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.