Effects of Choice Architecture and Chef-Enhanced Meals on the Selection and Consumption of Healthier School Foods A Randomized Clinical Trial

IMPORTANCE 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. DESIGN, SETTING, AND PARTICIPANTS 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). INTERVENTIONS 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 cafe), all schools after 3 months were then randomized to the smart cafe intervention or to the control group. MAIN OUTCOMES AND MEASURES 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 cafe intervention, fruit selection increased in the chef (OR, 3.08; 95% CI, 2.23-4.25), smart cafe (OR, 1.45; 95% CI, 1.13-1.87), and chef plus smart cafe (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 cafe (OR, 1.91; 95% CI, 1.46-2.50), and chef plus smart cafe 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 cafe (OR, 0.13; 95% CI, 0.05-0.19 cups/d) schools; however, the smart cafe intervention alone had no effect on consumption. CONCLUSIONS AND RELEVANCE 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.