (OR, 3.10; 95% CI, 2.26-4.25) schools compared with the control schools, and consumption increased in the chef schools (OR, 0.17; 95% CI, 0.03-0.30 cups/d). Vegetable selection increased in the chef (OR, 2.54; 95% CI, 1.83-3.54), smart café (OR, 1.91; 95% CI, 1.46-2.50), and chef plus smart café schools (OR, 7.38, 95% CI, 5.26-10.35) compared with the control schools, and consumption also increased in the chef (OR, 0.16; 95% CI, 0.09-0.22 cups/d) and chef plus smart café (OR, 0.13; 95% CI, 0.05-0.19 cups/d) schools; however, the smart café intervention alone had no effect on consumption.
  
  
  CONCLUSIONS
  Schools should consider both collaborating with chefs and using choice architecture to increase fruit and vegetable selection. Efforts to improve the taste of school foods through chef-enhanced meals should remain a priority because this was the only method that also increased consumption. This was observed only after students were repeatedly exposed to the new foods for 7 months. Therefore, schools should not abandon healthier options if they are initially met with resistance.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT02309840.
authors: Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts.
authors: Juliana F W
authors: JF
authors: Cohen
authors: Project Bread, Boston, Massachusetts.
authors: Scott A
authors: SA
authors: Richardson
authors: Project Bread, Boston, Massachusetts.
authors: Sarah A
authors: SA
authors: Cluggish
authors: Project Bread, Boston, Massachusetts.
authors: Ellen
authors: E
authors: Parker
authors: Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts4Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts.
authors: Paul J
authors: PJ
authors: Catalano
authors: Departments of Epidemiology and Nutrition, Harvard School of Public Health, Boston, Massachusetts6Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
authors: Eric B
authors: EB
authors: Rimm
mesh_terms: D000293:Adolescent; D002648:Child; D002755:Choice Behavior; D005518:Food Preferences; D005522:Food Services; D006801:Humans; D012574:Schools; D013334:Students; D014675:Vegetables