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Color Codes, Eye-Level Positions Boost Healthy Food Choices

Stacks of cafeteria trays (John Lester/Flickr)A hospital’s program encouraging more healthful cafeteria food choices through color-coded labels and the positioning of items in display cases was found successful across all categories of employees. A team from Massachusetts General Hospital in Boston, led by Harvard University public health professor Douglas Levy, published a study of the program online in the American Journal of Preventive Medicine.

Up to now, note the authors, actions such as posting nutritional information on signs or package labels have had uneven results. Many customers, particularly those with less language or reading ability, may have difficulty reading and understanding nutritional labels, but even those with relatively high educational levels do not always read the nutritional information.

The Mass General team tested two alternative approaches to conveying nutritional information and choices in the hospital’s employee cafeteria. The first approach, which began in March 2010, attached color-coded labels to all food items in the cafeteria (pictured below). Green labels signified the healthiest items, such as fruits, vegetables, and lean meats. Yellow labels indicated less healthy items, and red labels were attached to items with little or no nutritional value.

The second approach involved what the researchers call “choice architecture,” and focused on popular items likely to be purchased by customers with little time to spend, and that may be more influenced by location and convenience, such as cold beverages, pre-made sandwiches, and chips. Beginning in June 2010, the cafeteria arranged its refrigerated sections placing green-label items such as water, diet beverages and low-fat dairy products at eye level, while beverages with a red or yellow label were placed below eye level. Other cafeteria displays of sandwiches, chips, and bottled water were likewise arranged to make it easier to find the more healthy items.

Data for the study were collected through the cafeteria’s program that enables the 4,600 hospital employees to pay for meals through payroll deductions rather than using cash. The employees’ purchases were matched to the hospitals human resource data, although no data on specific individuals were available to the researchers. Educational level was reflected by job category: Service workers; Administrative and support staff; Technicians that cover radiology technicians and respiratory therapists; Health professionals such as pharmacists and occupational therapists; and Management and clinicians that include physicians and nurses. Employees’ race or ethnicity — white, black, Latino or Asian — was self-reported.

The results show after nine months of both phases of the program, employees in all groups purchased fewer red-label items and more green-label items. In contrast, at the beginning of the test period, black and Latino employees and those in job categories associated with lower education purchased more red-label items and fewer green-label items than did white employees or those in higher-education job types.

The researchers looked at purchases of beverages, focusing on sugar-sweetened drinks which are strongly linked to obesity, diabetes and heart disease, and where consumption is highest among black and low-income individuals. The findings show the purchase of healthful beverages increased for all groups. In addition black and low-education employees, who paid the highest cost per beverage at the start of the study, were paying significantly less per beverage purchased at the end of the study period.

Mass General has continued the color-coded labels and choice-architecture programs in its employee cafeteria, and extended them to all of the hospital’s food service sites. Levy notes the long-term effectiveness of these interventions still need to be studied, but adds, “because these measures are both simple and inexpensive to implement, they could easily be tried in a variety of food sales environments, such as cafeterias, convenience stories, and even vending machines.”

Color-coded labels indicate the healthiest sandwich choices (green), along with those designated less (yellow) and least (red) healthy. Courtesy, Massachusetts General Hospital

Color-coded labels indicate the healthiest sandwich choices (green), along with those designated less (yellow) and least (red) healthy. Courtesy, Massachusetts General Hospital

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Photo: John Lester/Flickr

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